by Rheiner Neil, RN, EdD
- Accurate assessment of the abdomen and
its organ contents can be very challenging.
- The abdominal cavity is the largest
cavity in the human body and contains the organs of the stomach, small
and large intestines, liver, gallbladder, pancreas, spleen, uterus and
ovaries in women, as well as major blood vessels. Lying
retroperitoneally to the abdominal cavity are the kidneys.
- Assessment of the abdomen can yield
direct and indirect information about the functioning of several organ
systems of the body.
- A timely and thorough assessment of the
abdomen may lead to early nursing and medical interventions that can
prevent medical and surgical emergencies.
- Adding to the challenge of assessing the
abdomen is the discomfort that may accompanies many abdominal
II. Anatomy and Physiology
- The abdominal cavity is lined
with a protective covering, the peritoneum. It is consists of two
layers, the parietal and the visceral peritoneum. The parietal
peritoneum lines the abdominal wall and the visceral peritoneum covers
the abdominal organs.
- The alimentary tract is a hollow
tube approximately 27 feet (8 meters) long extending from the mouth to
the anus and includes the esophagus, stomach, small intestine, and
large intestine. Its function is the ingestion, digestion, and
absorption of nutrients.
- The esophagus is a collapsible
tube about 10 inches long connecting the pharynx to the stomach. The
esophagus passes downward from the pharynx posterior to the trachea,
through the mediastinal cavity, and diaphragm.
- The hollow, flask-shaped stomach
lies directly below the diaphragm in the left upper quadrant of the
abdominal cavity. The stomach is a muscular organ that stores and
mixes food with the digestive enzymes to begin the breakdown of fats
- The small intestine is the
longest section of the alimentary tract being approximately 21 feet
(6.3 meters) long. The small intestines receive the content of the
stomach from the pyloric orifice of the stomach and while transporting
it to the ileocecal valve mixes, digests, and absorbs nutrients. It is
divided into three sections the duodenum (the first 12 inches of the
small intestines), the jejunum (the next 8 feet (2.5 meters), and the
ileum makes up the remaining 12 feet (3.5 meters) of the small
intestines. At the duodenum, bile and pancreatic secretions are
received from the common bile duct for digestion and absorption.
- The large intestine (colon) and
rectum is about 21 feet long (1.5 meters) and begins at the cecum
and extends to the rectum. It transport chyme from the ileum and
functions primarily to absorb water from the chyme. The colon is
divided into three sections: the ascending, transverse, and descending
- The liver lies on the right side
of the abdomen just below the diaphragm. The rib cage covers a large
portion of the liver with only the lower liver margin, if any, being
exposed beneath. The liver plays an import role in the metabolism of
carbohydrates, fats, and proteins. Other function of the liver include
storage of glucose, detoxification of substances, production of
substances important to coagulation of the blood, and the production
of the majority of the plasma protein. It has excretory function in
synthesis and excretion of bile, the secretion of organic wastes.
- The gallbladder is a saclike,
pear-shaped organ about 4 inches long (10 centimeters) lying behind
the lower margin of the liver and approaching the right sternal
boarder. Its function is to concentrate and store bile for release
into the duodenal papilla. Bile serves to maintain the alkaline pH of
the intestine to permit emulsification of fats so that absorption of
can be facilitated.
- The pancreas lies primarily in
the left upper quadrant of the abdomen under the left lobe of the
liver, behind the stomach. The pancreas has both an endocrine and
exocrine function. Its endocrine function consists of the secretion of
insulin, glucagon, and gastrin for carbohydrate metabolism; while its
exocrine function consist of secretion of bicarbonate, and pancreatic
enzymes used to break down proteins, fats, and carbohydrates for
absorption in the small intestine.
- The spleen is located in the
upper left abdominal cavity just below the diaphragm. The organ is
part of the reticuloendothelial system which filters blood and
manufacture lymphocytes and monocytes. It also has the capacity to
store and release several hundred milliliters of blood.
- The two kidneys have the primary
excretory function of removal of water-soluble waste and are located
in the retroperitoneal space of the upper right and left abdomen. Each
is located approximately between T12 to L3. The right kidney is
usually slightly lower than the left because of the liver being
directly above it. The kidney also serves an endocrine function. The
kidneys produce renin which is important for the control of
aldosterone secretion. It is also the primary source of erythropoietin
production which influences the body’s red cell production.
- The abdominal vasculature
consists primarily of the descending portion of the aorta. The
abdominal aorta travels from the diaphragm through the abdominal
cavity just to the left of midline. At the level of the umbilicus it
divides into the two common iliac arteries. The splenic and renal
arteries also branch off the aorta within the abdominal cavity.
For more information on this topic, please
III. History Questions
- Past Medical History - The first step in
evaluating the abdomen is to ask questions that will reveal any
important symptoms the client may be experiencing. Ask the client,
"Do you presently have, or in the past experienced ..."
- Abdominal discomfort?
- Nausea and/or vomiting?
- Abdominal distention?
- Fecal incontinence?
- Urinary frequency?
- Urinary incontinence?
- Chyluria (milky colored urine)?
- Gastrointestinal disorders: ulcers,
polyps, inflammatory bowel disease, bowel obstruction, pancreatitis?
- Liver disorders: hepatitis or
cirrhosis of the liver?
- Abdominal or urinary tract injury of
- Urinary tract infections?
- Weight changes?
- Major illnesses: cancer,
cardiovascular disease, kidney disease?
- Recent exposure to any contagious
- Blood transfusions?
- Hepatitis vaccine?
- If the answer to any of the above is yes
then follow with symptom analysis.
- Associated or accentuating symptoms
- Relieving factors
- Family History - Get a family history
including grandparents including: age, current health status, if
deceased cause of death, and any diseases that each individual has
- Personal and Social History
- 24 hour nutritional recall?
- Food dislikes and preferences?
- Food intolerances?
- Nutritional restrictions?
- Alcohol intake?
- Nutritional supplements being taken?
- Medications being taken?
- Allergies and allergic reactions?
- Current stressful events?
- Developmental Consideration
- Birth weight?
- Passage of first Meconium stool?
- Nausea and vomiting?
- Abdominal distention?
- Dietary intake?
- Nausea and vomiting?
- Abdominal discomfort?
- Abdominal discomfort?
- Any urinary symptoms?
- Fetal movement?
- Dietary patterns?
IV. Physical Assessment
- Examination gloves
- Measuring tape
- Felt-tip marker
- General - This
lesson will discuss the techniques used to examine the abdomen in
general (inspection, auscultation, percussion, and palpation) and then
go back and discusses how these techniques are used to examine
specific structures of the abdomen.
- When assessing the abdomen the
sequence for examination of the abdomen becomes.
Always auscultate the abdomen for
bowel sounds prior to percussion and/or palpation. Manipulation of
the abdomen may alter peristalsis & lead to erroneous data.
- To ensure more accurate communication of
your assessment findings mentally divide the abdomen into regions. It
is always helpful to think to yourself "what's under
there" when assessing the abdomen. Knowing the anatomical
location of the underlying organs helps with differential diagnosis.
- Quadrant method
The nine region method is not used
much anymore but you hear some of the terms used from time to time.
- RUQ - Liver, gallbladder, duodenum,
head of pancreas, right kidney, part of colon.
- RLQ - Cecum, appendix, right ovary
& tube, right ureter, right spermatic cord.
- LUQ - Stomach, spleen, left lobe
liver, pancreas, left kidney, part of colon.
- LLQ - Descending colon, sigmoid
colon, left ovary & tube, left ureter, left spermatic cord.
- Midline - aorta, uterus, bladder.
Inspect entire abdomen, noting
- Right hypochondriac
- Left hypochondriac
- Right lumbar
- Left Lumbar
- Right inguinal
- Left inguinal
Inspect abdomen contour, with client in
supine position, from the foot of the bed & the side
- Overall contour
- Skin integrity
- Areas of skin
- Striae/stretch marks
- Rashes or other lesions
- Dilated veins
- Scars - What caused the scar?
- Appearance of umbilicus & any
- Localized distention
- Peristaltic waves
- Irregular contours
- Unusual hair distribution
- Abdomen normally appears slightly
rounded with the maximum height of convexity at the umbilicus, and
gently curved symmetric lateral borders.
- Umbilicus is midline
- Have client raise head &
shoulders off bed (Valsalva maneuver) while remaining supine. Look for hernias (protrusions of the abdominal wall, symmetry of
abdomen wall, & recti abdominous. You may also have the
patient hold their breathe and bear down slightly to reveal
- Provides information on bowel motility
and the underlying vessels & organs
- Auscultate for bowel & vascular
- Warm the stethoscope
- Auscultate with the diaphragm of the
stethoscope in all four
- Bowel sounds are soft:
To determine if the clients has
hypoactive or hyperactive bowel sounds
- High pitched clicks
- Occurring every 5-15 seconds at a
rate of 5-35/minute.
- Listen & count sounds for 1 full
- If no bowel sounds are heard
initially listen for 5 minutes before determining bowel sounds are
- Hypoactive bowel sound are present
when they occur at a rate of less than one per minute.
- Hyperactive bowel sounds must be
determined in relationship to what is occurring with the client.
Bowel sounds will be hyperactive if the client is:
- Hungry-Borborygmi (bor'berig'mes)
- Eaten recently
- Taken a laxative recently
- Use the bell of the stethoscope to
auscultate for bruits in the:
- Right & left renal arteries
- Femoral arteries
- Friction rubs of liver or spleen
- Harsh, grating sound like two pieces
of sand paper rubbing together.
- Helps to determine the:
- size of organs
- location of organs
- the presence of excessive fluids or
air in the abdomen
- identify abdominal masses
- Percuss all quadrants
- Percussion sounds vary depending upon
the underlying structures
- Dull over solid objects
- Tympanic over air-filled spaces
- Resonant over hollow spaces
- Provides data concerning:
- Character of the abdominal wall
- Size, condition, & consistency of
- Abdominal masses
- Abdominal pain
- Abdominal palpation consists of:
- Light palpation - ½"-3/4"
pressure into abdomen
- Deep palpation - 1 ½" pressure
- Ballottment - light rapid bouncing or
tapping of the fingertip against the abdominal wall.
- Rebound tenderness - Deep palpation
with sudden withdrawal of your fingertips which produces abdominal
pain in the client (usually indicates appendicitis in the right
Do not palpate an, obviously, pulsating midline abdominal area.
- It may be an abdominal aortic
aneurysm & could rupture if palpated
- Rather explore the area with a
stethoscope for the presence of a bruit.
- Report the presence of a bruit to a
- Be suspicious if you palpate the
abdominal aorta and feel a "spreading pulsation" across
your fingers (usually you feel an upward thrust of the
pulsation). If you feel the pulse "spreading" it may
indicate an aneurysm and should be reported.
IX. Organ Assessment
- A part of the abdominal assessment is
the liver examination. You can estimate the size, consistency, &
position of the liver by palpation & percussion.
- To percuss the client's liver:
- Begin along the right midclavicular
line, starting a level just below the level of the umbilicus.
- Move upward until the percussive notes
change from tympanic to dull, usually no more than 2-3 cm below the
- This should be the lower edge of the
- Mark the position with a felt-tip
- Move up in the right midclavicular
line to just below the nipple & percuss downward until the
percussive notes change from resonant to dull
- Usually at the 5-7 intercostal space
- Mark this point with a felt-tip
- Do the same thing at the right
sternal border. Because of the bony structures in this area you
may find it difficult to determine liver span in this area.
- Measure distance between the two
marks you made at the right midclavicular line & the two at
the right sternal border. Distances should be no more than:
- 6-12 cm. (2½-4½") in the
right midclavicular line
- 4-8 cm. (1½-3") at the right
- If you have difficulty locating the
liver margins by percussion try the "scratch
- Place your stethoscope over the
approximate location of the liver margin
- Starting at the right iliac crest
in the midclavicular line
- Lightly stroke the abdominal
wall with the finger
- Move upward until the
scratching sound becomes louder
- The scratching sound should become
louder over the solid liver
- To check for liver tenderness:
Place the palm of you hand over
the lower right rib cage
Then lightly strike the back of
that hand with the fist of the other hand. This should not
The liver and gallbladder are usually
not palpable in adults. To palpate the liver:
- Remember the liver is a very
fragile organ & It
is not recommend that inexperienced practioners using the
"liver hooking technique" described in your textbook
as one might damage the liver.
- Place one hand on the client's
back at the approximate height of the liver & push up. This
may force the lower rib up exposing the lower liver margin
- Place your other hand below your
mark of liver dullness, at the midclavicular line.
- Point fingers toward the costal
margin & press gently in & up as the client inhales
- Continue palpating along the
liver's lower margin to the right sternal border.
- After initial palpation place
hands just below right rib margin
Depress the abdominal wall
Ask client to take a deep breath
Try to feel the liver edge as the
diaphragm pushes the liver down to meet you fingers or
You may feel the edge of the liver
raise from the abdomen and slide over your fingers
The liver margin normally is:
To percuss the spleen:
To palpate the spleen:
- Percuss just posterior to the left
- Spleen should lie between the 7-11
- Percuss before & while client
has taken a deep breath
- Deep breath will bring spleen
forward & downward
- Spleen is identified by an area of
dullness on percussion
- A larger area of dullness can occur
if the stomach is full or if the intestine is full of feces.
- Dullness can be obscured by tympany
of colonic air.
- Spleen is often not palpable in the
- Stand at clients side & place one
hand under the client at the left costovertebral angle.
- Press upward with that hand to lift
the spleen toward the abdominal wall
- Place your other hand on the abdominal
wall with the fingers at the left costal margin
- Press your finger upward toward the
spleen while asking the client to take a deep breath
- Try to feel the edge of the spleen as
it moves downward during deep breathing
- Spleen margin should be:
*Beginning practitioners should not
attempt rigorous palpation of the spleen (especially if you suspect it is
enlarged). Spleens are fragile and may rupture leading to hemorrhage.
X. Life Style Alterations/Developmental
- The Infant
- In the infant the inspection of the
abdominal contour will reveal protuberant because of the immature
abdominal musculature. The skin may display fine, superficial venous
patterns which may remain visible in children up to the age of
- The umbilical cord should be inspected
throughout the neonatal period. At birth, it is white and contains
two umbilical arteries and one vein surrounded by connective tissue,
called Wharton’s jelly. The umbilical cord dries within a week,
hardens, and falls off by 10 to 14 days.
- The infants abdomen should be
symmetric; however two abdominal irregularities are common.
Umbilical hernias appear at 2 to 3 weeks and are especially apparent
when the infant cries. The hernia may reach its maximum size at 1
month of up to 1 inch (2.5 centimeters). It usually disappears by
the age of 1 year. The other common abdominal irregularity is
diastasis recti, a separation of the rectus muscles with a visible
bulge along the midline. This condition is more common with black
infants, and it usually disappears by early childhood.
- The abdomen of the infant shows
respiratory movement. Auscultation of the abdomen yields only bowel
sounds. No vascular sounds should be heard. Percussion yields
tympany over the stomach, due to the infant swallow air during
feeding, and dullness over liver.
- Finding on palpation include: the
liver fills the right upper quadrant. You may palpate the spleen tip
and both kidneys as well as the bladder. The cecum is easily
palpated in the right lower quadrant. The sigmoid colon is also
easily palpated and feels like a sausage in the left inguinal area.
- The Child
- The abdomen looks protuberant in the
child until about age 4 years. After 4 year the protuberance remains
when standing because of lumbar lordosis, but the abdomen looks flat
when supine. Respiratory movement remains abdominal until the age of
- The liver remains palpable at 1 to 2
centimeters below the rib margin. On the left anterior axillary line
the spleen is also usually palpatable just below the rib margin.
Usually you can feel 1 to 2 centimeters of the right and left
- The school age child has lost the
abdominal protuberance in both the standing and supine position.
- Pregnant Women
- A variety of changes occur to women
during pregnancy. As the uterus enlarges, the colon is displaced
upward and to the rear. This displacement results in a variety of
problems including: decrease peristalsis and increased water
absorption leading to constipation, diminished bowel sounds, and
flatus. Blood flow is increased to the pelvis contributing to
hemorrhoid formation. A rise in gonatropin causes nausea and
vomiting early in the pregnancy. Late in pregnancy increased
progesterone causes esophageal regurgitation and decreased emptying
of the stomach with an accompanying occurrence of
"heartburn". The increased incidence of gallstone may be
attributed to a combination of upward pressure on the gallbladder,
delayed emptying, and increased viscosity of the bile.
- As the uterus continues to enlarge,
the abdominal muscles lose some of their tone. During the third
trimester, the recti abdomini muscle may separate, allowing the
abdominal contents to protrude through the muscle at the midline (diastasis
recti). As the abdomen continues to expand the umbilicus flattens or
protrudes. Striae and a midline abdominal pigmentation from the
umbilicus to the pubic area forms (linea nigra).
- The kidneys enlarge slightly, the
ureter elongate and dilate from estrogen and progesterone. These
changes along with the increased pressure on the bladder predispose
the women to frequency, urgency, and urinary stasis. These problem
increase the risk of urinary tract problems.
- The Aged Adult
- On inspection of the aged adult you
may note increased deposits of subcutaneous fat on the abdomen and
hips with a decrease of subcutaneous fat on the extremities.
Abdominal musculature is thinner and has reduced tone.
- Palpation of abdominal organ may be
easier because of the client being thinner and having a softer
abdominal wall. The liver and kidneys are usually easily palpatable.
- Changes in the structure and function
of the gastrointestinal system is not unusual. Motility of the
esophagus is reduces due thinning of the esophagus. As aging occurs,
gastric acid secretion is reduced; however gastric enzymes remain
sufficient for digestion, peristalsis slows. Liver size decreases
after age 50, and the gastric mucous may degenerate which may reduce
the secretion of intrinsic factor needed for vitamin B12