Abdomen Assessment – Health Assessment, Summer 2022

Overview of Abdomen Assessment

• Instructor: Janet Fletcher, MSN, RN – Health Assessment, Summer 2022
• Goal: Develop systematic skills for gathering subjective data, inspecting, auscultating, percussing, palpating, documenting, and interpreting findings in the abdominal exam.
• Key clinical pearl: “Knowing which organ lives in which quadrant/region = shortcut to identifying possible pathology.”

Abdominal Quadrants & Regions

• Four classic quadrants used in bedside discussion
  • RUQ – liver, gallbladder, duodenum, head of pancreas, right kidney/adrenal, hepatic flexure of colon, portions of ascending & transverse colon.
  • LUQ – stomach, spleen, left lobe of liver, body of pancreas, left kidney/adrenal, splenic flexure, parts of transverse & descending colon.
  • RLQ – cecum, appendix, right ovary & tube, right ureter, right spermatic cord.
  • LLQ – sigmoid colon, parts of descending colon, left ovary & tube, left ureter, left spermatic cord.
• Nine‐region scheme (more precise mapping)
  • Row 1: Right hypochondrium | Epigastric | Left hypochondrium
  • Row 2: Right lumbar | Umbilical | Left lumbar
  • Row 3: Right iliac/hypogastrium | Hypogastric (suprapubic) | Left iliac
• Landmarks practice prompt: Locate spleen (posterolateral LUQ, ribs 9{-}11), kidneys (retroperitoneal, costovertebral angle; left 1 cm higher), bladder (suprapubic midline).

Causes of Abdominal Pain by Area

• Epigastric / RUQ: hepatitis, gallstones, cholangitis, cholecystitis, hepatic abscess, peptic ulcer, oesophagitis, pancreatitis, gastric cancer.
• LUQ / left flank: splenic abscess/rupture/infarct, renal colic, pyelonephritis, early appendicitis (referred).
• Periumbilical / RLQ: mesenteric adenitis, Meckel diverticulitis, late appendicitis, Crohn disease.
• Suprapubic / pelvis: ectopic pregnancy, ovarian cyst/torsion, UTI, urinary retention, testicular torsion.
• LLQ / left iliac: diverticulitis, ulcerative colitis, ectopic pregnancy, ovarian cyst.
• Clinical message: an accurate pain map narrows differential before expensive imaging.

The Aging Adult

• Body habitus
  • Subcutaneous fat redistributes to abdomen/hips → altered contour.
  • Abdominal musculature relaxes/weaks → hernia risk ↑.
• GI physiology changes
  • ↓ Salivation → dry mouth, impaired taste, nutritional risk.
  • Delayed esophageal emptying → aspiration risk when supine soon after meals.
  • ↓ Gastric acid secretion → malabsorption of Ca, Fe, B12, some meds.
  • ↑ Incidence of gallstones.
  • ↓ Liver size → slower first-pass drug metabolism; monitor hepatically cleared meds.
  • Constipation NOT inevitable; explore diet, mobility, meds, hydration, depression.
• Broader geriatrics lens
  • IADLs, eating alone, dysphagia, poly-pharmacy side-effects (nausea, anorexia, xerostomia).

Subjective Data – Sample Interview Questions

• Appetite: usual intake, recent weight change (intentional?), early satiety.
• Dysphagia: onset, solids vs liquids, odynophagia.
• Food intolerance: lactose, gluten, fatty meals.
• Abdominal pain: OPQRST (onset, provoking, quality, radiation, severity 0{-}10, timing).
• Nausea/vomiting: triggers, hematemesis, bilious content, coffee-ground.
• Bowel habits: frequency, color (melena, hematochezia, clay-colored), consistency (Bristol).
• Past abdominal history: surgeries, ulcers, liver disease, gallbladder removal.
• Medications: NSAIDs (ulcer risk), opioids (constipation), iron (black stool).
• Nutrition: 24-hr recall, food security, ETOH use.

Key Terminology & Clarifications

• Anorexia: loss of appetite linked to illness or meds vs Anorexia Nervosa: psychiatric eating disorder.
• Dysphagia: difficulty swallowing.
• Pyrosis: heartburn, burning retrosternal pain
• Hematemesis: vomiting bright-red or coffee-ground blood.
• Melena: black, tarry stool (digested blood >50 mL).
• Borborygmus: hyperperistaltic “growling.”

Physical Assessment Sequence & Rationale

1. Inspection
2. Auscultation – performed second to avoid altering bowel motility with touch.
3. Percussion
4. Palpation – last so tenderness/resistance doesn’t mask true sounds or percussion notes.

Inspection Checklist

• Contour: flat, rounded, scaphoid, protuberant.
• Symmetry: bulges = hernia, mass.
• Umbilicus: midline/inverted. Cullen sign (periumbilical blue) → intraperitoneal bleed (e.g., pancreatitis, ectopic).
• Skin: color (jaundice = yellow sclera/skin from ↑ \text{bilirubin}), scars, lesions, striae (lineae albicantes = silvery stretch marks from rapid growth/Cushing).
• Pulsations: mild epigastric aortic pulsation normal; marked visible peristalsis + distention suggests obstruction.
• Hair distribution: diamond (male), inverted triangle (female).
• Demeanor: knees flexed, grimacing, rapid uneven respirations → peritonitis/colic.

Auscultation – Bowel Sounds

• Preparation: warm stethoscope, supine patient, knees slightly bent to relax muscles, distract conversation.
• Tool: diaphragm lightly on skin (don’t compress vessels).
• Start point: RLQ over ileocecal valve – most active.
• Normal frequency: “normoactive” ≈ 5{-}30 sounds/min; counting individual clicks not required clinically.
• Hyperactive: loud, high-pitched, rushing, “tinkling” → early obstruction, gastroenteritis, diarrhea, borborygmus.
• Hypoactive: less than 5/min; post-op ileus, peritonitis, late obstruction.
• Absent: none in >5 min continuous listen – surgical emergency till proved otherwise.

Auscultation – Vascular, Friction, Rubs

• Sites: aorta (epigastric), renal arteries (UQ flanks), iliac (RLQ/L), femoral (groin).
• Tool: bell, firm pressure.
• Normal: no bruits, hums, or rub.
• Systolic bruit: turbulent arterial flow (stenosis, aneurysm) – blowing sound.
• Venous hum: continuous, medium-pitch in epigastric/umbilical from collateral circulation (portal HTN).
• Peritoneal friction rub: rough grating over liver/spleen with respiration – tumor, abscess, infection.

Percussion

• Technique: indirect; pleximeter finger flat, brisk tap with plexor finger, compare bilaterally.
• Expected notes:
  • Tympany dominates (air in intestines).
  • Dullness over liver, spleen, distended bladder, solid tumor, feces, fluid.
  • Hyperresonance if gaseous distention.
• Quiz answer: underlying pelvic bones also produce dullness.

Palpation – General

• Purpose: estimate organ size, detect mass, elicit tenderness.
• Light (≈1 cm) – finger pads in gentle rotary motion; note skin temp, superficial pain, muscle guarding. Voluntary guarding: patient tenses on touch; decreases with exhalation/distraction.
• Deep (≈5–8 cm) – one or bimanual; evaluate organs & masses.
• Mild tenderness in sigmoid colon (LLQ, pelvic brim) common ➜ stool.

Palpating Specific Organs

• Liver
  • Left hand posterior 11{-}12 ribs, right hand RUQ parallel to midline, push under costal margin while patient inhales.
  • Normal: soft edge may tap fingers; often not palpable.
  • Abnormal: firm, hard, nodular border, pain. Enlargement ⇒ hepatitis, CHF, tumors.
• Spleen
  • Must be ×3 normal to feel.
  • Hands: left supports ribs posteriorly, right fingers LUQ toward left axilla; deep breath.
  • If tip felt (soft, pulsing), stop → rupture risk. Causes: mononucleosis, malaria, leukemia, portal HTN.
• Kidneys
  • “Duck-bill” bimanual capture at flank.
  • Right lower pole sometimes palpable (normal, smooth, round).
  • Left rarely palpable (sits higher).
• Aorta
  • Thumb–finger grasp, supra-umbilical left of midline.
  • Normal width 2.5{-}4\text{ cm}.
  • >4 cm suggests aneurysm (AAA); listen for bruit.

Special Test – Rebound Tenderness (Blumberg)

• Pick site distant from pain, press slowly \downarrow deep, release quickly \uparrow.
• Positive: pain ↑ on release → peritoneal irritation (e.g., appendicitis).
• Perform once to avoid spasm amplification.

Referred Pain Patterns (select)

• Shoulder: diaphragmatic irritation (liver, gallbladder).
• Back/flank: pancreatitis, renal colic.
• RLQ: appendix but may start peri-umbilical.
• Scapular/Right sub-scapular: biliary colic, cholecystitis.
• Chest/GERD: epigastric acid reflux.
• Suprapubic: rectal lesions, colon pain.

Sample Documentation Template

“Abdomen is flat and symmetric, skin warm, tan, no lesions, no striae, no scars.
Bowel sounds normoactive in all four quadrants; no bruits or friction rubs.
Tympany predominates on percussion; liver span X cm, no splenic dullness.
No tenderness, guarding, or masses with light and deep palpation; liver edge non-palpable, spleen and kidneys not felt; aortic pulsation 3 cm, midline, no thrill.
Blumberg sign negative.”

Connections & Clinical Implications

• Integration with cardiovascular & metabolic lectures: Auscultated bruits → plan Doppler study; decreased liver size → adjust drug dosing.
• Ethical / Practical: Respect privacy, warm hands, patient draping. Cultural norms for touch and modesty.
• Real-world: Abdominal pain is top ED complaint; rapid quadrant mapping speeds triage.