10 gastrointestinal nursing vol 7 no 1 February 2009

clinical skills

!"Abdominal examination! Clinical skills! Inspection!"Palpation!"Percussion and auscultation

This article has been subject to double-blind peer review

Key words

clinical skills

A step-by-step guide to performinga complete abdominal examination This clinical skills series is designed for the nursing professional as a basic overview on key clinical skills necessary for patient care, clearly presenting common clinical procedures and their rationale, together with the essential background theory. In this first article in the series, Carol Cox and Martin Steggall describe the process associated with abdominal assessment. It focuses on a systematic approach and highlights areas in which gastrointestinal nurses may enhance their knowledge and practice.

Carol Cox is Professor of Nursing, Advanced Clinical Practice, and Martin Steggall is Head of Department, Applied Biological Sciences, School of Community and Health Sciences, City University, London

Patients present with a variety of abdominal complaints and symptoms. Thus, it is important to have an understanding of the underlying problems that patients may have (Bickley and Szilagyi, 2007). The ability to undertake and document a clear, concise and systematic assessment of a patient is an essential skill for gastrointestinal nurses. In this article, a model of assessment (McGrath, 2004) is described, which gastrointestinal nurses can use to readily identify and prioritize patient care.

By undertaking a full and systematic assessment of the abdomen, the gastrointestinal nurse is in a unique position to act upon findings from the assessment and ensure that appropriate medical or nursing intervention occurs.

In this article, abdominal examination – which is the first part of a 2-part series – is presented. In part 2, digital rectal examination (DRE) is presented. DRE follows as the final element in a comprehensive abdominal examination.

BackgroundFor the purpose of review, the abdominal cavity is the centre for several of the body’s vital organs, including the liver, gallbladder, stomach, pancreas, spleen, small intestine, cecum, appendix, ascending, transverse, descending and sigmoid colon, kidneys, ureters, adrenal glands, abdominal aorta, inferior vena cava, bladder and rectum (Colbert et al, 2009; Marieb, 2009).

The alimentary tract, or gastrointestinal tube, is

approximately 27 feet long (Colbert et al, 2009; Marieb, 2009). It begins at the mouth and ends at the anus. Its function is to ingest and digest food, absorb nutrients, electrolytes and water, and excrete waste. Peristalsis moves food and the products of digestion under the control of the autonomic nervous system (Colbert et al, 2009; Marieb, 2009).

A patient with abdominal problems or disease may have a wide range of symptoms. Some problems may be dissociated from the abdominal system directly but impact upon organs in the abdomen, such as in diabetic gastroparesis and anticholinergic drug therapy in which the patient experiences unpleasant abdominal fullness after normal meals or early satiety and therefore has an inability to eat a full meal (Bickley and Szilagyi, 2007) or in pregnancy when, in the third trimester, there is upward displacement of the stomach.

In approximately 15–20% of pregnant women, the upper portion of the stomach herniates through the diaphragm. This is more common in older, obese and multiparous women after the seventh or eighth month of pregnancy (Seidel et al, 2006). In addition, increased progesterone production causes a decrease in motility and tone of smooth muscles. Therefore, there is a delayed emptying time of the stomach (Seidel et al, 2006; Swartz, 2006; Epstein et al, 2008).

Conversely, there is a range of symptoms that are associated with abdominal problems and/or

disease (Table 1), which should be explored fully if a tentative diagnosis is to be made (Seidel et al, 2006; Epstein et al, 2008; Jarvis, 2008). For example, ageing brings about changes in the functional ability of the gastrointestinal tract, motility of the intestine changes, and secretion and absorption are impacted.

Bacterial flora in the intestine undergo changes and become less biologically active, which impairs digestion (Seidel et al, 2006). Older people, therefore, often complain of food intolerance and wind. Furthermore, some older people are unable to report abdominal pain. This, in association with blunted fever and leukocyte response, complicate the diagnosis of abdominal infection in older people (Seidel et al, 2006; Talley and O’Connor, 2006). Assessment of abdominal pain in the older adult may be difficult because some of these patients can not communicate their pain (Cox, 2004a). Obtaining a good history from the family, or others who routinely care for the older adult, and using research-based pain assessment tools in association with behavioural cues, is the basis

for diagnosing abdominal problems or disease (Epstein et al, 2008; Cox, 2004a).

Preparation for abdominal assessmentAssessment of the abdomen usually includes assessment of the mouth, abdomen and rectum and is best undertaken in a warm, quiet, well-lit environment. Privacy should be provided so that a discrete interview can be conducted and the abdomen exposed for examination. The following equipment should be gathered: gloves, stethoscope, torch, measuring tape, felt-tip pen and a gown and drapes to cover the patient.

Explain to the patient that the assessment should not be painful, although they may experience some discomfort at times. As with other forms of assessment, such as cardiac and respiratory assessment, selective listening must be employed during auscultation.

Ensure that the patient urinates before beginning the assessment. Positioning of the patient is essential. The patient should be placed in a supine position with arms at their sides and their head on a pillow. To prevent abdominal muscle tensing, flex the patient’s knees slightly towards their chest. Putting a pillow under the patient’s knees promotes comfort – particularly for patients who find it difficult to maintain flexion of the knees.

Ask the patient to breathe quietly and slowly through their mouth. Then ask the patient to point to any areas that are tender and tell them that you will examine those areas last. Observe the patient’s facial expression as you undertake the assessment. A stoic patient may not admit to experiencing abdominal discomfort. Therefore, a change in facial expression may show when the patient is experiencing discomfort. Subsequently, the assessment can be modified accordingly. The order to be followed in an abdominal assessment is delineated in Table 2. Remember that unlike other forms of assessment, in abdominal assessment the gastrointestinal nurse always begins with inspection and follows this with auscultation so that the abdominal contents are not disturbed, which could alter bowel sounds during auscultation.

InspectionBegin the assessment by inspecting the patient’s entire abdomen. Since the liver and spleen lie

Abdominal pain Nausea

Anorexia Pain on swallowing (odynophagia)

Change in bowel habit Pale faeces

Change in abdominal girth Bloody faeces

Constipation Puritus

Dark urine Rectal bleeding

Diarrhoea Vomiting

Dyspepsia and belching Weight loss

Dysphagia Wind

Haematemesis Heartburn

Jaundice Mesenteric angina

From: McGrath (2004); Seidel et al (2006)

Table 1. Symptoms of abdominal disease

1. Inspection

2. Auscultation

3. Percussion

4. Palpation

Table 2. Order for examination of the abdomen

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protected under the ribs, the lower half of the chest must also be inspected. Assess abdominal symmetry, noting overall contour and skin condition as well as the appearance of the umbilicus and any visible pulsations. Assess abdominal contour by standing at the feet of the patient first. Then move to the side of the patient and stoop so that the abdomen is at eye level. Look at the abdominal profile. Is the abdomen fully rounded or distended? Is the umbilicus inverted or everted? Is the abdomen scaphoid in appearance, or is it distended in the upper or lower half only? Normally, the abdomen is concave, symmetrical and moves gently with respiration (Epstein et al, 2008). A concave (scaphoid) abdominal contour may indicate malnutrition, whereas distension may indicate the presence of a tumour, ascites or the accumulation of air. In thin patients, the pulsation of the aorta may be seen in the midline epigastric area (Barkauskas et al, 2002; McGrath, 2004; Jarvis, 2008). Aortic pulsations may be pronounced due to increased intra-abdominal pressure related to the presence of a tumour or ascites. Peristalsis is not normally visible. Strong visible peristalsis indicates intestinal obstruction.

Inspect the skin. It normally appears smooth and intact. Look for discolouration, striae, rashes, dilated veins, scars or other lesions. Skin abnormalities allude to underlying problems. Bulging around scars may indicate incisional hernias. Striae, in addition to resulting from pregnancy or obesity, may reflect the presence of an abdominal tumour or another disorder such as Cushing’s syndrome. Cushing’s syndrome characteristically causes thin-looking skin and purple striae to occur, which is due to the excessive secretion of cortisol (Seidel et al, 2006).

Tortuous or dilated superficial abdominal veins may indicate inferior vena cava obstruction and cutaneous angiomas may indicate liver disease. A blue coloration around the umbilicus may be an early sign of intra-abdominal bleeding. Normally, abdominal veins are not prominent. If abdominal veins are prominent, the direction of flow should be assessed. This can be readily undertaken by placing two fingers at one section of a vein and applying occlusive pressure. Move one of your fingers further along the length of the vein so that this section of vein is flattened (emptied). Then remove the finger that has been moved

along the vein. Look to see in which direction the vein refills. In inferior vena cava obstruction, the blood flow below the umbilicus flows up towards the umbilicus, whereas in portal hypertension the blood flows downwards away from the umbilicus (McGrath, 2004).

AuscultationAuscultation follows inspection and provides valuable information about gastrointestinal motility and underlying abdominal vessels and organs. Sounds heard upon auscultation can be characterized in the same fashion as in percussion (type of sound, pitch and location). It is preferable for the diaphragm of the stethoscope to be used to hear normal as well as abnormal bowel sounds.

The diaphragm transmits high-pitched sounds and provides a broader area of sound whereas the bell transmits softer sounds (Cox, 2004b). When the bell is used, pressure on the bell will, by stretching the patient’s skin underneath the bell, create a diaphragm effect. Lightly place the stethoscope diaphragm on the abdominal skin in all four quadrants of the abdomen. The four quadrants of the abdomen (right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant) are divided horizontally and vertically at the umbilicus. Take care not to put pressure on the diaphragm as this may stimulate peristalsis and subsequently mask the usual sounds that would be heard. A systematic approach should be undertaken when listening.

Before placing the diaphragm of the stethoscope on the patient’s abdomen, warm your hands and the diaphragm of the stethoscope in order to prevent muscular contraction. Muscular contraction can alter auscultation findings. Listen with the diaphragm for friction rubs in the area of the liver and spleen. Friction rubs are high pitched and, although in the abdomen are rare, it may indicate inflammation of the peritoneal surface of the organ from tumour, infection or infarction (Seidel et al, 2006; Swartz, 2006).

Listen for bowel sounds. Note their frequency and character. Normally, bowel sounds occur irregularly and range 5–35 per minute. Borborygmi is loud, prolonged gurgles, such as with diarrhoea. Increased sounds occur with gastroenteritis and may indicate intestinal obstruction or hunger.

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High-pitched sounds suggest intestinal fluid and air under pressure, which is frequently noted in early obstruction.

Decreased bowel sounds, on the other hand, occur in peritonitis and paralytic ileus. Seidel et al (2006) indicate the absence of bowel sounds can only be established after 5 minutes of continuous listening. McGrath (2004) indicates that you should listen for up to 7 minutes before deciding that bowel sounds are absent. After listening with the diaphragm, use the bell to listen for vascular sounds. Listen in the epigastric region and each of the four quadrants for bruits in the aortic, renal, iliac and femoral arteries (see Figure 1). Bruits may indicate atherosclerosis (Barkauskas et al, 2002). Abnormal auscultation sounds are listed in Table 3.

PercussionAbdominal percussion aids in determining the size and location of abdominal organs. Percussion also aids in the assessment of excessive accumulation of fluid and/or air in the abdomen. As in auscultation, a systematic approach should be used in percussing all four quadrants. Percussion sounds vary depending on the density of the organ and the underlying structures. Dull sounds are heard over dense structures, like the liver and spleen, and tympanic sounds are heard over air filled structures, such as the stomach and intestines (see Figure 2).

In the obese patient, it may be difficult to discern percussion sounds. Percussion involves striking one object against another to produce percussion sounds (sound waves), which are termed forms of resonance. These arise from vibrations 4–6 cm deep in the body’s tissues (Seidel et al, 2006; Bickley and Szilagyi, 2007).

In percussion, the finger of one hand functions as a hammer (plexor) and strikes the dorsal surface of the opposite hand’s finger on the interphalangeal joint. To perform this form of indirect percussion, as opposed to direct percussion which is when the hand strikes the patient’s abdomen directly, the non-dominant hand is placed on the surface of the patient’s abdomen with the fingers slightly spread. The distal phalanx of the middle finger is placed firmly on the abdominal surface of the patient while the other fingers are held slightly off the surface of the patient’s abdomen. The wrist

Bowel sounds Location Possible indication

Bowel sounds: hyperactive All four quadrants Hyperactive = diarrhoea or or hypoactive sounds early intestinal obstruction; created by air and fluid hypoactive/then absent movement through the sounds = paralytic ileus of bowel peritonitis; high pitched/ tinkling = intestinal fluid and air under tension in a distended bowel; high pitched/rushing with abdominal cramp = obstruction

Systolic bruits: vascular Abdominal aorta; Partial arterial obstruction or ‘blowing’ sounds resembling renal artery/iliac dissecting abdominal cardiac murmurs artery aneurysm; renal artery; stenosis; hepatomegaly

Venous hum: continuous, Epigastric or Hepatic cirrhosis medium-pitched sound umbilical caused by blood flow in a large vascular organ

Friction rub: harsh Hepatic and spleen Inflammation of the grating sound that sounds peritoneal surface of an like two pieces of leather organ; liver tumour rubbing together

From: McGrath (2004); Epstein et al (2008); Jarvis (2008)

Table 3. Abnormal auscultation sounds

Right renal artery

Right iliac artery

Right femoral artery

Aorta

Left renal artery

Left iliac artery

Left femoral artery

Figure 1. Ausculation sites.

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of the other hand is snapped downward and the tip of the middle finger, which is being used as the hammer, sharply taps the interphalangeal joint of the finger that is pressing on the patient’s abdomen (see Figure 3).

Refer to Table 4 for the classification of percussion sounds of the abdomen and where these may be heard. Remember, the quieter the percussion sound, the more dense the medium. Therefore, percussion sounds over air are loud and over fluid are less loud. Over solid areas, percussion sounds will be soft.

There are several points to consider when percussing the abdomen. The tap of the striking finger (plexor) should be done quickly, lifting the finger to prevent dampening of the sound. Only one location should be percussed at a time, and this should be repeated several times, in each area, in order to facilitate interpretation of the sound. Keep in mind that percussion as well as palpation are contraindicated in patients with suspected abdominal aortic aneurysm and patients who have received organ transplants.

Abnormal percussion findings occur in patients with abdominal distension either from the accumulation of air, ascites or masses. High-pitched tympanic sounds may indicate bowel distension associated with air. Ascites will produce shifting dullness. Shifting dullness can be assessed by having the patient lie supine. Percuss for areas of dullness and resonance and mark the borders with a felt-tip pen. Then have the patient lie on one side. Percuss for tympany and dullness and mark the borders again with a felt-tip pen. Ascites fluid settles with gravity. Therefore, you should expect to hear dullness in areas where the fluid has settled and tympany in the areas where the bowel has risen. In patients without ascites, the borders marked with a felt-tip pen will remain relatively the same, whereas in ascites the border of dullness will shift to the dependent side as the fluid resettles with gravity.

Whenever the patient has abdominal distension, this should be assessed by taking serial measurements of the patient’s abdominal girth. To do this, wrap a tape measure around the patient’s abdomen at the level of the umbilicus and record the measurement. Mark the point of measurement on the patient’s abdomen. Then explain what you have done either to the patient, their family or others who

are caring for the patient so that they can measure in the same location when subsequent readings are taken. They can then report any changes to you. Ascites presents in liver failure, peritonitis and abdominal tumour.

PalpationPalpation is the final component in an abdominal assessment and is used to assess the organs of

Sound Description Location

Tympany Musical sound/high Air-filled viscera pitch, little resonance

Hyperresonance Pitch sounds between Base of left lung tympany and resonance

Resonance Sustained sound of Vesicular lung tissue or moderate pitch the abdomen

Dullness Short, high pitched Solid organs sound with little resonance

From: Seidel et al (2006)

Table 4. Percussion sounds of the abdomen

Right upper quadrant

Left upperquadrant

Percussion sites

Hand placement for percussion

Figure 2. Percussion sites and hand placement.

the abdominal cavity, to detect muscle spasm, tumours, fluid and areas of tenderness (Seidel et al, 2006; Epstein et al, 2008). It is a sophisticated skill that involves the use of the hands and fingers to gather information about the size, shape, mobility, consistency and tension of abdominal contents through the sense of touch. Touch is considered therapeutic, and is the actuality of ‘laying on of hands’. Palpation of the abdomen is a particularly sensitive matter; therefore, the gastrointestinal nurse’s approach should be gentle. Your hands should be warm and fingernails short, as this is not only practical in terms of the approach to the patient but is also symbolic of the respect you hold for the patient and the privilege the patient gives you in allowing you to examine the patient’s body.

Begin with light palpation. Like auscultation and percussion, palpation should be systematic in assessing all four quadrants. Avoid palpating areas that have been identified by the patient as being tender or problematic.

Various parts of the hands and fingers are used for specific types of palpation due to their variance in sensitivity associated with position,

vibration and temperature. Refer to Table 5 for the areas of the hands to use in palpation. The palmar surface of the hand and fingers is more sensitive than the fingertips and is used to discern size and shape. The back of the hand is used to discern hot and cold. The ulner surface of the hand is used to assess vibration. Gently rest the palm of your hand with the fingers extended on the patient’s abdomen.

Use the palmar surface of your fingers to depress the abdominal wall approximately 1–2 cm. Employ a light even pressing motion as this helps to relax the patient. Avoid short quick jabs, which can frighten the patient and cause discomfort. If the patient is ticklish, ask the patient to rest their hand on the top of yours. This will often decrease the patient’s ticklish response. Move your hands in a circular fashion so that the abdominal wall moves over underlying organs. The patient’s abdomen should feel smooth and have a consistent softness throughout.

When inflammation or tenderness is present, the patient will guard their abdomen (Barkauskas, 2002). When this resistance occurs, determine whether it is voluntary or involuntary by placing a pillow under the patient’s knees (if you have not already done so) and ask the patient to breathe slowly through their mouth. If guarding remains then it is probably an involuntary response. Board-like hardness of the abdominal wall is an indication of peritonitis and appendicitis.

Deep palpation is required to assess abdominal organs and detect masses. Use the palmar surface of your extended fingers to press deeply into the abdominal wall, approximately 4–6 cm. Systematically assess all four quadrants. Be aware that deep palpation may evoke tenderness in healthy patients over the cecum, sigmoid colon and aorta. Identify any masses and determine whether they are superficial (located in the abdominal wall) or intra-abdominal by having the patient raise their head off the pillow. This action contracts the abdominal muscles; subsequently, masses in the abdominal wall will continue to be palpable whereas those in the abdominal cavity will be difficult to feel.

In addition to assessing all four quadrants, particular attention should be paid to the umbilical ring. This area should be smooth and free of bulges, nodules or granulation. If the umbilical

• Palmar surface of the hand and finger pads – to assess size, consistency, texture, fluid, surgical emphysema and the texture and form of a mass or structure

• Ulnar surface of the hand and fingers – to assess vibration

• Dorsal surface of the hands – to assess temperature

From: McGrath (2004)

Table 5. Areas of the hand used in palpation

Figure 3. Percussion technique.

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ring is soft in the centre, this suggests a hernia. Specific structures, such as the liver, should be palpated as well. The liver is difficult to assess because it lies under the eleventh and twelfth ribs. To assess the liver, place your right hand on the patient’s abdomen with your fingers pointing towards the patient’s head. Ask the patient to breathe regularly a few times and then to take a deep breath. As the patient takes a deep breath, try to feel the liver edge as the diaphragm pushes the liver down. Normally, the liver is not palpable except in very thin people. When a tumour or cirrhosis is present, the edge of the liver will feel hard and irregular.

ConclusionIn this article, the essentials of abdominal examination (excluding DRE) have been presented. The gastrointestinal nurse will find the information related to the processes of inspection, auscultation, percussion and palpation useful when examining patients at their first visit and subsequent visits when patient complaints occur or complications arise.

Examination of the abdomen can tell the gastrointestinal nurse much about the overall health status of the patient and provides a baseline for diagnoses and treatment. In part 2, the process of undertaking a thorough DRE will be presented. As with abdominal examination, DRE aids in the identification of serious complications/pathology that prompt further clinical investigation. !

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