Patient Assessment a Method of Monitoring

Abdomen Chapter 16 p 525-583 Sites & Sounds in the Abs. pp. 541

Terms You Should Know

linea alba inguinal ligament umbilicus ascites deep palpation light palpation epigastrum suprapubic gastric bubble fluid wave striae petechiae angiomas guarding scaphoid borborygmi rebound tenderness

Review the Anatomy

There are a number of structures to be assessed in the abdomen. The best way to review the underlying anatomy is to first divide the abdominal area into four quadrants (right upper, left upper, left lower and right lower). With this method, the dividing lines intersect at the umbilicus.

Review the Anatomy

Beginning in the RUQ: liver, lower right kidney; LUQ: spleen, stomach, left kidney; LLQ: descending colon, bladder, L ovary, uterus (female) RLQ: ascending colon, bladder, R ovary, uterus (female), appendix

Review the Anatomy

Vasculature: abdominal aorta, L & R renal artery L & R iliac artery L & R femoral artery See page 541 for the location

The Exam

Prior to the exam, the patient should empty their bladder. The patient should be assisted into a supine position with a pillow for their head, and their knees slightly bent, with a pillow under them. This enables abdominal relaxation. The patient should be draped so that xyphoid to pubis is exposed.

The Exam
Position their hands at their side or on the chest. Not under their head. Ask if they have any painful or tender areas, before you begin the exam. Be certain your hands and stethoscope are warm, and your fingernails are trimmed.

Inspection
Observe the skin of the abdominal area for color, lesions, rash, scars, striae or deformities. Assess symmetry. Using both overhead light and tangential light and look for pulsations.

Inspection
Inspect the umbilicus. Is it inverted or everted? Inflammation? Hernias? Assess abdominal contourflat, protuberant, round or scaphoid. Visible masses or visible organs? Visible peristalsis?

Auscultation

REMEMBER, in the abdominal assessment, the order is: Inspection Auscultation Percussion Palpation

Auscultation
Begin by listening for bowel sounds. Listen in each quadrant for at least 3 minutes. Frequency of bowel sounds ranges from 5-34 per minute. In actual practice, auscultation of the RLQ may be sufficient

Auscultation
Listen in the epigastrium and in each UPPER quadrant for bruits. Remember these are vascular sounds. When the patient eventually sits up, listen at the costovertebral angles. In arterial insufficiency, listen over the aorta, iliacs & femorals.

Percussion
The purpose of abdominal percussion is to identify gas patterns, and masses or enlarged organs. Lightly percuss over all four quadrants. Pay attention to the type of percussion note you hear and its location.

Percussion

Finally, percuss over the lower anterior chest. On the right you should move from resonant to dull as you encounter the liver. Note the location where the sound changed. On the left, you should hear tympany over the gastric bubble. What would you expect to hear over the splenic flexure of the colon?

Palpation
Begin with LIGHT palpation in all four quadrants. Feel for masses, areas of tenderness (look at the patients face), and muscular resistance or rigidity. Assess guarding. Is it voluntary or involuntary?

Palpation

Deep palpation follows after light in all four quadrants, especially where masses or abnormalities were located. Deep palpation aids in determining the location, size, consistency, shape, mobility, pulsations, and tenderness of a mass. Try to correlate percussion findings and palpation findings.

Liver Estimation

Using percussion, your text details a method of percussing from two different directions on the midclavicular line to discover the span of the liver. Range values for normal liver spans may be found on page 542-544.

Liver Estimation

On pages 548-550 the authors of your text describe a palpation method for evaluating the liver. With acquired skill and practice, you will be able to feel the edge of the liver as it descends.

Examination of the Spleen

Unless the spleen is enlarged, it cannot be palpated. On pages 544,550,551 you will find both a palpation and a percussion method for evaluating splenomegaly. You may want to practice the technique, even if your practice patient doesnt have an enlargement.

Kidney Palpation

With practice, a skilled practitioner can palpate the right kidney, especially in thin patients (well relaxed women). The usual technique which is described on p. 551552 is a trapping technique. The left kidney is rarely palpable unless it is enlarged. Kidney tenderness may be assessed at the costovertebral angles.

What Else?

On pages 550,553-555 you will find a method of aortic assessment as well as some special assessment techniques for patients with ascites, and cholecystitis.

What Can I Find?

Look for jaundice, cyanosis, or red coloration of the skin. Cushings disease, liver disease, intestinal obstruction, peritonitis, paralytic ileus; Other findings include hepatitis, cholecytitis, cirrhosis, neoplasms, and pregnancy.

Lets Review

The abdominal assessment is complex and comprehensive. It requires a number of special areas of auscultation, as well as some special percussion and palpation techniques. This is an assessment which you may want to break into smaller segments initially, to refine your skill then combine all aspects.

Lets Review

One more thing Pain originating in the viscera usually produces referred pain, that is pain which follows the nerve path and may not be directly over the affected organ. One example is the pain of appendicitis which may begin over the umbilical area and eventually moves to the RLQ.