abdomen
TRANSCRIPT
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Assessment of the Abdomen
Patricia Jackson AllenRN, MS, PNP, FAAN
Yale University, School of Nursing
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Abdominal Structures
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Abdominal Structures
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Abdominal Structures
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Abdominal Structures
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Abdomen Mapping Anatomical landmarks
Xiphoid process Costal margins Iliac crest Anterior superior iliac
spine Symphysis pubis Umbilicus
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Four Quadrants of Abdomen
When examining eachquadrant, remember what organs and structures are found found in each quadrant
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Four Quadrants of the Abdomen
Right Upper Quadrant Liver Pylorus valve of stomach Duodenum Right kidney and adrenal gland Hepatic flexure of colon Portions of ascending and transverse colon
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Four Quadrants of the Abdomen
Right Lower Quadrant Appendix and cecum Ascending colon Bladder if distended Ovary Uterus if enlarged Right spermatic cord Right ureter
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Four Quadrants of the Abdomen
Left Upper Quadrant Tip of medial lobe of liver Spleen Stomach Left kidney and adrenal gland Pancreas Splenic flexure of colon Portions of transverse and descending colon
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Four Quadrants of the Abdomen
Left Lower Quadrant Sigmoid colon Descending colon Bladder if distended Ovary Uterus if enlarged Left spermatic cord Left ureter
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History Chief complaint / present illness
Abdominal pain Indigestion Nausea Vomiting Diarrhea Constipation
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History Chief complaint / present illness
Fecal incontinence Jaundice Dysuria Urinary frequency Urinary incontinence Hematuria, blood in stool Weight loss, weight gain
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History Symptom characteristics
Onset and duration Getting better or worse Character or quality Associated symptoms Location, radiation
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History Symptom characteristics
Factors that relieve or exacerbate symptoms Alterations in activities of daily living Others in family with similar symptoms Home or prescribed treatment Prior evaluation or treatment
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Past Medical History Perinatal history
Pregnancies, abortions, miscarriages Birth defects Infant feeding problems Prematurity Short bowel syndrome
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Illnesses / infectious diseaseIllnesses / infectious disease
Past Medical History
– Acute GI infections– Hepatitis– PID, STI’s– HIV– UTI’s– Diverticulitis– Ulcers
– Gallbladder illness– Colitis– Cystic fibrosis– Food allergies / intolerance– Constipation– GERD– Irritable bowel
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Past Medical History Immunizations
Hepatitis B Hepatitis A Cholera Typhoid Rota virus Other
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Past Medical History Laboratory test
Stool cultures Abdominal x-ray, sonograms, ultrasounds Urinalysis H. pylori tests Ova and parasites Sigmoid or colonoscopy Organ biopsy
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Past Medical History Operations / hospitalizations / ER visits
Abdominal surgery Appendicitis Trauma to abdomen Births Blood transfusions Acute gastroenteritis (AGE) Organ inflammation (liver, pancreas,
gallbladder) Recurrent abdominal pain
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Past Medical History Accidents (unintentional injury)
Car Bike Skateboard Falls
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Past Medical History Medication use
Antibiotics Laxatives Suppositories, enemas Antacids Ulcer medications
Iron and vitamins Chronic steroid or ASA use Birth control Folk remedies
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Family History Infectious conditions (hepatitis, AGE) Constipation, irritable bowel Ulcers, diverticulitis, inflammatory bowel Gallbladder disease Symptoms similar to CC Colon cancer, ovarian cancer Ova and parasites
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Personal and Social History Nutrition Last menstrual period Sexual practices and protection Substance use, including caffeine, alcohol,
tobacco Recent stress Weight gain or loss Anorexia, bulimia, dieting Travel outside of country
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Preparation for Abdominal Examination
Have child empty bladder Have child lie supine with hips and knees flexed Drape for privacy Tell child what you will do before you do it Have warm room and warm hands Have good light source Examine identified painful areas last
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Position for Abdominal Examination
Correct Incorrect
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Drape for Modesty
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Assessment of the Abdomen Inspection Auscultation Percussion Palpation
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Assessment of the Abdomen Inspection
Skin Scars Striae Dilated veins, vein pattern Rashes Lesions
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Assessment of the Abdomen Inspection
Umbilicus Location Contour Signs of inflammation or bulging
Contour Symmetrical / asymmetrical Flat Rounded Protuberant Scaphoid
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Causes of Abdominal Distention
Obesity Pregnancy Tympanitis Ascites Feces Neoplasms
(Six “F’s”: Fat, Fluid, Flatus, Fetus, Fecus, Fatal growths)
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Location of Distention Xiphoid Umbilicus Pubis Midline
Diaphragmatic hernia Umbilical hernia Pregnancy, distended
bladder Diastasis recti
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Midline Contour Variation
Diastasis Recti
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Normal Variations ofContour with Age
Infant-toddler Protuberant
Preschool age child Rounded, lumbar lordosis
School age child Scaphoid
Adolescent / adult Varied
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Infant Abdomen
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Toddler / Preschooler Abdomen
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School-Age Abdomen
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Assessment of the Abdomen Inspection
Peristalsis May be seen in thin individuals or with obstructive
conditions Pulsation
Pulsations of descending aorta may be seen in thin individuals
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Assessment of the Abdomen Inspections
RespirationsAbdominal breathing normal until school age
Intercostal breathing occurs with Respiratory distress Abdominal inflammation
Pneumonia or pleural effusion may cause Abdominal pain Altered respirations
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Assessment of the Abdomen
Auscultation Bowel sounds Vascular sounds Organ size, location
Warm stethoscope before use
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Assessment of the Abdomen Auscultation
Increased bowel sounds Diarrhea Colic Malrotation Intussusception Diverticulitis
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Assessment of the Abdomen Auscultation
Decreased bowel sounds Total obstruction Paralytic ileus Peritonitis Severe ascites
Absence of bowel sounds established after 5 minutes of listening
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Assessment of the Abdomen Auscultation
Scratch test for liver size Intensity of sound increases as you approach liver
edge
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Abdominal Auscultation for Bruits
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Techniques for Relaxation of Children for Percussion and Palpation
Pacifier to encourage relaxation with sucking Flex knees and hips Distraction, support of caregiver Reassure procedure will not hurt Involve them in procedure Use of puppets or toys
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Assessment of the Abdomen Percussion
Percussion is excellent for assessing organ size, presence of masses, fluid or gas.
Tympany stomach, bowel Resonance bowel Dullness liver Flat thigh
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Percussion Tympany
High pitch note elicited over airfilled structures, such as viscera and stomach.
Dull Short high-pitched sound with little resonance.
Found in solid or fluid filled organs adjacent to air containing organs, i.e., liver, spleen, distended bladder.
Flat Very short, high-pitched sound produced over tissue
which contains no air, i.e., muscle, large solid mass.
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Assessment of the Abdomen Percuss
4 quadrants for gas or masses Liver span Spleen size Costovertebral angle (CVA) tenderness
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Abdominal Percussion
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Assessment of the Abdomen Liver percussion
At right mid-clavicular line, start below umbilicus and percuss upward until dullness of sound heard
Liver usually @ right costal margin +/- 2 cm Size and shape of liver vary
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Liver Percussion
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Assessment of the Abdomen Spleen Percussion
Splenic dullness may be heard near left 10th rib posterior to the mid-axillary line Usually not found unless enlarged Obscured by air in the colon
Percuss at 10th intercostal space to determine dullness with deep breath
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Percussion of Spleen
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Percussion of the Spleen
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Assessment of the Abdomen Percussion for tenderness of liver or
kidneys Place palm of one hand over organ. Strike
hand with ulnar surface of other hand. If organ is inflamed, this will result in pain.
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Bimanual Percussionfor Liver Inflammation
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Bimanual Percussionfor Kidney Inflammation
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Assessment of the Abdomen Palpation
Light palpation Assessment of skin turgor Muscle tone Superficial lesions or masses Areas of tenderness
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Assessment of the Abdomen Deep palpation
Assess for masses or enlarged organsMass descriptors
Location Size Shape Consistency Tenderness Pulsation Mobility
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Light palpation Deep palpation
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Structures CommonlyPalpated as Masses
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Assessment of the Abdomen Palpation
Areas of cutaneous sensitivity
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Assessment of the Abdomen Palpation
Liver Normally palpable near right costal margin, mid-
clavicular line. Palpate with right hand starting below umbilicus
and moving upward until liver palpable. Remember the liver is a superficial organ.
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Liver Palpation
Finger TipsSide of Hand
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Assessment of the Abdomen Palpation
Spleen Difficult to palpate unless enlarged Deep palpation under L costal margin at the
anterior axillary line Will descend with deep inspiration Can roll person to R side to move spleen towards
midline
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Spleen Palpation
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Spleen Palpation
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Assessment of the Abdomen Palpation
Kidneys Difficult to palpate unless enlarged With hands perpendicular to midline between rib
cage and iliac crest, press hands gently but firmly together.
Have person take deep breath. May feel kidney slide between hands. Right
kidney normally lower than left kidney.
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Kidney Palpation
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Assessment of the Abdomen Palpation
Stool Firm, movable, mildly tender, elongated mass
often palpable in sigmoid colon
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Assessment of the Abdomen Palpation
Bladder If distended, bladder is palpable midline above
symphysis pubis Smooth round mass, not moveable
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Assessment of the Abdomen Special maneuvers
Rebound tenderness Psoas maneuver Obturator sign Murphy’s sign
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Rebound Tenderness at McBurney Point
Sharp pain when pressure released in RLQ suggest appendicitis
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Obturator Muscle Test
Flex R leg at hip & knee. Rotate leg laterally & medially.Pain in hypogastric region may indicate ruptured appendix
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Iliopsoas Muscle Test
Ask to raise the R leg flexing at the hip while pressingdown on lower thigh. Lower quadrant pain may indicate appendicitis.
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Murphy’s Sign
Client complains of sharp pain when trying to take a deep breath while examiner performs deep palpation in URQ.
Inflamed gallbladder descends during inspiration resulting in pain
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Abdominal Signs of Abuse
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Common AbnormalAbdominal Findings
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Hernias Protrusions of the peritoneum or
intestine through a weakened spot in musculature of abdominal wall. Umbilical hernias rarely need intervention. Inguinal and femoral hernias are usually surgically corrected.
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Umbilical Hernia
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Hernia
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Inguinal & Femoral Hernias
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Hernias Inspection
Assess for bulges with crying or bearing down.
Auscultation Assess for hums or bruits - should not be
present. May hear bowel sounds.
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Hernias Percussion
Can not percuss hernia. Palpation
Mass soft, nontender and retractable. Measure opening in musculature with finger tips.
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Pyloric Stenosis Hypertrophy of the
pyloric valve prevents feed from leaving the stomach. Infant initially feeds well but then develops persistent vomiting.
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Pyloric Stenosis Inspection
Peristalic wave over stomach area Projectile vomiting
Auscultation Hyperactive sounds over stomach area Hyperactive sounds over intestines
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Pyloric Stenosis Percussion
Resonant stomach sounds. Contents expelled.
Palpation An enlarged, firm, “olive shape” mass may
be palpable in RUQ. Needs to be referred to MD for ultrasound testing and then surgery.
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Appendicitis Appendicitis is the most common cause of
acute surgical abdomen in childhood. Rare in early childhood, becoming more frequent
after age 10. History includes dull aching, steady peri-umbilical
pain that localizes to RLQ after 4-6 hours. Nausea and vomiting frequently occur but there
is no change in bowel habits. Low grade fever may be present.
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Appendicitis Inspection
Note guarding or pain with walking or coughing. Abdominal distention may be present. Prefer supine position with knees flexed.
Auscultation Bowel sounds may be decreased or
hyperactive. Need to auscultate RLL of lungs carefully to rule out lobar pneumonia with referred pain.
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Appendicitis Percussion
Increased tenderness may make percussion too uncomfortable to perform.
Palpation Tenderness over area of inflamed appendix,
usually RLQ (McBurney point). Rebound tenderness localized to same area. Unable to palpate inflamed appendix. Rectal
exam usually finds right-sided tenderness.
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Abdominal Pain
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Abdominal Pain Inspection
Limitation of movement or alterations in breathing pattern (shallow or chest breathing) are important assessment criteria. Watch client climb on or off the exam table
Periumbilical pain less likely to be serious than other locations
Evaluate for weight loss or gain
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Abdominal Pain Auscultation
Bowel sounds may be increased or decreased
Friction rub may be heard with pleural inflammation or peritoneal inflammation
Percussion Percussion over areas of inflammation may
result in pain Watch facial expressions as you attempt to
distract individual. Those who watch you have more pain.
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Abdominal Pain
Palpation Palpation may identify localized or generalized
pain. Watch facial expressions as you attempt to
distract during palpation. Firm but gentle palpation is best.
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Pregnancy Inspection
Enlargement of lower abdomen, midline Enlargement of breast Linea nigra, increase facial pigmentation,
striae Auscultation
Fetal heart sounds
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Pregnant Abdomen
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Pregnancy Percussion
Dull mass in lower abdomen Displaced tympany of bowel and stomach
Palpation Fetal outline Fundus of uterus
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