COLLEGE OF MEDICINE AND HEALTH SCIENCE

DEPARTMENT OF ADULT HEALTH NURSING

Advanced Abdominal Health Assessment

1
Objectives
 At the end of this presentation, the audiences
able to :
 Describe the anatomy and physiology of
abdomen.
 Clarify steps of abdominal examination.
 List special techniques of abdominal
examination

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Introduction
 An abdominal examination is a portion of
physical examination which a physician or nurse
uses to clinically observe the abdomen of a
patient for signs of disease.
 The physical examination typically occurs after
a medical history is taken.

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Anatomy and Physiology of
abdomen
 Abdomen is the body space between the thorax and
pelvis.
 The diaphragm forms the upper surface of the abdomen
and at the level the pelvic bones, the abdomen ends and
the pelvis begins.
 The abdomen contains all the digestive organs, including
the stomach, small and large intestine, pancreas, liver, and
gallbladder.
 These organs are held together loosely by connecting
tissue(mesentery) that allow them to expand and to slide
against each other.
 It also contain kidney and spleen.

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Cont…

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Cont…

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Cont…
 For descriptive purposes, the abdomen is often
divided by imaginary lines crossing at the
umbilicus, forming the right upper, right lower,
left upper, and left lower quadrants.
 Another system divides the abdomen into nine
sections.
 Terms for three of them are commonly used:
epigastric, umbilical, and hypogastric, or
suprapubic.

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Four quadrants of abdomen

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Nine regions of abdomen
 Nine regions of the abdomen can be marked
using two horizontal and two vertical dividing
lines.
 The vertical lines are the mid-clavicular lines
taken from the mid-point of each clavicle.
 The upper horizontal line is the subcostal line
taken from the inferior parts of the lowest costal
cartilages.
 The lower horizontal line is the intertubercular
line connecting the tubercles of the pelvis.

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Cont…
 The three main centrally positioned regions are
the epigastric region, the umbilical region, and
the hypogastric region also known as the
suprapubic region.
 On the side of the abdomen the other six regions
are the left and right hypochondriac region, on
either side of the epigastrium;
 The left and right lumbar flank region, on either
side of the umbilical region and left and right
iliac or inguinal regions on either side of
hypogastrium.

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Cont….
 (‘’Hypo-’’ means below; ”epi means above;’’
chondron’’ means cartilage(cartilage of the rib)
and ‘’gastric’’ means stomach.

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Cont…

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Abdominal assessment
Subjective Data –
 Ask the patient for;
 Appetite
 Food intolerance
 Abdominal pain
 Nausea
 Vomiting
 Bowel habits
 Rectal conditions and
 Past abdominal surgery

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Techniques of abdominal
examination
◦ The usual sequence of inspection, palpation,
percussion and auscultation is modified in the
examination of the abdomen.
Inspection
Auscultation
 percussion and
palpation.

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Equipment needed
 Stethoscope
 Small centimeter ruler
 Skin marking pen

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Inspection
 Stand on the right side and look down on the
abdomen ,with the patient in the supine position.
 Inspect for: bulges , masses , hernias , ascites ,
enlarged veins , pulsations or movements.

 Observe the size and shape of the abdomen: it is

described as flat, round, or scaphoid.
 See the profile from the rib margin to the pubic
bone.

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Dilated veins and hernia

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Cont…
 The contour describes the nutritional state and
normally ranges from flat to round.
 Abnormal protuberant abdomen as in pregnancy,
scaphoid (concave), and abdominal distension
(the 7 Fs- fat, fluid, faeces, foetus, fetal growth,
fibroids, flatus).
 Check for symmetry of the abdomen; the
abdomen should be symmetric bilaterally.
 Note any localized bulging visible mass or
asymmetric shape

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Cont…

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Cont…
 Umbilicus
Normally it is midline and inverted with no signs of
inflammation or hernia. It becomes everted and pushed
upward with pregnancy.
 Check for an umbilical hernia. During inspection ask
the patient to lift their head slightly. If the examiner
notice a protrusion around the umbilicus or any
incisions, a hernia may be present

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Cont…

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Cont…
 Normally, blood vessels are not evident on the abdomen.
However they may be present in the elderly or pregnant
client due to the loss of subcutaneous fat.
 A slight pulsation may be noted in the mid-epigastric area,
particularly in very thin clients.
 This is the pulsation of the abdominal aorta
 In adults, observable veins may reflect major health
problems.
-Increased peristaltic waves of intestinal
obstruction.
-Increased pulsation of an aortic aneurysm.

.
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Auscultation
Auscultate abdomen next to inspection
because percussion and palpation can
increase peristalsis.
Auscultation assesses the sounds of
peristalsis and vascular abnormalities.
Listen for bowel sounds and note their
frequency and character.
Normal sound consists of clicks and gurgles,
the frequency which has been estimated from
5 to 30 per minute.
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Cont…
 Borborygmi- loud prolonged gurgles of
hyper peristalsis.
 Bowel sounds may be altered in diarrhea,
intestinal obstruction, paralytic ileus, and
peritonitis.

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Table of bowel sounds

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Cont…
 Normal blood flow through the abdominal arteries cannot be
heard.
 Blood flow through dilated or constricted blood vessels
results in a turbulence that can be detected by auscultation.

 Use the diaphragm – end piece because bowel sounds are

relatively high pitched.

 Abdominal aorta in midepigasrium above the umbilicus.

 Renal arteries to the right and left slightly above the
umbilicus.
 Hepatic and splenic arteries in the right and left
hypochondrium.

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Cont…
 Friction rub: rough grating sound, occurs with
irritation of the peritoneal surface of an organ,
splenic infarction, primary or metastatic tumor
of liver, and peritonitis.

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Area of auscultation for major
arteries

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Cont…

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Percussion
 Percussion of the abdomen is performed to
determine:
Enlargement of an organ
The presence of abdominal distension or
the amount and distribution of gas in the
abdomen.

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Cont…
A dull percussion will be heard over the area
of a dense abdominal organ, such as liver or
spleen, and over a solid tumor or fluid.
Dull percussion also detected in the
suprapubic area may be from a distended
urinary bladder.
Tympany is the normal percussion note
present through-out the abdomen except for
areas over the liver, spleen and pubic
symphysis. With gaseous distension tympany
will be elicited throughout the abdominal area.

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Cont…

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Palpation
For palpation of the abdomen to be effective the
client should be as comfortable and relaxed as
possible.
To enhance complete muscle relaxation
 Bend the person’s knees.
 The examiner keep palpating hand low and
parallel to the abdomen.
 Teach the person to breathe slowly (in through
the nose and out through the mouth).

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Light palpation
 With the first fingers close together, depress the
skin about 1cm.
 make a gentle rotary motion sliding the fingers
and skin together. Then lift the fingers and move
clockwise to the next location around the
abdomen.
 The objective here is not to search for organs
but to form an overall impression of the skin
surface and superficial musculature

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Cont…
Feeling the abdomen gently is especially helpful in
identifying abdominal tenderness, muscular
resistance, and some superficial organs and masses.
If resistance is present, try to distinguish voluntary
guarding from involuntary muscular spasm.
Feel for the relaxation of abdominal muscles that
normally accompanies exhalation.
Ask the patient to mouth- breath with jaw dropped
open, voluntary guarding usually decreases with
this maneuvers.

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Cont…
 Abnormal: involuntary rigidity is a constant
board like hardness of the muscles as in
peritonitis.

Visceral pain generally is a poorly

localized, dull pain, whereas peritoneal pain
usually is easily localized and is described
as sharp, stabbing pain.
Abdominal pain on coughing or with light
palpation suggests peritoneal inflammation.

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Cont…

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Cont…
 Test for rebound tenderness by gently and
slowly pressing the examining hand deep in to
the abdomen away from the site of the pain,
quickly release the examining hand.
 As the inflamed peritoneum snaps back, the
client with rebound tenderness will experience
induced pain or increased pain, immediately
inquire where the pain is felt.

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Cont…

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Deep palpation

 is usually required to delineate abdominal masses.

 Again using the palmar surfaces of the examiner
fingers, feel in all quadrants.
 Identify any masses and note their location, size,
shape, consistency, tenderness, pulsations and
mobility.

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Cont…
 In deep palpation push down about 5-8cm.
moving clockwise explore the entire abdomen.
 In case of very large or obese abdomen use a
bimanual technique. The examiner should place
two hands on top of each other.
 The top hand does the pushing, the bottom hand
is relaxed and can concentrate on the sense of
palpation

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Bimanual technique

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Liver
 Is the largest internal organs 1.2-1.5kg.
 Divided into right and left lobes, then further in to 8
segments.
 Dual blood supply-25% through hepatic artery, 75%
through portal venous system.
 Located in right hypochondrium and epigastric areas,
and extends into the left hypochondrium.
 Liver have many essential functions include;
carbohydrate metabolism, lipid metabolism, synthesis
of albumin, synthesis of clotting factors,
immunological functions, bilirubin metabolism and
bile production, drug and toxin metabolism.
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Cont…

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Assessment of liver
 Auscultation;
 The liver is auscultated using moderately firm
pressure with the bell of the stethoscope.
 An arterial bruit may be confined to systole or
be systolic with extension in to diastole or be
continuous.
 A hepatic bruit suggests carcinoma of the liver
or alcoholic hepatitis.

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Liver Percussion
The vertical span of liver dullness represents
the size of the liver in the adult; this is
normally about 6-12cm.
Percuss down the right anterior chest in the
midclavicular line (MCL).
Resonance over the lung will be detected
until about the 5th to 7th intercostal space,
where liver dullness begins.
Continue percussion down ward until the
lower edge of liver dullness is heard.
The normal lower level is at the costal
margin

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Cont…
 Ask the client to inhale, and percuss down ward
again on inspiration, there should be an increase
of about 2 to 4cm from the previous lower edge
of liver dullness, because the liver moves down
ward on inspiration.
 In clients with emphysema, the lower level of
liver dullness may be any-where from 2 to 6cm
below the right costal margin.
 This is because continued lung inflation has
displaced the liver.

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Cont…
 The span of liver dullness is increased when the
liver is enlarged.
 The span of liver dullness decreased when the
liver is small.
 Dullness of a right pleural effusion or
consolidated lung, if adjacent to liver dullness
may falsely increase the estimated liver size.
 Gas in the colon may produce tymapny in the
right upper quadrant, obscure liver dullness and
falsely decrease the estimated liver size.

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Cont…

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Liver span in hepatomegaly

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Liver Palpation
 In normal condition the edge of the liver may be slightly
palpable just bellow costal margin.
 It is soft and smooth and may be slightly tender.
 The examiner put the right hand just below the lower
right costal margin with the examiner fingers pointing to
ward the client's right shoulder and parallel with the
abdominal rectus muscle.
 Push the fingers deeply in to the abdomen with a constant
pressure and simultaneously push up under the rib cage.
 Ask the client to take a deep breath: this will cause the
liver to descend.
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Cont…
 On inspiration, the liver below is palpable about
4cm below the right costal margin in the
midclavicular line.
 An obstructed, distended gall-bladder may form
an oval mass below the edge of the liver and
merging with it.
 Tenderness over the liver suggests
inflammation, as in hepatitis, or congestion, as
in heart failure.

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Cont…

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. Liver enlargement
 A palpable liver does not necessarily indicate
hepatomegaly.
 Clinical estimates of liver size should be based on both
percussion and palpation.
 a) Down wards displacement of the liver by a
diaphragm
 Common finding in emphysema.
 The liver edge may be readily palpable well below the
costal margins.

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Cont…
 b) Normal variations in liver shape
 In some persons, especially those with a lanky build,
the liver tends to be some what elongated so that its
right lobe is easily palpable as it projects downward
to ward the iliac crest.
 Riedel’s lobe – represents a variation in shape, not an
increase in liver volume or size.
-Is a simple anatomical variation, a downward
tongue-like projection of the anterior edge of the right
lobe of the liver to the right of the gallbladder but it is
rare.
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Spleen
 The spleen sits in the upper left of the abdomen,
protected by the rib cage.
 Is the largest organ of the lymphatic system-the
circulation of the immune system.
 It recycles old red blood cells and stores
platelets and white blood cells.

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Assessment of spleen
 A normal- sized spleen almost lies
entirely within rib cage and thus cannot
be palpated.
 But with enlargement displaces the
stomach and descends below the rib cage
like in case of liver cirrhosis,
malignancy(leukemia and lymphoma).

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Spleen Percussion

 The spleen lies slightly posterior to the left mid axillary

line, between the 8th and 11th ICS.
The vertical span of splenic dullness approximately 6
to 8cm in the adult.
For percussion of the spleen, have the client lie slightly
on his right side.
Percuss posteriorly to the left MAL, about the level of
the nipple (4th ICS), down ward.
The examiner will hear lung resonance before reaching
splenic dullness.
 Below the spleen the characteristic tympanic note of
the abdomen will be elicited.
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Cont…

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Spleen Palpation
 The spleen may be palpable in the normal infant and
young child; however, with the older child and adult,
the spleen must be considerably enlarged before it
can be palpated.
 The examiner place his/her left hand under the
client's left flank at the level of the 11th and 12th rib
 Push the right hand gently under the left anterior
costal margin.
 Instruct the client to take a deep breath.
 A grossly enlarged spleen will be able to be
visualized as asymmetry, with the entire left side of
the abdomen raised.

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Cont…
 The spleen is a highly vascular organ, if
enlargement is detected, it must be palpated very
gently.
 The enlarged spleen below is palpable about
2cm below the left costal margin on deep breath.

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Bimanual technique

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Kidney
 Each kidney weigh 150gm , is retro-peritoneal
organ
• 1700 liters of blood filtered -180 L of
Glomerular filtrate - 1.5 L of urine / day
• 4 components: blood vessels, glomeruli, tubules,
and interstitium.
• The kidney is richly supplied by blood vessels,
receive about 25% of the cardiac output.
• The cortex receives 90% of the total renal blood
supply.

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Cont…

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Functions of kidney
 Excretes the waste products of metabolism.
• Regulates the body's concentration of water and
salt.
• maintains the appropriate acid balance of
plasma.
• Secreting hormones as erythropoietin, renin, and
prostaglandins.

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Assessment of kidney
 Assessing kidney tenderness
 Use fist percussion- place the ball of the
examiner hand in the costovertebral angle and
strike it with the ulnar surface of the fist.
 Pain with pressure or with fist percussion in the
costovertebral angle suggests kidney infection,
but it may also have a musculoskeletal cause.

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Cont…

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Kidney Palpation

The kidneys are may be felt in children and in

adults with scaphoid abdomens
Palpation of the right kidney:
 Although kidneys are not usually palpable, you
should learn and practice the techniques.
The examiner place his/her left hand behind the
patient just below and parallel to the 12th rib, with
the fingertips just reaching the costo-vertebral
angle.
Lift, trying to displace the kidney anteriorly.

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Cont…
 Place the right hand gently in the right upper
quadrant, lateral and parallel to the rectus muscle.
 Ask the patient to take a deep breath.
 At the peak of inspiration, press the right hand firmly
and deeply in to the right upper quadrant, just below
the costal margin, and try to capture the kidney
between your two hands.
 Causes of kidney enlargement include
hydronephrosis, cysts, and tumors.
 Bilateral enlargement suggests poly cystic disease.

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Palpation of the left kidney
 To capture the left kidney
 Use the left hand to lift from in back, and the
right hand to feel deep in the left upper
quadrant.
 Instruct the client to take a deep breath while
you apply pressure with the examining hand.

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Cont…

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Abdominal examination:
special techniques

To Assess Possible Ascites

 A protuberant abdomen with bulging flanks suggests
the possibility of ascetic fluid
 The presence and extent of ascites are assessed by
percussing the abdomen for shifting dullness or by
detecting a fluid wave.

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A) Test for shifting dullness.
 After mapping the borders of tympany and
dullness, ask the patient to turn on to one side
percuss and mark the borders again.
 In ascites, dullness shifts to the dependent side,
while tympany shifts to the top.

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Cont…

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B) Test for a fluid wave
 An assistant’s hand is placed along the patient’s
midline of the abdomen.
 This pressure helps to prevent the fluid wave
from being transmitted through the tissues of the
abdominal wall.
 The examiner places the hands along the side of
the patent’s flank, then strikes or tap one flank
sharply, feel on the opposite flank for an
impulse transmitted through the fluid.

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Cont…

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2.To identify an organ or a mass in
an ascetic abdomen.

 Try to ballotte the organ or mass, exemplified here by

an enlarged liver.
 Straighten and stiffen the fingers of one hand
together, place them on the abdominal surface, and
make a brief jabbing movement directly toward the
anticipated structure.
 This quick movement often displaces the fluid so that
your finger tips can briefly touch the surface of the
structure through the abdominal wall.
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3. To assess possible appendicitis
Ask the patient to point to where the pain
began and where it is now.
Ask the patient to cough.
Determine whether and where pain results.
The pain of appendicitis classically begins
near the umbilicus and then shifts to the right
lower quadrant, where coughing increases it.

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Cont…
 Search for an area of local tenderness
 Localized tenderness anywhere in the right
lower quadrant may indicates appendicitis.
 Feel for muscular rigidity
 Early voluntary guarding may be replaced by
involuntary muscular rigidity
 Check the tender area for rebound tenderness
 Rebound tenderness suggests peritoneal
inflammation, as from appendicitis.

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Cont…
 Rebound tenderness.
 Choose a site away from the painful area.
 Hold your hand 90 degrees or perpendicular to
the abdomen
 push down slowly and deeply, then lift up
quickly
 a normal or negative response is no pain on
release of pressure.
 Pain in the right lower guardant during left-
sided pressure suggests appendicitis.

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Cont…
 Do at the end of the examination because it
causes sever pain and muscle rigidity
 psoas sign(Iliopsoas muscle test)
◦ With the person supine, lift the right leg
straight up, flexing at the hip; then push down
over the lower part of the right thigh as the
person tries to hold the leg up.
◦ When the test is negative, the person feels no
change.
◦ Abnormal pain in the right lower quadrant
indicates appendicitis.

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Cont…
 Obturator Test
 When appendicitis is suspected with the
person supine, lift the right leg, flexing at the
hip and 90 degrees at the knee.
 Hold the ankle and rotate the leg internally
and externally.
 Negative or normal response is no pain.
 Rovising’s sign
May be elicited by palpating the left lower
quadrant, which paradoxically causes pain to be
felt in the right lower quadrant.
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Cont…
 Aaron sign: Referred pain felt in the
epigastrium upon continuous firm pressure over
McBurney’s point(location of appendix)
indicative of chronic appendicitis.
 Dunphy sign: Increased abdominal pain,
localized to the right lower quadrant, with
coughing.
 Bassler sign: Pain induced by
compressing(pinching) the appendix between
the abdominal wall and iliacus, indicative of
chronic appendicitis.
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Cont…

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Cont…

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Dunphy, Aaron and Bassler signs

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4.To assess possible acute
cholecystitis
 Inspiratory arrest (Murphy's sign)
◦ Normally, palpating the liver causes no pain
◦ In a person with inflammation of the gall bladder or
cholecystitis, pain occurs.
◦ Hold the fingers under the liver border.
◦ As the descending liver pushes the inflamed
gallbladder on to the examining hand, the person
feels sharp pain and abruptly stops inspiration mid
way.

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5.To assess ventral hernias

◦ If the examiner suspect this type of hernia but do

not see an umbilical or incisional hernia, ask the
patient to raise both head and shoulders off the
examination coach.
◦ The bulge of a hernia which usually appear with
this action.

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6.To distinguish an abdominal mass
from a mass in the abdominal wall

◦ Ask the patient either to raise the head and

shoulders or to strain down, thus tightening the
abdominal muscles.
◦ Feel for the mass again.
◦ A mass in the abdominal wall remains palpable an
intra-abdominal mass is obscured by muscular
contraction.

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7. Sounds in the abdomen
a) Bowel sounds
 May be increased in clients with diarrhea or
early intestinal obstruction.
 Decreased, in paralytic ileus and peritonitis.
 High-pitched tinkling sounds suggest intestinal
fluid and air under tension in a dilated bowel.

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b) Bruits
 Arterial bruits with both systolic and diastolic
components suggest partial occlusion of the
aorta or large arteries.

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8.Tender abdomens
a) Abdominal wall Tenderness
 Tenderness may originate in the abdominal wall.
 When the patient raises head and shoulders, this
tenderness persists; whereas tenderness from a
deeper lesion decreases.
b) Visceral tenderness: Example – Enlarged liver
may be tender to deep palpation.
c) Tenderness from disease in the chest and pelvis

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References
 Barbara bates Guide to Physical Examination
and History Taking 11th Edition 2012. Lynn S.
Bickley. Pages 332-366
 Physical diagnosis, lecture note for health
science students Gonder university , 2005

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