ABDOMINAL

ASSESSMENT
JONALYN S. ESCO,.RN.,MAN
 ASSESSMENT OF THE ABDOMEN & GI SYSTEM
LANDMARKS FOR THE ABDOMINAL EXAMINATION
 CONTENTS OF NINE REGIONS
1) RIGHT HYPOCHANDRIAC: gallbladder, portion of liver, kidney,
duodenum
2) RIGHT LUMBSR: portion of right kidney, ascending colon,
duodenum, jejunum
3) RIGHT INGUINAL: cecum, appendix, ileum, right ureter, right
ovary, spermatic cord
4) EPIGASTRIC: portion of pancreas, pylorus, portion of the liver,
duodenum
5) UMBILICAL: lower duodenum, jejunum and ileum
6) HYPOGASTRIC: ileum, bladder (if distended), uterus (if
enlarged)
7) LEFT HYPOCHONDRIAC: stomach, spleen, portion of
pancreas and kidney
8) LEFT LUMBAR: descending colon, part of the left kidney
9) LEFT INGUINAL: sigmoid, left ureter, ovary or spermatic cord
 PHYSICAL ASSESSMENT
1) Empty bladder prior to exam
2) Work from right, client supine with knees
bent
3) Observe client’s face for signs of
discomfort
4) Short fingernails
5) Talk with clients
 Sequence of exam
Inspection
1) Size
2) Shape
3) Symmetry
4) Color
5) Contour
6) Lesions, scars
7) Bulges (Hernias)
8) Position of umbilicus
9) Distention
10) Striae
 Distention maybe caused by 8 Fs

1. Fluid
2. Feces
3. Fetus
4. Flatus
5. False pregnancy
6. Fat
7. Fibroid (benign tumor or muscular tissues, typically
developng in the wall of the uterus)
8. Fatal tumor
 ASSESSING CONTOUR
DISTENTION
1) Do not confuse a rounded abdomen with
distention.
2) A soft abdomen is not distended
3) Distention may be localized or generalized
4) Localized distention may occur in a soft
abdomen (distended bladder)
5) Area distended can point to cause
Example: bladder distention – central area of
lower abdomen above pubis
 REMINDERS:

AUSCULTATION
1) Perform before palpation and percussion
2) Warm stethoscope
3) Auscultate with diaphragm for Bowel
sounds in each quadrant
4) Auscultate with Bell for Vascular Sounds
over aorta, femoral, renal and iliac
arteries (bruits)
PERCUSSION
1) Percuss painful areas last
2) Can help determine organ size
3) Predominate sound over abdomen is tympany
4) Dullness is heard over organs masses, or fluid
PALPATION
1) Perform light palpation of abdomen
2) Palpate tender areas last, may tense muscles
3) Assess surface characteristics, tenderness,
guarding
4) Press down 1-2 cm using fingertips in rotating
fashion
5) Palpate as much of abdomen as possible
6) Observe for signs of pain (grimacing, guarding)
MURPHY’S SIGN: CHOLECYSTITIS
Stand at client’s right side, palpate at MCL at
costal angle
Client takes deep breath, moving gallbladder
closer to examiner’s hand, causing pain= Client
will stop inhaling
(+) pain = (=) MURPHY’S SIGN
MCBURNEY’S SIGN: APPENDICITIS
Located in RLQ
Test for rebound pain by pressing firmly and
slowly, then release quickly
(+) pain = (+) MCBURNEY’S SIGN
 COMMON ABNORMALITIES
A. ABDOMINAL AORTIC ANEURYSM
Weakness in wall of abdominal aorta, potential
for rupture
Is surgical emergency
SYMPTOM: tearing pain
Auscultation reveals bruit, exaggerated pulsation
or mass
Diminished femoral pulses
Hypotension, tachycardia, pale, clammy skin
B. APPENDICITIS
Inflammation of appendix, potential for
rupture
Pain unrelieved with position change
Anorexia, nausea, vomiting, fever
Decreased bowel sounds
C. CHOLECYSTITIS
Inflammation of gallbladder , often with stones

Indigestion or asymptomatic

May have bouts of acute pain of stone blocks duct

D. CIRRHOSIS
Major disease of the liver
E. DIVERTICULITIS
Characterized by damage and death of
alcoholism or hepatic cells, common effect
F. HEPATITIS
An inflammation of the liver that can result from
alcohol consumption or viral infection
G. HERNIAS
H. ULCERS
I. DIARRHEA
Any change in bowel habits in which stool is
frequency on volume is increased.
J. ULCERS
K. NAUSEA AND VOMITING
L. DYSPHAGIA
ODYNOPHAGIS
 Painful in swallowing
M. CONSTIPATION
 Slow movement of feces through the large
intestine
N. SKIN COLOR CHANGES
CULLEN’S SIGN: bluish umbilicus; intra
abdominal hemorrhage
TURNER’S SIGN: bruising of flank;
retroperitoneal hemorrhage
DILATED, TORTUOUS VISIBLE ABDOMINAL
VEINS: inferior vena cave obstruction
CUTANEOUS ANGIOMAS: liver disease
Cullen’s sign
Turner’s sign
DILATED, TORTUOUS VISIBLE ABDOMINAL
VEINS
CUTANEOUS ANGIOMAS
 REVIEW OF DIGESTIVE ANATOMY

The digestive system’s major functions

include ingestion and digestion of food and
elimination of waste products.
When these processes are interrupted, the
patient can experience problems ranging
from loss of appetite to acid-base
imbalances.
1. Gastrointestinal tract
 the GI track is a hollow tube that begins at the
mouth and ends at the anus. About 25 feet
(7.5m) long, the GI tract consist of smooth
muscles alternating with blood vessels and nerve
tissue.
a. Pharynx, esophagus, stomach, small intestines ,
and large intestines.
 Digestive process begin in the mouth with
chewing, salivating, and swallowing.
 Saliva is produced by three pairs of glands:
parotid, submandibular, and sublingual.
 The pharynx assist in swallowing process and
secretes mucus that aids in digestion.
 The epiglottis- a thin leaf shape- shaped
structure made of fibrocartilage- is
directly behind the root of the tongue.
 When food is swallowed the epiglottis closes
over the larynx and the soft palate fits to
block the nasal cavity.
 These actions keep food and fluid from being
aspirated
b. Esophagus- is a muscular, hollow tube about 10”
long that moves food from the pharynx to the
stomach.
c. Stomach- reservoir for food, is a dilated saclike
structure that lies obliquely in the left upper
quadrant below the esophagus and diaphragm.
d. The small intestine is about 20 feet (6 m) long
and is named for its diameter, not its length.
 It has three sections: the duodenum, the jejunum,
and the ileum.
 As chime passes into the small intestine, the end
products of digestion are absorbed through its
thin mucous membrane lining into the
bloodstream.
Enzymes from the pancreas, bile from the liver,
and hormones from glands of the small intestine
all aid digestion.
 These secretions mix the chyme as it moves
through the intestines by peristalsis.
e. The large intestine, or colon, is about 5 feet (1.5 m)
long.
 It includes the cecum; the ascending, transverse,
descending, and sigmoid colons; the rectum; and the
anus – in that order – and is responsible for
absorbing excess water and electrolytes, storing food
residue, and eliminating waste products in the form
of feces.
The appendix, a fingerlike projection, is attached to
the cecum.
Bacteria in the colon produce gas, or flatus.
Accessory Organs
a. The liver is located in the right upper quadrant
under the diaphragm.
It has two major lobes, divided by the falciform
ligament.
The liver is the heaviest organ in the body, weighing
about 3 lb (1.5 kg) in an adult.
The liver’s function include metabolizing
carbohydrates, fats, and proteins; detoxifying blood;
converting ammonia to urea for excretion; and
synthesizing plasma proteins, nonessential amino
acids, vitamin A, and essential nutrients, such as iron
and vitamins D, K, and B12.
The liver also secretes bile, cholesterol, and other
lipids. Bile also gives stool its color.
b. The gallbladder is a small, pear-shaped organ
about 4 inches (10 cm) long that lies halfway
under the right lobe of the liver.
Its main function is to store bile from the liver
until the bile is emptied into the duodenum.
This process occurs when the small intestine
initiates chemicals impulses that cause the
gallbladder to contract.
c. The pancreas, which measures 6 to 8 inches (15
to 20.5 cm) in length, lies horizontally in the
abdomen, behind the stomach.
 It consists of a of a head, tail and body.
The body of the pancreas is located in the right
upper quadrant, attached to the duodenum.
The tail of the pancreas touches the spleen.
The pancreas releases insulin and glycogen into
the bloodstream and produces pancreatic
enzymes that are released into the duodenum
for digestion.
d. The bile ducts provide passageways for bile travel
from the liver to the intestines.
Two hepatics ducts drain the liver and the cystic duct
drains the gallbladder.
These ducts converge into the common bile duct,
which then empties in the duodenum.
e. The abdominal aorta supplies blood to the GI
tract.
 It enters the abdomen, separates into the
common iliac arteries, and the braches into
many arteries extending the length of the GI
tract.
The gastric and splenic veins drain absorbed
nutrients into the portal vein of the liver.
After entering the liver, the venous blood
circulates and then exits the liver through the
hepatic vein, emptying into the inferior vena
cava.

OBTAINING A HEALTH HISTORY
If your patient has a gastrointestinal problem,
he’ll usually complain about pain, heartburn,
nausea, vomiting, or altered bowel habits.
To investigate these and other signs and
symptoms, ask him about the location, quality,
onset, duration, frequency, and severity of
each.
Knowing what precipitates and relieves the
patient’s symptoms will help you perform a more
accurate physical assessment and better plan
your care
Asking about Past Health
To determine if your patient’s problem is new or
recurring, ask about past GI illness, such as an
ulcer; liver, pancreas, or gallbladder disease;
inflammatory bowel disease; rectal or GI
bleeding; hiatal hernia; irritable bowel
syndrome; diverticulitis; gastroesophageal
reflux disease; or cancer.
Also, ask if he has abdominal surgery or trauma.
Asking about Current Health
Ask the patient’s if he’s taking any medication.
Several drugs – especially aspirin, nonsteroidal
anti-inflammatory drugs, antibiotic, and opioid
analgesics – can cause nausea, vomiting,
diarrhea, constipation, and other GI signs and
symptoms.
Be sure to ask about laxative use; habitual use
may cause constipation.
Also, ask the patient if he’s allergic to
medications or foods.
Such allergies commonly cause GI symptoms.
In addition, ask the patient about changes in
appetite, difficulty chewing or swallowing, and
changes in bowel habits.
Does he have excessive belching or passing of
gas?
Has he noticed a change in the color, amount,
and appearance of his stool?
Has he ever seen blood in his stool?
If the patient’s reason for seeking care is diarrhea,
find out if he recently travelled abroad.
Diarrhea, hepatitis, and parasitic infections can
result from ingesting contaminated food or
water.
Asking about Family Health
Because some GI disorders are hereditary, ask the
patient whether anyone in his family has had a GI
disorder.
When taking a health history, consider your patient’s
ethnic background. For example, patients from
japan, Iceland, Chile, and Austria are higher risk of
death from gastric cancer than patients from other
countries.
Also, Crohn’s disease is more common in patients
who are Jewish.
Disorders with a familial link include; ulcerative
colitis, colorectal cancer, peptic ulcers, gastric
cancer, diabetes, alcoholism, and Crohn’s disease.
Asking about Psychosocial Health
Inquire about your patient’s occupation, home
life, financial situation, stress level, and recent
life changes.
Be sure to ask about alcohol, caffeine, and
tobacco use as well as food consumption,
exercise habits, and oral hygiene.
Also ask about sleep patterns:
 How many hours of sleep does he feel he
needs?
 How many does he get?
PROCEDURE:
1. Perform hand hygiene.
R: To prevent the spread of microorganism.

2. Prepare client for abdominal assessment.

a. Ask if client needed to empty bladder or defecate.

R: Palpation of full bladder can cause discomfort
and feeling of urgency, and client is difficult
to relax.
b. Keep client’s upper chest and legs draped.
R: Maintains client’s warmth during
examination, promoting relaxation.

c. Ensure that room is warm

R: For the client to feel comfortable and to
prevent cold or chills.
d. Have client lie supine with arms down at
sides. A small pillow under client’s knees
may be desired.
R: Position promotes optimal relaxation
of abdominal muscles. Tightening of
muscles prevents adequate palpation of
underlying muscles.
e. Expose areas from just above the xiphoid process
down to the symphysis pubis.

f. Maintain conversation during assessment except

during auscultation. Explain steps calmly and slowly.
R: client’s ability to relax during assessment improves
accuracy of findings.

g. Ask client to locate tender areas.

R: Painful areas will be assessed last. Manipulation
of the body part can increase pain and client’s anxiety
and make remainder of assessment difficult to
complete.
 INSPECTION:
4. Perform abdominal assessment.
a. Identified landmarks dividing abdominal
region into quadrants.
R: Location of findings by common reference
point help successive examiners to
confirm findings and locate abnormalities.
Note: Some clinicians may also divide the
abdomen into nine equal sections for the
abdominal examinations
b. While inspecting client’s abdomen, first stand
on client’s right side or at foot part, then sit to
look across abdomen’s surface. Direct
examination light over abdomen.
R: Standing position helps to detect shadows
and movement. Sitting position allows
examiner to detect abnormal
protuberances.
c. Inspect skin of abdomen’s surface for color,
scars, venous patters, rashes, lesions, stretch
marks, and artificial openings.
R: Scars reveal evidence client has had past
trauma or surgery.
Striae indicate stretching of tissue by
growth, obesity, pregnancy, ascites, or edema.
Venous patterns may reflect liver disease
(portal hypertension).
Artificial openings indicate bowel or
urinary diversion.
d. Inspect the position , shape, and color of the
umbilicus.
 Note inflammation, discoloration, discharge or
protruding masses.
The umbilicus is normally flat and concave and
the same color as the skin.

R: An everted (pouched out) umbilicus usually

indicates distention. A hernia can also cause the
umbilicus to protrude upward.
 e. Note the contour or symmetry of the
abdomen.
Flat abdomen forms horizontal plane from
xiphoid process to symphysis pubis. Round
abdomen protrudes in convex sphere from
horizontal plane.
A concave abdomen sinks into muscular wall
(All are normal).
R: Changes in symmetry or contour may
reveal underlying masses, fluid collection
or gaseous distention.
 f. Ask if client self- administers injection if
bruising was noted.
R: Clients who are receiving insulin
injection are usually administer in the
subcutaneous area in abdomen. The back of
the upper arms, the upper buttocks or hips,
and the outer side of the thighs are also used.
 g. Measure size of abdominal girth.
R: Buildup of fluid in the abdomen, most
often caused by liver failure, heart failure,
or any cancer that has spread widely
throughout the abdomen.
Obesity
Buildup of intestinal gas, most often caused
by blockage or obstruction in the
intestines
 AUSCULTATION:
4. Place diaphragm of stethoscope lightly over one
of four abdominal quadrants. Listen until
repeated bubbling sound or gurgling sound are
heard. Repeat procedure for each quadrant.
Describe sounds as normal or audible, absent
hyperactive or hypoactive. Listen 3-5 minutes for
each quadrant before deciding bowel sounds are
absent.
R: Determines presence or absence of
peristalsis. Sounds occur irregularly normally
every 5- 15 seconds. Absent sound indicates
cessation of gastric motility.
 5. Place bell of stethoscope over midline of
abdomen and auscultate of vascular sound. If
aortic bruit is auscultated, stop assessment and
notify the physician.
R: Determines presence of turbulent blood
flow(bruits) through thoracic or abdominal
aorta. Percussion or palpation over
abdominal bruit can cause damage if bruit
is result of abdominal aneurysm. Palpation
can cause rupture of already weakened
vessels wall.
 6. Have client roll to side and place bell of
stethoscope posteriorly over costovertebral angle.
R: Determines presence of renal artery bruits.
PERCUSSION:
7. Have client return to supine position. Gently
percuss each of the four abdominal quadrants.
Note areas of tympany and dullness.
R: Reveals presence of air or fluid in the
intestines and stomach. Normal percussion
is tympanic because of swallowed air in the
gastrointestinal tract. Presence of fluid or
underlying masses is revealed by dull
percussion.
 8. To locate borders of liver, percuss intersection at
the right iliac crest and right midclavicular
line. Slowly inch pleximeter finger upward and
percuss toward right right costal margin until
note becomes dull.
R: Detects position of liver’s lower border.
Percussion note changes from tympanic to dull
at liver’s lower border, usually found at right
costal margin.
 9. Percuss down from nipple along right
midclavicular line. Slowly down pleximeter finger
downward toward right costal margin until note
becomes dull. Be sure pleximeter finger is in the
intercostal space when you percuss.
R: detects position of upper liver’s upper
border. Percussion note changes from resonant
to dull at liver’s upper border, usually found on
the sixth, or seventh intercostal space. Diseases
such as cirrhosis and cancer enlarge the liver.
10. Ask client to sit gently but firmly percuss over
each costovertebral angle along scapular lines. Use
ulnar surface of fist to percuss directly or
indirectly. Note if client experiences pain.
R: Determines presence of kidney
inflammations.
PALPATION:
11. Lightly palpate over each quadrant using palm
and pads of fingertips In smooth coordinated
movement. Depress skin approximately 1/2 inch.
Note the following:

 Muscular resistance
 Distention
 Tenderness
 Superficial masses
 Observe client’s face for signs of discomfort.
 Noted if abdomen is firm or soft to touch
TYPES OF PALPATION:

Li Mo De Bi
1. LIGHT PALPATION
 Place dominant hand lightly hand lightly on
the surface of the structure.
There should be very little or no
depression (less than 1 cm)
 Feel the surface with a circular motion
Use: feel the pulses, tenderness, surface skin
texture, temperature and moisture
Li Mo De Bi
2. MODERATE PALPATION
Dominant hand
Depress skin surface 1 to 2 cm
Use circular motion
Use: feel for easily palpable body
organs/ masses
Note: size, consistency,& mobility of
structures palpated
Li Mo De Bi
3. DEEP PALPATION
Dominant hand on surface with non- dominant
over the top of the dominant hand.
Apply pressure with skin depression of 2.5 to 5
cm (1 inch to 2 inches)
Use: feel very deep body organs/ structures
covered by thick muscles
 Li Mo De Bi
4. BIMANUAL PALPATION
 Use two hands-place one on each
side of the body part palpated
Use one hand to apply pressure and
the other to feel the structure
Use: uterus, breasts and spleen
Note: size, shape, consistency &
mobility of the structures
 Observe client’s face. Note if abdomen is firm or
soft to touch. Remember palpate painful ares
last. Avoid quick jabs.
R: Detects areas of localized tenderness, degree
of tenderness , and presence and character of
underlying masses.
Palpation of sensitive area causes gaurding,
voluntary tightening of abdominal muscles.
 Client;s verbal and nonverbal cues may indicate
discomfort from tenderness.
 Firm abdomen may indicatevactive obstruction
with fluid or gas building up.
12. Just below the umbilicus and above symphysis
pubis palpate for smooth, rounded mass
R: Detects presence of dome of distended
bladder.

13. If masses are palpated note the size , location,

shape, consistency, tenderness, mobility and
texture.
R: Characteristics hels you to reveal a mass.
14. If tenderness is present, press one hand slowly
and deeply into the involved area and then let
go quickly. Note if pain is aggravated.
R: Tests for rebound tenderness. Results are
positive if pain increases.
15. Locate liver’s lower border by placing left hand
under client's right posterior thorax.
Apply gentle upward pressure with left hand.
With fingers pointing towards client’s right costal
margin , place right hand on client's right upper
quadrant below costal margin.
Ask client to take a deep breath and gently
palpate right hand in and up.
As client inhales liver’s edge may be felt.
R: Allows for location of liver and determination if
organ is enlarged or disease is present.
 Upward pressure of left hand along with deep
breathing maneuver causes liver to descend and
be entrapped for palpation.
 Liver’s edge cannot be palpated in normal
adult.
Normal liver is non-tender and has regular
contour and sharp edge.
THANK YOU…