Physical assessment - Abdomen: Nursing

An assessment of the abdomen should be completed as part of a comprehensive assessment, like during a routine physical exam, during an admission to the hospital, or as part of a focused exam if a client is experiencing abdominal issues like pain, nausea, or changes to bowel patterns.

Let’s review the process of completing an abdominal assessment.Supplies needed for the abdominal assessment include drapes, a stethoscope with a diaphragm and bell, gloves, a measuring tape, a washable skin marker, and a good source of light.

Before beginning, ask your client to empty their bladder. Then prepare for the abdominal assessment by properly draping your client.

Remember to keep your client covered and only expose areas of their body as needed to perform your assessment. Also, ensure privacy by closing any curtains or closing the door.

Ensure your client is comfortable in the supine position, meaning they are lying flat on their back. You may also place a pillow under their knees to help relax their abdominal muscles.

Also warm your hands and stethoscope and ensure your client is comfortable with the temperature of the room, since cold temperatures can cause rigidity of the abdominal muscles, making it more difficult to perform some assessment techniques.

Before getting started, explain the procedure to your client and be sure to answer any questions they might have before obtaining verbal consent.

Then, perform hand hygiene and collect your supplies. Locating the anatomical landmarks of the abdomen will help guide the appropriate placement of your equipment and hands throughout your assessment.

Commonly used landmarks include the xiphoid process, costal margin, umbilicus, iliac crest, and the pubic crest. The abdomen can also be separated into four quadrants, to help you locate the abdominal organs.

First is the right upper quadrant, called the RUQ for short, which contains the liver, gallbladder, and right colic flexure.

Next, the left upper quadrant, also called the LUQ, which includes the stomach, pancreas, and left colic flexure. Then there’s the right lower quadrant, or RLQ, which contains part of the ascending colon, the cecum, and the appendix.

Finally, there’s the left lower quadrant, which is called the LLQ, that contains the descending and sigmoid colon. If your client is experiencing any abdominal symptoms, like pain, it can be helpful to identify which quadrant or quadrants are involved to determine which internal structure might be responsible.The abdomen can also be divided into nine regions including the right hypochondriac, left hypochondriac, the epigastric, the right lumbar, left lumbar, the umbilical, right inguinal, and left inguinal and the suprapubic or hypogastric regions.

Using this method of description allows you to be more precise in the description of abnormal findings, since structures located in the midline of the body have named regions.

For example, the bladder is located in the suprapubic region using this system, whereas it is located in both the right and left quadrant.Now, methods of abdominal assessment include inspection, auscultation, percussion, and palpation, as well as some special techniques used in certain circumstances.

Unlike other body system assessments, you should always auscultate first when performing an abdominal assessment, percussing or palpating, so you can avoid stimulating the bowel sounds or inflicting pain which could cause your client to tense their abdominal muscles.

You’ll also want to ask your client about any acute symptoms of pain or distress. And be sure to watch your client closely for indications of discomfort during your assessment, including facial expressions or other nonverbal cues, such as guarding, which is when the client tenses their abdominal muscles and uses their arms to protect their abdomen.Okay, begin your assessment with inspection.

As you look between the costal margins and the symphysis pubis, the abdomen’s normal contour will be either flat; slightly convex, which is a curved outward appearance; or slightly concave, which is curved inward appearance.

If the abdomen is profoundly concave or convex, it may indicate an underlying issue. For example, a protruding, convex abdomen is associated with obesity, or it might indicate ascites.

A profoundly concave abdomen might indicate malnourishment. The skin of the abdomen should be free from lesions, including open wounds or ecchymosis.

However, as a normal finding, you may note striae, or stretch marks, or hair distributed on the abdomen, as well as moles or freckles.

Also make note of any body modifications like tattoos, piercings, or surgical scars. Now, if you are inspecting the abdomen of a slender client, you might be able to see pulsations in the region of the abdominal aorta.

This can be normal, however, if pulsations are prominent, it may represent an abdominal aortic aneurysm and should be reported immediately.

Also, inspect for symmetry to make sure both sides of the abdomen appear equal with no obvious bulging or protrusions, since this can represent herniation.

If needed you could use a light source like a floor lamp to cross illuminate the abdominal surface to make slight irregularities more prominent.

Next up is auscultation. When auscultating, remember to use the diaphragm of the stethoscope.

Begin in the right lower quadrant and auscultate in a clockwise fashion, listening for bowel sounds, which sound like high-pitched clicks and gurgles.

It is normal to hear bowel sounds in each quadrant at a frequency of 5 to 35 sounds per minute. If bowel sounds are not heard, you should auscultate up to a full 5 minutes in each quadrant.

Bowel sounds are hypoactive if they occur at a rate of less than 5 sounds per minute, while greater than 35 bowel sounds per minute is considered hyperactive and might be caused by gastroenteritis or an early sign of bowel obstruction.

Borborygmi are a type of bowel sound that sounds like a prolonged gurgle. These sounds often occur as a normal part of the digestive process Next, using the bell of the stethoscope, you should listen for bruits, or low-pitched blowing sounds caused by turbulent blood flow through the abdominal arteries.

There are five places where you should auscultate the abdominal vasculature: the abdominal aorta, the bilateral renal arteries, and the bilateral iliac arteries.

To auscultate the abdominal aorta, place the bell of the stethoscope in the epigastric region. The renal arteries can be auscultated approximately 3 centimeters above the umbilicus laterally on both the left and right sides.

Lastly, the iliac arteries can be auscultated about 3 centimeters below the umbilicus and laterally on both the right and left sides.

Normally, you should not hear any vascular sounds. If a bruit can be heard, it might indicate an aneurysm or atherosclerotic arterial disease.

Okay, let’s move on to percussion, which is used to determine the density and size of organs in the abdomen, as well as checking for the presence of air and fluid.

Sounds you can expect to percuss in the abdomen include tympany over either air-filled or hollow organs, like the stomach, and dullness over bone or solid organs like the liver.

Percuss in each of the four quadrants. If there’s dullness in an area where it is not expected, it might mean there is a mass in the underlying tissue.

You can also use percussion to evaluate for liver span or the size of the liver. To do so, start at the right midclavicular line at approximately the third intercostal space.

Begin light percussion moving downwards until dullness is heard. Mark this location with your skin marker.

This is the upper border of the liver. Then, begin percussing from below the umbilicus on the right midclavicular line in an area of tympany moving upwards until dullness is noted.

Mark this location with your skin marker. This is the lower border of the liver.

Using your measuring tape, measure the distance between the two markings.The liver span should be approximately 6 to 12 centimeters.

If the liver span is noted to be larger, it may indicate hepatomegaly. You can also assess the kidneys using percussion.

Assist your client into a seated position and, standing behind them, locate the costovertebral angle, or CVA. The CVA is formed by the curve of the 12th rib and the spine.

Lay your hand flat on the client’s back at the level of the CVA. Make a fist with your second hand and provide a single, swift thump to your hand placed on the client’s back.

If the client appears uncomfortable with percussion, this is a positive finding that might indicate renal inflammation or infection.

A normal response is an absence of pain. Next, let’s look at palpation.

Beginning with light palpation, depress the abdomen in each quadrant approx 1 centimeter in depth using a gentle, circular motion.

If the client is experiencing any kind of abdominal pain, palpate that area last. Otherwise, begin in the right lower quadrant and move clockwise.

During light palpation you are assessing for any abnormalities close to the abdominal surface like hernias. After completing light palpation, proceed with deep palpation, compressing the abdomen about 4 to 5 centimeters using the same circular hand motion.

This allows you to feel the qualities of the underlying structures and assess the presence of pain. A potential abnormal finding is an abdominal mass which can indicate constipation or even malignancy.

Next, you can move on to palpate the border of the liver. With your client in the supine position, stand on their right side.

Using a bimanual, or two-handed, approach, place the tips of the fingers under the border of the rib cage in the right upper quadrant.

Instruct your client to take a deep breath in and then exhale. As they exhale, push your fingers upwards under the ribs to feel for the edge of the liver.

It should feel smooth against your fingers, and firm, like the tip of your nose. You can also palpate the borders of the aorta by palpating above the umbilicus along the midline with the thumb on one side and the fingers on the other.

This allows you to assess the border of the vasculature. Keep in mind that you may not be able to assess this in clients who are obese or have central adiposity.

Now, there are a couple of exam techniques that you would not typically perform but are used in certain circumstances. First, there is Murphy’s sign, also known as inspiratory arrest, which evaluates for gallbladder inflammation.

To perform this exam, position your hands as if you were going to assess the subcostal border, but this time, apply upward pressure and then instruct the client to take a deep breath.

If the client is unable to inhale or suddenly halts their inspiratory effort, this is a positive finding and likely indicates gallbladder inflammation.

The next exam technique is Blumberg sign, which is useful in identifying possible appendicitis or peritonitis. For this exam, assist your client to lie supine.

Then, using the finger tips of your dominant hand, compress the right lower quadrant of the abdomen to about 4 to 5 centimeters deep.

Now quickly release pressure. If the client experiences more pain with release than with compression, or rebound tenderness, this is a positive finding.As the nurse, it is your responsibility to correctly assess, interpret, report, and document your findings.

You should report immediately to the health care provider if your assessment reveals something that is potentially life-threatening like a mass.

Also, you should report any findings that indicate other possible issues like hyperactive bowel sounds which might mean a bowel obstruction or a bruit which might mean aneurysm.

Otherwise, continue to monitor your client’s progress and for changes from baseline. Alright, as a quick recap….

The abdominal assessment is an important component of a comprehensive physical exam that provides information on the integrity of the organs and structures of the abdominal cavity.

Supplies needed for the abdominal assessment include drapes, a stethoscope with a diaphragm and bell, gloves, a measuring tape, a washable skin marker, and a good source of light.

Methods of abdominal assessment include inspection, auscultation, percussion and palpation. Unlike other body system assessments, during the abdominal assessment, you should auscultate before percussing or palpating to avoid stimulating bowel sounds or causing pain.

First, you will inspect the abdomen for the quality of the skin, symmetry, pulsations, and contour. Next, you will auscultate with the diaphragm of your stethoscope for bowel sounds and bell of the stethoscope for bruits.

Then, you will percuss for tympany and dullness across the abdomen, and the CVA tenderness. You will palpate, beginning with light palpation, and then moving on to deep palpation.

Other specialty tests may include Murphy’s sign and Blumberg sign. As the nurse, it is your responsibility to correctly assess, interpret, report, and document your assessment findings.