Abdomen

• Quadrants of the abdomen

  • RUQ
  • RLQ
  • LUQ
  • LLQ
• Organs and structures in each quadrant

  • RUQ: ascending transverse colon, duodenum, gall bladder, hepatic flexure of colon, liver, pancreas, pylorus (small bowel or ileum – traverses all quadrants), right adrenal gland, right kidney (upper pole), right ureter
  • RLQ: Appendix, Ascending colon, Cecum, Right kidney (lower pole), Right ovary and tube, Right ureter, Right spermatic cord
  • LLQ: Left kidney (lower pole), Left ovary and tube, Left ureter, Left spermatic cord, Descending and sigmoid colon
  • LUQ: Left adrenal gland, Left kidney (upper pole), Left ureter, Pancreas (body and tail), Spleen, Splenic flexure of colon, Transverse descending colon, Midline – bladder, uterus, prostate gland
• Nine Regions of the Abdomen

  • Right hypogastric, Epigastric, Left hypochondriac, Right lumbar, Umbilical, Left lumbar, Right iliac/inguinal, Hypogastric, Left iliac/inguinal
• Peritoneum


  A thin, shiny, serous membrane acting as protective covering
• Abdominal cavity


  Contains GIT, reproductive (female), lymphatic and urinary
• Liver


  • Largest solid organ in the body, located below the right costal margin (where it may be palpated), composed of 4 lobes that fill most of the RUQ and extend to the midclavicular line, may extend just below the right costal margin and be palpable, has a soft consistency
• The liver has metabolic and regulatory functions like glucose storage, formation of blood plasma proteins and clotting factors, urea synthesis, cholesterol production, bile formation, destruction of RBC, storage of iron and vitamins, and detoxification
• Pancreas


  • Located mostly behind the stomach deep in the upper abdomen, normally not palpable, a long gland extending across the abdomen from the RUQ and LUQ
• Functions of the pancreas

  An endocrine gland and an accessory organ of digestion (filter blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver)
• When the spleen enlarges, the lower tip extends down and toward the midline
• Kidneys


  • Located high and deep under the diaphragm, posterior organs about 10x5x2.5 are approximate with the level of the T12 to L3 vertebrae, the top is protected by the posterior rib cage
• Costovertebral angle (CVA)


  Located on your back at the bottom of your ribcage at the 12th rib, the 90-degree angle formed between the curve of that rib and your spine
• The right kidney is positioned slightly lower because of the position of the liver
• Function of kidneys


  Filtration and elimination of metabolic waste products
• The pregnant uterus may be palpated above the level of the symphysis pubis in the midline
• The ovaries are located RLQ and LLQ and are normally palpated only during a bimanual examination of the internal genitalia
• Stomach


  • A distensible, flask-like organ, not usually palpable (store, churn, digest food)
• Gallbladder


  • Functions to concentrate and store the bile needed to digest fat, posterior surface of the liver lateral to the Midclavicular Line (MCL), not normally palpated
• Small intestine


  • Longest portion of the GIT, 7 meters, digestion and absorption of nutrients, coiled in the 4 quadrants, usually not palpable
• Colon/large intestines


  • Wider than the SI, 1.4 meters long – ascending, transverse, descending (sigmoid colon is felt as a firm structure on palpation, cecum and ascending colon are softer), functions to secrete large amounts of alkaline mucus to lubricate the intestine and neutralize acids formed by the intestinal bacteria
• Urinary bladder


  • A distensible muscular sac located behind the pubic bone in the midline of the abdomen (temporary receptacle of urine), a bladder filled with urine may be palpated in the abdomen above the symphysis pubis
• Abdominal aorta and its major branches

  • Supplied with arterial blood, palpations of the aorta are frequently visible and palpable midline in the upper abdomen
• The aorta branches into right and left iliac arteries just below the umbilicus
• Pulsations of the right and left iliac arteries may be felt in the RLQ and LLQ
• Collecting Subjective data: The Nursing Health History

  Focuses on symptoms of particular abdominal organs and the function of the digestive system along with the aspects of nutrition, usual bowel habits and lifestyle
• Patient may feel uncomfortable discussing some issues


  The nurse needs to facilitate client responses and quantitative answers by encouraging descriptive terms and examples (pain is sharp)
• Types of Pain


  • Visceral pain (occurs when hollow abdominal organs become distended or contract forcefully or when the capsules of solid organs become stretched, poorly defined and intermittently timed, dull, aching, burning, cramping, colicky)
  • Parietal pain (occurs when the parietal peritoneum becomes inflamed, localize more to the source and is characterized as a more severe and steady pain)
  • Referred pain (occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ, travels/refers from the primary site and becomes highly localized at the distant site)
• Examples of Referred Pain

  • Gall bladder, biliary tree, liver – RUQ/epigastric pain
  • Stomach, duodenum, or pancreas – epigastric pain
  • Appendix – periumbilical area to the RLQ pain
  • Kidney – flank pain and/or radiating down the lower abdomen from the ureter
  • Small bowel, appendix, proximal colon – periumbilical pain
  • Rectum, colon, bladder or prostate – suprapubic pain
  • Pancreas, spleen – left shoulder pain
  • Gallbladder – right shoulder pain
  • Pancreas, kidney – back, middle near flank
  • Rectal pain – near coccyx area
  • Ureter pain – left side near iliac
• Character of Abdominal Pain and Implications

  • Dull, aching (described as chronic or persistent pain, a deep ache felt in an area, but typically doesn't stop one from daily activities)
  • Burning, gnawing – stabbing, aching pain (usually related to nerve problems)
  • Pressure
  • Colicky (sharp pain often caused by obstruction, spasm, twisting)
  • Sharp, knifelike
  • Variable
• Purposes of abdominal exam: As part of comprehensive health assessment
• Pain - near coccyx area

  Ureter pain - left side near iliac
• Character of Abdominal Pain and Implications

  • Dull, aching (described as chronic or persistent pain, this is a deep ache felt in an area, but typically doesn't stop one from daily activities)
  • Burning, gnawing - stabbing, aching pain (usually related to nerve problems)
  • Pressure
  • Colicky (colic - sharp pain often caused by obstruction, spasm, twisting)
  • Sharp, knifelike
  • Variable
• Conditions associated with each type of abdominal pain

  • AP (Appendicitis)
  • Acute hepatitis
  • Biliary colic
  • Cholecystitis
  • Cystitis
  • Dyspepsia
  • Glomerulonephritis
  • Incarcerated or strangulated hernia
  • Irritable bowel syndrome
  • Hepatocellular CA
  • Pancreatitis
  • Pancreatic CA
  • Perforated gastric or duodenal ulcer
  • Peritonitis
  • PUD
  • Prostatitis
  • Dyspepsia
  • PUD
  • Acute mechanical obstruction
  • Colitis
  • Diverticulitis
  • GERD
  • BPH
  • Prostate CA
  • Prostatitis
  • Urinary retention
  • Colon CA
  • Splenic abscess
  • Splenic rupture
  • Renal colic
  • Renal tumor
  • Ureteral colic
  • Vascular liver tumor
  • Stomach CA
• Purposes of abdominal exam

  • As part of comprehensive health exam
  • To explore GI complaints
  • To assess abdominal pain, tenderness, or masses
  • To monitor clients post operatively
• Sequence of abdominal exam

  1. Inspection

  2. Auscultation - so as not to alter the patient's pattern of bowel sounds

  3. Percussion

  4. Palpation
• Step-by-step procedure for abdominal exam

  1. Adjust bed level

  2. Always approach the patient from the right side

  3. Use tangential lighting to optimize visualization of abdomen

  4. Let client empty bladder before beginning to eliminate bladder distention and interference

  5. Instruct patient to remove clothes and put on gown

  6. Help client to lie supine with the arms folded across the chest or resting by the side (relaxes the muscles, raising will tense the muscles)

  7. A flat pillow may be placed under the head for comfort

  8. Slightly flex the client's legs by placing a pillow or rolled blanket under the client's knees to help relax the abdominal muscles

  9. Drape the client with sheets so that the abdomen is visible from the lower rib cage to the pubic area

  10. Instruct client to breath through the mouth and to take, slow, deep breaths - to promote relaxation

  11. Before touching the abdomen, ask the client about painful or tender areas, as you have to assess these areas at the end of the examination

  12. Provide assurance that you will forewarn the patient before examining these areas

  13. Approach with slow, gentle, and fluid movement
• Tenderness


  Pain or discomfort when an affected area is touched
• Equipment for abdominal exam

  • Small pillow or rolled blanket
  • Centimetre ruler
  • Stethoscope
  • Marking pen
• Common Abdominal Findings


  • Abdominal edema/swelling - ascites
  • Abdominal masses - abnormal growths or constipation
  • Unusual pulsations - aneurysms of abdominal aorta
  • Pain - AP
• Head-to-toe Abdominal Exam


  1. Inspect Abdominal skin, Umbilicus, Aortic pulsations, Peristaltic waves

  2. Auscultate Bowel sounds

  3. Palpate superficial bulges or pulsations

  4. For more focused assessments, include percussion and deep palpation of the abdomen and abdominal organs, and performed in specialty areas or critical care settings where abnormalities are suspected or to be ruled out (R/O) as described