BACHELOR OF SCIENCE IN NURSING:

HEALTH ASSESSMENT
COURSE MODULE COURSE UNIT WEEK
3 14 13

Adult Physical Assessment: Abdomen

✓ Read course and unit objectives

✓ Read and comprehend study guide prior to class
attendance
✓ Read and comprehend required learning
resources
✓ Engage in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Describe the structure and the function of the abdomen.
2. Discuss the organs located in the four quadrants and the nine regions of the abdomen.
3. Perform a physical assessment of the abdomen using the correct techniques.
4. Differentiate between normal and abnormal findings of the abdomen.
5. Analyze the data from the interview and physical assessment to formulate valid nursing
diagnosis, collaborative problems, and/or referrals.
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing 6th Edition, Philadelphia:
Wolters Kluwer

ASSESSMENT OF THE ABDOMEN

Intraperitoneal Organs
• Organs covered with peritoneum and held in place by mesentery, it includes:
o spleen
o bile duct
o gallbladder
o small intestine
o stomach
o large intestine
o liver
Retroperitoneal Organs
• organs situated behind the peritoneum and without mesenteric attachment, it includes:
o pancreas
o ureters
o kidneys
o bladder
Anatomical Mapping
• 2 Methods of dividing the abdominal cavity:
o By quadrants

▪ most common assessment approach

▪ a vertical line from the xiphoid process to the pubic symphysis and a
horizontal line across the umbilicus
▪ The location of organs by quadrants

o By regions
▪ the vertical lines that extend superiorly from the midpoints of the inguinal
ligaments and 2 horizontal lines, one at the level of the edge of the lower ribs
and the other at the level of the iliac crest
THE ABDOMINAL VISCERA (ORGANS)
• Stomach
o J-shaped pouch like organ located in the left upper quadrant of the abdomen
beneath the diaphragm
o lies to the right of the spleen and is partially covered by the liver
o Functions
▪ reservoir where the complex mechanical and chemical processes of digestion
occurs
▪ breaksdown food particles into the molecular form of digestion
• Small Intestine
o tubular-shaped organ extending from the pyloric sphincter to the ileocecal valve at
the opening of the large intestine
o can measure from 10 feet to 30 feet
o Segments
▪ duodenum
• 1st and shortest section
• significant role in digestion
▪ jejunum
• composed of circular mucosal folds that provide surface area for
nutrient absorption
▪ ileum
• absorbs bile salts Vitamin B12
• Large Intestine
o tubular shaped organ extending from the ileocecal valve to the anus
 o greater diameter than the small intestine
o Segments
▪ ascending
▪ transverse
▪ descending
• Sigmoid Colon
o Functions
▪ form stool from cellulose, indigestible fibers, fat, bacteria, cellular debris and
inorganic materials
▪ carry these intestinal contents to the end of the GIT
▪ absorption of water and electrolytes
• Liver
o largest solid organ in the body lies directly below the diaphragm
o located in the right upper quadrant but extends across the midline into the left upper
quadrant
o storage
▪ carbohydrates amino acids vitamins
▪ minerals
▪ blood
o detoxification and filtration
▪ drugs hormones
▪ bacteria
o metabolism
▪ carbohydrates
▪ proteins
▪ fats
▪ ammonia to urea
o synthesis and secretion
▪ bile production; 600 to 1000 ml/day
▪ formation of lymph bile salts
▪ plasma proteins
▪ fibrinogen
▪ blood-clotting substances
▪ antibodies
• Gallbladder
o pear-shaped sac located in the right upper quadrant of the abdomen
o Functions
▪ store and concentrate bile produced by the liver
▪ contributes to fat digestion and absorption
▪ stores approximately 30 to 50 ml of bile
• Pancreas
 o elongated accessory organ of digestion lies in a transverse position along the
posterior abdominal wall
o Functions
▪ exocrine
• secretes bicarbonate and pancreatic enzymes which aid in digestion
▪ endocrine
• secretes the hormone insulin, glucagon and gastrin
• Spleen
o largest lymph of the body oval in shape found at the upper left quadrant of the
abdomen
o Functions
▪ serves the body as filter and reservoir for red blood cell mass
• Vermiform appendix
o finger-like shape that extends off the lower cecum in the right lower quadrant
• Kidneys
o bean-shaped organs that lie tucked against the posterior abdominal wall
o Functions
▪ get rid of the body waste products
▪ acid base balance fluid and electrolyte balance
▪ arterial blood pressure
• Ureters
o the passageway of urine from the kidneys
• Bladder
o stores urine can hold 200 to 400 ml of urine

ASSESSMENT PROPER
• Equipment
• Drapes
• Tape measure or small ruler with
centimeter markings
• Marking pen
• Stethoscope

Order of Assessment
• Inspection
• Auscultation
• Percussion
• Palpation
General Approach to Abdominal Assessment
1. Greet the patient and explain the assessment technique
2. Ensure that the room is at a warm, comfortable temperature to prevent patient chilling and
shivering
3. Use a quiet room that will be free from interruptions
4. Utilize an adequate light source. This includes a bright overhead light and a freestanding
lamp for tangential lightning
5. Ask the patient to urinate before the exam
6. Drape the patient from the xiphoid process to the symphisis pubis then expose the patient's
abdomen
7. Position the patient comfortably in a supine position with knees flexed over a pillow or
position the patient so that the arms are either folded across the chest or at the sides to
ensure abdominal relaxation
8. Stand to the right side of the patient for the examination
9. Visualize the underlying abdominal structures during the assessment process in order to
accurately describe the location of any pathology
10. Have the patient point to tender areas; assess these last. Mark these and other significant
findings on the body diagram in the patient's chart
11. Watch the patient's face closely for signs of discomfort or pain
12. Help the patient relax by using unhurried approach, diverting attention with questions and
so on
13. Ensure that your hands and the stethoscope are warm to promote patient comfort

Inspection
• Contour

o Normal
▪ the abdominal contour is flat (straight horizontal line from costal margin to
symphysis pubis)
▪ rounded (convexity of the abdomen from costal margin to symphysis pubis)
▪ abdomen should be evenly rounded
o Deviations from normal
 ▪ generalized protuberant or distended abdomen may be due to obesity, air or
fluid accumulation
▪ distended below umbilicus may be due to a full bladder, uterine enlargement,
or an ovarian tumor or cyst
▪ distended upper abdomen may be due to masses of pancreas or gastric
dilation
• Symmetry
o Normal
▪ abdomen should be symmetrical bilaterally
o Deviations from normal
▪ asymmetry may be seen with organ enlargement, large masses, hernia,
diastasis recti, or bowel obstruction
• Pigmentation and Color
o Normal
▪ abdominal skin may be paler than the general skin tone because it is seldom
exposed to the natural elements
o Deviations from normal
▪ purple discoloration at the flanks (Grey – Turner sign) indicates bleeding
within the abdominal wall, possibly from trauma of abdominal organs
(pancreas, kidneys, intestines, or from pancreatitis

▪ Pale, taut skin may be seen with ascites

▪ Redness may indicate inflammation

▪ Bruises or areas of discoloration
• Scar
o Normal
▪ Pale, smooth, minimally raised old scars may be seen
o Deviations from normal
▪ Nonhealing wounds, redness, inflammation
 ▪ Deep irregular scars may result from burns
• Striae
o Stretch Marks
o Due to past stretching of the reticular skin layers due to fast or prolonged stretching
o Normal
▪ Pink, bluish in color if new striae
▪ Silvery, white, linear if old striae
▪ Uneven stretch marks from past pregnancies or weight gain
o Deviations from normal
▪ Dark bluish – pink striae are associated with Cushing syndrome
▪ Stretch marks caused by ascites
• Masses / Nodules
o Normal
▪ No masses or nodules are present
• Umbilicus
o Normal
▪ Depressed and beneath the abdominal surface, protruding not more than
0.5cm
▪ Round or conical
▪ Skin tones are similar to surrounding abdominal skin tones
▪ Midline
o Deviations from normal
▪ Cullen sign
• Indicates intra – abdominal bleeding

▪ Deviated umbilicus
▪ Everted umbilicus
• Pulsation
o Normal
▪ Ripples of peristalsis may be observed in thin patient's
▪ Peristalsis movement slowly traverses the abdomen in a slanting downward
direction

Auscultation
• Bowel Sounds
 o Heard as intermittent gurgling sounds throughout the abdominal quadrants at a rate
of 5 – 30 per minute
o Normally, bowel sounds are always present at the ileocecal valve area (RLQ)
o Normal hyperactive bowel sounds referred to as “borborygmus” may also be heard
o loud, prolonged gurgles characterized of one’s stomach growling
o Deviations from normal
▪ Hyperactive bowel sounds
• gastroenteritis
• diarrhea
• use of laxatives
▪ Hypoactive bowel sounds
• paralytic ileus
• peritonitis
• bowel obstruction
• Vascular Sounds

o Bruits
▪ use bell of stethoscope
▪ low – pitched, murmur- like sound
▪ whooshing sound, blood flows through a narrow vessel
▪ important if the client has hypertension or if you suspect arterial insufficiency
to the legs
▪ auscultated over the abdominal aorta and renal, iliac, and femoral arteries
best heard over these areas
▪ not normally heard
• may indicate aneurysm and or renal arterial stenosis
o Venous Hum
▪ sounds produced by abdominal organs that suggests increased collateral
circulation heard over the umbilicus and epigastric area cirrhosis of the liver
not normally heard
o Friction Rub
▪ high-pitched grating sound produced by large surface of an abdominal organ
(liver, spleen) rubs the peritoneum
▪ associated with respiration rare, and not normally heard

Percussion
• Patterns
o Abdominal percussion sequences may proceed
clockwise or up and down over the abdomen
o Cover all quadrants
• General Assessment
o Normal
▪ Tympany
• is predominant sound heard because air is present in the stomach and
in the intestines
▪ Dullness
• is normally heard over organs such as the liver or a distended bladder

• Liver Span

o Lower Border
▪ Begin liver percussion in the RLQ and percuss upward toward the chest
▪ Mark the percussion changes
o Upper Border
▪ Percuss over the upper right chest at the MCL and percuss downward
▪ Mark the percussion changes
 o Measure the distance between the two marks:

▪ this is the span of the liver

o Normal liver span at the MCL is 8 – 12cm greater in men and taller clients, less in
shorter clients
o Normal liver span at the MSL is 4 – 8cm
o Deviations from normal
▪ Hepatomegaly, a liver span that exceeds normal limits (enlarged), is
characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement
▪ ATROPHY of the liver is indicated by a decreased span
▪ A liver in a LOWER POSITION than normal may be caused by emphysema
▪ A liver in a HIGHER POSITION than normal may be caused by an
abdominal mass, ascites, or a paralyzed diaphragm
• Spleen
o Normal
▪ an oval area of dullness approximately 7 cm wide near the left tenth rib and
slightly posterior to the MAL

▪ tympany (or resonance) is heard at the last left interspace

o Deviations from normal
 ▪ Splenomegaly has an area of dullness greater than 7cm wide
▪ enlargement may result from traumatic injury, portal hypertension
mononucleusis
▪ Dullness at the anterior axillary line suggests enlargement of the spleen
• Kidney
o Blunt Percussion

▪ To assess for tenderness in difficult-to-palpate structures

▪ Normally, no tenderness or pain is elicited or reported by the client
▪ Tenderness or sharp pain elicited over the costovertebral angles (CVA)
suggests kidney infection (pyelonephritis), renal calculi, or hydronephrosis

Palpation
• Normally palpable structures in the abdomen

• Light Palpation
 o Normal
▪ Abdomen should feel smooth and is nontender and soft
▪ There is no guarding
o Deviations from normal
▪ Involuntary reflex guarding reflects peritoneal irritation
▪ Right-side guarding may be due to cholecystitis
• Deep Palpation

o Normal
▪ (mild) tenderness is possible over the xiphoid, aorta, cecum, sigmoid colon,
and ovaries with deep palpation
▪ No organ enlargement should be palpable
▪ No abnormal masses, bulges, or swelling
▪ Only the aorta and the edge of the liver are palpable
o Deviations from normal
▪ Severe tenderness or pain may be related to trauma, peritonitis, infection,
tumors, or enlarged or diseased organs
• Liver
o Bimanual Technique

▪ Normal
• the liver is not palpable, although it may be felt in extremely thin adults
 • liver edge presents as a firm, sharp, regular ridge with a smooth
surface
▪ Deviations from normal
• A hard, firm liver may indicate cancer
• Nodularity may occur with tumors, metastatic cancer, late cirrhosis, or
syphilis
• Tenderness may be from vascular engorgement (e.g., congestive
heart failure), acute hepatitis, or abscess
• Spleen

o Normal
▪ Seldom palpable at the left costal margin
▪ If palpable, it should be soft and nontender
o Deviations from normal
▪ Palpable spleen suggests enlargement
• infections
• trauma
• chronic blood disorders
▪ Palpating the spleen in side – lying position
• NOTE:
o Be gentle when palpating the spleen to avoid rupture and
trauma of the organ
• Kidneys
 o Normal
▪ Usually not palpable
▪ If palpated, it should feel firm, smooth and rounded
o Deviations from normal
▪ An enlarged kidney may be due to a cyst, tumor, or hydronephrosis
• Urinary Bladder

o An empty bladder is neither palpable nor tender

o A moderately full bladder is smooth and round and it is palpable above the
symphysis pubis
o A full bladder is palpated above the symphysis pubis and it may be close to the
umbilicus
• Inguinal Lymph Nodes
o Normal
▪ Small, movable and palpable nodes are less than 1cm and are nontender

D’Amico, D., and Barbarito, C., (2019) Health & Physical Assessment in Nursing 3rd Edition,
Singapore: Pearson Education, Inc.
http://region9.dost.gov.ph/news/603-5-steps-of-a-breast-self-exam
https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2009/09000/making_sense_of_abdomi
nal_assessment.5.aspx#:~:text=With%20abdominal%20assessment%2C%20you%20inspect,perc
uss%2C%20palpate%2C%20and%20auscultate.
Weber, J.R., and Kelley, J. H., (2018) Health Assessment in Nursing
6th Edition, Philadelphia: Wolters Kluwer