Abdominal Assessment Rectal Examination by benbenzhou


Abdominal Assessment Rectal Examination

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        Dr. Beverly Fineman
        Nursing 309
   At the end of this class, the student will be able
   Identify landmarks for the abdominal
   Correctly perform techniques of inspection,
    auscultation, percussion and palpation
   Differentiate normal from abnormal findings
   Document findings
Overview of abdominal
   large oval cavity
   extends from diaphragm to
   viscera: solid and hollow
Landmarks for the
abdominal examination
   four quadrants
   nine sections
   bony landmarks
   muscles
More landmarks
     Bony landmarks on the anterior body include:
         xiphoid process of sternum
         costal margin, midline, umbilicus, anterior
      iliac spine, poupart’s ligament, superior
      margin of pubis
     Posterior landmark
         costovertebral angle
    Abdominal assessment
   Preparing the exam room
   preparing the patient
   positioning the examiner

   inspection
   skin: color, scars, veins, lesions,
   umbilical hernia, bleeding,
    Continued inspection
   contour of the abdomen:flat,rounded,
   symmetry
   enlarged organ
   masses
   peristalsis,pulsation,distention
                 -Definition: unusual stretching of
                    abdominal wall

   note position of umbilicus
   note portion of abdomen that is
   reasons for distention:flat(obesity),
    flatus(gas), feces, fluid,
    fetus(pregnancy or tumor)
   Where it occurs in abdominal
   listening for bowel sounds to
    assess motility
   normal sounds
   abnormal sounds
   how and where to listen
Auscultation continued
   Auscultation performed before
    palpation and percussion
   Use diaphragm of stethoscope
   Listen to bowel sounds
   Normal sounds are clicks and
    gurgles, irregular, 5-30 times per minute
   Influenced by digestion
More on Auscultation
   Increased bowel sounds are due to
    hypermotility of peristalsis
   Decreased are due to paralytic ileus or
       intestinal obstruction can present with
    increased or decreased sounds
    Additional Sounds
   Always listen in hypertensive patient
   Bruits:
   Bruits are low pitched, vascular sounds, resembling
   Caused by partially obstructed artery– turbulence
   Listen in epigastrum and each upper quadrant
   Listen in costovertebral angle(with patient seated)
   Listen over aorta, iliac arteries, femoral arteries
   Arterial insufficiency in legs
   Assessment technique used to
    assess size and density of organs
    in the abdomen
   Examples: used to measure size
    of liver or spleen
More on percussion
   Used to identify masses
   Used to identify air in stomach or in bowel
   Used alone or in conjunction with palpation or to
    validate palpatory findings
   Orient yourself to the abdomen by lightly
    percussing all 4 quadrants for tympany or
      tympany usually predominates due to gas in
    the bowel
Percussion Continued
   Dullness may be present due to feces or
    fluid or over organs or a solid mass
   Develop a specific percussion route and
    stick to it.
   To percuss the liver or estimate its size:
       in right midclavicular line, start below the
    umbilicus with tympany and percuss
    upward toward liver dullness.
   Mark to indicate the liver border
    Liver Percussion
   In the right midclavicular line, percuss down from
    lung resonance to liver dullness. This indicates
    the lower border of the liver
   Mark this and measure between the two lines
   This is the height of the liver
More about percussion
   Percussion provides most accurate
    clinical measurement of liver size as a
    gross measurement
Percussing the spleen
   Where is the spleen located?
       in the curve of the diaphragm just posterior
    to the left midaxillary line
   When the spleen enlarges, it does so
    anteriorly, downward and medially. This will
    replace the tympany of the stomach and
    colon with dullness
    Tricks to Assessing the Spleen
   Percuss in the lowest interspace in the left
    anterior axillary line for tympany.
   Ask the patient to take a deep breath and
    percuss on inspiration.
      the percussion note should remain tympanic
   A change to dullness suggest spenomegally
   This is known as a positive splenic percussion
Another trick
Percuss in several directions away
from tympany or resonance to
    outline edges
    a large dull area suggests
Other Findings
   To differentiate amongst fat, gas, tumor
    or ascites:
       fat—tympany with scattered areas of
       gas—distention with tympany
       tumor—dullness with tympany
       ascites—fluid seeks the lowest point
    in the abdomen. Flanks are dull to
    percussion with tympanic center. There
    is a protuberant abdomen with bulging
Assessing for Ascites
   With patient lying supine, find
    tympany in center of abdomen
   From center of abdomen, percuss
    outward in several directions to
    denote dullness
   To test for ―shifting dullness,‖ ask
    patient to turn to one side, then
    percuss from tympany to dullness
      fluid will sink to lowest point
More on ascites
   Assess for fluid wave
   Puddle sign
Assessing for kidney tenderness
    Find the costovertebral angle
    This is the angle formed by the lower
     border of the 12th rib and the transverve
     processes of the upper lumbar vertebrae
    Place left hand flat in this area on one
     side, hit the hand sharply with the fist of
     the other. Patient will admit to
     tenderness if present.
    Repeat on the other side
   Used to assess muscle tone, tenderness, fluid,
   May be light or deep
   Use pads of fingertips in light dipping motions
    and avoid short jabs
Palpation cont.
   To differentiate voluntary from involuntary
    resistance: rectus muscle will relax with
   Palpation is light or deep
   Deep palpation used to define and delineate
    organs or abdominal masses.
   Use palmar surface of fingers and feel in all
    four quadrants
Deep palpation
     If masses are felt, note: location, size, shalpe,
      consistency, tenderness, pulsations, mobility
      with respiration or with hand.
     If patient is obese or rigid, use 2 hands to
     Place one on top of other and feel with lower
The bladder
   Bladder percussion is unnecessary
    unless there is a suspicion of
    urinary retention
   Palpate above the symphysis
   An empty bladder is not palpable
Palpation of the liver
   Stand on patients right side
   Place left hand behind patient parallel to and
    supporting 11-12th ribs
   Patient should relax
   Press your left hand forward and place your
    right hand on abdomen with fingertips below
    lower edge liver dullness
   Press in and up while patient takes deep
    breath; if palpable, liver should come down
Palpation cont.
   Liver hook
   Kidney: not palpable in normal
   May be able to feel lower right
    kidney pole in very thin person
The spleen
   The spleen is usually not palpable
   From patient’s right side, reach over and
    around under patient with your left hand
   Place right hand below left costal margin and
    press in toward spleen. Ask patient to take
    deep breath---will feel if palpable
Assessing for peritoneal
   Ask patient to cough. Palpate lightly with one
    finger over area of pain produced by cough
   Test for REBOUND TENDERNESS: press
    finger in firmly and slowly then quickly
    withdraw. Rebound tenderness mean the
    withdrawal has caused the pain--- not the
   Other: Psoas sign and Obturator sign,
    cutaneous hyperesthesia
Assessing the Aorta
   Press firmly deep in upper abdomen slightly to
    left of midline.
   Feel for aortic pulsations
   Determine width of aorta by pressing deeply on
    either side of aorta
   What is the normal width of the aorta?
   If pulsatile mass is found, feel for femoral pulses
    which may be dimished.
This concludes the
examination of the
Examination of the anus
and rectum
This information is sometimes
  included with the abdominal
  assessment and at times
  with assessment of the
  male and female genitalia.
For our purposes, we are
  including it here
General Principles
   Anal canal is outlet of GI tract
   3.8cm long
   Merges with rectal mucosa @ anorectal
   Sensory nerves in anal area responsible for
    pain due to trauma
     2 concentric layers of muscle that keep anal
      canal closed
     Internal sphincter
         under involuntary control by autonomic
      nervous system
     External sphincter
        surround internal sphincters
        under voluntary control
     Intersphincteric groove: palpable separation
      between internal and external sphincter
   Anal columns - -folds of mucosa
    extend vertically from rectum and
    end in anorectal junction
   Can be seen with scope
   Each column contains and artery
    and vein
   With increased venous (portal) pressure, vein
    can enlarge.
      this is a hemorrhoid or a varicosity
   External hemorrhoids occur below the
    anorectal junction
      itch and bleed with defecation
      painful and swollen with thrombosis
      resolve and leave flabby skin top around
      anal opening.
   Internal hemorrhoids originate above anorectal
      covered with mucosa
      may appear as red mass with pressure

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