Abdomen Assessment : Checklist

Christian University of Thailand College of Nursing INUR3302: Nursing Process and Basic Health Assessment Performing Abdominal Assessment 1. ID No. ………….... Name. ………………………………………Score ……... 2 = Performed satisfactorily Procedure 1. Identify the patient. 2. Explain the purpose of the abdominal examination and answer any questions. 3. Perform hand hygiene. 4. Help the patient undress if needed and provide a patient gown. Assist the patient to a supine position and expose the abdomen. 5. Inspect the abdomen for skin color, contour, pulsations, the umbilicus, and other surface characteristics ( rashes, lesions, masses, scars). 6. Auscultate all four quadrants of the abdomen for bowel sounds by using the diaphragm of the stethoscope.Use a systematic method. 7. Auscultate the abdomen for vascular sounds by using the bell of the stethoscope. 1 = Needs practice 0 = No Performance Rationale Identification of the patient ensures that the assessment will be performed on the right patient. Explanation helps to alleviate anxiety, promotes cooperation, and facilitates the examination. Hand hygiene deters the risk of microorganism transmission. Having the patient wear a gown facilitates examination of the abdomen. The umbilicus should be centrally located and may be flat, rounded, or concave.The abdomen should be evenly rounded or symmetric,without visible peristalsis. In thin people, an upper midline pulsation may normally be visible. Performing auscultation before percussion or palpation prevents percussion and palpation techniques from interferring with findings. Auscultation detects the presence of bowel sounds, which indicate peristalsis. A bruiit on auscultation suggests an aneurysm or arterial stenosis. Evaluation 8. Percuss the abdomen for tones. 9. Palpate the abdomen lightly in all four quadrants and then palpate using deep palpation technique. 10. Palpate for the kidneys on each side of the abdomen. Palpate the liver at the right costal boarder. Palpate for the spleen at the left costal border. 11. Assess for rebound tenderness last if the patient reports pain by pressing deeply and gently into the abdomen with the hand and fingers downward and then withdrawing the hand rapidly. 12. Palpate and then auscultate the femoral pulses in the groin. 13. Replace the patient’s gown and assist the patient to a comfortable position. 14. Perform hand hygiene. 15. Document findings and the procedure done. Persussion assesses for the density of the abdominal contents, organs, or possible masses. Tympany over more air-filled regions and dullness over a solid organ are the predominant tones elicited. Percussion on the right side helps to evaluate the spleen;percussion over the symphysis pubis helps to evaluate the bladder for fullness. Palpation provides information about the location, size, tenderness, and condition of the underlying structures. A normal liver, spleen, and kidneys are often not palpable. Palpation helps detect enlarged organs. Rebound tenderness indicates peritioneal irritation, such as from appendicitis. This assessment is performed last because it can causepain and muscle spasm that could interfere with the rest of the examination. Continues palpation for rebound tenderness could lead to rupture of the appendix. This technique assesses vascular patency. This ensures the patient’s comfort. This deters the spread of microorganisms. Documentation prevents clinical errors during the practice Recommendations: …………………………………………………………………….. Instructor……………….. ………./………./……….