Download The Abdomen

The Abdomen/Rectal
The Abdomen
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Anatomy and Physiology
The Abdomen

Anatomy and Physiology
The Abdomen
Gastrointestinal Bleeding
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Upper
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Esophagus, stomach, duodenum
Causes:
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Peptic ulcers- localized erosions of wall of digestive
tract leading to damage of blood vessels and bleeding
Gastritis- general inflammation of stomach wall which
can result in bleeding
Esophageal varices- swelling in veins in esophagus or
stomach and usually associated with alcoholic liver
cirrhosis
Mallory-Weiss tears- a tear in the esophagus or
stomach wall after vomiting, forceful coughing,
laughing, lifting, childbirth, or recent binge drinking
Also, ingestion of caustic poisons or stomach cancer
Gastrointestinal Bleeding
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Lower
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Other segments of small intestine, large intestine, rectum,
anus
Causes:
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Diverticulosis- Small outpouchings from colon wall, usually in
weakened area of bowel
Angiodysplasia- Malformation in blood vessels of wall of GI tract.
Often associated with elderly & chronic kidney failure
Polyps- Noncancerous tumors of GI tract that occur mostly in
those >40 y/o. Small number become cancerous
Hemorrhoids- Swelling of veins around rectum, often from
straining
Anal fissures- tears in anal wall often from forced straining of
hard stool
 Blood in stool can results from cancer, inflammatory bowel
disease, infectious diarrhea
Gastrointestinal Bleeding
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Acute
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Vomiting blood (hematemesis) (franks vs.
coffee ground)
Bloody bowel movement (hematochezia)
Black tarry stools (melena)
Fatigue, weakness, shortness of breath, pale
appearance
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Associated with blood loss
Long-term
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Fatigue
Anemia
Black stools
Peritonitis
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An inflammation of the peritoneum the serous membrane that lines part of
the abdominal cavity and viscera
Causes:
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Peritoneal dialysis-An infection may occur during peritoneal dialysis
due to unclean surroundings, poor hygiene or contaminated
equipment.
Ascites- Diseases that cause liver damage, such as cirrhosis, can
result in a large amount of fluid buildup in your abdominal cavity,
which is susceptible to bacterial infection.
A ruptured appendix, stomach ulcer or perforated colon- Allow
bacteria to get into the peritoneum through a hole in your
gastrointestinal tract.
Pancreatitis-Inflammation of your pancreas complicated by infection
may lead to peritonitis if the bacteria spread outside the pancreas.
Diverticulitis-Infection of small, bulging pouches in your digestive tract
may cause peritonitis if one of the pouches ruptures, spilling intestinal
waste into your abdomen.
Trauma-Injury/trauma may cause peritonitis by allowing bacteria or
chemicals from other parts of your body to enter the peritoneum.
Peritonitis
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Common symptoms
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Acute abdominal pain
Abdominal tenderness
Abdominal guarding
Rigidity
Abdominal distention
Fever & chills
Nausea/vomiting
Anorexia
Decreased bowel sounds
Inability to pass stool or gas
Oliguria
Fatigue
Health History- GI
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Pain- Abdominal or rectal
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OLDCART
Normal bowel habits/Stool character
Presence of any of the following:
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Indigestion
Belching (more than usual)
Anorexia/Nausea/Vomiting
Weight loss
Difficulty swallowing (dysphagia)
Flatulence (more than usual)
Diarrhea
Constipation
Health History-GI
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Medications
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Aspirin, ibuprofen, steroids, antibiotics, laxatives,
cathartics, codeine, iron preparations
Abdominal surgery, trauma, or diagnostic
tests of GI tract
 Personal or family history of:
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Cancer, alcoholism, polyps, chronic inflammatory
bowel disease.
Chance that pregnant?
 Risk factors for HBV exposure
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Health care occupation, hemodialysis, IV drug
use, household/sexual contact with HBV +
person, unprotected sexual practices
Health History-GU
Urinary/Renal
 Suprapubic pain
 Dysuria, urgency, or frequency
 Hesitancy, decreased stream in males
 Polyuria (>3L in 24 hours) or nocturia
 Urinary incontinence
 Hematuria (trace or gross)
 Kidney or flank pain
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History of kidney disease
The Abdomen: Techniques of
Examination
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Have Patient:
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Empty bladder
Lye in Supine position
Arms to the side or laying across
chest
Bend knees
Point to any painful area
Examiner
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Warm hands and stethoscope
Watch patient’s face for signs of pain
Distract patient if necessary
Begin palpation with patient’s hand under yours if
patient is ticklish, then slip your hand underneath
directly
Inspection
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Demeanor
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Knees drawn up,
motionless, restlessness
Contour of the abdomen
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Distention causes:
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Symmetry
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Obesity, air/gas, ascites,
ovarian cyst, uterine
fibroids, pregnancy,
feces, tumor
Bulges, masses,
asymmetric shape
Pulsations or movement
Inspection
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Skin
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Scars, striae, dilated veins,
rashes, lesions, or ostomy
Umbilicus
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Assess for location,
discoloration,inflammation,
or hernia
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Everted- Ascites, pregnancy,
mass, hernia
Sunken- Obesity
Bluish- Cullin’s sign indicator
of intraabdominal bleeding
Have pt raise head
Abdominal wall mass,
hernias, muscle separation
Auscultation
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Listen to bowel sounds
using diaphragm of
stethoscope (high
pitch).
Begin in right lower
quadrant and move
clockwise to all 4
quadrants.
Temporarily turn off
GI tubes connected to
suction
Auscultation
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Bowel sounds
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Normal/Active - high pitched gurgling noise. Approx 5-35
sounds per minute, or at least 1 every 5-15 seconds.
Hypoactive – Often soft and widespread. Less than 5 BS
per minute.
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Absent – No bowel sounds heard. Must listen for 5
minutes before concluding that bowel sounds are absent
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Post operatively following general anesthesia
Late stage bowel obstruction, paralytic ileus, peritonitis
Hyperactive - Loud, gurgling, frequent sounds. Greater
than 35 BS a minute.
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Inflammation of bowel, anxiety, diarrhea, bleeding, excessive
ingestion of laxatives, rxn of intestines to certain foods
Borborygmi – Loud stomach growling, rumbling sound
produced by movement of gas in stomach and intestines.
Heard with or without stethoscope
Auscultation
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Arterial sounds for
bruits
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Aorta
Renal artery
Iliac artery
Femoral artery
Use Bell
Percussion
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Performed to detect
fluid, gaseous
distention, and
masses, and to assess
position and size of
liver and spleen.
Percuss in all 4 quads
for tympany and
dullness
Large dull areas may
indicate mass or
enlarged organ
Percussion
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The Kidney
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Assessing for
costovertebral angle
tenderness (CVA)
Normal= non-tender
Tenderness occurs in
acute infection
(pylonephritis)
Palpation- Light
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Press fingertips gently
into abdominal wall,
approx ½ inch
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Use one hand approach
Assess for abdominal
tenderness, muscle
guarding/rigidity,
pulsations, large or
superficial masses
Palpation-Light
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Routinely check the bladder for distention
if:
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Unable to void
Incontinent
Indwelling catheter is not draining well
Bladder non-palpable without
tenderness.
Palpation - Deep
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Use two hand approach
& press approx 1-3
inches.
Assess masses,
tenderness, and organ
enlargement.
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Masses: Note location,
size, shape, consistency,
tenderness, pulsation.
Never over surgical
incision, extremely
tender organs, or
pulsatile mass
Palpation - Deep
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Organs: liver
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Liver- Place left hand behind
patient parallel to right 11th
and 12th rib. Place right hand
lateral to rectus muscle and
well below lower border of
liver. Press in and up.
Ask patient to take deep
breath. On inspiration normal
liver palpable about 3cm below
right costal margin in the
midclavicular line
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Can use hooking technique
Note tenderness (normally may
be a little tender), should feel
soft/firm, sharp, and regular
with a smooth surface
http://www.youtube.com/watch?v=Si0PHV991t0&
feature=related
The Abdomen: Abnormal liver
Assessing for Cholecystitis
Hold fingers under liver border
 Ask person to take deep breath
 Assess for sharp pain and abruptly
stopping inspiration midway
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Negative Murphy’s sign (complete deep
breath without pain)
Assessing for Ascites
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A protuberant abdomen
with bulging flanks
suggests ascites
Testing for shifting
dullness
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Map borders between
tympany and dullness.
Ask patient to roll to side.
Percuss and mark
borders again. In ascites
dullness shifts to more
dependant side
Assessing for Ascites
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Test for fluid wave
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Ask patient or assistant
to press edges of both
hands firmly down on
midline of abdomen.
While you tap one flank
sharply with fingertips
feel for fluid pulse on
opposite flank with
other hand
Assessing for Appendicitis
& Peritonitis
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Rebound Tenderness- Pain upon removal of
pressure rather than application
Rovsing’s sign- Rebound tenderness on the left
lower quadrant
Psoas sign- Pain with flexion of the right leg at
the hip
Obturator sign: Pain with rotation of the right leg
internally at the hip
Rectum/Anus
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Rectal/Anus exam
includes inspection and
palpation
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Position patient in left
lateral or Sims’ position
For prostate exam have
bend over forward with
hips flexed and upper
body resting on table or
bed.
Drape the patient to avoid
unnecessary exposure of
genitalia
Rectum/Anus- Inspection
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Perianal areas/Anus
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Masses/Rectal Prolapse
Lesions
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Venereal warts, herpes,
syphilitic chancre, or
carcinoma
Hemorrhoids
Ulcers/Fissures/Fistulas
Inflammation/Rashes
Excoriation
Use clock reference to
describe lesion location
Rectum/Anus- Palpation
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Lubricate gloved index
finger prior to
insertion
As sphincter relaxes
gently insert finger
towards umbilicus
Do not force finger
Rotate hand clockwise
Feel for tenderness,
induration,
irregularities/ nodules
Colorectal Cancer
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Early stages often without symptoms so
screening is key
Change in frequency of bowel movements
Constipation or diarrhea
Pencil stools/feeling can’t empty bowel
completely
Hematochezia or melena
Abdominal discomfort, bloating, frequent gas
pains, or cramps
Unintentional weight loss
Anorexia
Fatigue
Anatomy of the Prostate Gland
and Seminal Vesicles
Prostate Gland
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Prostate gland
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Size
Shape
Surface
Consistency
Sensitivity
Sample Charting
Sample Charting (cont.)