SUBJECTIVE DATA:

• Abdominal Pain
• Indigestion
• Nausea and vomiting
• Appetite
• Any gastrointestinal disorders
• Urinary tract disease
• History of hepatitis
• Abdominal surgery or trauma to abdomen
• Family history
• Intake of alcohol
EQUIPMENT:
•Small pillow or rolled blanket
•Centimeter ruler /tape measure
•Stethoscope (with a warm diaphragm
and bell)
•Marking pen
CLIENT PREPARATION:
• Ask the client to empty the bladder before beginning
the examination
• Instruct the client to remove clothes and to put on a
gown if desired.
• Help the client to lie supine with the arms folded
across the chest or resting by the sides.
• A flat pillow may be placed under the client’s head
for comfort.
• Slightly flex the client’s legs by placing a pillow or
rolled blanket under the client’s knees
• Drape the client with sheets so the abdomen is visible
from the lower rib cage to the pubic area.
• Instruct the client to breathe through the mouth and
to take slow, deep breaths; this promotes relaxation.
• Before touching the abdomen, ask the client about
painful or tender areas. These areas should always
be assessed at the end of the examination.
• Reassure the client that you will forewarn him or her
when you will examine these areas.
• Approach the client with slow, gentle, and fluid
movements.
• IAPP
• locate any tender areas FIRST.
• OBSERVE client’s FACE for pain.
• Use WARM HANDS and a WARM STETHOSCOPE.
• Place client’s hand under your own for a few
moments, if the client is ticklish.
• Converse with client as distraction
• Use slow, gentle and fluid movement.
1. INSPECT
A. coloration of the skin.

• paler than the • Grey-Turner sign

general skin tone • Cullen’s sign
• intact with no lesions • Jaundice
or masses.
• Ascites
• Redness
• Bruises
B. vascularity of the abdominal skin.

•Scattered fine •Caput medusa

veins may be •Spider Angioma
visible.
C. striae
•New striae are pink •Cushing’s syndrome:
or bluish in color; old dark bluish-pink
striae are silvery, striae
white, linear, and
uneven stretch
marks from past
pregnancies or
weight gain.
D. scars
•Pale, smooth, •Nonhealing wounds,
minimally raised old redness,
scars may be seen. inflammation.

•Deep, irregular
scars may result
from burns.
E. lesions and rashes.
•Free of lesions and •Changes in moles:
rashes. size, color, and
border symmetry.
•Flat or raised •Bleeding moles or
brown moles, petechiae: reddish
however, are or purple lesions.
normal and may be
apparent.
F. umbilicus.
•Umbilical skin •Cullen’s sign
tones are similar
to surrounding
abdominal skin
tones or even
pinkish.
G. abdominal contour.
Sitting at the client’s side, look across the
abdomen at a level slightly higher than the
client’s abdomen.

Inspect the area between the lower ribs

and pubic bone.

Measure the abdominal girth.

•Abdomen is flat, • Generalized protuberant
rounded, or or Distended abdomen:
due to obesity, air (gas),
scaphoid. or fluid accumulation.
• Distention below the
umbilicus: due to a full
bladder, uterine
enlargement, or ovarian
tumor or cyst.
• Distention of the upper
abdomen: seen with
masses of the pancreas
or gastric dilation.
H. abdominal symmetry
•Abdomen is •Asymmetry
symmetric. It does •Hernia
not bulge when •Diastasis Recti
client raise head.
I. abdominal movement
• On a thin patient, • Increased peristaltic
peristalsis and aortic waves:
pulsations may be • Reverse peristaltic
visible. waves:
• Women’s respirations
are more thoracic, • Abnormal respiratory
whereas men tend to • Shallow respirations in
use their abdominal male patients
muscles more with
breathing. • Increased/diffuse
pulsations
2. Auscultate
A. bowel sounds
Use the diaphragm of the stethoscope and
make sure it is warm before you place it on
the client’s abdomen.

Begin in the RLQ and clockwise covering all

quadrants. Listen for 5 minutes.
•A series of •Hyperactive bowel
intermittent soft sounds
clicks and gurgles •Hypoactive bowel
are heard at the sounds
rate of 5-30/min
•Decreased or
absent bowel
sounds
B. vascular sounds
• Bruits are not normally • Bruits are heard over
heard over abdominal abdominal aorta or
aorta or renal, iliac or renal, iliac or femoral
femoral arteries. arteries.
• Venous hum is not • Venous hum is heard
normally heard over the over the epigastric and
epigastric and umbilical umbilical areas.
areas. • Friction rub is heard
• No Friction rub over over liver or spleen.
liver or spleen is present.
3. Percuss for:
A. tone
• Tympany (inflated • Accentuated tympany or
sound) hyperresonance - over a
gaseous distended
• Dullness over liver and abdomen
spleen • Enlarged area of dullness
- enlarged liver or spleen.
• Abnormal dullness -
distended bladder, large
masses or ascites.
B. span or height of the liver
•Lower border: begin in the RLQ at the
MCL and percuss upward.
•To assess the descent of the liver, ask
the client to take a deep breath and
hold; then repeat the procedure.
•Upper border: upper right chest at the
MCL and percuss downward
• The lower level of • The upper border of
liver dullness is located liver dullness may be
at the costal margin difficult to estimate if
to 1 – 2cm below. obscured by pleural
fluid of lung
consolidation.
• On deep inspiration,
the lower border of
liver dullness may
descend from 1 – 4
cm below the costal
margin.
• The upper border of • Measure the distance
liver dullness is located between the two marks:
between the left 5th this is the span of the
and 7th intercostal liver.
spaces.. • HEPATOMEGALY – a
• The normal liver span at liver span that exceeds
the MCL is 6-12 cm normal limits (enlarged)
(greater in men and • ATROPHY of the liver –
taller clients, less in indicated by a decreased
shorter clients). span.
Repeat percussion of the liver at the
midsternal line (MSL).
•The normal liver •An enlarged liver
span at the MSL is may be roughly
4-8 cm. estimated when
more intense sounds
outline a liver span
or borders outside
the normal range.
C. spleen
•Begin posterior to the left mid-axillary
line (MAL), and percuss downward,
noting the change from lung
resonance to splenic
dullness.
•The spleen is an •Splenomegaly is
oval area of characterized by
dullness an area of dullness
approximately 7 cm greater than 7 cm
wide near the left wide. The
tenth rib and enlargement may
slightly posterior to result from
the MAL. traumatic injury,
portal hypertension,
and mononucleosis.
To detect splenic enlargement
•Percuss the last left intercostal
space at the anterior axillary line
(AAL) while the client takes a deep
breath
•Normally tympany •On inspiration,
(or resonance) is dullness at the
heard at the last last left
left interspace. interspace at the
AAL suggests an
enlarged spleen
4. Perform blunt percussion on
liver and spleen
• Percuss the liver by placing your left
hand flat against the lower right
anterior rib cage. Use the ulnar side of
your right fist to strike your left hand.
• Perform blunt percussion on the
kidneys at the costovertebral angles
(CVA) over the 12th rib.
•No tenderness is •Tenderness or
elicited. sharp pain over
•Normally no the liver.
tenderness or •Tenderness or
pain is elicited or sharp pain elicited
reported by the over the CVA
client. The suggests ki d ney
infection
examiner senses (pyelonephritis),
only a dull thud. renal calculi, or
hydronephrosis.
5. Perform:
A. light palpation
Depress about 1 cm. Assess skin pulsations.
Always done first- clockwise

It is used to identify areas of tenderness

and muscular resistance.
Always assess tender areas last.
Watch patient’s expression during palpation.
•Abdomen is •Involuntary reflex
nontender and soft. guarding is serious
There is no and reflects
guarding. peritoneal irritation.
•The abdomen is
rigid and the rectus
muscle fails to relax
•Right side guarding
may be due to
cholecystitis
B. Deep palpation on all
quadrants
•Mild tenderness •Severe tenderness
over the xiphoid, or pain related to
aorta, cecum, trauma, peritonitis,
sigmoid colon and infection, tumors, or
ovaries. enlarged or
diseased organs.
C. masses
•No palpable masses •A mass detected in
are present. any quadrant may
be due to a tumor,
cyst, abscess,
enlarged organ,
aneurysm, or
adhesions.
D. umbilicus and surrounding area
for swellings, bulges, or masses.
• Umbilicus and surrounding • A soft center of the
area are free of swellings, umbilicus can be a potential
bulges, or masses. for herniation. Palpation of
a hard nodule in or around
the umbilicus may indicate
metastatic nodes from an
occult gastrointestinal
cancer.
E. Aorta
•Use your thumb and first finger or use
two hands and palpate deeply in the
epigastrium, slightly to the left of
midline
•Assess the pulsation of the abdominal
aorta.
• The normal aorta is • A wide, bounding pulse
approximately 2.5 to may be felt with an
3.0 cm wide with a abdominal aortic
moderately strong and aneurysm.
regular pulse. Possibly • A prominent, laterally
mild tenderness may pulsating mass above
be elicited. the umbilicus with an
accompanying audible
bruit strongly suggests
an aortic aneurysm
F. liver
• To palpate bimanually, stand at the client's right
side and place your left hand under the client's
back at the level of the eleventh to twelfth
ribs. Lay your right hand parallel to the right
costal margin (your fingertips should point
toward the client's head). Ask the client to
inhale then compress upward and inward with
your fingers.
• To palpate by hooking, stand to the right of
the client's chest. Curl (hook) the fingers of
both hands over the edge of the right costal
margin. Ask the client to take a deep breath
and gently but firmly pull inward and upward
with your fingers.
• The liver is usually not • hard, firm liver
palpable, although it • Nodularity may occur
may be felt in some
• Tenderness
thin clients. If the
lower edge is felt, it • Liver more than I to
should be firm, 3 cm below the costal
smooth, and even. margin
• Mild tenderness may
be normal.
G. spleen
• Stand at the client's right side, reach over the
abdomen with your left arm, and place your
hand under the posterior lower ribs. Pull up
gently.
• Place your right hand below the left costal
margin with the fingers pointing toward the
client's head.
• Ask the client to inhale and press inward and
upward as you provide support with your other
hand
•Alternatively asking the client to turn
onto the right side may facilitate
splenic palpation by moving thespleen
downward and forward
H. kidneys
• To palpate the right kidney, support the right
posterior flank with your left hand and place your
right hand in the RUQ just below the costal margin
at the MCL
• To capture the kidney, ask the client to inhale. Then
compress your fingers deeply during peak inspiration.
• Ask the client to exhale and hold the breath briefly.
Gradually release the pressure of your right hand. If
you have captured the kidney, you will feel it slip
beneath your lingers.
I. urinary bladder
•Palpate for a distended bladder when the
client's history or other findings warrant
(e.g., dull percussion noted over the
symphysis pubis).
•Begin at the symphysis pubis and move
upward and outward to estimate bladder
borders
 SPECIAL
ABDOMINAL TESTS/
MANEUVERS
TEST FOR ASCITES
 Test for Shifting dullness
• The borders between • A dull percussion tone will be
heard around the flanks.
tympany and dullness
• Air rises to the top and
remain relatively tympany is percussed around
constant throughout umbilicus.
position changes. • When patient turn onto one
side the fluid assumes a
dependent position and air
rises to the top.
• Not always reliable and
definitive testing by ultrasound
is necessary.
 Test for fluid wave
• The client should remain supine. You will need
assistance with this test.
• Ask the client or an assistant to place the
ulnar side of the hand and lateral side of the
forearm firmly across the midline of the
abdomen.
• Firmly place the palmar surface of the fingers
and hands against one side of the client’s
abdomen. Use the other hand to tap the
opposite side of the abdominal wall.
•No fluid wave is •Transmission of
transmitted. fluid waves.
 Ballottement Technique
•No palpable mass •A freely movable
or masses are mass moving
present upward (floats) can
be felt at the
fingertips.
 TEST FOR
APPENDICITIS
 Rebound Tenderness
•No rebound • Blumberg’sign
tenderness. perceives sharp,
stabbing pain as the
examiner releases
pressure from the
abdomen (positive
rebound tenderness)
• McBurney’s sign is a
severe right lower
quadrant pain with
rebound tenderness.
 Referred Rebound
Tenderness
•No rebound pain is •Pain in the RLQ
elicited. during pressure in
the LLQ is a
positive ROVSING’S
SIGN.
 PSOAS sign
•No abdominal •Pain in the RLQ is
pain. associated with
irritation of
Iliopsoas muscle
due to appendicitis.
 Obturator sign
•No abdominal pain •Pain in the RLQ
present. indicates irritation
of obturator
muscle due to
appendicitis or
perforated
appendix.
 Cutaneous Hyperesthesia

•Increased sensitivity •Cutaneous

to cutaneous hyperesthesia is
stimulation due to a present over the
diminished threshold point of maximal
or an increased tenderness and
response to stimuli. pain. (positive
appendicitis)
 TEST FOR
CHOLECYSTITIS
 MURPHY SIGN
•No increase in pain •Accentuated sharp
is present. pain that causes
the client to hold
his or her breath
(inspiratory arrest)
associated with
acute cholecystitis.
TEST FOR HERNIA
•No abdominal •Protrusion of
hernias noted. abdominal organ
is visible when
the client lift or
raise his head.