Download Abdominal Assessment Abbreviated Review

Abdominal Assessment*
*an abbreviated review…
Jerry Carley, RN, MSN, MA , CNE
Spring 2010
Treatments
I&O
History &
Physical
Name: James Hanngge
Age: 68 y.o Male
Vital Signs
& Graphics
Consults
Assessments
DRS Orders
Orders
Labs & Dx
Diagnostics
Patient
Record
Adm: 9-11- 2007
DX: Acute Abdominal Pain
Name: James Hanngge
Procedure(s): to be
Announced / determined
Reports
MISC
Nurse’s
Notes
M.A.R.
Vital Signs & Graphics
0600
1200
1800
0000
0600
T 102*
E
MT100*
PE
98.6*
M
P P 120
110
U
L
S
E
100
90
80
70
BP
I
152/96
NPO
NPO
850
U=180
NG=250
O
WT
140/90
98.2 kg
110/72
100/60
NPO
IV=750
NPO
IV=750
U= 188
NG=450
U= 140
NG=225
94/56
NPO
IV= 750
U=120
NG=200
95.6 kg
1200
1800
0000
History & Physical
This 68 y.o. caucasian male in usual good health until 4 p.m. yesterday,
when he reports onset of nausea, vomiting, and diarrhea. Soon thereafter
Developed acute diffuse abdominal pain, which he rated at 10/10 in the
Emergency department. History of diverticulosis, diverticulitis to which is
Non compliant with dietary and other measures.
VS: T=101.6*(O) P=110 R= 28 BP 162/116 SaO2=96% RA
NEURO: INTACT
HEENT= WNL, except some difficulty swallowing
Lungs = CTA BILAT
CV= s1, s2, (-) JVD regular rhythm; tachycardia 2* pain (?)
ABD = BOARDLIKE & TYMPANIC; hypoactive B.S. all 4 quadrants
(+) Rebound tenderness, (+) Iliopsoas, (-) Murphy’s
MS = INTACT
Dr’s Orders
9/11/2007
2200
1. Admit to ward x
2. Diagnosis: Abdominal Pain, R/O Small Bowel Obstruction
3. Activity: Bedrest, Bathroom Privileges
Vital Signs: Routine
3. Diet: NPO
4. NG Tube to Low Intermittent Suction
5. I&O
6. IV: D5RL w/ 20 mEq KCl to infuse at 125 mL/hr, continuous
7. Labs: CBC w/Diff; Complete Metabolic Panel; Stool cultures x 3;
guiac stools
8. Diagnostics: AAS; CXR
9. Medications: Demerol 100 mg IM q4h, PRN Severe Pain
Demerol 50 mg IM q4h PRN Moderate pain
J Friendly, MD
• So, now I need to do an
assessment on this patient,
with particular (focused)
assessment of the
abdomen….
No matter what shape you’re in…
Liver
THERE’S LOTS OF STUFF IN THERE!!!
Uterus,
Ovaries,
Fallopian Tubes
Gall Bladder
Esophagus
Pancreas
Spleen
Descending
Colon
Transverse
Colon
Ascending
Colon
Small
Intestines
Stomach
Urinary
Bladder
Ileocecal
valve
Vermiform
Appendix
Abdominal
Aorta
Descriptive Anatomy--Abdomen
4 Abdominal Quadrants (Regions)
• Know what organs
are found in each
quadrant!
RUQ
RLQ
LUQ
LLQ
Descriptive Anatomy
Epigastric
Right
Hypochondriac
Left
Hypochondriac
Right
Lumbar
Umbilical
Left
Lumbar
Right
Iliac
Hypogastric
Left
Iliac
9 Abdominal Regions
Any break in the peritoneum
May lead to peritonitis, which
Is life-threatening.
Abdominal Assessment
Steps (Slightly) Different
• Inspect
• Auscultate
• Percuss
• Palpate
Some Causes of Distention
•
•
•
•
•
•
Feces,
Flatus
Fetus
Fluid
Fibroid tumor
Fatal tumor
Bowel Sounds:
• What’s Normal?
• Normal bowel sounds are
low-to-medium-pitched
gurgling noises every 515 seconds;
• Normal Range= 5-30 b.s.
per minute
• Ileocecal Valve
•
What’s Not?
Significant alterations are:
• absence of any sound* or
extremely soft and widely
separated sounds
• ileus
• increased sounds with
high-pitched, loud,
rushing sound
*Must auscultate each quadrant for 5 minutes to say
Bowel Sounds Absent
Percussion
• Done to detect fluid,
gas/distention, and
masses (use indirect
method)
• Assessment of the liver
span
– Percuss liver borders at
MCL and MSL
• Percussion for tympany
and dullness: spleen and
stomach
• Fist percussion- to elicit
tenderness (usually done
at costovertebral angle)
Palpation: The Most Important Part
of the Exam
• Light palpation
– Assessment of
cutaneous
hypersensitivity
• Deep palpation
• Bimanual palpation:
superimposition of 1
hand, trapping,
detection of pulsatile
mass
Liver
•
Spleen
• usually not palpable
• turn patient to right
side (gravity) with
knees flexed
• Bimanual with left
hand on back
Gallbladder & Pancreas
• Gallbladder - normally not
palpable
– Murphy’s sign: deep
breath on deep
palpation, patient with
cholecystitis will stop
inspiratory movement
because of the pain
elicited
• Pancreas - normally not
palpable
– small and retroperitoneal
– masses may be a vague
sensation of fullness in
the epigastrium
Urinary Bladder and Umbilicus
• Urinary bladder - normally
not palpable unless
distended with urine
– when distended, smooth,
round, tense
– percussion can be used to
define outline
• Umbilicus - observe for
relationship to skin
surface, hernia,
inflammation, bleeding
Kidneys
• Usually not palpable
in normal adult
• Client supine,
bimanual technique
• Indirect percussion of
the CVA to elicit
tenderness related to
the kidney
Special Maneuvers
• Evaluation of ascites
– shifting dullness
– fluid wave
--Palpation to elicit rebound tenderness
--Palpation for abdominal masses:
--Note characteristics: consistency,
regularity of contour movement with
respiration tenderness, and mobility
--Sketching it may be useful
--Palpable bowel segments
AAA*
• Aorta
– Supine position
– Press firmly and
deeply in the upper
abdomen to left of
midline to palpate for
abdominal pulsations
(normal 1.3-3 cm)
– If you suspect or if
patient has history of
AAA, DO NOT palpate
*Abdominal Aortic Aneurysm
Shifting Dullness
Abdominal Assessment
Universal Steps
Inspection
Auscultation
Assess for color, contour,
pulsations, umbilicus, others
such as rashes, lesions,
Masses, scars
1.Auscultate 4 quadrants For bowel
sounds using Stethoscope diaphragm
2. Auscultate abdomen for vascular &
other sounds using Stethoscope Bell
Percussion
Palpation
Take Notes or
Document
findings
Normoactive
Hypoactive
Hyperactive
Absent
Vascular Sounds
Perityoneal friction rub
?
Tympany,
Dullness
?
Percuss 4 quadrants for tone
1.
2.
3.
4.
Lightly palpate all 4 quadrants
Deep palpation
Palpate kidneys
Assess for rebound tenderness
Femoral
Pulses:
Palpate &
auscultate
Document
Conditions associated with Left
Upper Quadrant
• Splenic trauma
• Pancreatitis
• Pyloric obstruction
Conditions associated with Right
Upper Quadrant (RUQ)
•
•
•
•
•
Liver hepatitis
Acute hepatic congestion
Biliary stones, colic
Acute cholecystitis
Perforated peptic ulcer
Conditions associated with Left
Lower Quadrant (LLQ)
• Ulcerative colitis
• Colonic diverticulitis
Assessing Abdominal Pain
• Nature of: burning, cramping, severe
cramping, aching, knifelike, radiation of
pain
• Onset of: gradual, acute, loss of
consciousness
• Referred or perceived: shoulders, back,
sacrum, beneath shoulder blades, to groin
area