| Skill 3-7 | Assessing the Abdomen | ||||||||||||||||||||||
The abdominal cavity, the largest cavity in the body, contains the stomach, small intestine, large intestine, liver, gallbladder, pancreas, spleen, kidneys, urinary bladder, adrenal gland, and major blood vessels. In women, the uterus, fallopian tubes, and ovaries are also located in the abdomen. Not all of these organs can be assessed. For identification and documentation purposes, the abdomen can be divided into four quadrants (Figure 1). The order of the techniques differs for the abdominal assessment from the other systems. Assessment of the abdomen starts with inspection, then auscultation, percussion, and palpation. The order of assessment differs for this system because palpation and percussion before auscultation may alter the sounds heard on auscultation. Advanced practice professionals perform percussion and deep palpation of the abdomen. Therefore, these techniques will not be discussed here. Before beginning the abdominal assessment, ask the patient to empty their bladder because a full bladder may cause discomfort during the examination. Delegation Considerations Assessment of the patient's abdomen should not be delegated to assistive personnel (AP). However, the AP may notice some items while providing care. The nurse must then validate, analyze, document, communicate, and act on these findings, as appropriate. Depending on the state's nurse practice act and the organization's policies and procedures, the licensed practical/vocational nurses (LPN/LVNs) may perform some or all the parts of assessment of the patient's abdomen. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A. Assessment Complete a health history, focusing on the abdomen. Identify risk factors for altered health by asking about the following:
Actual or Potential Health Problems and Needs Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include: Outcome Identification and Planning The expected outcome to achieve in performing an examination of the abdomen is that the assessment is completed without causing the patient to experience anxiety or discomfort, the findings are documented, and the appropriate referral is made to other health care professionals, as needed, for further evaluation. Other outcomes may be appropriate, depending on the specific diagnosis or patient problem identified for the patient. Implementation
Evaluation The expected outcomes have been met when the patient participated in the assessment of the abdomen; the patient verbalized understanding of the assessment techniques as appropriate; the assessment has been completed without the patient experiencing anxiety or discomfort; the findings have been documented; and the appropriate referrals have been made to the other health care professionals, as needed, for further evaluation. Documentation Guidelines Document assessment techniques performed, along with specific findings. Note assessment data related to color of the skin, presence of symmetry/asymmetry, distention, swelling, lesions, rashes, scars, or masses. Note the character of the bowel sounds and if any bruits are present. Note the overall softness or hardness of the abdomen, presence of palpable masses, the presence of pain or tenderness, and unusual pulsations. Developing Clinical Reasoning and Clinical Judgment Special Considerations General Considerations
Older Adult Considerations | |||||||||||||||||||||||
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
Practice documenting assessment techniques and findings in Lippincott DocuCare.