Assessment

1. Gather equipment (pillow/towel, For an effective and smooth procedure in Assessing the Abdomen, gown, pillow/towel, stethoscope,
centimeter ruler, stethoscope, marking skin marker, and metric ruler will be used.
pen).

2. Explain procedure to client. It is important that the patient have knowledge about the procedure, why is it necessary, and how he or
she can cooperate

3. Ask client to gown. To protect us nurse and patient from the spread of disease-causing microorganisms if the wearer comes
in contact with potentially infectious liquid or solid material.

Abdomen

1. Inspect the skin, noting color, vascularity, Abdominalskin may be paler than the general skin tone because this skin is seldom exposed to the
striae, scars, and lesions (wear gloves to natural elements, scattered fine veins may be visible. Blood in the veins located above the umbilicus
inspect lesions.) flows toward the head; blood in the veins is located toward the lower bod

2. Inspect the umbilicus, noting color, The umbilicus is midline at the lateral line. It is recessed or protruding no more than 0.5 cm and round
location, and contour.

3. Inspect the contour of the abdomen. The normal contour of the abdomen is typically flat or rounded.

4. Inspect the symmetry of the abdomen. The abdomen should be symmetrical

5. Inspect abdominal movement, noting Decreased in abdominal movement may reflect peritoneal irritation. Exaggerated pulsation in the aorta
respiratory movement, aortic pulsations, may note an abdominal aortic aneurysm.
and/or peristaltic waves.

6. Auscultate for bowel sounds, noting Auscultation (listening for bowel sounds) is part of an abdominal physical assessment and is performed
intensity, pitch and frequency. to determine whether normal bowel sounds are present. (clicks and gurgles)

7. Auscultate for vascular sounds and friction We need to listen if there are bruits as it indicates aneurysm or arterial stenosis. If friction rubs are
rubs. present it is associated with hepatic abscess or metastases.

8. Percuss the abdomen tone. To assess free fluid in the abdomen.

9. Percuss the liver. To determine the size of the liver.

10. Perform the scratch test. to detect the lower liver edge by using the difference in sound transmission through the abdominal
cavity over solid and hollow organs. The test is thought to be particularly useful if the abdomen is tense,
distended, obese, or very tender.

11. Percuss the spleen. To look for splenic enlargement. RLQ, tympanic

12. Perform blunt percussion on the liver and the percussion note is usually resonant, because of overlying loops of gas-filled bowel.
the kidneys.

13. Perform light palpation, noting tenderness allows for determination of the areas of tenderness and abdominal wall resistance due to rigidity
or masses in all quadrants. (involuntary muscle spasm) or guarding (voluntary contraction of the abdominal wall musculature).

14. Perform deep palpation, noting tenderness To palpate if there are masses. Severe pain may indicate.
or guarding in all quadrants.
 15. Palpate the umbilicus. for any defect, mass, or umbilical hernia. inverted

16. Palpate the aorta. The normal aorta is less then 3.0 cm wide. A periumbilical or upper abdominal pulsatile mass is
suggestive of an aortic aneurysm or ectasia.

17. Palpate the liver, noting consistency and to approximate liver size, feel for tenderness and masses. Not palpable. May be slightly tender
tenderness.

18. Palpate the spleen, noting consistency and not normally palpable except in slender young adults. almost always lies entirely within the rib cage and
tenderness. thus cannot be palpated, but with enlargement it displaces the stomach and descends below the rib cage

19. Palpate the kidneys. To assess kidney enlargement. The kidneys are not palpable in most normal patients, though may be
palpable in thin patients and children.

20. Palpate the urinary bladder. detect an enlarged bladder. An empty bladder is not palpable. A full bladder presents as a pelvis mass
which is typically, regular, smooth, firm, and oval-shaped. It arises in the midline.

21. Perform the test for shifting dullness. To detect fluid in the abdomen or ascites.

22. Perform the fluid wave test. To measure the amount of fluid in the abdomen.

23. Perform the ballottement test. To feel if there are floating mass.

24. Perform tests for appendicitis. to provide a prompt diagnosis for appendicitis, so you receive the care you need.

- Rebound tenderness To know if there are problems in the parietal layer of the peritoneum.

- Rovsing’s sign To know if there are signs of peritoneal irritation.

- Referred rebound tenderness. To determine whether there are signs of peritonitis.

- Psoas sign To indicate irritation in the iliopsoas and inflamed appendix.

- Obturator sign To determine acute appendicitis.

- Hypersensitivity test Tenderness in the RLQ may indicate appendicitis.

25. Perform test for cholecystitis (murphy’s The sharp pain that causes inspiratory test may be associated with cholecystitis
sign)

Analysis of data

1. Formulate nursing diagnoses (wellness,

risk, actual)

2. Formulate collaborative problems.

3. Make necessary referrals.