ABDOMEN

• Abdomen


  • Bordered superiorly by the costal margins
  • Bordered inferiorly by the symphysis pubis and inguinal canals
  • Bordered laterally by the flanks

  
• Abdominal Quadrants


  Four quadrants: right upper quadrant (RUQ), right lower quadrant (RLQ), left lower quadrant (LLQ), left upper quadrant (LUQ)

  
• Abdominal Quadrants

  Two imaginary lines (vertical/midline- from tip of the sternum to symphysis pubis, horizontal/lateral- from umbilicus across the abdomen)

  
• Regions commonly used


  • epigastric
  • umbilical
  • hypogastric
  • suprapubic
• Right Upper Quadrant


  • Ascending and transverse colon
  • Duodenum (first part of small intestine), pylorus (small bowel or ileum), gallbladder, hepatic flexure of colon, liver
  • Pancreatic head, right adrenal gland
  • Right kidney(upper pole), right ureter
• Right Lower Quadrant


  • Appendix
  • Ascending colon, cecum
  • Right kidney
  • Right ovary and tube
  • Right ureter
  • Right spermatic cord
• Left Upper Quadrant


  • Left adrenal gland
  • Left kidney
  • Left ureter
  • Pancreas, spleen, stomach
  • Transverse descending colon
• Left Lower Quadrant


  • Left kidney
  • Left ovary and tube
  • Left ureter
  • Left spermatic cord
  • Descending and sigmoid colon
• 9 Regions

  • Right Hypochondriac Region
  • Epigastric Region
  • Left Hypochondriac Region
  • Right Lumbar Region
  • Umbilical Region
  • Left Lumbar Region
  • Right Iliac (Inguinal) Region
  • Hypogastric Region
  • Left Iliac (Inguinal) Region
• Abdominal Wall Muscles


  • Three muscle layers from back, around flanks, to front: external and internal abdominus oblique, transverse abdominus
  • Abdominal wall muscles protect internal organs; allow normal compression of internal organs during functional activities

  
• The abdominal wall allows normal compression during functional activities such as childbirth
• Internal Anatomy


  • Parietal peritoneum
  • Visceral peritoneum
  • Gastrointestinal
  • Reproductive (female)
  • Lymphatic and urinary
• Abdominal viscera


  • Solid viscera: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
  • Hollow viscera: stomach, gallbladder, small intestine, colon, bladder
• Liver


  • Largest solid organ in the body
  • LOC: RUQ, below the diaphragm
  • Fx: accessory digestive organ, metabolic and regulatory functions: glucose storage, clotting factors formation, bile formation
• Kidney


  • Filtration and elimination of metabolic wastes
  • LOC: high and deep under the diaphragm, T12 to L3
  • Tenderness- best assessed at costovertebral angle (bellow Rib 12)
• Stomach


  • Distensible, flask-like organ
  • Loc:LUQ, below the diaphragm, in between the liver and spleen
  • FX: store, churn and digest food
• Gallbladder


  • Muscular sac, 10 cm long
  • Loc: near the posterior surface of the liver, lateral MCL
  • Fx: store and concentrate bile needed for fat digestion
• Small Intestine


  • Longest portion (7 m long, 2.5 cm in diameter)
  • FX: digestion and absorption of nutrients
• Colon


  • 6.0 cm in diameter
  • FX: water absorption
• Bladder


  • Distensible muscular sac
  • Loc: behind the pubic bone, midline of abdomen
  • FX: temporary receptacle for urine
• Viscera normally not palpable: pancreas, spleen, gallbladder, small intestine
• Vascular structures: abdominal aorta; right and left iliac arteries
• The small intestine is not normally palpated during a physical assessment
• Risk factors for Peptic Ulcer Disease

  • Presence of Helicobacter pylori in gastrointestinal tract
  • Excessive alcohol intake
  • Regular use of nonsteroidal anti-inflammatory medications (NSAIDs), as well as bisphosphonates
  • Smoking cigarettes or chewing tobacco
  • Serious illness (especially if on respirator)
  • Radiation treatments
  • Zollinger–Ellison syndrome
  • Uncontrolled stress
• Client Education for Peptic Ulcer Disease

  • Wash hands frequently with soap and water
  • Eat foods that have been cooked completely
  • Use all recommended cautions when taking pain relievers, such as taking as low a dose over as short a length of time as possible; take pain medications with food; avoid drinking alcohol while on the pain medications
  • Avoid excessive alcohol intake (more than one drink per day for women and two drinks per day for males)
• Client Education for Peptic Ulcer Disease

  • Avoid or stop smoking and chewing tobacco
  • If medications are ordered by your primary health care provider, follow the directions carefully and report if there are continuing symptoms, symptoms worsen, or more serious symptoms occur (such as severe pain, vomiting with bleeding, tarry stools)
• Risk factors for Gastroesophageal Reflux Disease

  • Obesity
  • Hiatal hernia- compression
  • Pregnancy
  • Smoking (weakens esophageal sphincter)
  • Dry mouth
  • Asthma
  • Diabetes
  • Delayed stomach emptying
  • Connective tissue disorders, such as scleroderma
  • Alcohol consumption (weakens esophageal sphincter)
• Current Symptoms


  • Abdominal pain
  • Factors that precipitate pain or make it worse
  • Description and location of pain
  • Other symptoms
  • Recent weight gain or loss
• History


  • Past: Abdominal surgery, trauma, injury, medications, Abdominal pain and treatment, Lab work or gastrointestinal studies
  • Family: Stomach, colon, liver cancer, Abdominal pain, appendicitis, colitis, bleeding, hemorrhoids
  • Nutritional habits in family
• Lifestyle and Health Problems


  • Smoking
  • Alcohol use
  • Diet
  • Antacid
  • Medications
  • Fluid intake
  • Exercise
  • Stress
• Preparing the Client


  1. Empty the bladder

  2. Remove clothes and put on a gown

  3. Lie supine with the arms folded across the chest or resting by the sides

  4. Drape the client

  5. Breathe through the mouth; take slow, deep breaths
• Equipment


  • Small pillow or rolled blanket
  • Centimeter ruler
  • Stethoscope (warm the diaphragm and bell)
  • Marking pen
• Inspection #1


  • Observe the coloration of the skin: usually paler than the rest of the body skin, Grey-Turner sign: pale flanks (indicates abdominal bleeding), Yellowish- Jaundice, Redness- inflammation
  • Note the vascularity of abdominal skin: Dilated veins may be seen in cirrhosis of the liver
  • Note any striae: Dark bluish-pink striae are associated w/ Cushing Syndrome
  • Inspect for scars: Surgery or trauma, Keloids (excessive scar tissue)
  • Assess for lesions and rashes: Changes in moles ABCDE
• Inspection #2

  • Inspect umbilicus: inverted or protruding no more than 0.5 cm, round
  • Inspect abdominal contour: flat, rounded, scaphoid abnormal: distended/ protuberant
  • Inspect abdominal movements when client breathes
  • Assess abdominal symmetry: Asymmetrical,- organ enlargement
  • Observe aortic pulsations: abdominal aortic aneurysm
  • Observe for peristaltic waves: Abnormal: ripple like LUQ -> RUQ, abd. obstruction
• Auscultation


  1. Start: RLQ -> Clockwise

  2. Auscultate for bowel sounds: Normal findings: series of intermittent about 5-15 max 30/min soft clicks and gurgles (= Breath sounds)

  3. Abnormal: "Hyperactive" rushing, tinkling, high-pitched (means very rapid motility in early bowel obstruction)

  4. Abnormal: "Hypoactive"- diminished bowel motility

  5. Auscultate for vascular sounds: bruits make a whooshing sound when blood flows through a narrow vessel

  6. Auscultate for venous hum: not heard normally, if present, in epigastric and umbilical areas because of increase collateral circulation as heard in liver cirrhosis

  7. Auscultate for friction rub: no friction rub is present over liver or spleen
• Percussion


  1. PATTERN: RUQ, LUQ, RLQ, LLQ

  2. Percuss for tone: NORMAL: Generalized tympany because of AIR (stomach and intestines), Dullness: Liver and Spleen, ABNORMAL: Hyperesonance- gaseous distended bladder, Enlarged area of Dullness: enlarged liver/spleen

  3. Percuss the span or height of the liver by determining its lower and upper borders: located 1-2 cm below the costal margin

  4. Percuss the spleen: Approx 7cm wide, Loc: L 10th Rib and slightly posterior to MAL

  5. Perform blunt percussion on the liver: Normal: No tenderness
• Palpation #1


  1. Perform light palpation: Involving the 9 regions, N: non tender and soft, AB: involuntary reflex guarding- rigid abdomen and rectus muscle fails to relax during expiration

  2. Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses: Deep Bimanual, N: mild tenderness (xiphoid, aorta, cecum, sigmoid colon,ovaries), AB: severe tenderness or pain (trauma, peritonitis, infection, tumors, enlarged or diseased organ)

  3. Palpate for masses: Size, shape, consistency, demarcation, pulsality, tenderness and mobility, N: no palpable masses
• Enlarged area of Dullness

  • Enlarged liver/spleen
• Percuss the span or height of the liver


  Determine lower and upper borders
• Liver location

  1. 2 cm below the costal margin