ASSESSMENT OF THE ABDOMEN

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ASSESSMENT OF THE ABDOMEN

• Prepared by
• Hamdia Mohammed

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Learning Objectives-

• At the end of this lecture each student will be
  able to
• Identify landmarks for the abdominal assessment
• Correctly perform techniques of inspection,
  auscultation, percussion and palpation
• Differentiate between normal abnormal findings.

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Overview of abdominal structure.

• 1- Large oval cavity.
• 2- Extends from diaphragm to symphysis.
• 3- Viscera solid and hollow.
• A- Solid viscera are those organs that maintain
  their shape consistently ( liver, pancreas,
  spleen, adrenal glands, kidneys, ovaries and
  uterus ).

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• The liver is the largest solid organ in the body.
• B- The hollow viscera consist of structures that
  change shape, depending on their contents . These
  include ( stomach, gallbladder, small intestine,
  colon , bladder ).
• 4- Vascular structures
• The abdominal organs are supplied with
  arterial blood by abdominal aorta its major
  branches.

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Locating abdominal structures by quadrants

• Divided to four quadrants-
• 1- Right upper quadrant ( RUQ )
• 2- Right lower quadrant ( RLQ )
• 3- Left upper quadrant ( LUQ )
• 4- Left lower quadrant ( LLQ )

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• Right upper quadrant
• ( RUQ ).

• Left Upper Quadrant
• (LUQ ).

• - stomach
• - spleen
• - left lobe of liver
• - body of pancrea
• - left kidney and adrenal
• - spleen flexure of colon
• - part of transverse descending colon

• - Liver
• - Gallbladder
• - Duodenum
• - Head of pancreas
• -Right kidney and adrenal
• - Hepatic flexure of colon
• - Part of ascending and transverse colon.
• - Right ureter.

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• Right Lower Quadrant

• Left Lower Quadrant

• -Part of descending colon
• -Sigmoid colon
• -Left ovary and tube
• -Left ureter
• -Left spermatic cord

• -Cecum
• -Appendix
• -Right ovary and tube
• -Right ureter
• -Right spermatic cord
• Midline
• -Aorta
• -Uterus.
• -bladder.

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Abdominal Landmarks
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Preparation for abdominal assessment

• Preparing the exam room
• preparing the patient
• positioning the examiner

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Health History

• Any chronic diseases that affect GIT or urinary
  systems? Describe.
• Does he drink alcohol? How much? How often? When
  was last drink?
• Smoke? How much and how long? Considered stopping
  or cutting down?
• How often do you have a bowel movement? When was
  the last one? What are color and consistency of
  stool?

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• Nausea or vomiting for how long? Frequency?
• How much do vomit? What does it look like?
  Contain blood? Have an odor?
• Abdominal pain
• How long have he had ? Where? When did he first
  feel pain? What activity were he doing?
• Describe pain. Constant/intermittent? Had
  episodes before? Did pain start suddenly?

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Types of pain

1. Vesceral pain.
2. Parietal pain as in appendicitis
3. Referred pain

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Character of abdominal pain

• Dull, aching( e.g cystitis )
• Burning (e.g dyspepsia )
• Colicky (e.g colon cancer)
• Sharp, knifelike (e.g renal colic )
• Pressure ( urinary retention )

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Assessment Techniques

• 1- Inspection.
• 2- Auscultation.
• 3- Percussion.
• 4- Palpation.

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1- Inspection

• skin color, scars, veins, lesions.
• umbilical hernia, bleeding, inflammation.
• contour of the abdomen flat ,rounded,
  protuberant .
• symmetry
• enlarged organ.
• Masses.
• Peristalsis ,pulsation , distention.

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Inspection
Deviation from normal Normal finding Procedure
1- Dark bluish striae is seen in cushing syndrome, redness in inflammation 2- Rashes or lesions. 3-Engorged veins. 1-Pale ,with white striae 2- No rashes or lesions. 3- Fine veins observable Skin 1-Color 2-Integrity 3-Venous pattern
1- Deviation from midline with mass ,hernia,everted with distention.. 2- Bluish 1- Sunken, centrally location 2- Pinkish Umbilicus 1- Position 2- Color
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Inspection cont
Deviation from normal Normal finding Procedure
Black, bright red, tarry ( melena ). Brown to dark brown Color of stool
Bloody ( hematemesis ) Varies Color of emesis
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Distention-

• Definition unusual stretching of abdominal wall
• Abdominal distention can be caused by three
  factors
• 1. Obesity Abdomen is soft and rounded with a
  sunken umbilicus.
• 2. Ascites Skin is shiny and glistening with an
  everted umbilicus. Veins are dilated and
  prominent (more visible in thin, malnourished
  skin).
• 3. Obstruction There may be visible, marked
  peristalsis restlessness lying with knees
  flexed grimacing facial expression and uneven
  respirations.

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Distention-

• note position of umbilicus
• note portion of abdomen that is
• distended
• reasons for distention flat(obesity),
• flatus(gas), feces, fluid, tumor ,
  fetus(pregnancy )

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2- Auscultation

• Auscultation performed before palpation and
  percussion.
• Use diaphragm of stethoscope
• Listen to bowel sounds for up 5 minutes in each
  quadrant.
• Normal sounds are clicks and gurgles, irregular,
  5-30 times per minute
• Influenced by digestion

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Auscultation cont

• Increased bowel sounds are due to hypermotility
  of peristalsis
• Decreased are due to paralytic ileus or
  peritonitis
• Intestinal obstruction can present with increased
  or decreased sounds

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Abdominal Vessels
Sites for Auscultating the Abdomen
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Additional Sounds

• Bruits
• Bruits are low pitched, vascular sounds,
  resembling murmur
• Caused by partially obstructed artery turbulence
• Listen in epigastrum and each upper quadrant
• Listen in costovertebral angle(with patient
  seated)
• Listen over aorta, iliac arteries, femoral
  arteries
• Arterial insufficiency in legs

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3- Percussion

• Assessment technique used to assess size and
  density of organs in the abdomen e.g used to
  measure size of liver or spleen.
• In the right midclavicular line, percuss down
  from lung resonance to liver dullness.

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Percussion cont

• Used to identify air in stomach or in bowel.
• Used to identify masses.
• Used alone or in conjunction with palpation or to
  validate palpatory findings.
• Orient to the abdomen by lightly percussing all
  4 quadrants for tympany or dullness.

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Percussion cont

• Tympany usually predominates due to gas in the
  bowel.
• Dullness may be present due to feces or fluid or
  over organs or a solid mass.
• Develop a specific percussion route and stick to
  it.

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Percussing the spleen

• Where is the spleen located?
• In the curve of the diaphragm just posterior to
  the left midaxillary line.
• When the spleen enlarges, it does so anteriorly,
  downward and medially. This will replace the
  tympany of the stomach and colon with dullness

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Tricks to Assessing the Spleen

• Percuss in the lowest interspace in the left
  anterior axillary line for tympany.
• Ask the patient to take a deep breath and percuss
  on inspiration.
• The percussion note should remain tympanic.
• A change to dullness suggest spenomegally
• This is known as a positive splenic percussion
  sign

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Percussion Sites for all
Quadtrants (Abdominal percussion seqences may
proceed clockwise)
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4- Palpation

• To differentiate voluntary from involuntary
  resistance rectus muscle will relax with
  expiration.
• Palpation is light or deep
• Deep palpation used to define and delineate
  organs or abdominal masses.
• Use palmar surface of fingers and feel in all
  four quadrants

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Palpation cont

• Used to assess muscle tone, tenderness, fluid,
  organs.
• Use pads of fingertips in light dipping motions
  and avoid short jabs.

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Palpation of the liver

• Stand on patients right side
• Place left hand behind patient parallel to and
  supporting 11-12th ribs
• Patient should relax
• Press with left hand forward and place right hand
  on abdomen with fingertips below lower edge liver
  dullness
• Press in and up while patient takes deep breath
  if palpable, liver should come down

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Palpation of the spleen

• The spleen is usually not palpable
• From patients right side, reach over and around
  under patient with left hand
• Place right hand below left costal margin and
  press in toward spleen. Ask patient to take deep
  breath---will feel if palpable

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B- Auscultating the abdomen
A-Inspecting the abdomen
D- Percussing the abdomen
C- Palpating the abdomen
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Assessment of the urinary system
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Learning Objectives-

• 1- Identify the important new terms related to
  urinary system.
• 2- List the factors which influencing urination.
• 3- Enumerate function of kidneys.
• 4- Differentiate between normal and abnormal
  finding.

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Important new Terms

• Oliguria voiding a scanty amount of urine.
• Anuria inability to produce urine, less
  common, but caused by a decrease in renal
  perfusion.
• Polyuria excessive output of urine.
• Hematuria blood noted in urine.
• Nocturia having to void at night.

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• Dysuria difficulty in voiding or pain in
  voiding.
• Enuresis involuntary loss of urine at
  night.
• Pyuria presence of pus in the urine.
• Glycosuria presence of sugar in urine.
• Albumin urea presence of albumin in the
  urine.

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Factors influencing urination

1. Socio cultural
2. psychological
3. muscle tone
4. fluid balance
5. surgical procedures
6. medication

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• Functions of the kidneys Kidney-
• Urine formation
• Excretion of waste products
• Regulation of electrolytes
• Regulation of acidbase balance
• Control of water balance
• Control of blood pressure
• Renal clearance
• Regulation of red blood cell production
• Synthesis of vitamin D to active form
• Secretion of prostaglandins.

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Palpation of kidney

• Find the costovertebral angle which formed by the
  lower border of the 12th rib and the transverve
  processes of the upper lumbar vertebrae.
• Place left hand flat in this area on one side,
  hit the hand sharply with the fist of the other
  patient will admit to tenderness if present.
• Repeat on the other side

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Palpation cont.

• Kidney not palpable in normal adult.
• May be able to feel lower right kidney pole in
  very thin person.

Technique for palpating the right kidney (top).
Technique for palpating the left kidney.
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Deep palpation

• If masses are felt, note location, size,
  shalpe, consistency, tenderness, pulsations,
  mobility with respiration or with hand.
• If patient is obese or rigid, use 2 hands to
  palpate
• Place one on top of other and feel with lower
  hand

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Palpation of the bladder

• Bladder percussion is unnecessary unless there is
  a suspicion of urinary retention.
• Palpate above the symphysis.
• An empty bladder is not palpable.

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• The bladder should be percussed after the patient
  voids to check for residual urine.
• Percussion of the bladder begins at the midline
  just above the umbilicus and proceeds downward.
• The sound changes from tympanic to dull when
  percussing over the bladder.

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• The bladder, which can be palpated only if it is
  moderately distended, feels like a smooth, firm,
  round mass rising out of the abdomen, usually at
  midline.
• Dullness to percussion of the bladder following
  voiding indicates incomplete bladder emptying.

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Assessing the Aorta

• Press firmly deep in upper abdomen slightly to
  left of midline.
• Feel for aortic pulsations
• Determine width of aorta by pressing deeply on
  either side of aorta
• What is the normal width of the aorta?
• If pulsatile mass is found, feel for femoral
  pulses which may be dimished.

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Special test for appendicitis

• Rebound tenderness mean deeply palpation
  withdrawal quickly, this caused pain in
  appendicitis.
• Psoas sign pt lie in supine position raise
  right leg , if the pain found this is indicate to
  appendicitis.
• Oburator sign pt flex right leg at hip and knee.
  Then rotate leg internally and externally.