Chapter 2: Admissions and assessment
Skip chapter table of contents and go to main content
Abdominal examination
Anatomy and physiology
The abdominal cavity houses large parts of the gastrointestinal (GI) system, the renal system and the reproductive system. It is therefore important to have an understanding of the anatomy and physiology of all three systems when examining the abdomen.
The GI system includes the entire GI tract as well as the accessory organs (Figure 2.17). When examining the abdominal area, it is important to be able to visualize which organs are in which quadrant. This will help to form possible differential diagnoses.
Figure 2.17 Organs of the gastrointestinal system. Source: Reproduced from Peate et al. ([61]) with permission of John Wiley & Sons, Ltd.
Related theory
A full abdominal examination combines the following techniques:
- inspection
- auscultation
- percussion
- palpation.
The assessment of the abdomen starts with inspection, followed by auscultation, then percussion and palpation. Auscultation is performed prior to percussion and palpation to avoid abdomen and small bowel manipulation, which may change findings (Fritz and Becker Weilitz [31]).
Inspection
Externally, the abdomen should appear flat and symmetrical. The most common causes of abdominal distension are:
- fat in obesity
- flatus in pseudo‐obstruction or bowel obstruction
- faeces in subacute obstruction or constipation
- fluid in ascites (accumulation of fluid in the peritoneal cavity)
- tumours (especially ovarian) or distended bladder
- the foetus in pregnancy
- functional bloating (often in irritable bowel syndrome) (Plevris and Parks [63]).
Look at the abdomen for any abnormally prominent veins on the abdominal wall suggestive of portal hypertension or vena cava obstruction. Any abdominal swelling, scars and stomas should also be noted (Plevris and Parks, [63]). The umbilicus position can sometimes help to identify why there is distension.
Auscultation
Bowel sounds should be listened for in all four quadrants of the abdomen (Figure 2.18). Bowel sounds are often described as ‘clicks’ or ‘gurgles’ and it should be possible to hear 5–35 clicks in 1 minute. Listening for up to 2 minutes may be required for someone with hypoactive bowel sounds (Fritz and Becker Weilitz [31]). Bowel sounds are often described as active (i.e. normal), absent or hyperactive. Absence of bowel sounds may indicate bowel obstruction and hyperactive bowel sounds may be present if patients are having altered bowel function.
Figure 2.18 The four quadrants of the abdomen. LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.
Assessment of bruits is an important component of physical assessment. Bruits are often described as ‘whooshing’ or harsh intermittent sounds and can indicate atherosclerotic arterial disease (Bickley and Szilagyi [9]). If the bruits are over the renal artery, it can be a sign of renal artery stenosis (Bickley and Szilagyi [9]). See Figure 2.19 for stethoscope positioning.
Figure 2.19 Stethoscope positioning for auscultating bruits.
Percussion
Percussion is used to detect air, fluid, faeces, organs and masses (Walsh [85]). Predominantly, the abdomen should have a distribution of tympany and dullness – tympany where there is gas in the GI tract and dullness where other organs and faeces lie (Bickley and Szilagyi [9]). Large areas of dullness may indicate organomegaly (enlarged organs), a tumour or ascites (Bickley and Szilagyi [9]). Percussion is also used to locate and measure the size of the liver (Fritz and Becker Weilitz [31]). A normal liver measures 6–12 cm (Talley and O'Connor [82]). See Figure 2.20 for the relevant percussion technique.
Figure 2.20 Percussion technique during abdominal examination.
Palpation
Percussion requires indirect tapping of the abdomen to assess the size of the organs and to check for the presence of air or fluid, or air‐filled or solid masses (Fritz and Becker Weilitz [31]). If a mass is found, palpation should be used to gather more information about it. Talley and O'Connor ([82]) suggest that the following information should be included when describing a mass:
- site
- tenderness
- size
- surface
- edge
- consistency
- mobility
- whether it has a pulse or not.
Likewise, if an organ is found, it should be described. The spleen and kidneys are not normally palpable if they are not enlarged but a normal liver edge can sometimes be felt (Talley and O'Connor [82]). If palpable, it should feel soft, regular and smooth with a well‐defined border (Talley and O'Connor [82]). See Figures 2.21 and 2.22 for light and deep palpation techniques to be used during abdominal examination.
Figure 2.21 Light palpation during abdominal examination.
Figure 2.22 Deep palpation during abdominal examination.
Evidence‐based approaches
Rationale
The patient's health history and the nurse's knowledge of anatomy and physiology will help to guide when it is appropriate to do an abdominal physical examination. The list of presentations that may lead to an abdominal examination is vast; as discussed in the anatomy and physiology section, they could involve the GI, renal and/or reproductive systems. Some examples include:
- abdominal pain
- nausea and/or vomiting
- change in bowel habits
- weight change
- jaundice
- bleeding
- dysuria/urgency or frequency
- flank pain
- suprapubic pain.
Procedure guideline 2.3
Abdominal examination
Post‐procedural considerations
Documentation
Nurses should ensure that the following components are documented.
- rationale for examination
- patient's consent to examination
- type of examination performed
- findings from the examination
- plan of care.
As with all record keeping, documentation in relation to physical examinations should be clear, concise, accurate and without jargon or abbreviations (NMC [55]).
Record keeping should include evidence of clinical reasoning in order to identify patients’ needs for nursing care. While this becomes more automatic with experience, it should always be possible for a nurse to explain how they arrive at a decision about an individual within their care (Gordon [34], Putzier and Padrick [67], Rolfe [69]).
