Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [55], C).
2. 2.Show
   Gain the patient's verbal consent.
   Consent must be gained before any procedure takes place (NMC [55], C).
3. 3.Show
   Check that the patient has an empty bladder.
   A full bladder will interfere with the examination (Walsh [85], P).
4. 4.Show
   Make sure the patient is warm and comfortable and ideally have them in the supine position, with their arms by their sides.
   If the patient is uncomfortable or cold the abdominal muscles will be tense (Rushforth [74]). The supine position helps to relax the abdominal muscles and is the optimum position for abdominal palpation (Talley and O'Connor [82]). E
5. 5.Show
   Expose the patient from nipple to pubis, maintaining patient dignity at all times.
   To ensure a thorough examination. E

Procedure

1. 6.Show
   Wash and dry hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).

General inspection

1. 7.Show
   Take a global view of the patient.
   See ‘Inspection’ above.
2. 8.Show
   Look at the patient's skin and nails. Feel the texture and turgor of the skin.
   Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example bowel disease, malnutrition, liver disease, dehydration and/or anaemia (Bickley and Szilagyi [9], Dover et al. [23], Tidman [84], E).
3. 9.Show
   Ask the patient to extend their arms, flex their wrists and part their fingers. Ask them to stay in this position for 15 seconds.
   To assess for liver flap; this can be a sign of liver and/or renal failure (Talley and O'Connor [82], E).
4. 10.Show
   Look at the patient's eyes.
   To assess for any abnormalities, particularly looking for any signs of jaundice, hypercholesterolaemia and anaemia (Talley and O'Connor [82], E).
5. 11.Show
   Look at the patient's nose.
   To assess for signs of telangiectasia, which can indicate liver disease (Bickley and Szilagyi [9], E).
6. 12.Show
   Look at and in the patient's mouth
   The mouth can give a snapshot of the patient's general state of health. Look for signs of malnutrition, infection and any sores (Innes et al. [39], E).
7. 13.Show
   Smell the patient's breath.
   To assess for signs of fetor (unpleasant‐smelling breath) (Talley and O'Connor, [82]). Sweet‐smelling breath can be a sign of ketoacidosis. E
8. 14.Show
   Ask the patient to shrug their shoulders and lightly palpate, using the finger tips, directly above the clavicle.
   To assess for a raised supraclavicular lymph node, which can indicate gastrointestinal malignancy (Talley and O'Connor [82], E).
9. 15.Show
   Move to the foot of the bed to inspect the abdomen.
   Assessing the abdomen from different angles will help to identify any abnormalities (Walsh [85], E).
10. 16.Show
    Observe the contour of the abdomen and position of the umbilicus.
    To assess for asymmetry or distension, peristalsis and/or pulsations (Bickley and Szilagyi [9], Walsh [85], E).
11. 17.Show
    Move to the side of the bed and observe the contour of the abdomen tangentially.
    This will allow any subtle changes in contour to be observed (Cox [16], E).
12. 18.Show
    Look at the patient's skin.
    To assess for any signs of spider naevi, striae, scars, caput medusa, bruising and rashes (Plevris and Parks [63], E).

Auscultation

1. 19.Show
   Using the diaphragm of the stethoscope, listen in all four quadrants for 1 minute each.
   To assess for bowel sounds (Bickley and Szilagyi [9], E). Bowel sounds normally occur every 5–10 seconds but frequency varies (Plevris and Parks [63], E).
2. 20.Show
   Using the bell of the stethoscope, listen over the aortic, renal, iliac and femoral arteries (see Figure 2.19).
   To assess for bruits (Bickley and Szilagyi [9], E).

Percussion

1. 21.Show
   Percuss in the nine areas of the abdomen.
   To listen for a normal distribution of tympany and dullness (see Table 2.3) (Bickley and Szilagyi [9], E).
2. 22.Show
   Percuss for liver span. To do this, percuss upwards, starting in the right lower quadrant at the mid‐clavicular line. Stop when you hear the dullness of the liver. Next percuss down, starting from the intersection of the nipple line and the mid‐clavicular line; stop when the sound changes from the resonant lung to the dull liver. Measure between those two points.
   To assess the size and location of the liver (Walsh [85], E).
3. 23.Show
   The above technique can be employed to percuss the spleen, bladder and kidneys.
   Not routinely done but may be useful if abnormality, in particular organomegaly, is suspected. E
4. 24.Show
   Percuss from the midline out to the flanks for dullness. Keep your finger on the site of dullness in the flank, ask the patient to turn onto their opposite side and then percuss again. If the area of dullness is now resonant, shifting dullness is present.
   To assess for shifting dullness (Plevris and Parks [63], E).

Palpation

1. 25.Show
   Lightly palpate the abdomen using one hand. Look at the patient's face at all times, to ensure they are not in discomfort.
   To assess for tenderness, rebound tenderness, superficial organs and masses (Talley and O'Connor [82], E).
2. 26.Show
   Deeply palpate the abdomen.
   To assess the organs, identify deeper masses and define masses that have already been discovered (Talley and O'Connor [82], E).
3. 27.Show
   Palpate for the liver. To do this, place your left hand in the small of the patient's back and your right in the right lower quadrant pointing towards the upper left quadrant. Ask the patient to take a deep breath and palpate up. If nothing is felt, move up towards the liver and repeat until you reach the ribcage.
   To assess for hepatomegaly or gallbladder tenderness (known as Murphy's sign) (Plevris and Parks [63], E).
4. 28.Show
   Palpate for the spleen. Ask the patient to tip slightly onto their right side. Start from the umbilicus region and mimic the technique above, moving towards the spleen.
   To assess for splenomegaly (Plevris and Parks [63], E).
5. 29.Show
   Palpate for the kidneys. Do each kidney separately. For the right side, stand on the right side of the patient, place your left hand just below the 12th rib and lift up. Place your other hand on the right upper quadrant of the abdomen. Ask the patient to take a deep breath. As they do, press your right hand deeply into the abdomen, trying to feel the kidney between your hands. Repeat for the left side, standing on the left of the patient.
   To assess for kidney enlargement; if the kidney is normal, it is not usually palpable (Plevris and Parks [63], E).
6. 30.Show
   Lightly palpate each costovertebral angle (the area directly overlying the kidneys) for tenderness; if none is felt, place one hand flat over the costovertebral angle and strike the hand firmly with the other fist.
   Pain can indicate pyelonephritis (Bickley and Szilagyi [9], E).

Post‐procedure

1. 31.Show
   Document fully.
   Accurate records should be kept of all discussions and/or assessments made (NMC [55], C).
2. 32.Show
   Report any abnormal findings to a senior nurse or to medical staff.
   Patients should be cared for as part of a multidisciplinary team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC [55], C).
3. 33.Show
   Clean the equipment used and wash hands.
   To prevent the spread of infection (NHS England and NHSI [54], C).
4. 34.Show
   Explain the findings to the patient.
   The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC [55], C).
5. 35.Show
   Explain the plan of care to the patient.
   Where possible, patients should be involved in planning their care (NMC [55], C).