Abdomen: Order of Assessment

Assessment Order of Assessment ● Inspection, auscultation, then palpation Tools ● Stethoscope, watch/clock, measuring tape Anatomy Quadrants Right Upper Quadrant (RUQ) ● Liver ● Gallbladder ● Duodenum ● Part of the ascending and transverse colon ● Head of the pancreas ● Right kidney Right Lower Quadrant (RLQ) ● Cecum ● Appendix ● Right ovary and fallopian tube (female) ● Right spermatic cord (male) ● Right ureter Left Upper Quadrant (LUQ) ● ● ● ● Stomach, Spleen Pancreas Left adrenal gland ● Part of the transverse and descending colon ● Left lobe of the liver ● Left kidney Left Lower Quadrant (LLQ) ● Sigmoid colon ● Left ovary and fallopian tube (female) ● Left spermatic cord (male) ● Part of the descending colon ● Left ureter Nine Regions Right Hypochondriac Region ● ● ● ● ● Upper right section of the abdomen Right lower lobe of the liver Gallbladder Top portion of the kidney Part of the duodenum Right Lumbar Region ● Just below the right hypochondriac ● Ascending colon ● Kidney Right Inguinal Region ● Bottom right ● Cecum ● Appendix ● Right ureter and ovary ● Right spermatic cord Epigastric Region ● Center top of the abdominal area; where the ribs split ● Aorta ● Pancreas ● Pyloric end of the stomach Umbilical Region ● Below the epigastric region; in the middle, where the navel is ● Omentum ● Mesentary ● Lower part of the duodenum Hypogastric/Suprapubic Region ● Lowest mid-region ● Ileum ● Bladder ● Uterus Left Hypochondriac Region ● Upper left of the abdomen ● Stomach ● Top portion of the kidney ● Spleen Left Lumbar Region ● Below the left hypochondriac region ● Descending colon ● Kidney Left Inguinal Region ● Bottom left ● Sigmoid colon ● Left ureter and ovary ● Left spermatic cord Gastrointestinal Tract/Alimentary Canal ● 27-feet-long route that food takes from the mouth through digestion and excretion ● Works with the urinary system to remove watersoluble waste ● Once food is chewed/swallowed, it forms a bolus ● It travels down the esophagus into the stomach ○ A hallow, expandable, muscular organ that processes food ○ Uses acids and enzymes, like pepsin ● After the stomach digests food, it forms chyme ● Pyloric sphincter permits chyme to enter the SI ○ Three parts of the small intestines: duodenum, jejunum, and ileum ○ The villi in the SI assist with digesting, mixing, and absorbing liquified food ● The food travels through th eileocecal valve into the LI ○ Responsible for water/nutrient absorption and feces formation ○ First main part is the cecum, in the RLQ ○ The appendix has no digestive function and is at the base of the cecum ● When food leaves the cecum, it travels up to the colon ○ Four parts: ascending, transverse, descending, and sigmoid ○ Sigmoid is the lower part ● The sigmoid colon leads food to leave through the rectum and anus as feces Accessory GI Organs and Vessels Liver ● Second largest organ below the diaphragm; RUQ, covered mostly by the ribcage ● ● ● ● ● ● Stores minerals and vitamins Protects against harmful bacteria Detoxifies ingested chemicals Stores and releases glycogen from carbohydrates Metabolizes proteins Produces clotting factors and bile, which breaks down fats during digestion Gallbladder ● Small organ attached under the liver; right hypochondriac region ● Concentrates and stores bile ● Releases it into the duodenum through the common bile duct Pancreas ● Behind the stomach; LUQ ● Two glands: ○ Exocrine: Releases enzymes for digestion ○ Endocrine: Releases insulin and glucagon to regulate blood sugar and metabolism ○ Insulin moves glucose into the cells ● Pancreatic enzymes allow for breakdown of food to be used as fuel Abdominal Aorta ● Runs down the abdominal cavity to the LUQ in the epigastric region ● Splits into left and right iliac arteries ○ Eventually become femoral arteries Spleen ● Next to the liver; LUQ ● Filters RBCs and roduces WBCs to fight infections Physiology Functions include motility, absorption, secretion, elimination, and digestion. Metabolism ● Gastric secretions have hormones and neuroregulators that control the amount of secretions and movement as food is digested ● Maintain blood glucose levels, fluid, and electrolytes during digestion Motility ● How food is moved through the GI tract by peristalsis ○ Small smooth muscle movements of the digestive tract organs ○ Controlled by the ANS Secretion ● Digestion starts with salivary enzymes and mechanically chewing ● The stomach then secretes enzymes and gastric acids to break down food chemically Digestion and Absorption ● Digestion: Breaking down large molecules of food into a small, water-soluble form so they can be absorbed by blood plasma ● The SI absorbs nutrients; the LI absorbs water, vitamins, and minerals Health History Interview Present Health Question Subjects ● Chronic conditions affecting the GI system ○ Ex. diabetes, hepatitis, or cirrhosis ● Abdominal pain ○ OLDCART ○ Other symptoms occuring with the pain ■ Ex. nausea, diarrhea, constipation, rectal bleeding, fever, fatigue, stress ● Medications (OTC or herbal) ● Abdominal distension ○ OLDCART and associated symptoms ● Problems with digestion ○ Ex. heartburn, indigestion, nausea, vomiting ● ● ● ● ○ OLDCART and associated symptoms ■ Sweating, lightheadedness, radiating pain, fever, chills ○ Travel history; exposure to infectious disease, unsanitary water/food ○ Vomiting: Color, texture, blood, undigested food particles Last bowel movement ○ Color, consistency, and frequency Changes in bowel habits ○ Associated symptoms ■ Ex. pain, fever, nausea, cramping, increased gas Changes in appetite ○ Changes in weight ○ What was eaten in last 24 hours Substance use Past Health History Question Subjects ● Past diagnosis with GI disease ○ Ex. ulcers, gallbladder problems, hepatitis, colitis, hernias ● Abdominal surgeries or colonoscopies ○ Complications and results Family History ● Immediate family GI cancer or hepatitis ○ Genetically related; can cause higher risk Inspection Preparation ● Client supine with their head on a pillow and knees slightly bent to relax the muscles Skin Tone and Appearance Expected Findings ● Smooth and dry abdominal skin ● Even and tone or lighter than the face/extremities Expected Variations ● Moles (nevi), healed scars, and silver striae ● If you observe striae, ask about their origin ● Document location, measurement, and characteristics Unexpected Findings ● ● ● ● ● Lesions, bruising, dilated veins, purple striae, rashes, or yellow coloring Yellow hue could indicate jaundice or a liver condition Glistening or taut skin could be due to ascites Pink/purple striae indicate recent stretching due to weight gain or abdominal distention Dilated veins and spider angiomas suggest liver disease Striae Rubrae and Scar Abdominal Distention Umbilical Hernia Symmetry and Masses Expected Findings ● Symmetry of movements associated with breathing ● No bulges or masses Expected Variations ● Slight aortic pulsations or peristaltic movements in very thin clients ● Bulges related to pregnancy Unexpected Findings ● Localized bulging, visible mass, asymmetry of movements, and visible intense pulsations ● Do not palpate an area of increased vascular pulsation ○ Could be from an abdominal aneurysm ● Visible GI peristalsis with a distended abdomen could indicate an intestinal obstruction Shape and Contour ● Observe from in front, behind, and from the side ● Lower to eye level slightly above the abdomen Expected Findings ● Flat, even, slightly convex, or rounded abdomen Expected Variations ● Related to body frame and weight ● Scaphoid (sunken looking) can be expected with a thin client ● Obese clients will have a rounded abdomen with rolls of subcutaneous fat along the sides Unexpected Findings ● Distention could be due to gas, tumors, fluid, constipation, or intestinal obstruction ○ Measure supine abdominal girth at the umbilical level ● Marked concavity could be from malnutrition or increased AP diameter of the rib cage Umbilicus Expected Findings ● Located at the body midline and inverted Expected Variations ● Umbilical piercings and extraversion (pushing upward) related to pregnancy ● Deeply sunken umbilicus due to adipose tissue in obese clients Unexpected Findings ● Redness, discoloration, swelling (herniations), lesions ● A protrusion, enlargement, or extruded umbilicus could be from a hernia ○ When the abdominal viscera protrudes through the muscle wall Auscultation Bowel Sounds ● Produced when air/fluid move through the stomach, SI, and LI via peristalsis ● Vascular sounds are not expected to be heard ● Allows data about bowel motility Preparation ● Place the diaphragm of the stethoscope lightly on the abdomen ● Pressing too hard can increase bowel sounds Assessment ● Have the client breathe normally ● Begin on the RLQ; bowel sounds are expected ○ The ileocecal valve, separating the SI and LI, is here ● Usually, if bowel sounds are heard in one quadrant, it is not necessary to listen to others ○ Generally always heard in the RLQ if present ● If bowel sounds are not heard in the RLQ, listen in other quadrants counterclockwise ● Note the location and frequency (overactive, underactive) of sounds ● If bowel sounds are not heard anywhere after five minutes, they are considered absent Expected Findings ● High-pitched with gurgling ● Frequency of 5-34 times per minute ● Can be cascading in volume and tone Expected Variations ● Borborygmus: A rumbling/growling sound due to hyperperistalsis ○ Often heard without a stethoscope Unexpected Findings ● Hyperactive sounds are louder and more intense due to increased motility/peristalsis ○ Rushing or tinkling sounds may be heard every few seconds, more than 34 times a minute (ex. with diarrhea) ● Hypoactive bowel sounds are diminished and soft; occur less than 5 times per minute ○ Could be related to impaired motility, side effects from medication/anesthesia, constipation, or bowel obstruction ● Absence of sounds could be associated with an intestinal obstruction ○ If five minutes pass without sounds, request another nurse validates the finding ● Vascular swishing sounds suggest blood vessel or liver disorders Palpation Preparation ● Ensure hand hygiene and warmth; have client in supine with knees bent/legs elevated ○ Arms at side; above head can cause muscle tightness ● Ask about painful areas; palpate them last ● Ask the client to take deep breaths through the mouth during palpation Assessment ● Use light palpation to assess for tenderness and muscle tone Deep Palpation ● Assesses for location, size, and shape of organs/masses Light Palpation ● Use the pads of four fingers and depress the surface 0.4 in a gentle dipping motion ● Move clockwise until all four quadrants have been palpated; do painful areas last ● If the client is ticklish, slide your hand over the surface or have them place their hand over/under yours as you palpate Expected Findings ● Nontender abdomen with relaxed muscles Expected Variations ● An anxious client can voluntarily guard and have difficulty relaxing their muscles ○ Encourage exhalation while palpating ● Older clients can have increased subcutaneous fat and decreased muscle tone ● Increased adipose tissue is present in overweight clients; distinguish from masses Unexpected Findings ● Tenderness, masses, and involuntary rigidity ● Involuntary rigidity/muscle guarding: Persistent hardness of the abdominal muscles despite relaxation/exhalation ○ May be bilateral or unilateral ○ Typically indicates the presence of inflammation Health Promotion Exercise ● A sedentary lifestyle increases the risk for GI conditions, like constipation ● Moderate exercise for 30 mins/day; promotes peristalsis and prevents constipation ● Decreases stress levels, which can aggravate some bowel conditions Diet ● A balanced diet that is high in whole grains, vegetables, and fruit is recommended ● High fiber helps the colon maintain an efficient pattern of peristalsis ○ Removes fat and waste products Water ● Consumption of 8-10 glasses of water/day ● Dietary fiber in the intestinal tract absorbs water and creates a larger, softer stool mass ○ Easier to pass Testing ● ● ● ● ● ● Regular screenings for colorectal cancer for those above 45 Check stool for occult or hidden blood, and stool DNA tests that screen for altered DNA Flexible sigmoidoscopy, which examines the rectum and descending colon Colonoscopy, which exams the rectum and entire LI Double contrast barium enema, which uses x-rays and a dye to examine the LI Those at a high-risk due to family history may be advised to start screening in their 20s Probiotics ● Alternative therapy for clients with frequent gastrointestinal discomforts ● Promote the growth of normal “good” microorganisms in the GI tract ● Can be found in oral dietary supplements, yogurt, suppositories, and creams