Head-To-Toe Assessment (R. Abdomen)
In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles.
Inspection of the abdomen
- Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
- Contour (flat, rounded, scapold)
- Respiratory movement.
- Visible peristalsis.
- Skin color is uniform, no lesions.
- Some clients may have striae or scar.
- No venous engorgement.
- Contour may be flat, rounded or scapoid
- Thin clients may have visible peristalsis.
- Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen
- This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion.
- The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles.
- Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum.
These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel.
Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:
1. Divide the abdomen in four quadrants.
2. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement.
3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present.
4. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.
Some factors that affect bowel sound:
- Presence of food in the GI tract.
- State of digestion.
- Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).
- Bowel surgery
- Constipation or Diarrhea.
- Electrolyte imbalances.
- Bowel obstruction.
Percussion of the abdomen
- Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid structures within the abdomen.
- The direction of abdominal percussion follows the auscultation site at each abdominal guardant.
- The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.
- Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the mid axillary line on the left side.
- Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.
Percussion of the liver
The palms of the left hand is placed over the region of liver dullness.
- The area is strucked lightly with a fisted right hand.
- Normally tenderness should not be elicited by this method.
- Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
- Can be done by either indirect or direct method.
- Percussion is done over the costovertebral junction.
- Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen
- It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel to the floor.
- The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion.
- This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.
Tensing of abdominal musculature may occur because of:
- The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.
- The client is ticklish or guards involuntarily.
- Presence of subjacent pathologic condition.
- No tenderness noted.
- With smooth and consistent tension.
- No muscles guarding.
- It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall.
- The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.
- Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with this method.
- In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta.
There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand.
- Ask the patient to take 3 normal breaths.
- Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation.
- Press hand deeply over the RUQ
The second methods:
- The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.
- Place the examiner’s right hands parallel to the costal margin or the RUQ.
- An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the abdominal wall.
- Ask the client to breath deeply.
- As the client inspires, the liver maybe felt to slip beneath the examining fingers.
- The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt a the costal margins.
- When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender.