Abdominal Assessment: Percussion and Palpation

Percussion

  • Generalized Tympany: Predominates over the abdomen due to air in the stomach and intestines.
  • Dullness: Heard over the liver and spleen; may also be elicited over a non-evacuated descending colon.
  • Accentuated Tympany/Hyperresonance: Heard over a gaseous distended abdomen.
  • Abnormal Dullness: Heard over a distended bladder, large masses, or ascites.

Liver Span

  • Normal Liver Span (MCL): 6-12 cm (greater in men/taller clients, less in shorter clients).
  • Normal Liver Span (MSL): 4-8 cm.
  • Hepatomegaly: Liver span exceeds normal limits, characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement.
  • Atrophy: Decreased liver span.
  • Lower Position: May be caused by emphysema.
  • Higher Position: May be caused by an abdominal mass, ascites, or a paralyzed diaphragm.
Liver Span Percussion Technique
  1. Lower Border: Percuss upward from RLQ at MCL, noting change from tympany to dullness.
  2. Upper Border: Percuss downward from upper right chest at MCL, noting change from lung resonance to liver dullness.
  3. Measurement: Measure distance between the two marked points.
  4. Repeat: Percuss at the midsternal line (MSL).

Kidney Percussion

  • Procedure: Blunt percussion on the kidneys at the costovertebral angles (CVA) over the twelfth rib.
  • Normal: No tenderness or pain elicited; examiner senses a dull thud.
  • Abnormal: Tenderness or sharp pain suggests kidney infection, renal calculi, or hydronephrosis.

Palpation Considerations

  • Avoid tender areas initially.
  • Light palpation before deep palpation.
  • Normal abdomen may be tender over xiphoid process, liver, aorta, lower pole of kidney, gas-filled cecum, sigmoid colon, and ovaries.
  • Techniques to minimize guarding: self-palpation, pillow under knees, slow deep breaths, light pressure over sternum.

Light Palpation

  • Normal: Abdomen is nontender and soft; no guarding.
  • Abnormal: Involuntary reflex guarding indicates peritoneal irritation; rigid abdomen, failure of rectus muscle to relax.
  • Right-sided guarding may indicate cholecystitis.

Deep Palpation

  • Normal: Possible mild tenderness over xiphoid, aorta, cecum, sigmoid colon, and ovaries.
  • Abnormal: Severe tenderness or pain may relate to trauma, peritonitis, infection, tumors, or enlarged/diseased organs. Palpable mass may be tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.

Umbilicus Palpation

  • Normal: Free of swellings, bulges, or masses.
  • Abnormal: Soft center may indicate potential herniation; hard nodule may indicate metastatic nodes from gastrointestinal cancer.

Aorta Palpation

  • Normal: Approximately 2.5–3.0 cm wide, moderately strong and regular pulse; possible mild tenderness.
  • Abnormal: Wide, bounding pulse may indicate abdominal aortic aneurysm; prominent, laterally pulsating mass with audible bruit strongly suggests aortic aneurysm.

*Clinical Tip: Do not palpate a pulsating midline mass. Avoid deep palpation over tender organs.

Liver Palpation

  • Normal: Usually not palpable, but may be felt in thin clients; if felt, should be firm, smooth, and even; mild tenderness may be normal.
  • Abnormal: Hard, firm liver may indicate cancer; nodularity may occur with tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may be from vascular engorgement, acute hepatitis, or abscess. A liver more than 1–3 cm below the costal margin is considered enlarged.

Hooking Technique

  • Fingers of both hands are hooked over the edge of the right costal margin. The client takes a deep breath as the examiner gently pulls inward and upward.

Kidney Palpation

  • Normal: Usually not palpable; sometimes the lower pole of the right kidney may be palpable by the capture method because of its lower position. If palpated, it should feel firm, smooth, and rounded; may or may not be slightly tender.
  • Abnormal: An enlarged kidney may be due to a cyst, tumor, or hydronephrosis.

Urinary Bladder Palpation

  • Normal: Empty bladder is neither palpable nor tender.
  • Abnormal: Distended bladder is palpated as a smooth, round, and somewhat firm mass extending as far as the umbilicus; validated by dull percussion tones.

Tests for Appendicitis/Peritoneal Irritation

  • Psoas sign
  • Rovsing’s sign
  • Obturator sign
  • Blumberg’s sign

Psoas Sign

  • Procedure: Hyperextend the client’s right leg while they lie on their left side.
  • Positive: Pain in the RLQ, indicating irritation of the iliopsoas muscle due to appendicitis.

Rovsing’s Sign

  • Procedure: Palpate deeply in the LLQ and quickly release pressure.
  • Positive: Pain in the RLQ during pressure in the LLQ, suggesting acute appendicitis.
    *Safety Tip: Avoid continued palpation when test findings are positive for appendicitis due to the danger of rupturing the appendix.

Obturator Sign

  • Procedure: Flex the client’s hip and knee, and rotate the leg internally and externally.
  • Positive: Pain in the RLQ, indicating irritation of the obturator muscle due to appendicitis or a perforated appendix.

Blumberg’s Sign

  1. Palpate deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest (McBurney point).
  2. Suddenly release pressure.
  • Positive: Rebound tenderness; sharp, stabbing pain as pressure is released, indicating peritoneal irritation.