clinical skills

clinical skills

A step-by-step guide to performing

a complete abdominal examination
This clinical skills series is designed for the nursing professional as a basic overview on key clinical skills necessary
for patient care, clearly presenting common clinical procedures and their rationale, together with the essential
background theory. In this first article in the series, Carol Cox and Martin Steggall describe the process associated
with abdominal assessment. It focuses on a systematic approach and highlights areas in which gastrointestinal
nurses may enhance their knowledge and practice.

Carol Cox is Professor of
Nursing, Advanced Clinical
Practice, and Martin Steggall is
Head of Department, Applied
Biological Sciences, School
of Community and Health
Sciences, City University,
London
Key words
■ Abdominal examination
■ Clinical skills
■ Inspection
■ Palpation
■ Percussion and auscultation
This article has been subject to
double-blind peer review
Patients present with a variety of abdominal
complaints and symptoms. Thus, it is important
to have an understanding of the underlying
problems that patients may have (Bickley and
Szilagyi, 2007). The ability to undertake and
document a clear, concise and systematic
assessment of a patient is an essential skill for
gastrointestinal nurses. In this article, a model
of assessment (McGrath, 2004) is described,
which gastrointestinal nurses can use to readily
identify and prioritize patient care.
By undertaking a full and systematic assessment
of the abdomen, the gastrointestinal nurse is in
a unique position to act upon findings from the
assessment and ensure that appropriate medical
or nursing intervention occurs.
In this article, abdominal examination – which
is the first part of a 2-part series – is presented.
In part 2, digital rectal examination (DRE) is
presented. DRE follows as the final element in
a comprehensive abdominal examination.
Background
For the purpose of review, the abdominal cavity
is the centre for several of the body’s vital
organs, including the liver, gallbladder, stomach,
pancreas, spleen, small intestine, cecum, appendix,
ascending, transverse, descending and sigmoid
colon, kidneys, ureters, adrenal glands, abdominal
aorta, inferior vena cava, bladder and rectum
(Colbert et al, 2009; Marieb, 2009).
The alimentary tract, or gastrointestinal tube, is
approximately 27 feet long (Colbert et al, 2009;
Marieb, 2009). It begins at the mouth and ends
at the anus. Its function is to ingest and digest
food, absorb nutrients, electrolytes and water,
and excrete waste. Peristalsis moves food and
the products of digestion under the control of
the autonomic nervous system (Colbert et al,
2009; Marieb, 2009).
A patient with abdominal problems or
disease may have a wide range of symptoms.
Some problems may be dissociated from the
abdominal system directly but impact upon
organs in the abdomen, such as in diabetic
gastroparesis and anticholinergic drug therapy
in which the patient experiences unpleasant
abdominal fullness after normal meals or early
satiety and therefore has an inability to eat
a full meal (Bickley and Szilagyi, 2007) or in
pregnancy when, in the third trimester, there
is upward displacement of the stomach.
In approximately 15–20% of pregnant women,
the upper portion of the stomach herniates through
the diaphragm. This is more common in older,
obese and multiparous women after the seventh
or eighth month of pregnancy (Seidel et al, 2006).
In addition, increased progesterone production
causes a decrease in motility and tone of smooth
muscles. Therefore, there is a delayed emptying
time of the stomach (Seidel et al, 2006; Swartz,
2006; Epstein et al, 2008).
Conversely, there is a range of symptoms that
are associated with abdominal problems and/or

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clinical skills

for diagnosing abdominal problems or disease

Table 1. Symptoms of abdominal disease (Epstein et al, 2008; Cox, 2004a).
Abdominal pain Nausea
Preparation for abdominal assessment
Anorexia Pain on swallowing (odynophagia)
Assessment of the abdomen usually includes
Change in bowel habit Pale faeces
assessment of the mouth, abdomen and rectum
Change in abdominal girth Bloody faeces and is best undertaken in a warm, quiet, well-
Constipation Puritus lit environment. Privacy should be provided so
Dark urine Rectal bleeding that a discrete interview can be conducted and
Diarrhoea Vomiting the abdomen exposed for examination. The
following equipment should be gathered: gloves,
Dyspepsia and belching Weight loss
stethoscope, torch, measuring tape, felt-tip pen
Dysphagia Wind
and a gown and drapes to cover the patient.
Haematemesis Heartburn Explain to the patient that the assessment
Jaundice Mesenteric angina should not be painful, although they may
From: McGrath (2004); Seidel et al (2006) experience some discomfort at times. As with
other forms of assessment, such as cardiac and
respiratory assessment, selective listening must
disease (Table 1), which should be explored fully be employed during auscultation.
if a tentative diagnosis is to be made (Seidel et Ensure that the patient urinates before
al, 2006; Epstein et al, 2008; Jarvis, 2008). For beginning the assessment. Positioning of the
example, ageing brings about changes in the patient is essential. The patient should be placed
functional ability of the gastrointestinal tract, in a supine position with arms at their sides and
motility of the intestine changes, and secretion their head on a pillow. To prevent abdominal
and absorption are impacted. muscle tensing, flex the patient’s knees slightly
Bacterial flora in the intestine undergo towards their chest. Putting a pillow under the
changes and become less biologically active, patient’s knees promotes comfort – particularly
which impairs digestion (Seidel et al, 2006). for patients who find it difficult to maintain
Older people, therefore, often complain of flexion of the knees.
food intolerance and wind. Furthermore, some Ask the patient to breathe quietly and slowly
older people are unable to report abdominal through their mouth. Then ask the patient to
pain. This, in association with blunted fever and point to any areas that are tender and tell them
leukocyte response, complicate the diagnosis of that you will examine those areas last. Observe
abdominal infection in older people (Seidel et al, the patient’s facial expression as you undertake
2006; Talley and O’Connor, 2006). Assessment the assessment. A stoic patient may not admit to
of abdominal pain in the older adult may be experiencing abdominal discomfort. Therefore, a
difficult because some of these patients can change in facial expression may show when the
not communicate their pain (Cox, 2004a). patient is experiencing discomfort. Subsequently,
Obtaining a good history from the family, or the assessment can be modified accordingly. The
others who routinely care for the older adult, order to be followed in an abdominal assessment is
and using research-based pain assessment tools delineated in Table 2. Remember that unlike other
in association with behavioural cues, is the basis forms of assessment, in abdominal assessment
the gastrointestinal nurse always begins with
Table 2. Order for examination inspection and follows this with auscultation so that
of the abdomen the abdominal contents are not disturbed, which
1. Inspection could alter bowel sounds during auscultation.
2. Auscultation
Inspection
3. Percussion
Begin the assessment by inspecting the patient’s
4. Palpation
entire abdomen. Since the liver and spleen lie

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protected under the ribs, the lower half of the
chest must also be inspected. Assess abdominal
symmetry, noting overall contour and skin condition
as well as the appearance of the umbilicus and
any visible pulsations. Assess abdominal contour
by standing at the feet of the patient first. Then
move to the side of the patient and stoop so
that the abdomen is at eye level. Look at the
abdominal profile. Is the abdomen fully rounded
or distended? Is the umbilicus inverted or everted?
Is the abdomen scaphoid in appearance, or is
it distended in the upper or lower half only?
Normally, the abdomen is concave, symmetrical
and moves gently with respiration (Epstein et al,
2008). A concave (scaphoid) abdominal contour
may indicate malnutrition, whereas distension may
indicate the presence of a tumour, ascites or the
accumulation of air. In thin patients, the pulsation
of the aorta may be seen in the midline epigastric
area (Barkauskas et al, 2002; McGrath, 2004; Jarvis,
2008). Aortic pulsations may be pronounced due
to increased intra-abdominal pressure related to
the presence of a tumour or ascites. Peristalsis
is not normally visible. Strong visible peristalsis
indicates intestinal obstruction.
Inspect the skin. It normally appears smooth
and intact. Look for discolouration, striae,
rashes, dilated veins, scars or other lesions. Skin
abnormalities allude to underlying problems.
Bulging around scars may indicate incisional
hernias. Striae, in addition to resulting from
pregnancy or obesity, may reflect the presence
of an abdominal tumour or another disorder
such as Cushing’s syndrome. Cushing’s syndrome
characteristically causes thin-looking skin and
purple striae to occur, which is due to the excessive
secretion of cortisol (Seidel et al, 2006).
Tortuous or dilated superficial abdominal veins
may indicate inferior vena cava obstruction and
cutaneous angiomas may indicate liver disease. A
blue coloration around the umbilicus may be an
early sign of intra-abdominal bleeding. Normally,
abdominal veins are not prominent. If abdominal
veins are prominent, the direction of flow should
be assessed. This can be readily undertaken by
placing two fingers at one section of a vein and
applying occlusive pressure. Move one of your
fingers further along the length of the vein so
that this section of vein is flattened (emptied).
Then remove the finger that has been moved
vol 7 no 1 February 2009 gastrointestinal nursing
clinical skills
along the vein. Look to see in which direction the
vein refills. In inferior vena cava obstruction, the
blood flow below the umbilicus flows up towards
the umbilicus, whereas in portal hypertension
the blood flows downwards away from the
umbilicus (McGrath, 2004).
Auscultation
Auscultation follows inspection and provides
valuable information about gastrointestinal
motility and underlying abdominal vessels
and organs. Sounds heard upon auscultation
can be characterized in the same fashion
as in percussion (type of sound, pitch and
location). It is preferable for the diaphragm of
the stethoscope to be used to hear normal as
well as abnormal bowel sounds.
The diaphragm transmits high-pitched sounds
and provides a broader area of sound whereas
the bell transmits softer sounds (Cox, 2004b).
When the bell is used, pressure on the bell will,
by stretching the patient’s skin underneath the
bell, create a diaphragm effect. Lightly place the
stethoscope diaphragm on the abdominal skin
in all four quadrants of the abdomen. The four
quadrants of the abdomen (right lower quadrant,
right upper quadrant, left upper quadrant, left
lower quadrant) are divided horizontally and
vertically at the umbilicus. Take care not to put
pressure on the diaphragm as this may stimulate
peristalsis and subsequently mask the usual sounds
that would be heard. A systematic approach
should be undertaken when listening.
Before placing the diaphragm of the stethoscope
on the patient’s abdomen, warm your hands and
the diaphragm of the stethoscope in order to
prevent muscular contraction. Muscular contraction
can alter auscultation findings. Listen with the
diaphragm for friction rubs in the area of the
liver and spleen. Friction rubs are high pitched
and, although in the abdomen are rare, it may
indicate inflammation of the peritoneal surface
of the organ from tumour, infection or infarction
(Seidel et al, 2006; Swartz, 2006).
Listen for bowel sounds. Note their frequency
and character. Normally, bowel sounds occur
irregularly and range 5–35 per minute. Borborygmi
is loud, prolonged gurgles, such as with diarrhoea.
Increased sounds occur with gastroenteritis and
may indicate intestinal obstruction or hunger.
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clinical skills
Table 3. Abnormal auscultation sounds
Bowel sounds
Bowel sounds: hyperactive
or hypoactive sounds
created by air and fluid
movement through the
bowel
Systolic bruits: vascular
‘blowing’ sounds resembling
cardiac murmurs
Venous hum: continuous,
medium-pitched sound
caused by blood flow in a
large vascular organ
Friction rub: harsh
grating sound that sounds
like two pieces of leather
rubbing together
From: McGrath (2004); Epstein et al (2008); Jarvis (2008)
Right femoral
artery
Figure 1. Ausculation sites.
14
High-pitched sounds suggest intestinal fluid and
air under pressure, which is frequently noted in
Location Possible indication early obstruction.
Decreased bowel sounds, on the other hand,
All four quadrants Hyperactive = diarrhoea or
early intestinal obstruction; occur in peritonitis and paralytic ileus. Seidel et al
hypoactive/then absent (2006) indicate the absence of bowel sounds can
sounds = paralytic ileus of only be established after 5 minutes of continuous
peritonitis; high pitched/ listening. McGrath (2004) indicates that you should
tinkling = intestinal fluid
listen for up to 7 minutes before deciding that
and air under tension in a
bowel sounds are absent. After listening with
distended bowel; high
pitched/rushing with the diaphragm, use the bell to listen for vascular
abdominal cramp = sounds. Listen in the epigastric region and each
obstruction of the four quadrants for bruits in the aortic,
Abdominal aorta; Partial arterial obstruction or renal, iliac and femoral arteries (see Figure 1).
renal artery/iliac dissecting abdominal Bruits may indicate atherosclerosis (Barkauskas
artery aneurysm; renal artery;
et al, 2002). Abnormal auscultation sounds are
stenosis; hepatomegaly
listed in Table 3.
Epigastric or Hepatic cirrhosis
umbilical
Percussion
Abdominal percussion aids in determining the size
Hepatic and spleen Inflammation of the and location of abdominal organs. Percussion also
peritoneal surface of an aids in the assessment of excessive accumulation
organ; liver tumour of fluid and /or air in the abdomen. As in
auscultation, a systematic approach should be
used in percussing all four quadrants. Percussion
sounds vary depending on the density of the
organ and the underlying structures. Dull sounds
are heard over dense structures, like the liver
and spleen, and tympanic sounds are heard
over air filled structures, such as the stomach
and intestines (see Figure 2).
In the obese patient, it may be difficult to
Aorta discern percussion sounds. Percussion involves
striking one object against another to produce
Right renal Left renal
artery artery percussion sounds (sound waves), which are
termed forms of resonance. These arise from
Right iliac Left iliac
artery artery vibrations 4–6 cm deep in the body’s tissues (Seidel
Left femoral et al, 2006; Bickley and Szilagyi, 2007).
artery
In percussion, the finger of one hand functions as
a hammer (plexor) and strikes the dorsal surface of
the opposite hand’s finger on the interphalangeal
joint. To perform this form of indirect percussion,
as opposed to direct percussion which is when
the hand strikes the patient’s abdomen directly,
the non-dominant hand is placed on the surface
of the patient’s abdomen with the fingers slightly
spread. The distal phalanx of the middle finger
is placed firmly on the abdominal surface of the
patient while the other fingers are held slightly off
the surface of the patient’s abdomen. The wrist
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 clinical skills

of the other hand is snapped downward and the Figure 2. Percussion sites and hand placement.
tip of the middle finger, which is being used as
the hammer, sharply taps the interphalangeal
joint of the finger that is pressing on the patient’s
abdomen (see Figure 3).
Refer to Table 4 for the classification of Percussion sites
percussion sounds of the abdomen and where Right upper Left upper
these may be heard. Remember, the quieter the quadrant quadrant

percussion sound, the more dense the medium.

Therefore, percussion sounds over air are loud
and over fluid are less loud. Over solid areas,
percussion sounds will be soft.
There are several points to consider when
percussing the abdomen. The tap of the striking
finger (plexor) should be done quickly, lifting the
finger to prevent dampening of the sound. Only
one location should be percussed at a time, and
this should be repeated several times, in each
area, in order to facilitate interpretation of the
sound. Keep in mind that percussion as well as Hand placement for
palpation are contraindicated in patients with percussion

suspected abdominal aortic aneurysm and patients

who have received organ transplants.
Abnormal percussion findings occur in patients
with abdominal distension either from the
accumulation of air, ascites or masses. High-pitched
tympanic sounds may indicate bowel distension
associated with air. Ascites will produce shifting are caring for the patient so that they can measure
dullness. Shifting dullness can be assessed by in the same location when subsequent readings
having the patient lie supine. Percuss for areas are taken. They can then report any changes to
of dullness and resonance and mark the borders you. Ascites presents in liver failure, peritonitis
with a felt-tip pen. Then have the patient lie and abdominal tumour.
on one side. Percuss for tympany and dullness
and mark the borders again with a felt-tip pen. Palpation
Ascites fluid settles with gravity. Therefore, you Palpation is the final component in an abdominal
should expect to hear dullness in areas where assessment and is used to assess the organs of
the fluid has settled and tympany in the areas
where the bowel has risen. In patients without Table 4. Percussion sounds of the abdomen
ascites, the borders marked with a felt-tip pen
Sound Description Location
will remain relatively the same, whereas in ascites
the border of dullness will shift to the dependent Tympany Musical sound/high Air-filled viscera
pitch, little resonance
side as the fluid resettles with gravity.
Hyperresonance Pitch sounds between Base of left lung
Whenever the patient has abdominal distension,
tympany and resonance
this should be assessed by taking serial measurements
Resonance Sustained sound of Vesicular lung tissue or
of the patient’s abdominal girth. To do this, wrap a
moderate pitch the abdomen
tape measure around the patient’s abdomen at the
Dullness Short, high pitched Solid organs
level of the umbilicus and record the measurement.
sound with little
Mark the point of measurement on the patient’s
resonance
abdomen. Then explain what you have done
From: Seidel et al (2006)
either to the patient, their family or others who

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clinical skills
Figure 3. Percussion technique.
the abdominal cavity, to detect muscle spasm,
tumours, fluid and areas of tenderness (Seidel et
al, 2006; Epstein et al, 2008). It is a sophisticated
skill that involves the use of the hands and fingers
to gather information about the size, shape,
mobility, consistency and tension of abdominal
contents through the sense of touch. Touch is
considered therapeutic, and is the actuality of
‘laying on of hands’. Palpation of the abdomen
is a particularly sensitive matter; therefore, the
gastrointestinal nurse’s approach should be gentle.
Your hands should be warm and fingernails
short, as this is not only practical in terms of
the approach to the patient but is also symbolic
of the respect you hold for the patient and the
privilege the patient gives you in allowing you
to examine the patient’s body.
Begin with light palpation. Like auscultation
and percussion, palpation should be systematic
in assessing all four quadrants. Avoid palpating
areas that have been identified by the patient
as being tender or problematic.
Various parts of the hands and fingers are
used for specific types of palpation due to their
variance in sensitivity associated with position,
Table 5. Areas of the hand used in palpation
• Palmar surface of the hand and finger pads – to assess size, consistency,
texture, fluid, surgical emphysema and the texture and form of a mass or
structure
• Ulnar surface of the hand and fingers – to assess vibration
• Dorsal surface of the hands – to assess temperature
From: McGrath (2004)
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vibration and temperature. Refer to Table 5 for
the areas of the hands to use in palpation. The
palmar surface of the hand and fingers is more
sensitive than the fingertips and is used to discern
size and shape. The back of the hand is used to
discern hot and cold. The ulner surface of the
hand is used to assess vibration. Gently rest the
palm of your hand with the fingers extended
on the patient’s abdomen.
Use the palmar surface of your fingers to
depress the abdominal wall approximately
1–2 cm. Employ a light even pressing motion as
this helps to relax the patient. Avoid short quick
jabs, which can frighten the patient and cause
discomfort. If the patient is ticklish, ask the patient
to rest their hand on the top of yours. This will
often decrease the patient’s ticklish response.
Move your hands in a circular fashion so that the
abdominal wall moves over underlying organs.
The patient’s abdomen should feel smooth and
have a consistent softness throughout.
When inflammation or tenderness is present,
the patient will guard their abdomen (Barkauskas,
2002). When this resistance occurs, determine
whether it is voluntary or involuntary by placing a
pillow under the patient’s knees (if you have not
already done so) and ask the patient to breathe
slowly through their mouth. If guarding remains
then it is probably an involuntary response.
Board-like hardness of the abdominal wall is an
indication of peritonitis and appendicitis.
Deep palpation is required to assess abdominal
organs and detect masses. Use the palmar
surface of your extended fingers to press deeply
into the abdominal wall, approximately 4–6 cm.
Systematically assess all four quadrants. Be aware
that deep palpation may evoke tenderness in
healthy patients over the cecum, sigmoid colon
and aorta. Identify any masses and determine
whether they are superficial (located in the
abdominal wall) or intra-abdominal by having the
patient raise their head off the pillow. This action
contracts the abdominal muscles; subsequently,
masses in the abdominal wall will continue to
be palpable whereas those in the abdominal
cavity will be difficult to feel.
In addition to assessing all four quadrants,
particular attention should be paid to the umbilical
ring. This area should be smooth and free of
bulges, nodules or granulation. If the umbilical
gastrointestinal nursing vol 7 no 1 February 2009

ring is soft in the centre, this suggests a hernia.
Specific structures, such as the liver, should be
palpated as well. The liver is difficult to assess
because it lies under the eleventh and twelfth
ribs. To assess the liver, place your right hand
on the patient’s abdomen with your fingers
pointing towards the patient’s head. Ask the
patient to breathe regularly a few times and
then to take a deep breath. As the patient takes
a deep breath, try to feel the liver edge as the
diaphragm pushes the liver down. Normally, the
liver is not palpable except in very thin people.
When a tumour or cirrhosis is present, the edge
of the liver will feel hard and irregular.
Conclusion
In this article, the essentials of abdominal
examination (excluding DRE) have been
presented. The gastrointestinal nurse will find
the information related to the processes of
inspection, auscultation, percussion and palpation
useful when examining patients at their first visit
and subsequent visits when patient complaints
occur or complications arise.
Examination of the abdomen can tell the
gastrointestinal nurse much about the overall
health status of the patient and provides a baseline
for diagnoses and treatment. In part 2, the process
of undertaking a thorough DRE will be presented.
As with abdominal examination, DRE aids in the
identification of serious complications/pathology
that prompt further clinical investigation. ■
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