so now for the objective physical exam of the abdomen so now this is different for the abdomen we do it in a different order different than any other body system so write this down because it comes up over and over again on test questions uhoh the order for this one is going to be I AP so the pneumonic I want you to remember in order to remember this order because not only does oscultation get mixed up but palpation and percussion also get flipped so I want you to think of this pneumonic i always percuss patients i standing for inspection that first step always but now the second step A for always that stands for oscultation so inspect oscultate listen and then percuss stands for that first P which is now percussion and then the patience will be the PA in patience should help you remember the PA for palpate so one of the reasons why we do this order different we want to oscultate or listen with our stethoscope before we start pressing around because once we start pressing around we can actually increase bowel motility so it'll change what we're going to hear so let's go ahead and get started all right so you would want to look at the patient's bare abdomen so first I'm looking at my patient and I'm inspecting and you would notice the contour of the abdomen so a contour is just a fancy name for the shape and you're looking rib cage to hipbone what is the generalized shape if you can draw a straight line then we say their abdomen is flat so this patient's abdomen there's a straight line from the rib cage to the hipbones so they have a flat abdomen if you had a patient that was really thin so maybe they were cexic malnourished and they had a scooping out from the hips from the hips to the rib cage that would be called scaffoid scaffoid scaffoid i like to think scavoid and think there's a void where it's been scooped out and again you can see that with someone who's really thin or even might have keic or be anorexic or someone who's malnourished if you had a roundness to it you we call that rounded appearance and that happens with someone who is overweight early signs of pregnancy that can also happen with an infant they have those little infant pot bellies oh that's cute yeah and then if it was very much rounded over the top we call that protuberant so we can see that with someone in third trimester pregnancy so very far along also sometimes a toddler because toddlers can have that lordosis of the spine which gives them that little toddler pot belly looks so cute in bikinis or if they have a sites or if they're morbidly obese so again the four different shapes are flat scaffoid or I call it scaffoid rounded and protuberant it's important to know the difference between those four now for a practice question the nurse is assessing a 2-year-old child the toddler what type of abdomen would the nurse expect to find the correct answer is protuberant hey everyone nurse Mike here from simple nursing.com did you get your beautifully handcrafted study guide bundle yet it highlights the key points and memory tricks in this video plus get 900 more videos not here on YouTube all neatly organized in the playlist along with thousands of practice questions written by actual Enclelex writers so don't be scared be prepared try it free today visit simple nursing.com [Music] so now that we've looked at the shape and the contour of the abdomen we're now going to look and see if it's symmetric remember we love symmetry we like the right side to match the left side so we want to make sure that there's no bulging no pulsations you can even look and see if the client bears down or they do that valva maneuver or maybe even if they cough if there's anything that pokes out which could be a sign of a herniation which that could happen at the umbilicus that could also happen if they'd had a surgery anywhere you can get an incisional hernia so you're looking for anything that pokes out or pops out at you cough or if they bear down do any type of pressure or lift a heavy object and remember it's also just skin so you're assessing the generalized skin tone looking to see are there any piercings any tattoos any concerning moles so we would still do our normal skin check is there any moles that would be at risk for skin cancer and also any scars in the abdomen will tell us if they've had surgery in the past and then finally like we talked about before we'll look for any stretch marks or stria and we'll know if they're fresh or if they're a little bit older based on the color because remember that fresh ones are going to look purple red blue whereas older ones are going to look silvery or white in color which could let us know say if someone had new onset of ascites where all of a sudden their their abdomen became pruberant then they would have those new stretch marks so we might be looking for some new finding that caused that edema fluid build up in the abdomen so next we can move on to our second step oscultation so with oscultation and actually the pattern that we are going to utilize for the rest of the abdominal assessment is we're always going to start in the right lower quadrant and we are going to move clockwise so we're going to start in the right lower quadrant moving clockwise and one of the big reasons that we do that is because that's the way feal matter moves oh okay and so oftentimes we can expect to hear sounds primarily in this quadrant or say if a patient had gone to surgery and they had anesthesia so we're waiting for bowel sounds to return then that might be one of the first places they start and so one of the big things especially is we're going to be going three to four spots in each quadrant and moving in a side to side zigzag pattern so we're going to listen with our diaphragm because remember our diaphragm listens for those louder sounds those normal bowel sounds and so that's what we'll be listening for so we'll make sure we click it to the right side and we'll start oscultating and what we're listening for are these little clicks and gurgles kind of sounds like a little stream or like a a bubbling brook mhm and I can tell my patient might have just had lunch because I've got a lot of activity going so it sounds like And so we do this side to side zigzag pattern going clockwise and what we want to hear is five to 30 clicks and gurgles per minute also what's important is when we're listening to say that the sounds are as active as we want we not only want to hear five to 30 clicks and gurgles per minute but we also kind of want to take our time to do an appropriate abdominal assessment we want to take a minute to a minute and a half in each quadrant a whole minute a whole minute so I actually went a little bit fast for the purpose of the demonstration so you want to do a minute to a minute and a half in each quadrant so that should take you at least four minutes and that's if you hear things however if you don't hear anything uhoh in order to say that your patient has no bowel sounds at all you have to listen for five full minutes in each quadrant five full that's a long time that's 20 minutes total wow to say that it is absent because you don't want to say it's absent but really you just moved on before it happened and so that would be in order to say that it's absolutely absent so what's the difference between absent and what we are expecting to hear so the terms that we use if you hear the 5 to 30 clicks and gurgles per minute we call that normactive like sounds like normal right like normal normal and activity and they smooshed it together into one word normal active which makes it easier to remember so normally we hear 5 to 30 clicks and girdles per minute so if we hear normactive bowel sounds which are loud kind of uh easy to hear with your stethoscope then you can do a minute to a minute and a half in each quadrant so let's say it was more than that let's say they're either louder or much more than that 5 to 30 clicks and gurgles then we call them hyperactive so that extra activity just like if you're hyper and you have extra energy so who might have hyperactive bowel sounds well someone who drink a lot of coffee because we know coffee and caffeine increases bowel activity also laxative use can additionally cause hyperactive bowel sounds sometimes early in bowel obstruction they can have hyperactive bowel sounds at first but later it's going to be hypo or absent which again say absent oh no 20 minutes you're going to be so 20 minutes of your life you're going to be trying to listen oh my gosh so then that hypoactive bowel sounds is if it's less than that 5 to 30 range so you can't say it's absent but they're either very light so difficult to hear but there's still a little something which we can hear this hypoactive bowel sounds in patients who have hypothyroidism maybe patients who are constipated oftentimes patients after surgery when they come back and they're NPO after surgery or you know NPO and they haven't had anything to eat or drink so this is actually a pretty important assessment postsurgical because when they come back we don't want to start giving them a ton of food until their bowels are active and ready for it otherwise we can cause an ilas or an obstruction so often times after surgery and I worked a lot in post-surgical settings we'd constantly be listening to bowel sounds and asking the patient "Are you passing gas?" And it'd be asking constantly "Are you passing gas are you passing gas?" Why do we care so much about our patients tooting because it indicates their bowels have woken up after surgery and reasons why also they're at risk for that post-operative ilas would be narcotic pain medication being more immobile because of surgery other people who are at risk for hypoactive would be aging because we know as we slow down everything stiffens up with that aging process including our bowel motility can slow down pregnant women can also have slower bowel motility partially because that baby's kind of a parasite and as that baby sort of takes some of the nutrients for the food that we eat that bowel movement slows down through time really it's also because of those hormones and hormones slow down all the smooth muscles in the body and so including that chi tract so as you guys know it's always about that baby taking up a lot of room the hormones increasing and all that blood flow increasing in the body now one another thing that can actually slow down bowel sounds or early bowel movements is being immobile our bedridden clients who are typically in a sniff or some type of skilled nursing facility or for any reason they can't get out of bed and move which increases paristalysis now the next key term to know is bore barrier this is a loud gurgling type of sound and we all hear it when we're hungry you're just not you when you're hungry and you're and your stomach just makes all these noises right so what is borigmi and can you explain that more it's really just your stomach growling so it's technically a type of hyperactive but the thing is usually like you said you don't even need a stethoscope to hear it you can just be next to a person and hear their stomach growl oh yes and then the last term to know is an ilas which I mentioned a little bit earlier that's when someone has either minimal or no bowel activity and so they'll have either absent or hypoactive bowel sounds and so if someone came with an ILAS they would not have any bowel sounds but they also might be distended they're not going to be passing gas and oftentimes that's a huge concern and oftentimes they earn themselves an NG tube oh NG tube okay a nasogastric tube is that for gastric decompression or doing Absolutely so next in oscultation after we've listened in all four quadrants going starting the right lower quadrant then going clockwise in that zigzag pattern three to four spots in each quadrant then you will flip over to the bell and you're going to listen at that abdominal aorta so between the zyoid process and the umbilicus a little bit to the left of that midline and you're trying to listen for that brewy so you're listening with the bell and you're hoping that you don't hear that swoosh swoosh that would indicate turbulent blood flow cuz then that would mean we have a triple A now for a practice question the nurse is oscultating a client's abdomen and is unable to discern any bowel sounds how should the nurse proceed with the assessment correct answer is listen for 5 minutes before documenting an absence of bowel sounds in that particular quadrant now next is percussion or basically tapping and we want to use indirect percussion so use two hands here so let's see how this is completed so again we're going to start in that right lower quadrant going side to side in a zigzag pattern roughly three to four spots in each quadrant and so here the abdomen gets its own percussion term that we really don't use for any of the other spots in the body we call it Tony and so Tony it sounds like when you puff out your cheek oh and tap on it and so that's what that Tony sounds just like your puffed out cheek because if you think about it so before the terms we've used for percussion resonance which meant mostly air dullness which meant like fluid and then we have hyper resonance but if you think about even the inside of your mouth you have some air some fluid some solid stuff also in your abdomen you have some air some fluid some solid stuff so it gets that own word meaning Tony so how I like to remember it is I think Tony kind of sounds like the word symphony okay and it sounds drumlike like just like in a symphony you might have a drum there so it helps me remember that tony so next step in our percussion we were we can percuss for CVA tenderness which like we said it's different than the stroke type of CVA right so this stands for costto costal meaning ribs costtovertebral angle so you look at that costal margin that margin of the ribs right here and the vertebrae and so where those two meet you have this little piece of pie almost there or piece of pizza and that is overlying where the kidneys are so if our patients came in with back pain or flank pain and we were concerned for some type of kidney infection we would percuss for CVA tenderness or as I like to call it the kidney punch the kidney punch so essentially you're going to place your hand right in that costtovertebral angle oh no and if they're having lots of pain you can be nice and do indirect percussion oh wow like this or you can hit directly and see if there's any pain you actually literally punch the client the kidney punch okay and then we're looking for obviously pain if pain is elicited then that can be indicative of kidney pain versus if they had a muscularkeeletal pain it would hurt not just with the punch but usually more with movement so getting on the bed you know or changing position could cause more pain but specifically here they might have pain with walking just cuz every time you drop your heels you sort of rattle the kidney in its cage but then when they sit here if we were to whack and hit it that would cause that pain and so we'd want to investigate further for kidney inflammation or kidney infection now it's not just inflammation or infection we can also assess for kidney stones right absolutely and if they have any type of kidney injury or let's just say the client is guarding him do an indirect punch or just very lightly here because we want to hurt the client less here so the last step of our four steps of if you think about our pneumonic I always percuss patients i inspect a oscultate percuss the percuss and then finally is palpation but this time for palpation we're going to do two types of palpation first we're going to do light second we're going to do deep so the light palpation we're going to go through again starting right lower quadrant going clockwise in a zigzag pattern we're just going to use one hand and we're only going about 1 to 2 cm deep and right now we're just trying to feel for generalized skin tone musculature watching for any tender areas or any guarding lots of times patients we say they don't have any stomach pain but then when you kind of press you'll see them wse and so you want to investigate that further so the first time through again is for any generalized skin tone and musculature if you're feeling just any topical uh bulges or any topical growths or anything like any masses or which can indicate tumors or really just any masses at all absolutely so then the second one we're going to do with two hands we're going to do deep palpation oh man so when we go deep you're going to try to have the patient relax as much as possible so now we're going to go about 3 in or so 3 in and you want to imagine cuz at first it seems like you're really poking into the patient but instead think about you're trying to find a hidden marble maybe okay so you're trying to find any hidden masses any tumors or organ omegaly which is a fancy name for organ enlargement so just a mega organ yes okay and finally with this you're going to start in the right lower quadrant go clockwise like we said unless the patient comes in already complaining of pain if they have pain you want to save that tender area for last so skip it okay so for example if they have pain in the right lower quadrant you'll start in the right upper then go left upper then left lower and then there last because once you touch that area the patient's not going to let you touch them anymore they're not going to like you at all you know but also they're going to be guarding and tensing up and it's going to be harder to feel anything at all so always save a tender area for very last now moving on to liver palpation so there's two techniques and here you're not really going to wrap your hand around the whole liver you're really just going to feel bop and it's going to feel like you're bopping the tip of your nose however if you had someone that was an alcoholic someone who had an enlarged liver then you might be able to feel a little easier also we should not be able to feel the gallbladder if the gallbladder were inflamed though you know because typically it's hidden under the liver it's its little buddy like we said if it were inflamed then it'd be poking out and this would cause them pain so what we're wanting to see is that there's no pain with liver palpation and that we just feel a little on the tip of your fingers so now we'll start with the bimanual technique so Mike's going to stand at the patient's right side using his left hand he's going to lift up the patient's rib cage and then he's going to slide his right hand just underneath that costal margin so we're going to have the patient breathe in to move the diaphragm out of the way and sliding underneath that costal margin you'll feel just the tip of the liver and with the normal liver you're not going to feel very much or feel very far but we would just want to document that there wasn't any pain and that there was not any enlargement so once again you're putting the hand underneath the ribs asking the client to breathe in deep and really pushing down firmly you're sliding right under yep okay next you're going to do the hooking technique so this one you do you're going to be standing at the patient's shoulders looking towards their hips and you're just going to hook your fingers underneath that rib margin so hooking underneath and have the patient breathe in and again you'll feel that little bop and there shouldn't feel any pain oh yeah all right now does the client hold their breath for a certain amount of time or they just kind of breathe in once you find your assessment they can exhale and you're done okay just looking for that little bop now for a practice question for which assessment would the nurse use deep palpation the size of the liver is the correct answer not temperature not texture of a mole and not for bowel tampony