abdominal assessment

1. Nursing Assessment of the
Gastrointestinal System
DR\ Nermen Abd Elftah

2. OBJECTIVES
At the end of this class, the student will be
able to:
Identify landmarks for the abdominal
assessment
Correctly perform techniques of inspection,
auscultation, percussion and palpation
Differentiate normal from abnormal findings
Document findings

3. The digestive system

4. Concepts of Structures and Functions
The GI System consists of the GI tract and its associated organs and glands
A.GI tract
1. mouth
2. esophagus
3. stomach
4. small intestines
5. large intestines
6. rectum
7. anus
B. Associated organs
1. liver
2. gall bladder
3. pancreas

6. Structures and Function of the
GastroIntestinal System
Main Function of the GI System?????
Supply Nutrients to body cells

7. Process of Digestion and Elimination
A.Ingestion ( Taking In Food)
B.Digestion ( Breakdown of Food)
C.Absorption ( transfer of food products into
the circulation)
D.Elimination

8. Digestion and Absorption
Food is broken down into small and simple
compounds enough to be absorbed into the
bloodstream by diffusion or active
transport.

9. Effects of Aging on the
Gastrointestinal Tract
A.Teeth may loosen up from the supporting gums and bones.
B.Decreased output of the salivary glands leads to dryness of mucous
membranes and increased susceptibility to breakdown, difficulty
swallowing and decrease stimulation of the taste buds.
C.Decreased secretion of digestive enzymes and bile – decrease ability
to digest and absorb food.
>> impaired absorption of fat and fat soluble vitamins
D. Atrophy of gastric mucosa leads to decrease HCl acid production.
>>decrease iron and B12 absorption – anemia
>>proliferation of bacteria – diarrhea and infection
E.Decrease peristalsis in the large intestine, decrease muscular tone of
the intestinal wall and decrease abdominal muscle strength –
decrease sensation to defecate and increase incidence of
constipation.

10. Regions of the Abdomen
Epigastric: area between costal margins
Umbilical: area around umbilicus
Suprapubic or hypogastric: area above
pubic bone.
or
RUQ LUQ
RLQ LLQ

12. Abdomen

13. Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum, right
kidney and
hepatic flexure
of colon

14. Abdominal Anatomy &
Physiology
Left Upper Quadrant (LUQ):
Stomach
Spleen
Left lobe of liver
Body of Pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and descending colon

15. Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,
right ovary &
Right ureter

16. Abdominal Anatomy &
Physiology
Left Lower Quadrant (LLQ):
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord

17. Abdominal Anatomy &
Physiology
Midline:
Aorta
Uterus
Bladder

19. Peripheral Exam Abdominal Exam
Hand
Arms
Face
Neck: LN
Chest
Inspection
Palpation
Percussion (Ascites)
Auscultation
GIT Exam

20. Nail
Clubbing
thickening of the fingertips
that gives them an abnormal
rounded appearance

Hand

21. Palm
Pallor
Palmer erythema
reddening of the palms of the
hands

Hand

22. Flapping tremor(Asterixis)


This motor disorder is characterized by an inability to actively
maintain a position. tremor of the hand when the wrist is extended.
Hand

23. Abdominal Exam

25. Abdominal Assessment
Subjective Data: (Health history questions)
Change in appetite
Usual weight; Changes in usual weight
Difficulty swallowing
Are there any foods you have difficulty
tolerating?
Have you felt nauseated? Have you vomited
(emesis)?

26. Abdominal Assessment
Experience indigestion?
Heart burn (pyrosis) or Belching (eructation)
Use antacids, if so, how often
Abdomen feel bloated after eating (distension)
Abdominal pain? Associated with eating?
Alcohol use? Medications?

27. Abdominal Assessment
Bowel habits:
Frequency
Usual color and consistency
Any diarrhea/constipation/ excessive flatulence
Any recent change
Use of laxatives… Frequency

28. Abdominal Assessment
Past abdominal history:
GI problems: ulcer, hepatitis, jaundice,
appendicitis, colitis, hernia
Surgical history of abdomen
Surgical problems in the past
Abdominal x-rays, sonograms, CT results,
colonoscopy results, etc..

29. Assessment….
. Abdomen
a. Skin changes ( color, texture, scars,
striae, dilated veins, rashes, and lesions.)
. umbilicus – location and contour
. symmetry
. contour – flat, rounded, distended.
. observable masses – hernias and other
masses.
. movement – observable peristalsis and
pulsation.

30. Physical Exam
Preparation for physical exam:
Good lighting, warm room, empty bladder
Supine, head on pillow or raised, knees
flexed or on pillow, arms at side
Expose abdomen so it is fully visible
Enhance relaxation through breathing
exercises, imagery, use of a low/soothing
voice and ask pt. to tell about abd. Hx.

32. Inspection

(7S)
Symmetrical & movement with
respiration.
Scar.
Striae.
Stoma.
Shape of the umbilicus (inverted,
flat, exerted).
Shape of the flank (full, straight,
empty).
Skin lesions.
(4P)
Prominent veins (caput medusa,
SVC obstruction)
Pulsation Visible (aortic
aneurysm).
PeristalsisVisible (NL in thin,
intestinal obstruction).
Pigmentation (Cullen’s sign,
Gery-Turner’s sign)
(1D)
Abdominal Distension (fat, fluid, fetus, flatus, faeces).

33. Physical Exam: Inspection
Contour: Normal ranges from flat to round.
Symmetry: should be symmetric, note bulging,
masses or asymmetry.
Umbilicus: normal is midline, inverted and no
discoloration.
Skin: surface normally smooth and even color.

34. Abdominal contour
in healthy person abdomen is usually flat from
xiphoid to symphysis pubis , the umbilicus is
located in the abdominal center. depending on the
nutritional status, the abdominal contour may be
lightly protuberant or scaphoid.

35. Abdominal bulge
generalized abdominal bulge is usually caused by
ascites When the patient is in supine position, the
flanks of patient is bulging
some causes for ascites:
heart failure
cirrhosis of liver
nephrotic syndrome
TB peritonitis

36. Cont,
the other causes of abdominal
bulge:
include the distention of the bowel
with trapped gas, such as intestinal
obstruction, massive tumor,
obesity

38. Appearance of the abdomen
(Skin)
•Abnormal venous
patterns
•Abnormal
discoloration
•Umbilicus is sunken .

39. Striae
•Stretch marks are
silvery white linear
marked about 1-6cm
In Pregnancy and
obese individuals
•Cushing’s syndrome
( purple or blue).

40. Cullen’s sign
Ecchymosismlocal areas
of discoloration about the
umbilicus and in the
region of the loins, in
acute hemorrhagic
pancreatitis and other
causes of retroperitoneal
hemorrhage ( bluish
perumblical colour )

41. Abdominal veins
in healthy person abdominal
vein can not be seen or can be
seen a little in thin person, but
not dilated, in patient with
obstruction of the portal
venous system or in the vena
cava,You may find distended
veins.

42. when you find distended veins on
the abdomen you should ascertain
the direction of flow. the normal
direction of flow is away from the
umbilicus , that is the upper
abdominal veins carry blood up
ward to the superior vena cava.
And the lower abdominal veins
flow downward to the inferior
vena cava.

43. Outward flow pattern from umbilicus in all directions Portal HTN

44. An aortic aneurysm
•Palpable mass
•Patient feeling of
pulsation
•On rare occasions,
a lump can be
visible.

45. •Gastric peristalsis is
commonly seen in
neonates with
congenital hypertrophic
pyloric stenosis
Visible gastric Peristalsis
Intestinal peristalsis in
partial and chronic
intestinal obstruction
Colonic obstruction is
usually not manifest as
visible peristalsis
Visible intestinal Visible intestinal
PeristalsisPeristalsis
Visible Peristalsis

46. Gastric or intestinal pattern
and peristalsis
in healthy person peristalsis is not
visible, but in patient with pyloric or
intestinal obstruction you can see
peristalsis, in pyloric obstruction on
epigastrium the peristalsis is from left
costal margin to right, in intestinal
obstruction you can see peristalsis
around umbilicus the direction of
peristalsis is irregular.

47. Auscultation for bowel sounds
•Normal sounds are due to
peristaltic activity
5- 30 time \min.
• peristalsis: A progressive
high pitched
gurgeling,cascading sound
sound begin with RLQ.

48. Auscultation for bowel sounds
It is performed before percussion and
palpation

49. Increased or decreased bowel
sounds
Normoactive, hypoactive, hyperactive, or
absent

50. Bowel sound abnormalities
•Hyperactive sound :
•Auscultate peristaltic sounds which are
normally loud, high pitched
•Hypoactive sound : less than 5 time \min
•Silent abdomen : listen for at least "5"
minutes before concluding that no bowel
sound (. In case of abdominal
surgery,inflammation

51. Palpation
Before starting palpation,
remember:
Relax the abdominal muscles.
If necessary, ask the patient to bend the
knee to relax the muscle.
Ask if any particular area is tender and
palpate that area last.
Look into patient facial expression while
palpating the abdomen.

52. 2 Palpation
mainly used in abdominal
examination
mass:
location size contour
consistency mobility
tenderness pulsation

53. palpation

54. The methods of palpation

Light palpation
Deep Palpation
deep slipping palpation
bimanual palpation
deep press palpation
two hand deep
palpation

56. The methods of palpation
light palpation
abdominal muscle tensity
abdominal tenderness

57. Deep Palpation
deep slipping palpation
---deep mass
bimanual palpation
---liver spleen kidney
deep press palpation
---tenderness point

58. bimanual palpation
liver and spleen

59. Intra abdominal masses or enlargements of Intra abdominal masses or enlargements of
the liver, gallbladder or spleenthe liver, gallbladder or spleen
They will They will shift downshift down
with inspiration and with inspiration and
backback with with expiration.expiration.
(It will become more (It will become more
evident and palpable evident and palpable
when patient flexes when patient flexes
neck as this contracts neck as this contracts
rectus muscles. ).rectus muscles. ).

60. Standard Method Liver palpation
Ask the patient to take a
deep breath You may feel
the edge of the liver press
against your fingers when
diaphragm push it down.
•Palpating hand is held
steady while patient
inhales and moved while
the patient breathes out

61. Cont
•Murphy’s Sign- “inspiratory arrest”
palpate the liver should be painless but if
pain present patient cant complete deep
breathing = cholecystitis

62. Rebound Tenderness- Blumberg’s Sign
Technique used for tenderness when abdominal
pain reported. Hold your hand 90 degree or
appendicular to abdomen done after
examination occur normally no pain response
after palpation
indication of peritonitis.

63. Hooking Technique
An alternative method of palpating liver is to
stand up at person’s shoulder and swivel your
body to right so that you face person’s feet
•Hook your fingers over costal margin from
above. Ask person to take a deep breath
•Try to feel liver edge bump your fingertips

64. Spleen palpation
•Normally spleen is not
palpable and must be
enlarged three times its
normal size to be felt
•(LUQ) Support lower left rib
cage with left hand while
patient is supine and lift
anteriorly on the rib cage
normally not palpable must
enlarge 3 time
•.

65. Cont
•It can be palpable in case of
(trauma ,leukemia , lymphoma) if it
palpated avoid moving it to avoid
rapture
You should feel nothing firm

66. Examination of Kidney
•Patient take a deep
breath.
•Feel lower pole of
kidney and try to
capture it between
your hands.

67. Cont
–Kidneys
•Search for right kidney by placing your hands
together in a “duck-bill” position at person’s
right flank
•Press your two hands together firmly (you need
deeper palpation than that used with the liver
or spleen) and ask person to take deep breath
•In most people, you will feel no change
•Occasionally, you may feel lower pole of right
kidney as a round, smooth mass slide between
your fingers

68. Cont
•Left kidney sits 1 cm higher than right
kidney and is not palpable normally
•Search for it by reaching your left hand
across abdomen and behind left flank for
support
•Push your right hand deep into abdomen
and ask person to breathe deeply
•You should feel no change with
inhalation

69. Kidney palpation
•Left kidney sits 1 cm higher
than right kidney and is not
palpable normally
•Place left hand posteriorly
just below the right 12th rib.
Lift upwards.
•Palpate deeply with right
hand on anterior abdominal
wall.

70. Objective Data (cont.)
•Palpate surface and deep areas (cont.)
–Aorta
•palpate for the abdominal aorta to check whether it
is expansile, which could be suggestive of an
aneurysm. Note that the aortic pulsation can often
be felt in thin patients
Slide 21-70

71. Percussion (technique)Percussion (technique)

72. Indirect percussion

73. PERCUSSION
Determine the presence of fluid, distention,
and masses. Presence of air – tymphany,
•Assessment technique used to assess size
and density of organs in the abdomen
•Examples: used to measure size of liver or
spleen
• lightly percussing all 4 quadrants for
tympany or dullness
• tympany usually predominates due to gas
in the bowel

74. Percussion Sounds
Resonance
Dullness
Tympany
Flatness
Hyperresonance

76. Dullness:

This is a short high pitched and
is not loud. The sounds heard
over liver .

77. Flatness:

Flatness will be present when
there is an extensive pleural
effusion or over a solid organ
such as the liver and heart

78. ii) Guarding: This is an involuntary reflex contraction of the
muscles of the abdominal wall overlying an inflamed
viscus and peritoneum. It produces local rigidity and indicates localised peritonitis.
The spasms of the muscle will prevent palpation of the underlying viscus.
Guarding is seen for example in acute appendicitis

79. iii) Rigidity: Generalised or “board
like” rigidity is an indication of
generalised peritonitis. It is an
extension of guarding with
involvement of all the muscles of
the abdominal wall.The patient may
also manifest “rebound tenderness”
where deep palpation is associated
with pain but even more pain when
the palpating hand is suddenly
withdrawn.

80. Sites of Referred Abdominal Pain

82. Example: Typical pain in Acute
appendicitis
Site: poorly localized, periumbilical pain followed usually
by RLQ pain
Onset: vague
Character: dull periumbilical pain, may be cramping
Radiation: periumbilical  RLQ
Associated factors: anorexia, nausea/vomiting, low fever
Timing: Periumbilical (4-6h), RLQ (depends on
intervention)
Exacerbating/relieving factors: if subsides temporarily,
suspect perforation of the appendix, movement/cough.
Severity: periumbilical (mild but increasing), RUQ
(steady/more severe)

83. •Liver dull pain in right upper quadrant or
epigastric
•Esophagus : GER burrning in midepigastrim or
behind lower sternum
•Gallbladder : cholecystitis is biliary colic sudden
pain in right upper quadrant , Rt &Lt scapula
•Pancreas: acute boring midepigastrium radiate to
back & Lt scapula
•Stomach :dull ,aching,gnawing, epigastric radiate
to back or substernal

84. •Kidney :sudden onset of sever colicky flank
or lower abdominal pain
•Small intestine : generalized abd.pain with
neasea ,vomiting
•Colon : large bowel sharp, burning
obstruction, colicky &cramping

85. Abnormal Findings:
Abdominal Distention
•Obesity
•Air or gas
•Ascites
•Ovarian cyst
•Pregnancy
•Feces
•Tumor
Slide 21-85

86. Abnormal Findings:
On Palpation of Enlarged Organs
•Enlarged liver
•Enlarged nodular liver
•Enlarged gallbladder
•Enlarged spleen
•Enlarged kidney
•Aortic aneurysm
Slide 21-86

88. Ascites
•Accumulation of free fluid in peritoneum
•Assessment involve single curve, everted
umblicus, bluging flanks ,glistening skin
recnt wt. gain

89. Abdominal distention; dilated veins
Air \ gas: Decrease or
absent bowel sound
Percussion : tympany over
large area
But
feces :inspection :local
distention
Auscaltation normal bowel
sound
Percussion :dullness over
fecal mass

90. Obese abdomen

91. Tumor
localized distention
Auscultation normal bowel sound
Percussion :dull over mass

92. Hepatomegaly

93. ascites

94. Hernia
Soft skin covered
mass ,protrusion
intestine trough
weakness increased due
to increase abdominal
pressure
Epigastria , incisional &
Diastasis Recti