1) Empty bladder prior to exam

ABDOMINAL ASSESSMENT
2) Work from right, client supine with knees bent
** Assessment of the Abdomen & GI System -- Landmarks for the
Abdominal Examination ** 3) Observe client’s face for signs of discomfort

Quadrants of the Abdomen 4) Short fingernails

5) Talk with clients – explain

 SEQUENCE OF EXAM
INSPECTION
1) Size

2) Shape

3) Symmetry

4) Color

5) Contour

6) Lesions, scars

7) Bulges (Hernias – have client lift head while supine)

Nine Regions of the Abdomen
8) Position of umbilicus

9) Distention

10) Striae

Distention maybe caused by 8 F’s

1. Fluid

2. Feces

3. Fetus

4. Flatus

5. False pregnancy

6. Fat

7. Fibroid

8. Fatal tumor.

 CONTENTS OF NINE REGIONS

1) RIGHT HYPOCHANDRIAC: gallbladder, portion of liver,  ASSESSING CONTOUR
kidney, duodenum DISTENTION
2) RIGHT LUMBSR: portion of right kidney, ascending 1) Do not confuse a rounded abdomen with distention.
colon, duodenum, jejunum
2) A soft abdomen is not distended
3) RIGHT INGUINAL: cecum, appendix, ileum, right ureter,
right ovary, spermatic cord 3) Distention may be localized or generalized
4) EPIGASTRIC: portion of pancreas, pylorus, portion of the 4) Localized distention may occur in a soft abdomen
liver, duodenum (distended bladder)
5) UMBILICAL: lower duodenum, jejunum and ileum 5) Area distended can point to cause
6) HYPOGASTRIC: ileum, bladder (if distended), uterus (if Example: bladder distention – central area of
enlarged) lower abdomen above pubis
7) LEFT HYPOCHONDRIAC: stomach, spleen, portion of
pancreas and kidney

8) LEFT LUMBAR: descending colon, part of the left kidney

9) LEFT INGUINAL: sigmoid, left ureter, ovary or spermatic

cord
REMINDERS:
AUSCULTATION
1) Perform before palpation and percussion

2) Warm stethoscope
♥ PHYSICAL ASSESSMENT
 3) Auscultate with diaphragm for Bowel sounds in each B. APPENDICITIS
quadrant
 Inflammation of appendix, potential for rupture
4) Auscultate with Bell for Vascular Sounds over aorta,
femoral, renal and iliac arteries (bruits)  Pain unrelieved with position change

 Anorexia, nausea, vomiting, fever

 Decreased bowel sounds

C. CHOLECYSTITIS

 Inflammation of gallbladder , often with stones

 Indigestion or asymptomatic

 May have bouts of acute pain of stone blocks duct

D. CIRRHOSIS

 Major disease of the liver

E. DIVERTICULITIS

 Characterized by damage and death of alcoholism or

hepatic cells, common effect

F. HEPATITIS
PERCUSSION  An inflammation of the liver that can result from alcohol
1) Percuss painful areas last consumption or viral infection

2) Can help determine organ size G. HERNIAS

3) Predominate sound over abdomen is tympany H. ULCERS

4) Dullness is heard over organs masses, or fluid I. DIARRHEA

 Any change in bowel habits in which stool is frequency on

PALPATION volume is increased.

1) Perform light palpation of abdomen J. ULCERS

2) Palpate tender areas last, may tense muscles K. NAUSEA AND VOMITING

3) Assess surface characteristics, tenderness, guarding L. DYSPHAGIA ODYNOPHAGIS

4) Press down 1-2 cm using fingertips in rotating fashion  Painful in swallowing

5) Palpate as much of abdomen as possible M. CONSTIPATION

6) Observe for signs of pain (grimacing, guarding)  Slow movement of feces through the large
intestine
 MURPHY’S SIGN: CHOLECYSTITIS N. SKIN COLOR CHANGES
 Stand at client’s right side, palpate at MCL at costal angle  CULLEN’S SIGN: bluish umbilicus; intraabdominal
hemorrhage
 Client takes deep breath, moving gallbladder closer to
examiner’s hand, causing pain = Client will stop inhaling  TURNER’S SIGN: bruising of flank; retroperitoneal
hemorrhage
 (+) pain = (=) MURPHY’S SIGN
 DILATED, TORTUOUS VISIBLE ABDOMINAL
 MCBURNEY’S SIGN: APPENDICITIS
VEINS: inferior vena cave obstruction
 Located in RLQ
 CUTANEOUS ANGIOMAS: liver disease
 Test for rebound pain by pressing firmly and slowly,
 Cullen’s Sign
then release quickly

 (+) pain = (+) MCBURNEY’S SIGN

COMMON ABNORMALITIES
A. ABDOMINAL AORTIC ANEURYSM

 Weakness in wall of abdominal aorta, potential for rupture

 Is surgical emergency

 SYMPTOM: tearing pain

 Auscultation reveals bruit, exaggerated pulsation or mass

 Turner’s Sign
 Diminished femoral pulses

 Hypotension, tachycardia, pale, clammy skin

 moves food from the pharynx to the stomach.

 Dilated, Tortuous Visible Abdominal Veins

c) Stomach - reservoir for food, is a dilated saclike structure that

lies obliquely in the left upper quadrant below the esophagus
and diaphragm.

 Cutaneous Angiomas

d) The small intestine is about 20 feet (6 m) long and is named

for its diameter, not its length.

 It has three sections: the duodenum, the jejunum, and the

ileum.

 As chime passes into the small intestine, the end products

of digestion are absorbed through its thin mucous
membrane lining into the bloodstream.

 REVIEW OF DIGESTIVE ANATOMY
 The digestive system’s major functions include ingestion
and digestion of food and elimination of waste
products.
 When these processes are interrupted, the patient can
e)
experience problems ranging from loss of appetite to acid-
base imbalances.
1) Gastrointestinal Tract
 The GI track is a hollow tube that begins at the
mouth and ends at the anus. About 25
feet (7.5m) long, the GI tract consist of smooth
muscles alternating with blood vessels and nerve
tissue.
a) Pharynx, esophagus, stomach, small intestines , and large
intestines.
Accessory Organs
 Digestive process begin in the mouth with chewing,
salivating, and swallowing.
 Saliva is produced by three pairs of glands: parotid,
submandibular, and sublingual.
 The pharynx assist in swallowing process and secretes
mucus that aids in digestion.
 The epiglottis- a thin leaf shape- shaped structure made of
fibrocartilage- is directly behind the root of the tongue.
 When food is swallowed the epiglottis closes over the
larynx and the soft palate fits to block the nasal cavity.
 These actions keep food and fluid from being aspirated
b) Esophagus - is a muscular, hollow tube about 10” long that
 Enzymes from the pancreas, bile from the liver, and
hormones from glands of the small intestine all aid
digestion.
 These secretions mix the chyme as it moves through the
intestines by peristalsis.
The large intestine, or colon, is about 5 feet (1.5 m) long.
 It includes the cecum; the ascending, transverse,
descending, and sigmoid colons; the rectum; and the anus –
in that order – and is responsible for absorbing excess water
and electrolytes, storing food residue, and eliminating
waste products in the form of feces.
 The appendix, a fingerlike projection, is attached to the
cecum.
 Bacteria in the colon produce gas, or flatus.
a. The liver is located in the right upper quadrant under the
diaphragm.
 It has two major lobes, divided by the falciform
ligament.
 The liver is the heaviest organ in the body,
weighing about 3 lb (1.5 kg) in an adult.
 The liver’s function include metabolizing
carbohydrates, fats, and proteins; detoxifying
blood; converting ammonia to urea for excretion;
and synthesizing plasma proteins, nonessential
amino acids, vitamin A, and essential nutrients,
such as iron and vitamins D, K, and B12.
  The liver also secretes bile, cholesterol, and other
lipids. Bile also gives stool its color.
b. The gallbladder is a small, pear-shaped organ about 4
inches (10 cm) long that lies halfway under the right lobe
of the liver.
 Its main function is to store bile from the liver
until the bile is emptied into the duodenum.
 This process occurs when the small intestine
initiates chemicals impulses that cause the
gallbladder to contract.
c. The pancreas, which measures 6 to 8 inches (15 to 20.5
cm) in length, lies horizontally in the abdomen, behind the
stomach.
 It consists of a of a head, tail and body.
 The body of the pancreas is located in the right
upper quadrant, attached to the duodenum.
 The tail of the pancreas touches the spleen.
 The pancreas releases insulin and glycogen into
the bloodstream and produces pancreatic
enzymes that are released into the duodenum for
digestion.
d. The bile ducts provide passageways for bile travel from the
liver to the intestines.
 Two hepatics ducts drain the liver and the cystic
duct drains the gallbladder.
 These ducts converge into the common bile duct,
which then empties in the duodenum.
e. The abdominal aorta supplies blood to the GI tract.
 It enters the abdomen, separates into the
common iliac arteries, and the braches into many
arteries extending the length of the GI tract.
 The gastric and splenic veins drain absorbed
nutrients into the portal vein of the liver.
 After entering the liver, the venous blood
circulates and then exits the liver through the
hepatic vein, emptying into the inferior vena
cava.
 OBTAINING A HEALTH HISTORY
 If your patient has a gastrointestinal problem, he’ll usually
complain about pain, heartburn, nausea, vomiting, or
altered bowel habits.
 To investigate these and other signs and symptoms, ask him
about the location, quality, onset, duration, frequency, and
severity of each.
 Knowing what precipitates and relieves the patient’s
symptoms will help you perform a more accurate physical
assessment and better plan your care
 Asking about Past Health
 To determine if your patient’s problem is new or recurring,
ask about past GI illness, such as an ulcer; liver, pancreas,
or gallbladder disease; inflammatory bowel disease; rectal
or GI bleeding; hiatal hernia; irritable bowel syndrome;
diverticulitis; gastroesophageal reflux disease; or cancer.
 Also, ask if he has abdominal surgery or trauma.
 Asking about Current Health
 Ask the patient’s if he’s taking any medication.
 Several drugs – especially aspirin, nonsteroidal anti-
inflammatory drugs, antibiotic, and opioid analgesics – can
cause nausea, vomiting, diarrhea, constipation, and other
GI signs and symptoms.
 Be sure to ask about laxative use; habitual use may cause
constipation.
 Also, ask the patient if he’s allergic to medications or
foods.
 Such allergies commonly cause GI symptoms.
 In addition, ask the patient about changes in appetite,
difficulty chewing or swallowing, and changes in bowel
habits.
 Does he have excessive belching or passing of gas?
 Has he noticed a change in the color, amount, and
appearance of his stool?
 Has he ever seen blood in his stool?
 If the patient’s reason for seeking care is diarrhea, find out
if he recently travelled abroad.
 Diarrhea, hepatitis, and parasitic infections can result from
ingesting contaminated food or water.
 Asking about Family Health
 Because some GI disorders are hereditary, ask the patient
whether anyone in his family has had a GI disorder.
 When taking a health history, consider your patient’s ethnic
background. For example, patients from japan, Iceland,
Chile, and Austria are higher risk of death from
gastric cancer than patients from other countries.
 Also, Crohn’s disease is more common in patients who are
Jewish.
 Disorders with a familial link include; ulcerative colitis,
colorectal cancer, peptic ulcers, gastric cancer, diabetes,
alcoholism, and Crohn’s disease.
 Asking about Psychosocial Health
 Inquire about your patient’s occupation, home life,
financial situation, stress level, and recent life changes.
 Be sure to ask about alcohol, caffeine, and tobacco use as
well as food consumption, exercise habits, and oral
hygiene.
 Also ask about sleep patterns:
 How many hours of sleep does he feel he needs?
 How many does he get?
PROCEDURE:
1. Perform hand hygiene.
R: To prevent the spread of microorganism.
2. Prepare client for abdominal assessment.
a. Ask if client needed to empty bladder or defecate.
R: Palpation of full bladder can cause discomfort and feeling
of urgency, and client is difficult to relax.
b. Keep client’s upper chest and legs draped.
R: Maintains client’s warmth during examination,
promoting relaxation.
c. Ensure that room is warm
R: For the client to feel comfortable and to
prevent cold or chills.
 d. Have client lie supine with arms down at sides. A small
pillow under client’s knees may be desired.
R: Position promotes optimal relaxation of abdominal
muscles. Tightening of muscles prevents adequate palpation of
underlying muscles.
e. Expose areas from just above the xiphoid process
down to the symphysis pubis.
f. Maintain conversation during assessment except during
auscultation. Explain steps calmly and slowly.
R: client’s ability to relax during assessment improves
accuracy of findings.
g. Ask client to locate tender areas.
R: Painful areas will be assessed last.
Manipulation of the body part can increase pain and
client’s anxiety and make remainder of assessment difficult to
complete.
INSPECTION:
3. Perform abdominal assessment.
a. Identified landmarks dividing abdominal region into quadrants.
R: Location of findings by common reference point help
successive examiners to confirm findings and locate abnormalities.
Note: Some clinicians may also divide the abdomen into
nine equal sections for the abdominal examinations
b. While inspecting client’s abdomen, first stand on client’s right side
or at foot part, then sit to look across abdomen’s surface. Direct
examination light over abdomen.
R: Standing position helps to detect shadows
and movement. Sitting position allows examiner to detect
abnormal protuberances.
c. Inspect skin of abdomen’s surface for color, scars, venous patters,
rashes, lesions, stretchmarks, and artificial openings.
R: Scars reveal evidence client has had past
trauma or surgery.
Striae indicate stretching of tissue by growth, obesity,
pregnancy, ascites, or edema.
Venous patterns may reflect liver disease
(portal hypertension).
Artificial openings indicate bowel or
urinary diversion.
d. Inspect the position , shape, and color of the umbilicus.
 Note inflammation, discoloration, discharge or
protruding masses.
 The umbilicus is normally flat and concave and
the same color as the skin.
R: An everted (pouched out) umbilicus usually indicates distention.
A hernia can also cause the umbilicus to protrude upward.
e. Note the contour or symmetry of the abdomen.
Flat abdomen forms horizontal plane from
xiphoid process to symphysis pubis. Round abdomen protrudes in
convex sphere from horizontal plane.
A concave abdomen sinks into muscular wall
(All are normal).
R: Changes in symmetry or contour may reveal underlying
masses, fluid collection or gaseous distention.
f. Ask if client self- administers injection if bruising was noted.
R: Clients who are receiving insulin injection are usually
administer in the subcutaneous area in abdomen. The back of the
upper arms, the upper buttocks or hips, and the outer side of the
thighs are also used.
g. Measure size of abdominal girth.
R: Buildup of fluid in the abdomen, most
often caused by liver failure, heart
failure, or any cancer that has spread
widely throughout the abdomen.
 Obesity
Buildup of intestinal gas, most often caused by blockage
or obstruction in the intestines
AUSCULTATION:
4. Place diaphragm of stethoscope lightly over one of four
abdominal quadrants. Listen until repeated bubbling sound
or gurgling sound are heard. Repeat procedure for each
quadrant. Describe sounds as normal or audible, absent
hyperactive or hypoactive. Listen 3-5 minutes for each
quadrant before deciding bowel sounds are absent.
R: Determines presence or absence of
peristalsis. Sounds occur irregularly
normally every 5- 15 seconds. Absent sound
indicates cessation of gastric motility.
5. Place bell of stethoscope over midline of abdomen and
auscultate of vascular sound. If aortic bruit is auscultated,
stop assessment and notify the physician.
R: Determines presence of turbulent blood
flow(bruits) through thoracic or
abdominal aorta. Percussion or
palpation over abdominal bruit can
cause damage if bruit is result of
abdominal aneurysm. Palpation can cause
rupture of already weakened vessels wall.
6. Have client roll to side and place bell of stethoscope
posteriorly over costovertebral angle.
 R: Determines presence of renal artery bruits.

PERCUSSION:

7. Have client return to supine position. Gently percuss each

of the four abdominal quadrants. Note areas of tympany
and dullness.

R: Reveals presence of air or fluid in the intestines and

stomach. Normal percussion is tympanic because of swallowed air in
the gastrointestinal tract. Presence of fluid or underlying masses is
revealed by dull percussion.

8. To locate borders of liver, percuss intersection at the right

iliac crest and right midclavicular line. Slowly inch
pleximeter finger upward and percuss toward right right
costal margin until note becomes dull.

R: Detects position of liver’s lower border.

Percussion note changes from tympanic 2. MODERATE PALPATION
to dull at liver’s lower border, usually found at
right costal margin.  Dominant hand

9. Percuss down from nipple along right midclavicular line.  Depress skin surface 1 to 2 cm
Slowly down pleximeter finger downward toward right
 Use circular motion
costal margin until note becomes dull. Be sure pleximeter
finger is in the intercostal space when you percuss.  Use: feel for easily palpable body organs/ masses
R: Detects position of upper liver’s upper border.  Note: size, consistency,& mobility of structures palpated
Percussion note changes from resonant to dull at liver’s upper border,
usually found on the sixth, or seventh intercostal space. Diseases such
as cirrhosis and cancer enlarge the liver.

10. Ask client to sit gently but firmly percuss over each
costovertebral angle along scapular lines. Use ulnar surface
of fist to percuss directly or indirectly. Note if client
experiences pain.

R: Determines presence of kidney inflammations.

PALPATION:

11. Lightly palpate over each quadrant using palm and pads of
fingertips In smooth coordinated movement. Depress skin
approximately 1/2 inch.

Note the following:

 Muscular resistance
3. DEEP PALPATION
 Distention
 Dominant hand on surface with non-dominant over the top
 Tenderness of the dominant hand.

 Superficial masses  Apply pressure with skin depression of 2.5 to 5 cm (1 inch

to 2 inches)
 Observe client’s face for signs of discomfort.
 Use: feel very deep body organs/ structures covered by
 Noted if abdomen is firm or soft to touch thick muscles

TYPES OF PALPATION:

Li Mo De Bi

1. LIGHT PALPATION

 Place dominant hand lightly hand lightly on the surface of

the structure.

 There should be very little or no depression (less than 1

cm)

 Feel the surface with a circular motion

 Use: feel the pulses, tenderness, surface skin texture,

temperature and moisture
4. BIMANUAL PALPATION

 Use two hands-place one on each side of the body part

 palpated

 Use one hand to apply pressure and the other to feel the
structure

 Use: uterus, breasts and spleen

 Note: size, shape, consistency & mobility of the structures

 Observe client’s face. Note if abdomen is firm or soft to

touch. Remember palpate painful ares last. Avoid quick
jabs.

R: Detects areas of localized tenderness, degree of tenderness ,

and presence and character of underlying masses.

 Palpation of sensitive area causes gaurding, voluntary

tightening of abdominal muscles.

 Client;s verbal and nonverbal cues may indicate

discomfort from tenderness.

 Firm abdomen may indicatevactive obstruction with fluid

or gas building up.

12. Just below the umbilicus and above symphysis pubis

palpate for smooth, rounded mass

R: Detects presence of dome of distended

bladder.

13. If masses are palpated note the size , location, shape,

consistency, tenderness, mobility and texture.

R: Characteristics hels you to reveal a mass.

14. If tenderness is present, press one hand slowly and deeply

into the involved area and then let go quickly. Note if pain
is aggravated.

R: Tests for rebound tenderness. Results are

positive if pain increases.

15. Locate liver’s lower border by placing left hand under

client's right posterior thorax.

 Apply gentle upward pressure with lefthand.

 With fingers pointing towards client’s right costal

margin , place right hand on client's right upper
quadrant below costal margin.

 Ask client to take a deep breath and gently

palpate right hand in and up.

 As client inhales liver’s edge may be felt.

R: Allows for location of liver and determination if organ is enlarged

or disease is present.

 Upward pressure of left hand along with deep

breathing maneuver causes liver to descend and
be entrapped for palpation.

 Liver’s edge cannot be palpated in normal adult.

 Normal liver is non-tender and has regular

contour and sharp edge.