- Wash hands.
- Reduces transmission of microorganisms.
- Explain procedure to patient.
- Explanation reduces the patient's anxiety.
- Position the patient supine with arms down at sides, and place a small pillow beneath the knees.
- Supine position facilitates the examination of the entire abdomen. Pillow supports the patient's back.
- Provide adequate cover for the patient.
- This helps to reserve the patient's privacy and provide warmth before proceeding with rest of the assessment.
- The nurse must stand on the patient's right side and sit in a position to look across the abdomen's surface.
- Standing helps detect abnormal shadows and movement. Sitting position provides horizontal view that allows detection of abnormal protuberances and contours.
- Divide the abdomen into four quadrants.
- Landmarks help the nurse map out the abdominal regions.
- Inspection.
- Examiner needs to make sure the patient is disrobed and provide privacy with adequate covers and warmth of the examination room.
- Inspection of skin.
- The location of scars, venous patterns, rashes, lesions, pigmentation changes, and stretch marks are noted. This can help identify previous surgeries or trauma and show if skin has been stretched from obesity or pregnancy. Striations can also signal possible adrenal problems.
- Inspection of umbilicus.
- Normally the umbilicus is flat. You may notice a different shape or color, which could indicate pathology.
- Underlying masses may displace the umbilicus, and an everted umbilicus indicates distention.
- Watch for umbilical discharge; this is an abnormal sign.
- Inspect contour and symmetry.
- The presence of a mass or masses on one side may indicate a problem. Intestinal gas, tumor, or fluid in the abdomen may cause distention.
Do not confuse distention with obesity. - Observe the abdomen while asking the patient to take a deep breath.
- This moves the diaphragm downward and decreases the size of the abdominal cavity; any enlarged organs may cause a bulge.
- Observe the abdomen while the patient raises his or her hands over the head.
- This helps to evaluate the abdominal musculature. Any hernias, masses, and muscle separation will become more apparent.
- Inspect for movement and pulsations.
- With pain, respiratory movement is diminished, and the patient may guard against the pain by tightening the abdominal muscles. (Women breathe costally, and men breath more abdominally.)
Looking across the abdomen, the nurse may see peristaltic movement and aortic pulsations (midline, above the umbilicus).
- Auscultation.
- Auscultation comes next in the physical examination.
- The examiner should listen to bowel sounds before palpating or percussing.
- These actions will stimulate bowel action and provide unreliable data for the examiner.
- Warm the diaphragm of the stethoscope, and with light pressure auscultate in all four quadrants to detect normal, high-pitched bowel sounds.
- Sounds are normally described as
- Normal
- Audible
- Absent—absence of gastrointestinal motility and a late stage of bowel obstruction
- Hyperactive or hypoactive—Hyperactive sounds indicate hypermotility caused by inflammation of the bowel, anxiety, diarrhea, bleeding, excess ingestion of laxatives, and reaction of the intestine to certain foods.
- You must listen 5 to 15 seconds in each quadrant.
- Place the bell of the stethoscope diaphragm over the epigastrium to auscultate for bruits, which manifests as a whooshing or blowing sound. Renal-artery bruits can be heard by placing the stethoscope over each upper quadrant anteriorly or over the costovertebral angle posteriorly.
- If a bruit is heard, it is not normal and should be reported to a physician immediately.
- Place bell of the stethoscope above the liver and spleen and listen for a friction rub.
- An inflamed liver or spleen may rub against the peritoneum during inspiration, creating a grating sound.
- Percussion.
- Percussion allows the examiner to determine borders of the spleen, liver, and other major organs in the abdomen. It also provides information regarding presence of fluid in the abdominal cavity.
- Systematically percuss each quadrant to assess areas of tympany and dullness.
- Tympany is percussed when there is air in the stomach or intestine. Dull percussion is heard over solid masses as in an enlarged liver, spleen, tumor, or a full bladder.
- Percuss to identify the liver border by starting at the iliac crest and proceeding upward on the right midclavicular line. As you percuss upward, the percussion note changes from tympanic to dull at the liver's lower border. (Mark the point.) The upper border is found by percussing downward from the nipple along the midclavicular line. When the note changes from resonance to dull, make a mark. The distance between the points should be 6 to 12 cm.
- Percussion allows the nurse to identify borders of the liver and to detect any organ enlargement. Diseases such as cirrhosis, cancer, and hepatitis can cause this liver enlargement.
- Percuss for the gastric air bubble in the left lower anterior rib cage and left epigastric area.
- Note: The tympany heard when percussing the gastric bubble is lower in pitch than the tympany of the intestines.
- Have the patient sit or stand erect to assess for kidney inflammation. With the ulnar surface of a partially closed fist, percuss the costovertebral angle at the scapular line.
- If the kidneys are inflamed, the patient will feel tenderness during percussion.
- Palpation.
- Palpation is the last process of the abdominal examination and provides the examiner with data concerning areas of tenderness and presence of fluid, masses.
- Hold the palm of your hand and forearm horizontally and lightly palpate each quadrant.
- Superficial palpation (1 cm)
- Deep palpation (2.5 to 7.5 cm). If you are experienced, you may do this.
- You are palpating for muscular resistance, distention, tenderness, and superficial organs or masses.
- Wash hands.
- Reduces transmission of microorganisms, which could cause infection.