Download Assessment of fluid accumulation - Dietitians in Nutrition Support

ABDOMINAL EXAMINATION
AND THE
ASSESSMENT OF FLUID ACCUMULATION
Susan Roberts, MS, RD, CNSC
Andrea JeVenn, RD, LD, CNSC
THE
ABDOMINAL EXAMINATION
ANATOMY AND TERMINOLOGY
RUQ
Right lobe of liver,
gallbladder, pylorus, first 3
parts of duodenum, head of
pancreas, right suprarenal
(adrenal) gland, right kidney,
right colic (hepatic) flexure,
sup. part of ascending colon,
right half of transverse colon
RLQ
Cecum, appendix, most of
ileum, inferior part of
ascending colon, right
ovary, right uterine tube,
right ureter
LUQ
Left lobe of liver, spleen,
most of stomach, jejunum
& proximal ileum, body &
tail of pancreas, left
suprarenal (adrenal) gland,
left kidney, left colic
(splenic) flexure, sup part
of descending colon, left
half of transverse colon
LLQ
Sigmoid colon, inf part of
descending colon, left
ovary, left uterine tube,
left ureter
COMPONENTS OF EXAM
Inspection
• Visual review
• Assess symmetry and contour
Auscultation
• Assess bowel and vascular sounds
• Done prior to palpation
Percussion
• assess location & density of underlying
body masses/organs, gas/fluid patterns
AUSCULTATION
Use diaphragm of stethoscope
Begin in RLQ (ileo-cecal valve)
Listen in each quadrant
• What are bowel sounds?
• Gas and fluid movement
• Active
• Hypoactive
• Absent
BOWEL SOUNDS
Hyperactive
Hypoactive
• Increased motility
• Decreased motility
• Stenosis
• Inflammation
• Early SBO
• Paralytic ileus
• Resolving ileus
• Peritonitis
• Gastroenteritis
• Surgical manipulation
• Late SBO
• Lower lobe pneumonia
PERCUSSION
Light tapping on abdomen
• Assess size and position of solid organs
• Differentiate gas versus liquid vs solids
Tympany
Dullness
ILEUS
Absence of peristalsis or function
• Lack of mechanical issue
Causes
• Peritonitis
• Sepsis
• Medications, especially narcotics
• Metabolic disturbances
• Hyperglycemia and hypokalemia
Absent or hypoactive BS
Abdominal distention
ILEUS
MILD ILEUS
ILEUS
ILEUS IN NEONATE
BOWEL OBSTRUCTION
Defined as a partial or complete blockage
Causes
• Extrinsic
• Adhesions, volvulus, or hernias
• Intrinsic
• Tumor, stricture, stenosis
• Intraluminal
• Bezoars, fecal material, gallstones
BOWEL OBSTRUCTION
General signs &
symptoms
Tests
• Abdominal film
• Distention
• CT
• Hyperactive or high
pitched BS
• UGI and/or small
bowel series
• Minimum rebound
• Crampy pain
SITE OF OBSTRUCTION
Proximal
Distal
• Acute onset
• Less vomiting
• Greater vomiting
• Greater explosive
diarrhea
• Bilious emesis
• Less distention
• Greater distention
POSSIBLE OBSTRUCTIONS
IMAGING STUDY OF OBSTRUCTION
Barium was instilled
through a nasogastric
tube
Picture shows loops of
bowel >4cm in diameter
Green arrow shows
transition point
ILEUS VS OBSTRUCTION
Ileus
• No source of obstruction
• Gas in colon/rectum
• Distention but without pain
• May have bowel sounds
ASSESSING
FLUID ACCUMULATION
WHAT IS FLUID RETENTION?
Abnormal retention of fluid in interstitial spaces and
cavities (e.g., peritoneal/abdominal cavity)
• may not clinically manifest until it accounts for at least
10% of body weight or fluid volume is increased by
2.5-3 liters
• fluid accumulation around the heart, in the lungs,
small pockets of ascites, or hematomas may only be
seen on imaging studies
Braunwald, Loscalzo. Ch 36: Edema. In: Longo DL, Kasper DL, et al. Harrisons Principles of Internal Medicine; 2012
Epocrates: Evaluation of Peripheral Edema; accessed 11/26/14
Sterns RH. Clinical manifestations and diagnosis of edema in adults; UpToDate 1/30/14
Ch 15: I have a patient with edema. How do I determine the Cause? In: Symptom to Diagnosis: An Evidence-Based Guide; 2009
Causes
Conditions Associated with Fluid
Accumulation
Increased capillary
hydrostatic pressure
Hypervolemia; kidney disease, pregnancy,
CHF
Loss of plasma proteins
Kidney disease, liver disease, burn victims,
malabsorption, malnutrition
Obstruction of lymphatic Obstructing tumor, infection, damages to the
lymph nodes or lymph node removal (cancers)
circulation
Increased capillary
permeability
Usually from inflammatory response or
response to infections
ACADEMY / ASPEN CLINICAL CHARACTERISTICS
– EDEMA / FLUID ACCUMULATION
Context
Malnutrition
Chronic Illness or
Social / Environmental
Acute Illness or Injury Circumstances
Moderate Severe
Moderate Severe
Edema
Mild
Moderate
to severe
Mild
Severe
White et al, Characteristics for identification/documentation of adult malnutrition; JPEN 2012
ACADEMY / ASPEN CLINICAL CHARACTERISTICS
– EDEMA / FLUID ACCUMULATION
• Weight loss is frequently masked by fluid retention and
weight gain may be present
• If severe, can also mask evaluation of muscle/fat loss
• Usually SUPPORTIVE evidence
- RARELY ever directly related to malnutrition
White et al, Characteristics for identification/documentation of adult malnutrition; JPEN 2012
ASSESSING FLUID RETENTION
• Primarily found in dependent areas such as the sacrum,
ankles, feet, calves, scrotum, vulva
• The clinician may evaluate generalized or localized fluid
accumulation during a physical exam
• Localized:
• extremities, abdomen (ascites), vulva/scrotal
area
• Generalized:
• if severe, is referred to as anasarca
DEPENDENT EDEMA – AMBULATORY PATIENTS:
LEGS, ANKLES, FEET
DEPENDENT EDEMA – BED BOUND PATIENTS:
SCROTUM, VULVA, SACRUM
Additional fluid
OTHER AREAS:
EDEMA AND ASCITES
ASSESSMENT STRATEGY
• Perform general survey, then head-to-toe
• Use inspection and palpation
• gloves optional
• Determine if onset is acute vs chronic
• Acute: < 72 hours
• Chronic: better? worse? same?
• Correlate physical findings of fluid accumulation with
other evidence
• vital signs, input/output records, labs, weight, history,
imaging studies
PALPATION TECHNIQUE
Severity of edema is rated on a scale from +1 to +4
Press firmly but gently with your thumb for at least 5
seconds over
• the dorsum of the foot
• behind each malleolus
• over the shins
0
Depth
Description
none
No impression or distortion
observed, bone structure easily
identified
mild
1+
2+
3+
2 mm or
less
moderate
2 – 4 mm
4 – 6 mm
severe
4+
6 – 8 mm
Slight pitting without distortion,
rapidly disappears
Somewhat deeper pit, distortion
not easily apparent, disappears
10-25 seconds later
Noticeably deep pitting, entire
extremity looks full, swollen;
indentation can last longer than
1 minute
Very deep pitting, extremity is
grossly misshapen, indentation
lasts 2-5 minutes
Table adapted from: Grading: Pitting Edema - http://www.med-health.net/EdemaGrading.html
Grade
FEASIBILITY OF ACCESSING DATA IN
HOSPITALIZED PATIENTS…
• Cross-sectional survey at 4 different hospitals: 2 tertiary teaching,1
urban, 1 rural; included 262 adults
• Determined availability of data to support the proposed
Academy/ASPEN malnutrition characteristics
• Data on edema available at time of nutrition assessment
• All patients – 84.4%, Non-ICU – 85.9%, ICU – 82.7%
• Edema used as one of the characteristics to define malnutrition
• All patients – 26.6%, Non-ICU – 16.2%, ICU – 39.1%
Nicolo et al. JPEN 2013
SUMMARY
• Nutritional and medical history, & current medical picture must be
considered before determining whether fluid accumulation is a
relevant characteristic to use in identifying malnutrition
• Many patients have fluid accumulation but not all are malnourished
• RARELY a direct result of malnutrition
• Fluid accumulation may not always be readily visible
• Fluid accumulation will falsely increase weight / mask weight loss
and can prevent muscle mass / SQ fat assessment
• Continue to partner with nurses, physicians and other health care
team members to enhance assessment of fluid status