physical Assessment of abdomen Anus & Rectum

abdominal assessment presentation for nursing students to review anatomy , focussed history and detailed physical examination

1. Assessment of Abdomen, Anus & Rectum Presented By: Azra Mahmood Shumaila AR

2. Objectives At the end of the session learners will be able to Identify the landmarks for the abdominal assessment Differentiate GI variations due to Age Discuss the system-specific history for the Abdomen, Anus & Rectum . Correctly perform the assessment of the Abdomen, Anus & Rectum Differentiate normal from abnormal findings Know about Special Tests used for Abdominal assessment

3. Cont… Understand the structure and functions of anus & Rectum Know about the different assessment techniques used for anus & Rectum examination

4. Introduction The word "abdomen" has a curious story behind it. It comes from the Latin "abdodere", to hide. The abdomen is a single large cavity that extends from the diaphragm to the pelvic outlet. It contains vital body organs

5. Structure The abdomen is bordered superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and laterally by the flanks. It is important to understand the anatomic divisions known as the Abdominal quadrants the abdominal wall muscles, and the internal anatomy of the abdominal cavity

6. Internal Anatomy A thin, shiny, serous membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also provides a protective covering for most of the internal abdominal organs(visceral peritoneum). Within the abdominal cavity are structures of several different body systems: gastrointestinal, reproductive (female), lymphatic, and urinary. T hese structures are typically referred to as the abdominal viscera and can be divided into two types

7. Solid viscera are those organs that maintain their shape consistently : liver, pancreas, spleen, adrenal glands, kidneys, ovaries , and uterus . The liver is the largest solid organ in the body. The hollow viscera consist of structures that change shape depending on their contents. These include the stomach , gallbladder, small intestine, colon, and bladder.

8. The stomach’s main function is to store, churn , and digest food. The gallbladder, a muscular sac approximately 10 cm long, functions primarily to concentrate and store the bile needed to digest fat. The spleen functions primarily to filter the blood of cellular debris, to digest microorganisms, and to return the broken down products to the liver

9. The kidneys are located high and deep under the diaphragm. These glandular, bean-shaped organs measuring approximately 10 × 5 × 2.5 cm are considered posterior organs and approximate with the level of the T12 to L3 vertebrae. The tops of both kidneys are protected by the posterior rib cage .

10. The right kidney is positioned slightly lower because of the position of the liver. The primary function of the kidneys is filtration and elimination of metabolic waste products. However , the kidneys also play a role in blood pressure control and maintenance of water, salt, and electrolyte balances . In addition, they function as endocrine glands by secreting hormones.

11. The pregnant uterus may be palpated above the level of the symphysis pubis in the midline . The ovaries are located in the RLQ and LLQ, and are normally palpated only during a bimanual examination of the internal genitalia .

12. 4 Quadrants

13. 9 Regions

14. Right Upper Quadrant Ascending and transverse colon Duodenum Gallbladder Hepatic flexure of colon Liver Pancreas (head) Right adrenal gland Right kidney (upper pole) Right ureter

15. Right Lower Quadrant Appendix Ascending colon Cecum Right kidney (lower pole) Right ovary and tube Right ureter Right spermatic cord

16. Left Upper Quadrant Left adrenal gland Left kidney (upper pole) Left ureter Pancreas (body and tail) Spleen Splenic flexure of colon Stomach Transverse descending colon

17. Left Lower Quadrant Left kidney (lower pole) Left ovary and tube Left ureter Left spermatic cord Descending and sigmoid colon Midline Bladder Uterus Prostate gland

18. GI Variations Due to Age Aging- should not affect GI function unless associated with a disease process Decreased: salivation, sense of taste, gastric acid secretion, esophageal emptying, liver size, bacterial flora Increased: constipation!

19. GI Variations with pregnancy Decrease in gastric motility Bowel sounds diminished r/t enlarged uterus displacing intestines Linea nigra- increased pigmentation of abd midline Striae Gravidarum

20. Nursing History - Abdomen Subjective Data : Ask about: Appetite Wt gain or loss Dysphagia Intolerance or allergy to certain foods Any Abdominal Pain Nausea and Vomiting Bowel movements Any past history

21. Nursing History Infants and Children – Ask: bottle or breast fed, any table foods, how often & how well & how much the baby eat, any problems with constipation, c/o of any abdominal pain Teenagers- Ask: nutritional assessment, activity & exercise patterns, recent wt. loss or gain

22. Nursing History Older Adults Ask: how do you get your groceries? prepare your meals? do you have any trouble swallowing? how often do your bowels move? how often do you take anything for constipation? what meds do you take?

23. Nursing Assessment Objective Data : General Observation Inspection Auscultation Percussion Palpation(always last)

24. Focused Health History Nutrition Allergies Medications Cigarette/tobacco Recreational drug use Stool characteristics Urine characteristics Exposure to infectious dz. Recent stressful life events Possibility of Pregnancy

25. Equipment Small pillow or rolled blanket Centimeter ruler Stethoscope (warm the diaphragm and bell) Marking pen

26. Preparing the Client Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination. Instruct the client to remove clothes and to put on a gown. Help the client to lie supine with the arms folded across the chest or resting by the sides CLINICAL TIP Raising arms above the head or folding them behind the head will tense the abdominal muscles.

27. Physical Examination Preparation Provide privacy Good lighting/appropriate temp in room Expose the abdomen Empty bladder Position pt supine, arms by side & head on pillow with knees slightly bent or on a pillow Warm stethoscope & hands Painful areas last Distraction techniques

28. Abdominal Exam Inspection Auscultation Percussion Palpation percussion includes percussion of liver span, light and deep palpation, palpation of liver edge, spleen tip, kidneys, and aorta. The abdominal exam is done with the patient supine at 90 o Order of exam is critical. Auscultate BEFORE palpating!

29. Inspection Overall observation Abd contour- flat, round, protuberant Abd symmetry and skin color - note any masses, striae, scars, veins, pigmentation Pulsations

30. ABDOMEN: Inspection There should be adequate exposure of the abdomen for proper inspection. The patient should be exposed from the inferior chest to the anterior iliac spines bilaterally.

31. Auscultation Always done before percussion & palpation Use diaphragm of stethoscope Listen lightly Start with RLQ

32. Auscultation What makes a bowel sound? Note character & frequency of bowel sounds (5-30 times/minute) Listen for 5 minutes before documenting absent bowel sounds Listen for bruits- aortic, renal, iliac, femoral Hyper- gastroenteritis, obstruction, hungry Hypo- pregnancy, peritonitis

33. Auscultation Auscultation can be done with the diaphragm or the bell; most examiners use the diaphragm. You should listen for at least 10-15 seconds and note the pitch and frequency of bowel sounds . If you do not hear any bowel sounds, you should listen for a full two minutes before you can state that the patient does not have any bowel sounds. Bowel sounds should occur from every other second to every 12 seconds.

34. Percussion Percussion: the left and right abdomen should be percussed above and below the umbilicus. Most examiners will percuss 8 or more areas.

35. Percussion: Liver span The liver span is estimated by percussion. Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness . Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull. Lower border: In the midclavicular line begin percussion below the umbilicus and proceed upward until dullness is encounter. The distance between the two areas where dullness is first encountered is the liver span. Liver span is normally 6 to 12 cm in the midclavicular line.

36. Liver Span: Scratch Test Start in the same areas above and below the liver as you would with percussion. Instead of percussing lightly, scratch moving your finger back and forth while listening over the liver. Since sound is conducted better in solids than in air, when the louder sounds are heard you are over the liver. Mark the superior and inferior boarders of the liver span in the midclavicular line

37. Percussion Gently tapping on the skin to create a vibration Detect fluid, gaseous distention and masses Tympany- gas (dominant sound because of air in small intestine) Dullness- solid masses, distended bladder Percuss liver, spleen ,kidneys

38. Palpation of Abdomen Light palpation- depress about 1 cm. Assess skin pulsations. Always done first- clockwise Deep palpation- depress skin about 5-8 cm Always assess tender areas at last Watch pt’s expression during palpation

39. Abdominal Palpation Palpate lightly in all 4 quadrants. Press down around 1 cm. Remember to look at the patient’s face during palpation to see if any tenderness is elicited

40. Palpation: Deeply, all 4 quadrants One should use two hands. Press down around 4 cm

41. Palpation: Liver Stand on the pt’s right side. Place your left hand behind the patient’s R side under the 11 th and 12 th rib area. Press upward with the L hand. Place your R hand on the pt’s abdomen well below where you percussed the liver edge

42. Palpation of Liver: Alternative Method It is acceptable during palpation of the liver to use both hands to palpate abdomen. You use the fingers of one hand to palpate and the other hand is used to apply pressure to the dorsum of the other hand. Thus the hand you are using to palpate does not need to be used to apply pressure .

43. Palpation: Spleen Palpation: Spleen (correctly - position, breaths, palpating deepest full inspiration, 1 hand under L side, 1 feeling) Palpation: Spleen (if not palpable, R lateral decubitus)

44. PALPATION OF SPLEEN Right lateral decubitus

45. Palpation of Kidneys Right kidney (take a deep breath, capture kidney, exhale, slowly release kidney Left kidney (take a deep breath, capture kidney, exhale, slowly release kidney) R L

46. Palpation: For abdominal aorta Palpation : For abdominal aorta (to feel both the left and right walls of the aorta) In correct order : Inspection, auscultation, percussion and palpation

47. Inspection Abnormal Findings Visible or distended veins- ascites Visible peristalsis- obstruction Spider nevi (cutaneous angiomas)- cirrhosis Asymmetry/ Distention- mass or intestinal obstruction Color changes- jaundice, bluish/cyanotic

48. Abnormal Auscultation Absence/Hyperactive bowel sounds- “borborygmi” Bruits- “swoosh” Peritoneal Friction Rub- rough, grating heard over liver & spleen- inflammation of peritoneal surface from tumor, infection, etc.

49. Percussion Abnormal Findings Enlarged organs, palpable masses, distention, ascites Marked tenderness

50. Palpation Abnormal Findings Tenderness- rebound- done away from painful area- done at end of exam Masses- document location, size, shape, mobile, pulsating, smooth, nodular, firm Firmness or muscle guarding/rigidity- intra abdominal bleeding- DO NOT CONTINUE TO PALPATE!!!!!!

51. Special Procedures Fluid Wave- need 3 hands- feel for impulse of the wave of fluid across the abdomen= ascites Rebound Tenderness- Blumberg’s Sign Iliopsoas Muscle Test- thigh muscle lift R leg and push down on R thigh= appendicitis Obturator Test- lift R leg and rotate at 90 degrees= muscle is irritated by appendicitis Murphy’s Sign- “inspiratory arrest” palpate the liver should be painless= cholecystitis

52. Special Procedures Mc Burney’s Point- RLQ midclavicular= appendicitis Referred pain- location of pain is not necessarily where the involved organ is! May be felt where the organ was located in fetal development ex: spleen= L shoulder pain/ kidney= groin pain Hooking technique- palpate the liver- feeling for the liver edge

53. Special Procedures Cullen’s Sign- bluish discoloration around the umbilicus EMERGENCY!!! Kehr’s Sign- abd pain radiating to R shoulder= spleen or pancreatitis

54. Tests for ascites Test for shifting dullness. If you suspect that the client has ascites because of a distended abdomen or bulging flanks, perform this special percussion technique. The client should remain supine. Percuss the flanks from the bed upward toward the umbilicus. Note the change from dullness to tympany and mark this point. Now help the client turn onto the side. Percuss the abdomen from the bed upward. Mark the level where dullness changes to tympany

55. F luid wave test. A second special technique to detect ascites is the fluid wave test. The client should remain supine. Ask the client or an assistant to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Firmly place the palmar surface of your fingers and hand against one side of the client’s abdomen. Use your other hand to tap the opposite side of the abdominal wall No fluid wave is Movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites ).transmitted.

56. Tests for appendicitis Assess for rebound tenderness. If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen away from the painful or tender area. Then suddenly release pressure. Listen and watch for the client’s expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred.

57. No rebound tenderness is present . The client has rebound tenderness when the client perceives sharp, stabbing pain as the examiner releases pressure from the abdomen ( Blumberg’s sign)

58. Test for referred rebound tenderness. Palpate deeply in the LLQ and quickly release pressure. No rebound pain is elicited . Pain in the RLQ during pressure in the LLQ is a positive Rovsing’s sign . It suggests acute appendicitis. Avoid continued palpation when test findings are positive for appendicitis because of the danger of rupturing the appendix .

59. Assess for psoas sign. Ask the client to lie on the left side. Hyperextend the right leg of the client . Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).

60. Assess for obturator sign. Support the client’s right knee and ankle. Flex the hip and knee, and rotate the leg internally and Externally Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix .

61. Test For Cholecystitis Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder ). Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply . Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy’s sign and is associated with acute cholecystitis .

62. Abdominal Distention PREGNANCY ( NORMAL FINDING ) Constipation FLATUS FAT FIBROIDS AND OTHER MASSES ASCITIC FLUID Abdominal Bulges ( Hernia)

63. Enlarged Abdominal Organs and Other Abnormalities ENLARGED LIVER An enlarged liver (hepatomegaly) is defined as a span greater than 12 cm at the mid-clavicular line (MCL) and greater than 8 cm at the mid sternal line (MSL ). An enlarged non tender liver suggests cirrhosis. An enlarged tender liver suggests congestive heart failure, acute hepatitis, or abscess.

64. Liver lower than normal A liver in a lower position than normal with a normal span may be caused by emphysema because the diaphragm is low. LIVER HIGHER THAN NORMAL A liver that is in a higher position than normal span may be caused by an abdominal mass, ascites, or a paralyzed diaphragm ENLARGED NODULAR LIVER An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis.

65. ENLARGED SPLEEN An enlarged spleen (splenomegaly) is defined by an area of dullness exceeding 7 cm. When enlarged, the spleen progresses downward and in toward the midline. ENLARGED GALLBLADDER An extremely tender, enlarged gallbladder suggests acute cholecystitis. A positive finding is Murphy’s sign (sharp pain that causes the client to hold the breath ).

66. ENLARGED NODULAR LIVER An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis

67. ENLARGED KIDNEY An enlarged kidney may be due to a cyst, tumor, or hydronephrosis. It may be differentiated from an enlarged spleen by its smooth rather than sharp edge, the absence of a notch, and tympany on percussion . AORTIC ANEURYSM A prominent, laterally pulsating mass above the umbilicus strongly suggests an aortic aneurysm. It is accompanied by a bruit and a wide, bounding pulse.

68. Sample Documentation Normal Exam- Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.

69. MECHANISMS AND SOURCES OF ABDOMINAL PAIN Abdominal pain may be formally described as visceral, parietal, or referred. Visceral pain occurs when hollow abdominal organs—such as the intestines Parietal pain occurs when the parietal peritoneum becomes inflamed, as in appendicitis or peritonitis Referred pain occurs at distant sites This type of pain travels, or refers, from the primary site and becomes highly localized at the distant site PAIN

70. CHARACTER OF ABDOMINAL PAIN AND IMPLICATIONS Dull, Aching Appendicitis Acute hepatitis Biliary colic Cholecystitis Cystitis Dyspepsia Glomerulonephritis

71. Pancreatitis Perforated gastric or duodenal ulcer Peritonitis Peptic ulcer disease Burning , Gnawing Dyspepsia Peptic ulcer disease Cramping (“crampy ”) Acute mechanical obstruction Appendicitis, Gastro esophageal reflux disease (GERD Colitis, Diverticulitis

72. Pressure Benign prostatic hypertrophy Prostate cancer Prostatitis Urinary retention Colicky Colon cancer

73. Sharp, Knifelike Splenic abscess Splenic rupture Renal colic Renal tumor Ureteral colic Vascular liver tumor

74. Measuring Abdominal Girth In clients with abdominal distention, abdominal girth (circumference) should be assessed to evaluate the progress or treatment of distention Waist circumference measurement is also recommended in screening for cardiovascular risk factors To facilitate accurate assessment and interpretation , the following guidelines are recommended :

75. 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 .

76. 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).

77. Anus & Rectum

78. Structure and Function Anus and Rectum Anal canal Sphincters Anal columns Anorectal junction Rectum Slide 25- 80

79. Anus and Rectum Slide 25- 81

80. Health History Questions Usual bowel routine Change in bowel habits Rectal bleeding or blood in the stool Medications (laxatives, stool softeners, iron) Rectal conditions (pruritus, hemorrhoids, fissure, fistula) Family history Self-care behaviors (diet of high-fiber foods, most recent examinations) Slide 25- 82

81. Objective Data—The Physical Exam Preparation Position Equipment needed Penlight Lubricating jelly Glove Test container Slide 25- 83

82. Rectal Examination Positions Slide 25- 84

83. Physical Exam cont. Inspection of the Perianal Area Skin Anal opening Sacro - coccygeal area Slide 25- 85

84. Palpation of the Anus and Rectum Palpation technique Canal wall Perianal tissue Rectal wall Slide 25- 86

85. Abnormal Findings in Anus and Perianal Region Anorectal fistula Fissure Hemorrhoids Rectal prolapse Pruritus ani Slide 25- 87

86. Pilonidal cyst or sinus Slide 25- 88

87. Anorectal fistula Slide 25- 89

88. Fissure Slide 25- 90

89. Hemorrhoids Slide 25- 91

90. Pruritis Ani Slide 25- 92

91. Abnormal Findings Rectum Abscess Rectal polyp Fecal impaction Carcinoma Slide 25- 93

92. Rectal prolapse Slide 25- 94

93. References • Bickley , L. (2012).  Bates’ Guide to Physical Examination and History Taking. Lippincott Williams & Wilkins. Weber, J. R., & Kelley, J. H. (2013).  Health assessment in nursing. Lippincott Williams & Wilkins . Jarvis, C. (2019). Physical Examination and Health Assessment . Elsevier .