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  1. 1. Abdomen Nursing 330 Governors State University Shirley Comer
  2. 2. History – Review of Systems <ul><li>GI </li></ul><ul><ul><li>Indigestion/anorexia </li></ul></ul><ul><ul><li>N&V, hematemesis </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Dysphasia </li></ul></ul><ul><ul><li>Change in bowel function </li></ul></ul><ul><ul><li>Constipation or Diarrhea </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><li>Renal /GU </li></ul><ul><ul><li>Supra-pubic pain </li></ul></ul><ul><ul><li>Dysuria/urgency/freq </li></ul></ul><ul><ul><li>Hesitancy, decreased stream (males) </li></ul></ul><ul><ul><li>Polyuria or nocturia </li></ul></ul><ul><ul><li>Urinary incontinence </li></ul></ul><ul><ul><li>Hematuria </li></ul></ul><ul><ul><li>Kidney/flank pain </li></ul></ul><ul><ul><li>Ureteral colic </li></ul></ul>
  3. 3. Inspection <ul><li>Contour </li></ul><ul><ul><li>Stand at pt right side and observe at pt height </li></ul></ul><ul><ul><li>Inspect from ribs to pubic bone </li></ul></ul><ul><ul><li>Concave, flat, rounded, distended </li></ul></ul><ul><li>Symmetry </li></ul><ul><ul><li>Shine a light across </li></ul></ul><ul><ul><li>Note any masses, bulges or asymmetry </li></ul></ul><ul><ul><li>Hernia - Protrusion of bowel loop through abdominal wall </li></ul></ul><ul><li>Umbilicus </li></ul><ul><ul><li>Normally midline /s discoloration, inflammation or hernia </li></ul></ul><ul><ul><li>Inverted or everted </li></ul></ul><ul><ul><li>Everted /c pregnancy, ascites, distension, congenital. </li></ul></ul>
  4. 4. Inspection Cont <ul><li>Skin </li></ul><ul><ul><li>Smooth with even color </li></ul></ul><ul><ul><li>Redness(inflammation)Jaundice(liver dysfunction) </li></ul></ul><ul><ul><li>Skin taunt and shinny /c ascites </li></ul></ul><ul><ul><li>Spider nevi (cutaneous angiomas) /c liver disease </li></ul></ul><ul><ul><li>Rash with allergic reaction </li></ul></ul>
  5. 5. Inspection cont <ul><li>Pulsation or movement </li></ul><ul><ul><li>In thin pt or children may see aortic pulsations in epigastric area </li></ul></ul><ul><ul><li>May see respiratory movement esp in males </li></ul></ul><ul><ul><li>Visible peristalsis may indicate intestional obstruction </li></ul></ul><ul><li>Hair distribution </li></ul><ul><ul><li>Uneven may mean vascular problems </li></ul></ul>
  6. 6. Inspection Cont <ul><li>Demeanor </li></ul><ul><ul><li>Should be comfortable and relaxed </li></ul></ul><ul><ul><li>Should be lying flat </li></ul></ul><ul><ul><li>Restlessness may indicate pain (gastrointeritis or obstruction </li></ul></ul><ul><ul><li>Stillness and resisting movement indicates pain (Peritonitis) </li></ul></ul><ul><ul><li>Knees flexed, facial grimacing, and shallow respirations also indicate pain </li></ul></ul>
  7. 7. Auscultation <ul><li>Exception to assessment rule as palpation can stimulate bowel sounds not really there. </li></ul><ul><li>If pt has Nasogastric tube to suction, turn the suction off for assessment </li></ul><ul><li>Use diaphragm of stethoscope </li></ul><ul><li>Auscultate ileocecal valve in right lower quad </li></ul><ul><ul><li>Bowel sounds almost always present here </li></ul></ul>
  8. 8. Quadrants of Abdomen
  9. 9. Underlying Abdominal organs
  10. 10. Bowel sounds <ul><li>Caused by peristalsis </li></ul><ul><li>Note character and frequency </li></ul><ul><li>Normally high pitched gurgling sounds (5 to 30 per min) </li></ul><ul><li>Don’t count but determine character </li></ul><ul><li>Hyperactive - occur with early bowel obstruction, diarrhea, laxative use, subsiding paralytic ileus </li></ul><ul><li>Hypoactive - or absent- follows anesthesia, bowel obstruction </li></ul>
  11. 11. Vascular sounds <ul><li>Normally can not hear vascular sounds </li></ul><ul><li>Note any bruits </li></ul><ul><li>Listen over </li></ul><ul><ul><li>Aorta </li></ul></ul><ul><ul><li>Renal arteries </li></ul></ul><ul><ul><li>Iliac arteries </li></ul></ul><ul><ul><li>Femoral arteries </li></ul></ul>
  12. 12. Percussion <ul><li>Percuss entire abdomen </li></ul><ul><ul><li>Should hear tympany </li></ul></ul><ul><ul><li>Dullness over distended bladder, fluid or mass </li></ul></ul><ul><li>Percuss Liver Span </li></ul><ul><ul><li>Measure height in right MCL (usually at 5 th ICS) </li></ul></ul><ul><ul><li>Measure bottom of liver by percussing up from abdomen </li></ul></ul><ul><ul><li>Span = 6 to 12 cm </li></ul></ul><ul><ul><li>Hepatomegaly = enlarged liver </li></ul></ul>
  13. 13. Percussion Cont <ul><li>Percuss Spleen </li></ul><ul><li>Percuss along 9 th to 11 ICS at left mid axillary line </li></ul><ul><li>Span not greater then 7 cm </li></ul><ul><li>Dullness forward of the midaxillary line indicates enlarged spleen (mononucleosis, trauma, infection) </li></ul>
  14. 14. Palpation <ul><li>Light Palpation </li></ul><ul><ul><li>One hand, 1cm deep, rotary motion </li></ul></ul><ul><ul><li>Move clockwise over abdomen </li></ul></ul><ul><ul><li>Note muscle guarding, rigidity, masses, tenderness </li></ul></ul><ul><li>Deep Palpation </li></ul><ul><ul><li>5 to 8 cm, clockwise, use 2 hands if needed </li></ul></ul><ul><ul><li>Don’t do deep palpation if elicit pain on light </li></ul></ul><ul><ul><li>Sigmoid colon may be normally tender </li></ul></ul>
  15. 15. Palpating Masses <ul><li>If Mass if felt, note </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Shape </li></ul></ul><ul><ul><li>Consistency (soft, hard, firm) </li></ul></ul><ul><ul><li>Smooth or nodular </li></ul></ul><ul><ul><li>Mobile or fixed </li></ul></ul><ul><ul><li>Pulsation </li></ul></ul><ul><ul><li>tenderness </li></ul></ul>
  16. 16. Palpation continued <ul><li>These structures may be normally palpable in the abdomen </li></ul><ul><ul><li>Right kidney </li></ul></ul><ul><ul><li>Liver boarder </li></ul></ul><ul><ul><li>Xiphoid process </li></ul></ul><ul><ul><li>Aorta </li></ul></ul><ul><ul><li>Rectus muscles </li></ul></ul><ul><ul><li>Cecum </li></ul></ul><ul><ul><li>Uterus </li></ul></ul><ul><ul><li>Full bladder </li></ul></ul><ul><ul><li>Sacrum </li></ul></ul><ul><ul><li>Sigmoid colon </li></ul></ul>
  17. 17. Palpate Liver <ul><li>2 techniques </li></ul><ul><ul><li>1. Place one hand under waist and lift up. Put other on top of abdomen under ribs on right </li></ul></ul><ul><ul><li>2. Hook both hand around ribs while standing at pt shoulder </li></ul></ul><ul><ul><li>/c both, have pt take deep breath and feel for liver boarder sliding over fingers </li></ul></ul><ul><ul><li>May not be palpable </li></ul></ul><ul><ul><li>Is enlarged if felt more than 1 or 2 cm below rib boarder </li></ul></ul>
  18. 18. Palpate Spleen <ul><li>Normally not palpable </li></ul><ul><ul><li>On left side place hands as in technique 1 to palpate liver </li></ul></ul><ul><ul><li>On deep inspiration may feel margin against your finders </li></ul></ul><ul><ul><li>If felt is probably enlarged </li></ul></ul><ul><ul><li>Don’t continue to palpate-is friable and can rupture </li></ul></ul>
  19. 19. Palpate Kidney <ul><li>Palpate right kidney-left too high </li></ul><ul><li>Place hands in Duckbill position at right flank </li></ul><ul><li>Press finger tips together </li></ul><ul><li>On deep inspiration may feel kidney lower surface move against fingers </li></ul><ul><li>If easily felt = enlarged kidney or mass </li></ul><ul><li>Easier to feel in children or very thin adults </li></ul>
  20. 20. Kidney location pix
  21. 21. Rebound tenderness <ul><li>Use If tender elicited on deep palpation </li></ul><ul><li>Position hand away from tender area </li></ul><ul><li>Place hand perpendicular to abdomen and push down slowly </li></ul><ul><li>Release hand quickly and note any tenderness </li></ul><ul><li>Indicates peritonitis </li></ul><ul><li>Perform at end of exam r/t possible severe pain </li></ul>
  22. 22. Fluid Wave for Ascites <ul><li>Ascites can occur with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer </li></ul><ul><li>Place pt had in middle of abdomen and your hands on either side. </li></ul><ul><li>Firmly tap right right side of abdomen. If fluid present will feel wave on left side </li></ul>
  23. 23. Special Techniques <ul><li>Murphy's sign - Tenderness in the R upper quadrant (the costal margin, mid-clavicular) during inspiration.  Suggestive of cholecystitis. </li></ul><ul><li>Rovsing's sign - Pain in R lower quadrant during L lower quadrant palpation. Suggests appendicitis. </li></ul><ul><li>Psoas sign - Pain on extension of R thigh.  Suggestive of retro-cecal appendicitis. </li></ul><ul><li>Obturator sign - Pain on internal rotation of the R thigh at the hip.  Suggestive of pelvic appendicitis. </li></ul>
  24. 24. Age specific <ul><li>Infant </li></ul><ul><ul><li>Contour is protuberant r/t immature abdominal muscles </li></ul></ul><ul><ul><li>Skin has visible blood vessels until puberty </li></ul></ul><ul><ul><li>Abdomen will show resp movement </li></ul></ul><ul><ul><li>Peristalsis may be visible </li></ul></ul>
  25. 25. Age specific considerations <ul><li>Children </li></ul><ul><ul><li>Have potbelly look until middle childhood </li></ul></ul><ul><li>Pregnancy </li></ul><ul><ul><li>Will obscure may structures </li></ul></ul><ul><li>Elderly </li></ul><ul><ul><li>Increases fat deposits on abd as compared to extremities. </li></ul></ul><ul><ul><li>Poor abd muscle tone </li></ul></ul><ul><ul><li>Less abd rigidity with acute abdominal conditions </li></ul></ul>
  26. 26. Practice Exam Question <ul><li>Your 76 year old pt is complaining of “gas Pains”. His abdominal looks larger than an hour ago. His umbilicus is now everted. His bowel sounds are Hyperactive. What condition may he be experiencing? </li></ul><ul><li>A. Hernia </li></ul><ul><li>B. early intestinal obstruction </li></ul><ul><li>C. late intestinal obstruction </li></ul><ul><li>D. Gas </li></ul>
  27. 27. Rationale <ul><li>B is the correct answer. Distention, pain and hyperactive bowel sounds are associated with early obstruction. </li></ul><ul><li>A is usually not accompanied by increased bowel sounds </li></ul><ul><li>C in late obstruction sounds are hypoactive </li></ul><ul><li>D. gas may cause pain an mild distention but should not increase bowel sounds </li></ul>