anatomy & physiologyhistoryphysical assessmentinspectionauscultation | percussionpalpation
organ assessment
life cycle alterations

HEALTH ASSESSMENT
ABDOMEN

by Rheiner Neil, RN, EdD

I.  Introduction

  1. Accurate assessment of the abdomen and its organ contents can be very challenging.
  2. 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.
  3. Assessment of the abdomen can yield direct and indirect information about the functioning of several organ systems of the body.
  4. A timely and thorough assessment of the abdomen may lead to early nursing and medical interventions that can prevent medical and surgical emergencies.
  5. Adding to the challenge of assessing the abdomen is the discomfort that may accompanies many abdominal problems.

II. Anatomy and Physiology

 

  1. 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.
  2. 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.
  3. 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.
  4. 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 and proteins.
  5. 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.
  6. 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 colon.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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 click:
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III. History Questions

  1. 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 ..."
    1. Abdominal discomfort?
    2. Indigestion?
    3. Nausea and/or vomiting?
    4. Abdominal distention?
    5. Diarrhea?
    6. Constipation?
    7. Fecal incontinence?
    8. Jaundice?
    9. Dysuria?
    10. Urinary frequency?
    11. Urinary incontinence?
    12. Hematuria?
    13. Chyluria (milky colored urine)?
    14. Gastrointestinal disorders: ulcers, polyps, inflammatory bowel disease, bowel obstruction, pancreatitis?
    15. Liver disorders: hepatitis or cirrhosis of the liver?
    16. Abdominal or urinary tract injury of surgery?
    17. Urinary tract infections?
    18. Weight changes?
    19. Major illnesses: cancer, cardiovascular disease, kidney disease?
    20. Recent exposure to any contagious diseases?
    21. Blood transfusions?
    22. Hepatitis vaccine?
  2. If the answer to any of the above is yes then follow with symptom analysis.
    1. Onset
    2. Location
    3. Duration
    4. Character
    5. Associated or accentuating symptoms
    6. Relieving factors
    7. Treatment
  3. 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 had.
  4. Personal and Social History
    1. 24 hour nutritional recall?
    2. Food dislikes and preferences?
    3. Food intolerances?
    4. Nutritional restrictions?
    5. Alcohol intake?
    6. Nutritional supplements being taken?
    7. Medications being taken?
    8. Allergies and allergic reactions?
    9. Current stressful events?
  5. Developmental Consideration
    1. Infants
      • Birth weight?
      • Passage of first Meconium stool?
      • Nausea and vomiting?
      • Diarrhea?
      • Abdominal distention?
    2. Children
      • Constipation?
      • Dietary intake?
      • Diarrhea?
      • Nausea and vomiting?
      • Abdominal discomfort?
    3. Pregnant women
      • Abdominal discomfort?
      • Any urinary symptoms?
      • Fetal movement?
      • Contractions?
      • Dietary patterns?

IV. Physical Assessment

  1. Equipment
    1. Examination gloves
    2. Stethoscope
    3. Flashlight
    4. Measuring tape
    5. Felt-tip marker
    6. Gown
  2. 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.
    1. When assessing the abdomen the sequence for examination of the abdomen becomes.
      • Inspection
      • auscultation
      • percussion
      • palpation
    2. Always auscultate the abdomen for bowel sounds prior to percussion and/or palpation. Manipulation of the abdomen may alter peristalsis & lead to erroneous data.

V. Inspection

  1. 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.
     
    1. Quadrant method                                    Common Organs                            
      • 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.
    2. The nine region method is not used much anymore but you hear some of the terms used from time to time.
      1. Right hypochondriac
      2. Epigastric
      3. Left hypochondriac
      4. Right lumbar
      5. Umbilical
      6. Left Lumbar
      7. Right inguinal
      8. Suprapubic
      9. Left inguinal
  2. Inspect entire abdomen, noting
    1. Overall contour
    2. Skin integrity
    3. Areas of skin
      • Discoloration
      • Striae/stretch marks
      • Rashes or other lesions
      • Dilated veins
      • Scars - What caused the scar?
    4. Appearance of umbilicus & any visible pulsations
    5. Localized distention
    6. Peristaltic waves
    7. Irregular contours
    8. Unusual hair distribution
  3. Inspect abdomen contour, with client in supine position, from the foot of the bed & the side
    finger15.8.jpg (305968 bytes)
    1. Abdomen normally appears slightly rounded with the maximum height of convexity at the umbilicus, and gently curved symmetric lateral borders.
    2. Umbilicus is midline
    3. 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 hernias.

VI. Auscultation

  1. Provides information on bowel motility and the underlying vessels & organs
  2. Auscultate for bowel & vascular sounds
    1. Warm the stethoscope
    2. Auscultate with the diaphragm of the stethoscope in all four quadrants
    3. Bowel sounds are soft:
      • Bubbles
      • Gurgles
      • High pitched clicks
      • Occurring every 5-15 seconds at a rate of 5-35/minute.
    4. To determine if the clients has hypoactive or hyperactive bowel sounds
      • Listen & count sounds for 1 full minute.
      • If no bowel sounds are heard initially listen for 5 minutes before determining bowel sounds are absent
      • 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:
    • Aorta
    • Right & left renal arteries
    • Femoral arteries
  • Friction rubs of liver or spleen
    • Harsh, grating sound like two pieces of sand paper rubbing together.

 

VII. Percussion

  1. Helps to determine the:
    1. size of organs
    2. location of organs
    3. the presence of excessive fluids or air in the abdomen
    4. identify abdominal masses
  2. Percuss all quadrants
  3. Percussion sounds vary depending upon the underlying structures
    1. Dull over solid objects
    2. Tympanic over air-filled spaces
    3. Resonant over hollow spaces

VIII. Palpation

  1. Provides data concerning:
    1. Character of the abdominal wall
    2. Size, condition, & consistency of abdominal organs
    3. Abdominal masses
    4. Abdominal pain
  2. Abdominal palpation consists of:
    1. Light palpation - ½"-3/4" pressure into abdomen
    2. Deep palpation - 1 ½" pressure into abdomen
    3. Ballottment - light rapid bouncing or tapping of the fingertip against the abdominal wall.
    4. Rebound tenderness - Deep palpation with sudden withdrawal of your fingertips which produces abdominal pain in the client (usually indicates appendicitis in the right lower quadrant).
    5. CAUTION: 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 physician immediately.
      • 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 costal margin.
    • This should be the lower edge of the liver.
    • Mark the position with a felt-tip marker
    • 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 marker
      • 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 sternal border.
      • If you have difficulty locating the liver margins by percussion try the "scratch test."
        • 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 produce discomfort.
    • 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 deeply
      • 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 1-1½"
        • 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:
        • Smooth
        • Firm
        • Regular
        • Rounded
  • To percuss the spleen:
    • Percuss just posterior to the left midaxillary line
      • Spleen should lie between the 7-11 intercostal spaces
      • 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.
  • To palpate the spleen:
    • Spleen is often not palpable in the adult
    • 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:
      • Firm
      • Smooth
      • Regular

*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.

  • Costovertebral percussion of the kidney:
    • With client in the sitting position place palm over the costovertebral angle (the point on the back where the ribs attach to the spinal column).
    • Gently strike the back of that hand with the fist of the other hand
    • The client should not experience pain
    • Costovertebral angle tenderness most commonly indicates urinary infections or pyelonephritis (kidney infections)

  • Palpation of the kidney
    • Often the kidney cannot be identified by palpation. Because of its position the right kidney is more likely to be palpatable since it is lower than the left in the abdominal cavity.
    • Place one hand under the back midway between the lower costal margin and the iliac crest
    • Place the other hand on the client's abdomen directly over the other hand
    • Angle the top hand slightly toward the costal margin
    • Press up with the lower hand while gently place the upper hand about 1½" above the right iliac crest or 2" above the left iliac crest
    • Press the upper hand down
    • Have client inhale deeply so the kidney moves down between your hands
    • The kidney is:
      • Smooth
      • Solid
      • Firm
  • Palpation of the aorta
    • With the client in the supine position and with the finger tips of one hand palpate deeply:
      • Slightly to the left of midline
      • Approximately 1-1½" above the umbilicus for the aortic pulsation.
      • Locate the aortic pulsation.
    • Determine the width of the pulsation by:
      • Moving the opposing thumb & forefinger to the right & left side of the identified aortic pulse
      • Move them toward the aortic until the aortic pulse can first be distinguish by the thumb & then the finger. Measure the distance between the thumb & forefinger.
      • This distance in the approximate width of the aorta.
  • Abdominal reflex
    • With the client in the supine position
      • Stroke each quadrant of the abdomen with the end of the reflex hammer or some similar object
      • Stroke each quadrant of the abdomen
      • Stroke diagonally across each quadrant from the umbilicus
        • Upper in the upper quadrants
        • Downward in the lower quadrants
    • A slight movement of the umbilicus toward the area being stimulated should occur & movement should be equal bilaterally.
      • Abdominal wall guarding due to being ticklish or abdominal discomfort can easily obscure this reflex
      • Absence of reflex may indicate a motor neuron disorder at T7-T10.

 

X. Life Style Alterations/Developmental Considerations

  1. The Infant
    1. 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 puberty.
    2. 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.
    3. 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.
    4. 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.
    5. 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.
  2. The Child
    1. 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 7 years.
    2. 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 kidney.
    3. The school age child has lost the abdominal protuberance in both the standing and supine position.
  3. Pregnant Women
    1. 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.
    2. 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).
    3. 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.
  4. The Aged Adult
    1. 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.
    2. 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.
    3. 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 absorption.

 

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Last Updated 03/08/2006