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Abdomen N1037 Assessment of the Abdomen Provides information regarding the functions of : – gastrointestinal tract – cardiovascular system – genitourinary system Anatomy and Physiology Abdominal cavity - btwn the diaphram & symphysis pubis Anatomy and Physiology Peritoneum – 2 linings : parietal/viseral – intraperitoneum spleen, gallbladder, liver, bile duct, stomach, sm & lrg intestine – retroperitoneum pancreas, kidneys, ureters. bladder – linea alba - tendonous tissue – 4 muscles groups abdominis rectus transverse abdominis external oblique internal oblique Anatomy and Physiology Abdominal vasculature – descending aorta – abdominal aorta – L4 - aorta bifurcates into R & L common iliac arteries above umbilicus Anatomical Mapping Anatomical Mapping Assessment Landmarks 1. Xiphoid process 2. Costal margin 3. Abdominal midline 4. Umbilicus 5. Rectus abdominis muscle 6. Ant superior iliac crest 7. Inguinal ligament 8. Symphysis pubis Anatomy and Physiology Stomach – – – – J shaped, located in LUQ, under diaphram, R of spleen reservoir for digestine (HCL acid + digestive enz) liquefies foodstuff into chyme duodeum for dig + absorption capacity = 1-1.5L , Small intestine – 30 ft convoluted loops – extends form pyloric sphincter to ileocecal valve at lrg intestine – 3 segments – duodenum - digestion via common bile & pancreatic ducts – jejunum - nutrient absorption occurs – ileum - absorbs bile salts & Vit B12 Anatomy and Physiology Large intestine – extends from ileocecal valve to anus – 4 segments (ascending, transverse, descending, colon) – forms stool & absorption of H20 & electrolytes Liver – RUQ – storage, detoxification & filtraton, metabolism, synthesis & secretion Gallbladder – pear shaped sac under liver – store & concentrate bile produced in liver – contracts , releases bile into cystic ducts to common bile duct into duodeneum Anatomy and Physiology Pancreas – URQ & ULQ of posterior abdominal wall – exocrine gland= secrets Bicarbonate &pancreatic enz for digestion – endocrine gland= secretes hormones (insulin, glucagon, gastrin) Spleen – lymph organ in ULQ – filters (old and deformed RBC/platelets) – stores RBC for use in hemorrhage/exercise Vermiform appendix – RLQ, fingerlike appendage – often obstructs with content from cecum Anatomy and Physiology Kidneys, ureters, and bladder – kidneys = bean shaped, at T12 & T13 posteriorly – Kidneys= rid body of waste products, maintain homeostasis via acid base balance, fluid & electrolyte balance, arterial BP – urine leaves kidneys via ureters to bladder =peristaltic wave – Bladder = stores urine (200-400ml) Lymph nodes – inguinal area = deep & superficial lymph nodes – only superficial are palpable inguinal & popliteal nodes Health History Patient profile – Age Child to young adult: appendicitis Adult: peptic ulcers, cholecystitis, diabetes mellitus – Gender Female: gallbladder disease Male: GI cancers, cirrhosis, duodenal ulcers Common Chief Complaints Nausea and vomiting Diarrhea or constipation Abdominal distension Abdominal pain Increased eructation or flatulence Dysuria Nocturia Incontinence Characteristics of Chief Complaint Quality Quantity Associated manifestations Aggravating factors Alleviating factors Setting Timing Past Health History Medical – Abdomen specific – Nonabdomen specific Surgical – GI procedures Common Medications Histamine-2 antagonists PPI Antibiotics Lactulose Antacids Antidiarrheals Laxatives or stool softeners Antiemetics Antiflatulents Past Health History Communicable diseases Allergies Injuries and accidents Family Health History Malignancies of stomach, liver, pancreas, colon; peptic ulcer disease, diabetes mellitus, irritable bowel syndrome, colitis Social History Alcohol use Drug use Travel history Home and work environments Hobbies and leisure activities Economic status Health Maintenance Activities Sleep Diet Exercise Stress management Use of safety devices Health check-ups Assessment of the Abdomen Equipment Order ……NOTE CHANGE – Inspection – ***Auscultation*** – Percussion – Palpation Inspection of Abdomen Observe for : Contour Symmetry Rectus abdominis muscles Pigmentation and color Scars Striae Respiratory movement Masses or nodules Visible peristalsis Pulsation Umbilicus Inspection of Abdomen Normal Findings Abdomen is flat or round, symmetrical Uniform in color and pigmentation No scars or striae present No respiratory retractions No masses or nodules Ripples of peristalsis may be visible Nonexaggerated pulsation of the abdominal aorta may be present Umbilicus is depressed Auscultation of Abdomen Bowel sounds – Assess all four quadrants – Listen for at least 5 minutes before concluding bowel sounds are absent N = BS are heard in all quadrants Usually are high pitched Occur 5 to 30 times per minute Abnormal findings: – Absent or hypoactive BS indicate motility and possible obstruction – Hyperactive BS indicate motility and possible diarrhea, gastroenteritis Auscultation of Abdomen Vascular sounds – use bell over vascular landmarks – listen for bruits N = no audible bruits Abnormal Finding : bruit present indicating turbulent bld flow & parietal obstruction or stenosis Venous hum – listen for venous hum in all 4 Quads N = not present Abnormal Finding : continuous pulsating sound in periumbilical area dt portal obstruction caused by HPTN Friction rubs – listen for rub over R & L costal margins, liver, spleen N= no rub heard (dt inflammation, tumors if heard) Percussion Percuss all four quadrants Assess liver span, liver descent, margins of spleen, stomach, kidneys, liver, bladder Sounds heard: tympany or dullness Percussion of Abdomen Percuss all four quads N= Tympany heard over air-filled areas, such as stomach and intestines N = Dullness heard over solid areas, such as liver or a distended bladder Abnormal Findings : – Dullness over areas where tympany is normally heard may indicate a mass or tumor, pregnancy, ascites, full intestine Percussion of Abdomen Assess liver span – percuss upwards from umbilicus to lower border of liver on R midclavicular line – mark where sound chgs – percuss from lung to upper liver border R midclavicular line N= no tenderness, 6-12 cm btwn lines or – Scratch Test using stethoscope Place stethoscope on R midclavicular line and scratch RLQ q 1-2 cm towards stethoscope …when you reach the lower border the sound will be louder. Abnormal Findings – Liver span > 12 cm or < 6 cm – May indicate hepatomegaly or cirrhosis Percussion of Abdomen Percuss the Spleen Percuss the lower level of the L lung posterior to the midaxillary line Percuss downwards until dullness is heard N= splenic dullness heard from the 6th to 10th rib approx 6-8 cm above the L costal margin Abnormal Findings: Spleen dullness > 8 cm line May indicate splenic enlargement Percussion of Abdomen Percuss Stomach – Percuss for gastric air bubble – LUQ at L lower anterior rib cage and L epigastric region N = tympany of gastric bubble is lower in pitch that of intestines Fist Percussion Kidney Direct method Indirect method N= No tenderness Abnormal Findings: – Costovertebral angle tenderness may indicate pyelonephritis Fist Percussion Liver Indirect method R lower rib cage N= No tenderness Abnormal Findings: – Pain indicates cholecystitis or hepatitis Percussion of Abdomen Bladder – Percuss upwards from symphysis pubis to umbilicus – Note sound changes form dullness to tympany N =Urine filled bladder is dull to percussion = Empty bladder is not percussable above the symphysis pubis Abnormal Findings: Ability to percuss a recently emptied bladder may indicate urinary retention Palpation of Abdomen Palpate all 4 quadrants Light vs. deep N= No tenderness, Smooth with consistent softness, No muscle guarding Abnormal Findings: Tenderness on palpation May indicate inflammation, masses, or enlarged organs Muscle guarding on expiration May indicate peritonitis Presence of masses, bulges, or swelling May indicate enlarged organs, cholecystitis, hepatitis, cirrhosis Deep Palpation of Abdomen One hand Method Bimanual Method Assessing for Ascites Fluid Wave Test Position pt supine Firmly place ulnar side of hand midline on abdomen to prevent displacement of fat Place hand on pt’s R hip or flank area Deliver a blow to pt’s L hip or flank area N= no fluid wave felt Abnormal Findings: – Presence of fluid wave = ascites Assessing the Liver Bimanual Method Hook Method N= liver edge presents firm sharp regular ridge Abnormal Findings: Liver is palpable below costal margin – May indicate CHF, hepatitis, cirrhosis, encephalopathy, cancer – Enlrged liver Assessing for Cholecystitis Murphy’s Sign – Palpate below the liver margin at lateral border – Have pt take deep breath – N= no pain elicited – Abnormal Finding: Pt stops inhaling to guard against pain indicates a +ve Murphy’s sign = inflammation of gallbladder dt cholecystitis Assessing the Spleen Bimanual Method – Reach over pt and place L hand under rib cage, lift upwards – R hand deeply palpates – Ask pt to take deep breath N= the spleen is not palpable Abnormal Findings: Spleen is palpable – May indicate inflammation, CHF, cancer, cirrhosis, mononucleosis Assessing the Kidneys Bimanual Method N = kidneys are not palpable Abnormal Findings: Kidneys are palpable – May indicate hydronephrosis, neoplasms, polycystic kidney disease Palpation of the Arota Press the upper abdomen with one hand on either side of the aorta N= aorta width is 2.5-4 cm Abnormal Findings: – Aorta width > 4 cm May indicate abdominal aortic aneurysm Assessing for Abdominal Inflammation Rebound Tenderness “Mc Burney’s Point” Apply firm pressure at 90° in RLQ for 5 secs Quickly release N= no pain in McBurneys point Abnormal Findings: – Pain in RLQ indicates appendicitis Assessing for Appendicitis Rovsing’s Sign – Press firmly in LLQ for 5 secs – Note pts response N= no pain elicited – Abnormal Findings: – Pain in RLQ indicates appendicitis +ve Rovsing’s Sign Assessing the Bladder Deep palpation Midline starting at symphysis pubis upward to umbilicus N = empty bladder is not palpable Full bladder= smooth & round Abnormal Findings: Able to palpate recently emptied bladder – May indicate urinary retention Assessing Lymph Nodes Pt supine , knees slightly flexed Palpate lymph nodes in R & L inguinal area N= palpable non- tender small, movable nodes <1cm in diameter Abnormal Findings: Palpable inguinal lymph nodes > 1 cm in diameter or tender – May indicate systemic infections, cancer Gerontological Variations Abdominal musculature diminishes in mass and tone Increased fat deposition in abdominal area Altered GI motility results in changes in digestion and absorption Decreased secretion of gastric acid Increased incidence of malignant disease Changes in bowel habits