good day class and welcome to assessing the abdomen and health assessment understanding the importance of assessing the abdomen one we must note that the abdomen is used to protect vital organs the abdomen um is also considered the largest cavity in the body as nurses when we begin to assess the abdomen we must start with the sequence of inspection so it's important that we inspect the patient's abdomen we want to look at the abdomen to determine if any abnormalities exist any strier so that's looking at any maybe stretch marks we want to see if there's any type of abdominal distension um we're just going to look that's what the inspection piece of it is now oscilation of course is the listening piece that's when we're going to take our stethoscope and we're going to place it on the pap patient stomach and then we're going to listen to abdominal sounds next we want to do percussion when it comes to the patient and that's the tapping motion that we generally use and then we want to do palpation now palpation can be done light and deep and we're going to use four fingers when we do this why do we want to use a different sequence it's because if you start pressing on the abdomen you might begin to hear bow sounds that wouldn't normally exist so it might give us a false assessment if we do it out of this sequence okay so it's important to know we want to look listen feel okay now the pregnant client the pregnant client may present slightly different because of course their abdomen is already distended also some things that you may see or find in the pregnant client is that they may experience something called mour sickness and or some nausea or vomiting the reason why they experien that is because there's a rise in the HCG levels and because of that rise a lot of patients or a lot of clients tend to experience this nausea and vomiting this tends to subside sometimes or somewhere in the second trimester but the first and second trimester is where we would generally see this happen also the bowel sounds may become diminished why are bow sounds diminished when it comes to this patient population well just think when when the patient is pregnant um the uterus begins to enlarge and because the uterus begins to enlarge the intestines are displaced so that's that leads to diminish bow sounds which also leads to constipation now the skin changes that you see there's a lot of stretching in that area in the abdominal area when a woman becomes pregnant so not not all the time but often we may see some strier or linear Negra okay in the Aging adult you may see an increase of fat accumulation um in the abdominal area in females this is often called caused by uh menopause and we have a decrease in in our levels of estrogen in men it could be related to having a seditary lifestyle but you can see it in both men and women you also may see decreased gastric secretions and this comes with aging it can be related to anemia you may also see constipation constipation can be Rel related to um slowing down of of uh periostosis it can also be related to medications that the patient may be taking you may also see a decrease in um salivation which will cause the patient to have a dry mouth you want to encourage them to take like mints or um chew gum if that's the case you may also see decrease in the liver size which also impairs the liver function and the patient ability to metabolize medication now collecting a health history when we're collecting a health history on a patient it's important for us to make sure we ask specific questions but prior to that there are certain things that we want to just look at we want to think about appetite weight gain urination flatulence indigestion um nausea vomiting all of these things um focus on or are related to uh the abdominal system with that being said we want to make sure that we ask questions these are just a few questions that touch on the same information that I just went over so you want to talk to the patient and ask do you have a difficult time swallowing have you experienced stinny gas though that's not right here on the slide but that's still similar to the line of questions that you want to ask do you have any abdominal pain if so what's the precipitating factor what's a relieving Factor you want to ask them about weight gain was this a planned weight gain or was this unplanned did you intentionally do this you want to ask them about how frequently they go to the bathroom meaning having a bow movement and or urinate you want to also talk to the patient about nausea and vomiting are they taking medications that create or that caus them to have nausea and vomiting is this a normal is this does this occur normally you want to ask them how frequently these things take place you want to make sure that you that you touch on different things you also when you start thinking about gas and even maybe if the patient says that they experience diarrhea we want to start talking to patients about um any bloating or does this happen when you use milk products have you traveled outside of the country so is this a new occurrence for you what type of supplements do you take like iron because iron sometimes can cause you to have um constipation so we want to make sure that we inquire about all of these things okay prep for assessment you want to make sure that you're providing the patient with privacy that the room is warm that your stethoscope is warm because you're going to be listening to the abdominal area you also want to make sure that there's no pain you want to ENC encourage the patient to go to the bathroom to empty their um bladder before you start um your abdominal assessment you want to make sure that they understand the importance of this assessment why you're doing it what it is that you're looking for you want to explain this uh assessment completely before you start and make sure that the patient is comfortable with you with you touching them you also want to make sure that you assess painful areas last which means I'm not going to um if the patient is saying that they were having left-sided pain I'm going to wait and assess the left side last inspection it's important to know inspection inspection does not mean touching so it doesn't mean touching in any space so inspection mean I'm just using my eyes to look I want to make sure that I note or document symmetry or um asymmetry when I'm looking at the patient's abdomen I want to see and look at the patient's um umbilicus and I need to make sure that it's centered I need to say whether or not it was inverted or everted I need to make sure that I look at the color of the skin notate any type of um strier that that may be seen on the patients's abdom abdomen I also want to look for hair and or lack thereof and document that you also want to look for any type of abdominal pulsations that you may see in this patient okay now when we begin to osculate osculate the bowel sounds we want to make sure that we use the diaphragm so that's the biggest part of of the stethoscope so you know you have two sides you have a bell and then you have the diaphragm you want to use the DI diaphragm when we're listening to the patient's bowel sounds generally that's high pitched so when we're listening for like high pitched sounds that's going to be the Bell that I mean the diaphragm that's the big part low pitch we switch it up okay we're going to use the Bell which is the smaller part when we begin this we want to start with the right lower quadrant that's with the the r lq is four the reason why we start there is because often times that's where bow sounds are heard you listen for five minutes before documenting if no bow sounds occur meaning initially I want to start with my right lower quadrant and I'm going to listen it is not important that we listen to each quadrant though years ago it was mandatory so you needed to listen to all four quadrants now based off of the reading you don't have to listen to all four quadrants but you would listen to all four quadrants if in fact bow sounds were not present so if bow sounds were not present in the right lower quadrant I would begin to move to the other quadrants to see if I hear bow sounds you want to in this information is also information that you report to the healthc care provider so if you're not able or you're unable to hear bow sounds at all or they're low or hypo not low but hypoactive bow sounds these are bowel sounds that we report so a hypoactive bowel sound will be anything that's less than five hyper active bow sounds would be greater than 30 and that's within um within one minute okay you don't want to use the stethoscope to press down hard because that can also increase paralysis and we want to make sure that we get an accurate reading or AC an accurate assessment when we're listening to our patient abdominal mapping abdominal mapping is the order in which we would begin to listen to the patient's abdominal area so we want to start with the right lower quadrant and go up to the right upper quadrant then to the left upper quadrant and to the left lower lower quadrant is important to note that certain organs sit in certain quadrants so for instance the right lower quadrant you you'll find the appendix there you'll find um the right ovary in the right upper quadrant that's where we'll see the liver or we'll find the liver the gallbladder you'll see like the beginning or excuse me the head of the pancreas you may also see the right kidney in that space when you move over to the left it's good A good rule of thumb is whatever you have if you have a right something you generally have a left something something too meaning if you have a right kidney generally you have a left kidney unless something happen right unless you um only have one kidney because maybe you had kidney failure but that's neither here nor there just for the most part whatever you have on the right side generally we will also see it on the left side so the left upper quadrant we would see we would see the stomach we may see the spleen you're also going to see that left kidney and then you may see the rest of the pancreas now when you think about the left L quadrant some things that you may see you're going to start to see the colon or the sigmoid colon you're going to also see the left ovary there oscilating vascular sounds when we osculate vascular sounds we're going to use the bell of the stethoscope we're going to listen to the aortic the renal the iliac and the Emeral arteries over the liver you assess uh you assess for the the Venus hum now ideally we don't want to hear any any sounds so when you're listening to vascular sounds we don't want to hear any however in a few cases we may see that people under the age of 40 may have what we call a brewery a brewery is turbulent blood gr sounds and we generally see this in patients that have a that have CKD they also have hypertension um prio vascular disease now the Venus hum is medium is a medium pitch sound with turbulent blood flow in the in the liver caused by therosis percussing the abdomen we have indirect percussion over the quadrants and then we also have direct percussion so generally when we're percussion again we think about our quadrants right so we have four quadrants and left unless you split those up in the nines and in this space when we're you should hit temp here Tony over all four of the quadrants now when we get to certain organs we're going to hear dullness so again it's tempany in all of the quadrants and over organs we expect to hear dullness now what can be an abnormality that we find so if we see abdominal distension if um maybe if the patient had a distended bladder so we want to make sure again that's the reason why we want to make sure we encourage the patients to go to the bathroom hyper resonance can also be seen and so that can also appear or look like distension so we want to make sure that we're assessing the patient we also want to make sure that the patient isn't experiencing any pain we want to make sure that we encourage the patient to void palpating the abdomen so remember we have light palpation we have deep palpation so in light palpation we're only going to use our four fingers and we're going to press about a centimeter if you think about a centimeter that's not really deep and we're going to use a clockwise motion or movement as we assess each other each area so that's like that circular motion and it's pretty quick when we're palpating now when you think about the Deep palpation that means our fingers have to go a whole lot deeper and so we're going to go about 5 to 8 cm down and we're going to be pressing in the same areas but we're going to do it in a clockwise motion most of the time if we're going to begin we begin with light palpation and then we move to deep palpation now in this space we want to make sure that the patient isn't experiencing any pain if the patient tells us that they are experiencing pain while we're assessing them then what we would do is to make note of the pain if the patient feels or seems a little guarded then we are a little concerned with are you ticklish could it be cold in this space maybe I need to warm my hands up as a nurse before I get started palpation of specific organs the three organs that we're usually palpating would be the liver the spleen and the kidneys now to palpate the liver we want to make sure that we're in the right upper quadrant we want to place our left hand under the person's back parallel to the 11th and 12th ribs okay now we want to place our right hand on the right upper quad quadrant and then push deeply down and under the right Coastal margin you want to ask the patient to breathe slow so nice and slow okay and then that's our way of palpating the liver we want to try to feel the edge of the liver with our with our fingertips now when it comes to the spleen most of the time the spleen is not a palpable organ and it must be enlarged in order for it to be felt which means that will also be an abnormality and then when we're assessing the kidneys we want to place our right kidney if we're assessing the right kidney or the left kidney we want to make sure if we're doing the right kidney that we place our we place our hands together kind of like making a like a opening and this if we want to do like a V or or a duck bill and you want to push it you want to position it at the patient's right flank and then you want to press your hands together so that you can feel again we want to ask our patient to take a nice deep breath most of the time you won't feel any changes okay abdominal distension it can be related to various things but a few things that I want to make sure I touch on is pregnancy of course the pregnant um the pregnant patient their stomach is enlarged if in fact a patient is experiencing obesity or has obesity you may see like a uniform round um round its stomach um again tempany would be heard if we were percussing palpation it would be normal now aites aites is a is a little bit different because it's a single curve curve and a everted umbilicus and in that space bow sounds you may hear normal bow sounds tempany at the top where the intestines are and then dull over that fluid field area now the skin on this patient may be ta or tight which is similar to what we would see in the pregnant patient now if the patient may have if the patient has an ovarian cyst you may see a curve in a portion or a section of the abdomen again that uh umbilicus is inverted the bow sounds tend to be normal you see dullness over fluid and you may it may also upon palp uh palpation it may transmit aortic pulsation always remember to document any abnormalities