HEALTH ASSESMENT SKILLS LECTURE

TUPAS, Mary Daniella s.

BSN1-B2

ASSESSMENT OF THE ABDOMEN

PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS
1. Explain the
procedure
2. Inspects the
abdomen for:
a. Color Color Color Color
 View the color of the patient’s  The abdomen should be  Uneven skin color
abdomen from the costal margin to the uniform in color and  Bruises or areas of local
symphysis pubis pigmentation discoloration
 Cullin’s sign – a hemorrhagic
discoloration of the umbilical area
due to intraperitoneal
hemorrhage from any cause; one
of the more frequent causes is
acute hemorrhagic panniculitis.
 The yellow hue of jaundice may
be more apparent on the
abdomen
 Pale, taut skin may be seen with
ascites (significant abdominal
swelling indicating fluid
accumulation in the abdominal
cavity).
 Redness may indicate
inflammation.
 Engorged abdominal veins
 Network of dilated veins on the
abdomen
 HEALTH ASSESMENT SKILLS LECTURE
PRCEDURE HOW TO PERFORM  NORMAL FINDINGS
b. Lesions Lesions Lesions
 Assess for lesions and rashes. Inspect  Flat or raised brown
the abdomen for scars, striae. moles are normal and
may be apparent
 There should be no
abdominal scars present
 No evidence of stiae is
present
 ABNORMAL FINDINGS
Cullen’s sign & Grey Turner’s sign
Lesions
 Changes in moles including size,
color, and border symmetry.
Bleeding moles or petechiae
(reddish or purple lesions)
 Scars and striae are present
Abdominal scar from a hysterectomy
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS
c. Vascularity Vascularity Vascularity
 Note the vascularity of the abdominal  Scattered fine veins may
skin. be visible. Blood in the
veins located above the
umbilicus flows toward
the head; blood in the
veins located below the
umbilicus flows toward
the lower body
d. Contour Contour Contour
 View the contour of the patient’s  In the normal adult , the
abdomen from the costal margin to the abdominal contour is flat
symphysis pubis (straight horizontal line
from costal margin to
symphysis pubis) or
 ABNORMAL FINDINGS
Abdominal striae
Vascularity
 Dilated veins may be seen with
cirrhosis of the liver, obstruction
of the inferior vena cava, portal
hypertension, or ascites.
Contour
 Large convex symmetrical profile
from the costal margin to the
symphysis pubis
 A convex abdomen that has a
marked increased at the height of
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

rounded (convexity of the umbilicus
abdomen from costal  A concave symmetrical profile
margin to symphysis from the costal margin to the
pubis) symphysis pubis

e. Symmetry Symmetry Symmetry Symmetry

 View the symmetry of the patient’s  Abdomen should be  Asymmetrical abdomen
abdomen from the costal margin to the symmetrical bilaterally
symphysis pubis
 Move to the foot of the examination
table and recheck the symmetry of the
patient’s abdomen.
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

f. Movements Movements Movements Movements
 Observe the abdomen for smooth,  There is no evidence of  Abnormal respiratory movements
even respiratory movement when the respiratory retractions. and retractions are observed
client breathes  Abdomen rises with  Diminished abdominal respiration
inspiration and falls with or change to thoracic breathing
expiration
3. Measures Measures abdominal girth
abdominal girth  Measure abdominal girth at the same
time of day, ideally in the morning just
after voiding, or at a designated time
for bedridden clients or those with
indwelling catheters.
 The ideal position for the client is
standing; otherwise, the client should
be in the supine position. The client’s
head may be slightly elevated (for
orthopneic clients). The client should
be in the same position for all
measurements.
 Use a disposable or easily cleaned tape
measure. If a tape measure is not
available, use a strip of cloth or gauze,
then measure the gauze with a cloth
tape measure or yardstick.
 Place the tape measure behind the
client and measure at the umbilicus.
Use the umbilicus as a starting point
when measuring abdominal girth,
especially when distention is apparent.
 Record the distance in designated
units (inches or centimeters).
 Take all future measurements from the
same location. Marking the abdomen
with a ballpoint pen can help you
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

identify the measuring site. As a
courtesy, the nurse needs to explain
the purpose of the marking pen and
ask the patient not to wash the mark
off until it is no longer needed.
4. Checks umbilicus
for:
a. Position Position Position
 Umbilicus is midline at  A deviated umbilicus may be
lateral line caused by pressure from a mass,
enlarged organs, hernia, fluid, or
scar tissue
b. Contour Contour Contour
 It is recessed (inverted)  An everted umbilicus is seen with
or protruding no more abdominal distention.
than 0.5 cm, and is  An enlarged, everted umbilicus
round or conical. suggests umbilical hernia

Umbilical hernia

5. Checks abdominal  Ask the client to raise the head.  Abdomen does not bulge  A hernia (protrusion of the bowel
reflex when client raises head. through the abdominal wall) is
seen as a bulging in the
abdominal wall. Diastasis recti
appears as a bulging between a
 HEALTH ASSESMENT SKILLS LECTURE
PRCEDURE HOW TO PERFORM
6. Auscultates for
a. Bowel sounds Bowel sound
 Place the diaphragm lightly on the
abdominal wall beginning at the RLQ
 Listen to the frequency and character
of the bowel sounds. It is necessary to
listen for at least 5 minutes in an
abdominal quadrant before concluding
that bowel sounds are absent
 Move diaphragm to RUQ, LUQ, LLQ
 NORMAL FINDINGS
Bowel sound Bowel sound
 A series of intermittent,
soft clicks and gurgles
are heard at a rate of 5–
30 per minute.
 Normal hyperactive
bowel sounds are called
“borborygmi”, they are
loud, audible, gurgling
sounds. May be due to
hyperperistalsis
(‘stomach growling’)
 ABNORMAL FINDINGS
vertical midline separations of the
abdominis rectus muscles. This
condition is of little significance.
An incisional hernia may occur
when a defect develops in the
abdominal muscles because of a
surgical incision. A mass within
the abdominal wall is more
prominent when the head is
raised, whereas a mass below the
abdominal wall is obscured
 “Hyperactive” bowel sounds
that are rushing, tinkling, and
high pitched may be abnormal
indicating very rapid motility
heard in early bowel obstruction,
gastroenteritis, diarrhea, or with
use of laxatives.
 “Hypoactive” bowel sounds
indicate diminished bowel
motility. Common causes include
paralytic ileus following
abdominal surgery, inflammation
of the peritoneum, or late bowel
obstruction. May also occur in
pneumonia.
 Absence of bowel sounds
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

b. Vascular sound Vascular. Vascular. Vascular.
i. Abdominal  Place the bell of the stethoscope over  No audible bruits  Audible bruits are auscultated
aorta the abdominal aorta, renal arteries,
ii. Renal iliac arteries
arteries  Note the presence of bruit over each
iii. Iliac arteries area
7. Percusses the Percussion Percussion Percussion
different quadrants  Percuss all four quadrants in a  Tympany is the  Dullness over areas where
a. RLQ systematic manner. Begin percussion predominant sound tympany normally occurs, such as
b. RUQ in the RLQ moving up to the RUQ heard because air is over the stomach and intestines,
c. LUQ crossing over to the LUQ and moving present in the stomach is considered abnormal
d. LLQ down to the LLQ and in the intestines. It
 Visualize each organ in the is a high-pitched sound
corresponding quadrant; note when of long duration.
tympany changes to dullness  In obese patients it may
be difficult to elicit
tymppany due to the
quantity of adipose
tissue.
 Dullness is normally
heard over organs such
as the liver or a
distended bladder. Dull
sounds are high- pitched
and moderate duration
8. Percusses the Bladder: Bladder:
bladder  Percuss upwards from the symphysis  It is abnormal to percuss
to the umbilicus a bladder that has
 Note where the sound changes from recently been emptied.
dullness to tympany The urine that remains in
the bladder after
urination is called
residual urine. A
bladder may also be dull
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

to percussion when the
patient has difficulty
voiding.

9. Percusses the liver Liver span Liver span Liver span

span  Percuss the span or height of the liver
by determining its lower and upper
borders.
 To assess the lower border, begin in
the RLQ at the mid-clavicular line
(MCL) and percuss upward (Fig. 23-14).
Note the change from tympany to
dullness. Mark this point: It is the lower
border of liver dullness. To assess the
descent of the liver, ask the client to
take a deep breath and hold; then
repeat the procedure. Remind the
client to exhale after percussing.
 To assess the upper border, percuss
over the upper right chest at the MCL
and percuss downward, noting the
 The lower border of liver
dullness is located at the
costal margin to 1 to 2
cm below.
 On deep inspiration, the
lower border of liver
dullness may descend
from 1 to 4 cm below the
costal margin.
 The upper border of liver
dullness is located
between the left fifth
and seventh intercostal
spaces.
 The normal liver span at
the MCL is 6–12 cm
(greater in men and
taller clients, less in
shorter clients).
 The normal liver span at
the MSL is 4–8 cm.
 The upper border of liver dullness
may be difficult to estimate if
obscured by pleural fluid of lung
consolidation.
 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, whereas a liver in a
higher position than normal may
be caused by an abdominal mass,
ascites, or a paralyzed
diaphragm. A liver in a lower or
higher position should have a
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

change from lung resonance to liver normal span.
dullness. Mark this point: It is the upper  An enlarged liver may be roughly
border of liver dullness. estimated (not accurately) when
 Measure the distance between the two more intense sounds outline a
marks: this is the span of the liver. liver span or borders outside the
normal range.

 Repeat percussion of the liver at the

midsternal line (MSL).

10. Percusses the Kidneys Kidneys Kidneys

kidneys  Perform blunt percussion on the  No tenderness or pain is  Tenderness or sharp pain elicited
kidneys at the costovertebral angles elicited or reported by over the CVA suggests kidney
(CVA) over the 12th rib the client. The examiner infection (pyelonephritis), renal
senses only a dull thud. calculi, or hydronephrosis

11. Performs light Light palpation Light palpation Light palpation

palpation  With your hands and forearm on a  The abdomen should feel  Light palpation reveals changes in
horizontal plane, use the pads of the smooth with consistent skin temperature, tenderness or
fingers to depress the abdominal wall 1 softness large masses.
cm
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

 Avoid short, quick jabs
 Lightly palpate all four quadrants in a
systematic manner
12. Performs Deep palpation Deep palpation Deep palpation
deep palpation  With the first four fingers close  Mild tenderness normally  Tenderness occurs with local
together, push down about 5 to 8 cm is present when inflammation, inflammation of the
 Moving clockwise, explore the entire palpating the sigmoid peritoneum or underlying organ,
abdomen. colon. Any other and with an enlarged organ
 To overcome the resistance of a very tenderness should be whose capsule is stretched.
large or obese abdomen, use a investigated.
bimanual technique. Place your two
hands on top of one another (Fig. 21-
23). The top hand does the pushing;
the bottom hand is relaxed and can
concentrate on the sense of palpation
 Note the location, size, consistency,
and mobility of any palpable organs
and the presence of any abnormal
enlargement, tenderness, or masses
13. Palpates the Bladder Bladder Bladder
bladder  Using deep palpation, palpate the  An empty bladder is not  Bladder that is nodular or
abdomen at the midline, starting at the usually palpable. asymmetrical to palpation is
symphysis pubis and progressing up to  A moderately full abnormal
the umbilicus bladder smooth and  It is abnormal to palpate a
 If the bladder is located, palpate the round, and it is palpable bladder that has been recently
shape, size and consistency. above the symphysis emptied
pubis
 Full bladder is palpated
above the symphysis
pubis, and it may be
close to the umbilicus
14. Performs
special assessment
procedure
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PRCEDURE HOW TO PERFORM  NORMAL FINDINGS  ABNORMAL FINDINGS

a. Rebound Rebound tenderness
tenderness  Apply several seconds of firm pressure
to the abdomen, with the hand at a 90
degree angle(perpendicular to the
abdomen) and the fingers extended
 Quickly release the pressure
b. Rovsing’s sign Rovsing’s sign
 Press deeply and evenly in the LLQ for
5 seconds
 Note the patient’s response
Rebound tenderness
 Pain is not elicited
Rovsing’s sign
 No pain should be
elicited
Rebound tenderness
 As the abdominal wall returns to
its normal position, the patient
complains of pain at the pressure
site (direct rebound tenderness)
or at another site (referred
rebound tenderness)
 Pain in the RLQ can indicate
appendicitis. This location is
known as McBurney’s point.
Rovsing’s sign
 Abdominal pain felt in the RLQ is
abnormal and is a positive
Rovsing’s sign

c. Obturator sign Obturator sign Obturator sign Obturator sign

 Support the client’s right knee and  No abdominal pain is  Pain in the RLQ indicates irritation
ankle. Flex the hip and knee, and present of the obturator muscle due to
rotate the leg internally and externally appendicitis or a perforated
appendix.

d. Murphy’s sign Murphy’s sign Murphy’s sign Murphy’s sign

 Hold your fingers under the liver  Ask the person to take a  When the test is positive, as the
border. deep breath. A normal descending liver pushes the
response is to complete inflamed gallbladder onto the
the deep breath without examining hand, the person feels
pain. (Note: This sign is sharp pain and abruptly stops
less accurate in patients inspiration midway.
older than 60 years;
evidence shows that
25% of them do not
have any abdominal
tenderness.
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References:
Calleja, P., & Theobald, K., & Harvey. T. (2020). Estes Health Assessment and Physical Examination (3rd ed.). n.p.
Weber, J., & Kelley, J. (2014). Health Assessment in Nursing [PDF] (5th ed.). Wolters Kluwer Health, Philadelphia