Abdominal Assessment

Welcome to Abdominal Assessment This program will be divided into 3 parts: 1) A review of the Anatomy & Physiology of the abdomen 2) A review of history taking - Abdominal Assessment 3) The actual abdominal physical examination

Important landmarks of the abdomen include: Xiphoid Process (Basic Life Support BLS) Costal Margin (along ribs) Midline (center) Umbilicus Anterosuperior Iiac Spine (situated in front of, at a higher level from the iliac spine) Superior margin of os pubis (Top of pubis bone) Poupart ligament (groin) - The inguinal lig. extends from the anterior superior spine of the ilium to the pubis on each side.

White Line (linea Alba) is a tendonous band in the abdomen that is located in the midline of the abd. between the rectus abdominus muscles.

Abdominal Muscles include Rectus abdominis Transversus abdominis Internal & external obliques Function of Abdominal muscles Form the abdominal cavity Protect the abdominal cavity Assist in movement

Stomach Small intestine Large intestine Liver

Organ Structure & Function STOMACH Consists of 3 lobes: fundus, body, pylorus Aids in the breakdown of food particles, very little absorption takes place in the stomach. Secretes hydrochloric acid and digestive enzymes to breakdown fats and proteins. Two digestive enzymes include: Pepsin acts to digest proteins Gastric lipase acts on emulsified fats

Small Intestine Duodenum Jejunum Ileum Approx. 21 feet long. Begins at the pyloric orific and ends at the ileocecal valve. Digestion is completed through the action of pancreatic enzymes, bile, and several small intestine enzymes. Nutrients are absorbed through the walls of the small intestine.

Large Intestine Cecum Ascending Colon Transverse Colon Descending Colon Sigmoid Colon Approx. 4.5 - 5 feet long & 2.5 in. in diameter Absorption of water takes place Lubrication of contents by secreted mucus. Neutralization of acids by an alkaline mucous secreted. Live bacteria decompose undigested food, unabsorbed amino acids, cell debris, and dead bacteria.

Liver Heaviest organ in the body (approx. 3 lbs.) Composed of 4 lobes containing lobules Plays a role in the metabolism of carbohydrates, fats, and proteins Glucose conversion, storage & release Amino acids are converted into glucose Bile salt formation from cholesterol Storage of several minerals & iron Detoxification & release of harmful substances -“excretory organ” Other functions include: Production of antibodies Synthesis of fats from carbohydrates & proteins Proteins are broken down to amino acids Excretion of steroid hormones Production of prothrombin, fibrinogen and other substances for blood cloagulation production of proteins that circulate in the blood converts fat-soluble waste into water soluble waste for renal excretion

Removal of the stomach, small intestine, and the large intestine Gallbladder Pancrease Spleen Kidneys Ureters Bladder

Gallbladder Saclike, pear shaped organ about 4 in. Long. It concentrates & stores bile from the liver. Bile is composed of cholesterol, bile salts, & pigments. Bile acts to maintain the alkaline (basic) pH of the small intestine to permit emulsification (breakdown) of fats so that absorption can be accomplished.

Pancreas Lies behind & beneath the stomach Both an exocrine & an endocrine gland Exocrine gland Digestive juices are produced by the acinar cells of the pancreas. The juices contain inactive enzymes for the breakdown of proteins, fats, and carbohydrates. Endocrine gland Islet cells within the pancreas produce both insulin & glucagon. These are secreted directly into the blood to regulate the body's level of glucose.

Spleen Located in the upper left quadrant Consists of white pulp (lymphoid tissue) & red pulp. White pulp (lymphoid tissue) Constitutes most of the spleen Part of the reticuloendothelial system to filter blood & manufacture lymphocytes & monocytes. Red pulp A capillary network & venous system that allows for the storage and release of blood. Allows the spleen to hold up to several hundred milliliters at 1 time.

Kidneys 2 Kidneys containing more than 1 million nephrons each. Nephrone are composed of a tuft of capillaries, the glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule. The distal tubule empties into a collecting tubule. Glomeruli filter the blood of: electrolyes, glucose, water, & small proteins. Both an excretory organ & an endocrine gland. Excretory organ - responsible for the removal of water-soluble waste. Endocrine gland - produces renin, which controls aldosterone secretion. Aldosterone acts in the renal tubule to retain sodium, conserve water, and increase potassium excretion in the blood.

Ureters & Bladder Ureters 2 ureters connecting the kidneys to the bladder. Peristaltic waves move the urine from the kidneys to the bladder. Bladder Serves as a urinary reservoir Capacity of approx. 400 - 500 ml in the adult

Vessels of the abdomen

Abdominal Vasculature Abdominal Aorta (descending aorta) Brances off into 2 common iliac arteries, and the splenic & renal arteries Supplies oxygenated blood to parts of the body Inferior Vena Cava Receives blood from the 2 common iliacs, the lumbar veins & the testicular veins. Returns deoxigenated blood to the heart from parts of the body. Superior Mesenteric Artery & Vein Supplies & draws blood from most of the small intestine, the cecum, and the ascending & transverse colons.

OLD CARTS Review of Related History Present Problem Onset and duration: sudden or gradual, persostent, intermittent Character:dull, sharp, burning, stabbing, aching Location: radiates, superficial or deep, change over time Associated symptoms: n/v/d/c, change in abd. girth, belching Relationship to internal or external stressors and bodily functions: menses, time of day Recent stool characteristics: color, consistency, odor, frequency Urinary characteristics: frequency, color, odor. volume Medications: (past & current), perscription, nonperscription Present Problems: Abdominal pain, Indigestion, vomiting, diarrhea, constipation, fecal incontinence, jaundice, dysurea, urinary frequency, urinary incontinence, hematuria, chyluria (milky urine)

Past Medical History Gastrointestinal disorders: ulcers, IBS, intestinal obstruction, pancreatitis Hepatitis or cirrhosis of the liver Abdominal or urinary tract surgery: For what & when, how many Urinary tract infections: number & treatment, sees a urologist? Major illnesses: cancer, kidney disease, cardiac disease, arthritis Blood transfusions: How many, when? Hepatitis vaccine: Series of 3 completed? Titers?

Family History Familial Mediterranean Fever (periodic peritonitis, brucellosis) A disease caused by the gram neg. coccobacillus Brucella. Humans usually acquire it from contaminated milk or milk products. S&S: fever, chills, sweating, maliase, and weakness Gallbladder disease: cancer, cholecystitis Kidney disease: renal stone, polycystic disease, renal or bladder carcinoma Malabsorption syndrome: cystic fibrosis, celiac disease Colon Cancer

Personal & Social History Nutrition: 24-hour recall intake, food likes & dislikes, food intolerences, ethnic or religious foods frequently eaten, recent weight loss or gain. First day of last menstrual period: Esp. college aged females Alcohol intake: How often, how much, what type Recent stressful life events: physical & psychologic changes Exposure to infectious diseases: hepatitis, flu, travel history Trauma: through type of work, physical activity, abuse Use of street drugs: types, frequency & usual amounts

Examination Equipment Stethoscope: for auscultation Centimeter ruler & measuring tape: to measure abdominal girth Marking pens: to mark the areas of measurment for consistency in measuring

Examination Inspection Auscultation Percussion Palpation Complete in this oder so as not to distrupt the normal abdominal sounds & movement with percussion & palpation.

Four quadrants of the abdomen include the: Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant Imaginary line from the sternum to the pubis, through the umbilicus. Second imaginary line is perpendicular to the first, horizontally across the abdomen through the umbilicus. See page with anatomic correlations

Nine regions of the abdomen 1. Epigastric 2. Umbilical 3. hypogastric (pubic) 4 & 5. Right & left hypochondriac 6 & 7 Right & left lumbar 8 & 9 Right & left inguinal See page with anatomic correlations

Inspect for : Generalized skin color changes and surface characteristics: jaundice, cyanosis Ecchymosis: brusing Striae: stretch marks, indicate weight loss Lesions & nodules Scars: cause? Abnormal movements: ie-gastroenteritis Contour, symmetry, and surface motion: abd. should be symmetrical on both sides. Surface motion should be smooth and wave-like

Abdominal profiles: 1. Flat 2. Rounded - slightly distended 3. Scaphoid - Sunken anterior wall 4. Protruberant - Distended The Fs of abdominal distention Fat Fluid Feces Fetus Flatus Fibroid Full bladder False pregnancy Fatal tumor

Auscultation Auscultate for: Bowel Sounds Auscultate all 4 quadrants Note frequency & character Usually 5 - 35 per minute Absence is established only after 5 minutes of continuous listening. Vascular Sounds Bruits in the aortic, renal, iliac, and femoral arteries Friction rubs over the liver & spleen Venous hum in the epigastric region - occurs with increased collateral circulation between portal & systemic venous systems. soft, low pitch & continous.

Percussion To detect fluid, air, and an fluid-filled or solid masses. Stomach & intestines - tympany Organs & solid masses - dullness Percuss all 4 quadrants in a systematic route (May begin on the right side just below the liver, span hortizontally to the spleen & pancreas, travel down the stomach, the horizontally once again across the lower abdomen Note: Liver span (at midsternal line usually 2-3 cm) - Usual span is 6-12 cm. On right Spleen - just posterior to the midaxillary line on the left Gastric bubble - Left lower anterior rib cage and the left epigastric region The tympany produced by the gastric bubble is lower in pitch than the tympany of the intestine.

Palpation Light, moderate, & deep palpation Palpate for masses, tenderness, organ enlargement, and ascites Palpation of specific structures: (TO BE REVIEWED IN LAB) Liver: with finger hooked over costal margin also push up from back & mead down Gallbladder (Murphy sign): two handed Spleen: push up from the left back and mead downward on the abd. Kidneys: Side of hand or fist over flank area, also pushing up from back, then down. Aorta:Slightly left of the midline. Feel for aortic pulsation. Urinary Bladder: Not palpable in the healthy pt. unless the bladder is distended. Abdominal reflexes: Stroke away from umbilicus. Should see contraction of the rectus abdominus muscles & a pulling of the umbilicus toward the stroked side.

Common conditions producing abdominal pain: appedicitis cholecystitis pancreatitis Perforated gastric or duodenal ulcer diverticulitis intestinal obstruction volvulus leaking abd. aneurysm biliary stones, colic salpingitis ectopic pregnancy pelvic inflammatory disease ruptured ovarian cyst renal calculi spleenic rupture peritonitis

Additional Procedeures in Abdominal Assessment Ascites Assessment - fluid wave, auscultatory percussion, puddle sign Pain Assessment - use pain scale - assess using "old carts" Rebound tenderness - fingers at 90 degree angle with abd., press deeply, remove fingers quickly. Return to position of organs causes a sharp pain. Iliopsoas muscle test - + lower quad. pain. Appendicitis. raise leg & flex at hip while examiner pushes downward Obturator muscle test - ruptured appendix or pelvic abscess. while supine, flex right leg at hip & knee to 90 degrees. Hold the leg just above the knee, grasp the ankle, & rotate the leg laterally & medially. Ballottement - floating mass. push inward on abd., while palpating flank area.

Older Adults Fecal Incontinence Urinary Incontinence Stress incontinence - leakage due to increased intraabd. pressur from coughing, laughing, etc. Urge incontinence - inability to hold urine once the urge to void occurs. Overflow incontinence - mechanical dysfunction from an overdistended bladder. Functional incontinence - intact urinary tract, but cognitive abilities, immobility, or musculoskeletal impairments lead to incontinence.

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