Assessment Normal Findings Abnormal Findings Clinical Older Considerations Cultural

Procedure Tip Considerations

Abdomen
Abdominal Structures by Quadrants
Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ)
• Ascending and transverse colon • Appendix • Left adrenal gland • Left kidney (lower pole)
• Duodenum • Ascending colon • Left kidney (upper pole) • Left ovary and tube
• Gallbladder • Cecum • Left ureter • Left ureter
• Hepatic flexure of colon • Right kidney (lower pole) • Pancreas (body and tail) • Left spermatic cord
• Liver • Right ovary and tube • Spleen • Descending and sigmoid colon
• Pancreas (head) • Right ureter • Splenic flexure of colon
• Pylorus • Right spermatic cord • Stomach
• Right adrenal gland • Transverse descending colon
• Right kidney (upper pole)
• Right ureter

INSPECT
Observe the No discoloration, Grey-Turner sign - Purple discoloration at the Dilated superficial capillaries
coloration of the paler than general flanks without a pattern may be seen
skin. skin. Trauma to the kidneys, pancreas, or in older clients. They are more
duodenum or from pancreatitis – Grey-Turner visible in sunlight.
Note the vascularity Scattered fine veins Sign
of the abdominal may be visible.
skin. Jaundice – yellow hue
Fluid accumulation – pale, taut skin (ascites)
Inflammation – redness
Bruises – areas of local discoloration

Liver cirrhosis/Obstruction of the inferior

vena cava/Portal Hypertension/Ascites -
Dilated veins

Liver Disease/Portal Hypertension – Spider

angioma, dilated surface arterioles and
capillaries.
Note any striae, New Striae – pink or Cushing’s syndrome -Dark bluish-pink striae Scarring should be an alert Keloids (excess
scars. bluish color Liver Failure/Liver Disease – Striae caused by for possible internal adhesions. scar tissue)
Old Striae – silvery, ascites. result from
Assess for lesions white linear Inflammation/Burns - Nonhealing wounds, trauma or
and rashes. Uneven Striae – past redness, inflammation or Deep, irregular scars surgery and are
pregnancies or more common
weight gain. Changes in mole size and symmetry, Bleeding in African
moles and petechiae (reddish or purple Americans and
Free of lesions and lesions) all abnormal. Asians
rashes.
Inspect, Observe and Similar to skin tones Cullen’s sign - A bluish or purple discoloration
assess umbilicus. even pinkish, at around the umbilicus (periumbilical
midline and inverted ecchymosis) intra-abdominal bleeding.
or protruding no Grey-Turner’s sign - bluish of purplish
more than 0.5 cm, discoloration on the abdominal flanks.
round and conical.
Mass/Enlarged Organs/Hernia/Fluid/Scar
Tissue - Deviated umbilicus
Abdominal distention - Everted umbilicus
Umbilical Hernia - Enlarged, everted umbilicus
Assess abdominal Abdomen is flat, Obesity/Air(gas)/Ascites - generalized The major causes of abdominal
symmetry, Observe rounded, or scaphoid protuberant or distended abdomen distention are sometimes
aortic pulsations. referred to as the “6 Fs”:
Abdomen does not Full Bladder/Uterine Enlargement/Ovarian Fat, feces, fetus, fibroids,
Observe peristaltic bulge when client tumor or cyst - Distention below the umbilicus flatulence, and fluid
waves. raises head. Pancreatic Mass/Gastric Dilation - Distention
of the upper abdomen
Abdominal Severe weight loss/Cachexia – scaphoid
respiratory (sunken) abdomen
movement may Organ Enlargement/Large
be seen, especially in masses/Hernia/Diastasis Recti/Bowel
male clients. Obstruction – Asymmetry
Peritoneal Irritation - Diminished abdominal
No peristaltic waves respiration
visible. Abdominal Aortic Aneurysm - Vigorous, wide,
exaggerated pulsations
Intestinal wall obstruction - Increased
peristaltic waves.
AUSCULTATE
Auscultate for bowel Series of Early Bowel Obstruction/Gastroenteritis/ Bowel sounds may be more
sounds. intermittent, soft Diarrhea, or with use of laxatives – active over the ileocecal valve in
clicks and gurgles are “Hyperactive” bowel sounds (rushing, tinkling, the RLQ.
Use the heard at a rate of and high pitched)
diaphragm of the 5–30 per minute. Postoperatively, bowel
stethoscope Paralytic Ileus/Peritonitis/Late Bowel sounds resume gradually
Borborygmus - Obstruction/Pneumonia – “Hypoactive” depending on the type of
Hyperactive bowel bowel sounds (diminished bowel motility) surgery. The small intestine
functions normally in the first
Stomach Growling - Absence of bowel motility - Decreased or few hours postoperatively;
loud, prolonged absent bowel sounds (requires immediate stomach emptying takes 24–48
gurgles referral) hours to resume; and the colon
requires 3 to 5 days to recover
propulsive activity.
Auscultate for No bruits heard, but Renal arterial stenosis (RAS) - bruit with both Auscultating for vascular sounds
vascular sounds some client’s bruits systolic and diastolic is especially important if the
confined to systole client has hypertension or if you
Use the are normal. For a more accurate diagnosis, an ultrasound suspect arterial insufficiency to
bell of the or an angiogram is needed. the legs.
stethoscope

Listen for venous No venous hum Liver Cirrhosis – venous hums are rare
hum heard over the increased collateral circulation
epigastric and
umbilical areas
Auscultate for a No friction rub over Liver or spleen rubbing the peritoneum –
friction rub over the liver or spleen is Friction rubs are rare.
liver and spleen. present.
Heard over the lower right costal area
is associated with hepatic abscess or
metastases.

Splenic infarction, abscess, infection, or

tumor - rub heard at the anterior axillary line
in the lower left costal area
PERCUSS
Percuss for tone. Tympany heard over Gaseous Distended Abdomen - Accentuated
the abdomen. tympany or hyperresonance
Dullness heard over
the liver and spleen. Hepatomegaly/Splenomegaly - enlarged area
of dullness
Distended bladder, large masses, or ascites –
Abdominal dullness.
Percuss the span or The lower border of Hepatomegaly - liver span that exceeds If you cannot find the lower Normally, liver size decreases
height of the liver liver dullness is normal limits (enlarged) greater than 6–12 cm. border of the liver, keep in mind after age 50.
by determining its located at the costal Emphysema – liver in lower position that the lower border of liver
lower and upper margin to 1 to Ascites/Abdominal Mass/Paralyzed dullness may be difficult to
borders. 2 cm below. May Diaphragm – liver in higher position. estimate when obscured by
descend from 1 to 4 intestinal gas.
cm. (Liver span is
6–12 cm)
Percuss the spleen. The spleen is an oval Splenomegaly - Dullness greater than 7 cm Other sources of dullness (e.g.,
area of dullness wide or dullness at the last left interspace full stomach or feces in the
approximately 7 cm at the AAL colon) must be ruled out
wide near the before confirming splenomegaly
left tenth rib and
slightly posterior to
the MAL.
Perform blunt No tenderness is Hepatitis/Cholecystitis - Tenderness elicited This technique requires that the
percussion on the elicited. over the liver client sit with his or her back to
liver and the kidneys Pyelonephritis/Renal Calculi/Hydronephrosis you. Therefore, it may be best
-Tenderness or sharp pain elicited over the to incorporate blunt percussion
CVA (costovertebral angles) of the kidneys with your
thoracic assessment because
the client will already be in this
position.
Perform light Abdomen is Peritoneal Irritation - Involuntary reflex
palpation. nontender and soft. guarding
There is no guarding Abdomen is rigid and the rectus muscle fails
to relax with palpation when the client
exhales.
Cholecystitis - Right-sided guarding
Deeply palpate all Normal (mild) Trauma, peritonitis, infection, tumors, or
quadrants to tenderness is enlarged or diseased organs - Severe
delineate abdominal possible over the tenderness or pain
organs and detect xiphoid, aorta,
subtle masses. cecum, sigmoid
colon, and ovaries
with deep palpation.
PALPATE
Palpate for masses. No palpable masses Tumor, cyst, abscess, enlarged organ,
are present. aneurysm, or adhesions - mass detected in
any quadrant
Palpate the Umbilicus and Herniation - soft center of the umbilicus
umbilicus and surrounding area are Metastatic nodes from an occult
surrounding free of swellings, gastrointestinal cancer - Palpation of a hard
area for swellings, bulges, or masses. nodule in or around the umbilicus
bulges, or masses.
Palpate the aorta, Aorta is Abdominal Aortic Aneurysm - wide, bounding Do not palpate a pulsating If the client is older than age 50
liver, spleen, approximately 2.5– pulse, prominent, laterally pulsating mass midline mass; it may be a or has hypertension, assess the
kidneys, urinary 3.0 cm wide. above the umbilicus with an accompanying dissecting aneurysm that can width of the aorta.
bladder. audible bruit. rupture from the pressure of
Liver not palpable palpation. Also avoid deep
Spleen seldom Tumors, metastatic cancer, late palpation over tender organs as
palpable. cirrhosis, or syphilis – Nodularity in the case of polycystic kidneys,
Kidneys not Cancer - hard, firm liver Wilms’ tumor, transplantation,
palpable. Vascular engorgement – tenderness or suspected splenic trauma.
Bladder is neither Hepatomegaly/Hepatitis/Liver
palpable nor tender. Tumor/Cirrhosis/Vascular Engorgement – Be sure to palpate with your
Enlargement of liver. fingers below the costal margin
so you do not miss the lower
Infections, trauma, mononucleosis, chronic edge of an enlarged spleen.
blood disorders, and cancers - palpable
spleen suggests enlargement

Cyst, tumor, or Hydronephrosis - Enlarged

kidney
Distended bladder - smooth, round, and
somewhat firm mass extending as far as the
umbilicus.
TESTS FOR ASCITES
Test for shifting The borders There is a marked increase in the
dullness. between tympany height of the dullness. This test is not always
and dullness remain reliable, thus definitive testing by ultrasound
relatively constant is necessary.
throughout position
changes. Severe Liver Disease due to portal
hypertension (high pressure in the blood
vessels of the liver and low albumin levels) –
Ascites cause
Perform the fluid No fluid wave is Movement of a fluid wave against the resting Because this test is not
wave test. transmitted. hand suggests large amounts of fluid are completely reliable, definitive
present (ascites) testing by ultrasound is needed.
TESTS FOR APPENDICITES
Assess for rebound No rebound Blumberg’s sign - the client perceives sharp, Avoid continued palpation
tenderness. tenderness is stabbing pain as the examiner releases when test findings are positive
present. pressure from the abdomen. for appendicitis because of the
danger of rupturing the
appendix.
Test for referred No rebound pain is Acute appendicitis - Pain in the RLQ during
rebound tenderness. elicited. pressure in the LLQ is a positive Rovsing’s sign
Assess for psoas sign No abdominal pain is Irritation of the iliopsoas muscle due to
present. appendicitis - Pain in the RLQ (Psoas Sign)
Assess for obturator No abdominal pain is Appendicitis or a perforated
sign. present Appendix - Pain in the RLQ indicates irritation
of the obturator muscle
Perform The client feels no Appendicitis - Pain or an exaggerated
hypersensitivity test.
pain and no sensation felt in the RLQ is a positive skin
exaggerated hypersensitivity test.
sensation
TESTS FOR CHOLECYSTITIS
Assess RUQ pain or No increase in pain is Murphy’s sign (Acute Cholecystitis) -
tenderness for signs present. Accentuated sharp pain that causes the client
of cholecystitis. to hold his or her breath.