HEALTH ASSESSMENT RLE

ABDOMINAL ASSESSMENT
◼ 1. Gather equipment) pillow/towel,
centimetre ruler, stethoscope, marking
pen)
◼ 2. Explain procedure to client.
◼ 3. Ask client to put on a gown.
 ABDOMINAL QUADRANTS
◼ 4 Quadrants- RUQ, RLQ, LLQ, LUQ
◼ Imaginary vertical line- Midline ( From
sternum ( Xiphoid ) through the umbilicus
to symphysis pubis
◼ 9 regions- epigastric, umbilical
hypogastric/ suprapubic, hypochondric,
lumbar, inguinal
 LANDMARKS OF ABDOMEN
◼ Liver- largest solid organ in the body,
located below diaphragm in RUQ.
Composed of 4 lobes that fills most of the
RUQ and extend to the left midclavicular
line. In many people it extends just
below the right costal margin. The liver
functions as an accessory digestive organ
and metabolic and regulatory functions
◼ Pancreas- located mostly behind
the stomach, deep in the upper
abdomen. Normally not palpable.
Extending across the abdomen
from the RUQ to the LUQ.
Accessory organ of digestion and
endocrine gland
◼ Spleen- approximately 7 cm wide and is
located above the kidney, just below the
diaphragm at the level of the ninth, tenth
and eleventh ribs. It is posterior to the
midaxillary line and posterior and lateral to
the stomach. Soft flat structure and
usually not palpable. In some patients the
lower tip can be felt below the left costal
margin
◼ Kidneys- located high and deep under the
diaphragm. Glandular, bean shaped organs
measuring 10X5X2.5 cm are considered
posterior organs and approximately with
the level of T12 to L3 vertebrae. The tops
of both kidneys are protected by posterior
rib cage. Kidney tenderness is best assssed
at the costovertebral angle.
◼ Right kidney is slightly lowered because of
the position of the liver.
◼ Function: Filtration and elimination
of metabolic waste products. Role
in blood pressure control,
maintenance of salt, water and
electrolyte balance. Function as
endocrine glands by secreting
hormones.
◼ The pregnant uterus may be
palpated above the level of
symphysis pubis in the midline.
The ovaries are located in THE
RLQ and LLQ and are normally
palpated only during bimanual
examination of the internal
genitalia.
 HOLLOW VISCERA
◼ The abdominal cavity starts with stomach-
flashlike organ located in LUQ just below
diaphragm and in between the liver and
spleen. It is not usually palpable. Stomach
main function is to store, churn, and digest
◼ Gallbladder- a muscular cas approximately
10 cm long, primarily to concentrate and
store the bile needed to digest fat. It is
located near the posterior surface of the liver
lateral to the midclavicular line.
◼ It is not usually palpated because it is
difficult to distinguish the gallbladder and the
liver.
◼ The Small intestine is the longest portion of
the digestive tract approximately 7 cm long
and diameter of 2.5 cm
◼ For digestion and absorption of nutrients
through millions of mucosal projections lining
its wall.
◼ Lies coiled in all 4 quadrants of the abdomen
is not usually palpable
◼ Colon/ Large intestine has a wider
diameter than small intestine
approximately 6 cm and 1.4 m
long.
◼ It originates in RLQ where it
attaches to the small intestine at
the illeocecal valve.
◼ Composed of 3 major sections:
ascending, transverse and
descending
◼ Ascending colon extends up along the
right side of the abdomen, at the junction
of the liver in the RUQ.
◼ Transverse colon runs across the upper
abdomen. In the LUQ near the spleen, the
colon forms another right angle and then
extends downward along the left side of
the abdomen as the descending colon
◼ Sigmoid colon is often felt as a firm
structure on palpation, the cecum and
ascending colon may feel softer
◼ The colon functions primarily to
secrete large amounts of alkaline
mucus to lubricate the intestine
and neutralize acids formed by the
intestinal bacteria.
◼ Water is also absorbed in the large
intestine, leaving waste products
to be eliminated in stool
◼ Urinary Bladder- a distensible muscular sac
located behind the pubic bone in the
midline of the abdomen as receptacle for
urine.
◼ A bladder filled urine may be palpated in
the abdomen above the symphysis pubis
VASCULAR STRUCTURES
◼ Abdominal aorta- supplies arterial
blood to abdominal organs. And its
major branches.
◼ Pulsations of the aorta are
frequently visible and palpable at
the midline in the upper abdomen.
◼ Pulsations of the Right and Left
iliac arteries may be felt in RLQ
and LLQ
 INSPECTION
◼ 1. Inspect the skin, noting colour,
vascularity, striae, scars, and lesions (wear
gloves to inspect lesions)
Color of the Skin
Normal Findings- Abdominal skin
may be paler than the general skin
tone because this skin is seldom
exposed.
◼ Pale, taut skin may be seen with ascites
(abdominal swelling indicating fluid
accumulation in the abdominal cavity.
◼ Redness may indicate inflammation.
◼ Bruises or areas of local discoloration are
also abnormal.
◼ Purple discoloration at the flanks (Grey
Turner sign) indicates bleeding within the
abdominal wall, possibly from trauma to
the kidneys, pancreas, or duodenum or
from pancreatitis.
◼ The yellow hue of jaundice may be more
apparent on the abdomen.
Grey Turner sign
Scars
◼Ask the source of a scar and use centimeter
ruler to measure the scar’s length. Document
the location by quadrant and reference lines
◼ ex. 3cm vertical scar in RLQ below the
umbilicus
 VASCULARITY
Normal Findings
◼ Scattered fine veins may be visible.
Abnormal Findings
◼ Dilated veins may be seen with
cirrhosis of the liver, portal
hypertension, or ascites.
LIVER CIRRHOSIS
◼ Ascites is a build up of fluid
between the tissue that lines the
abdomen and the peritoneal cavity
(or the abdominal organs).
ASCITES
Striae

Normal Findings
◼Old, silvery, white striae or stretch
marks from past pregnancies or
weight gain are normal.
Striae
◼ Abnormal Findings
◼ Dark bluish-pink striae
◼ Striae may also be caused by ascites,
which stretches the skin. Ascites
usually results from liver failure or liver
disease.
Assess for lesions and rashes.
Normal Findings
◼Abdomen is fee from lesions or
rashes.
◼Flat or raised brown moles,
however, are normal and may be
apparent.
KELOID
◼ Changes in moles including size, color,
and border symmetry. Any bleeding moles or
petechiae (reddish or purple lesions may
also be abnormal.
2. Inspect the umbilicus, noting color,
location and contour.
Umbilical location

◼ Umbilicus is midline at lateral line.

◼ A deviated umbilicus may be
caused by pressure from a mass,
enlarged organs, hernia, fluid, or
scar tissue.
Contour of the umbilicus.
◼ It is recessed (inverted) or
protruding no more than 0.5cm
and is round or conical.
◼ An everted umbilicus is seen with
abdominal distention. An enlarged,
everted umbilicus suggests
umbilical hernia.
3.Inspect the contour of the abdomen.
Look across the abdomen at eye level at
the client’s side.
Observe the general contour of the
abdomen (flat, protuberant, scaphoid, or
concave; local bulges).
Contour
◼ Look the abdomen at eye level
from the client’s side, from behind
the client’s head, and from the
foot of the bed.
◼A generalized protuberant or distended
abdomen may be due to obesity, air (gas),
or fluid accumulation.
◼ Distention below the umbilicus may be
due to a full bladder, uterine enlargement,
or an ovarian tumor or cyst.
◼ Distention of the upper abdomen may be
seen with masses of the pancreas or
gastric dilation.
4. Inspect the symmetry of the abdomen.

Look at the client’s abdomen as he or she

lies in a relaxed supine position.

To further assess the abdomen for

herniation or mass within abdomen, ask
client to raise the head
◼ 5. Inspect abdominal movement,
noting respiratory movement ,
aortic pulsations, and or peristaltic
waves.
Aortic Pulsations
◼ A slight pulsation of the abdominal
aorta, which is visible. In the
epigastrium
◼ Vigorous wide, exaggerated
pulsations may be seen with
abdominal aortic aneurysm.
 Peristaltic Waves
◼ Normally peristaltic waves are not
seen although they may be visible in very
thin people as slight ripples on the
abdominal wall.
◼ Peristaltic waves are increased and
progress in a ripple-like fashion from the LUQ
to the RLQ with intestinal obstruction
(especially small intestine). In addition,
abdominal distention typically is present with
intestinal wall obstruction.
◼ 6. Auscultate for bowel sounds,
noting intensity, pitch and
frequency.
◼ High-pitched, irregular gurgles 5-35
times/min; present equally in all
quadrants
 Auscultation
1. Place the diaphragm of
your stethoscope lightly
on the abdomen.
2. Listen for bowel sounds.
Are they normal,
increased, decreased, or
absent? Borborygmi =
“growling”
3. Listen for bruits over the
renal arteries, iliac
arteries, and aorta.
◼ Use the diaphragm of the stethoscope
and make sure that it is warm before you
place on the client’s abdomen.
Apply light pressure or simply rest the
stethoscope on a tender abdomen.
Begin in the RLQ and proceed clockwise,
covering all quadrants.(bowel sounds
may be more active over the ileocecal
valve in the RLQ).
◼ Confirm bowel sounds in each quadrant.
Listen for up to 5 minutes (minimum of
1min./quadrant) to confirm the absence
of bowel sounds.
◼ bowel sounds normally occur every 5 to
15 seconds / 5-35 times/min
◼ Note the intensity, pitch, and frequency
of the sounds.
◼ Hypoactive bowel sounds indicate
diminished bowel motility. Common causes
include abdominal surgery or late bowel
obstruction.
◼ Hyperactive bowel sounds indicate
increased bowel motility. Common causes
include diarrhea, gastroenteritis, or early
bowel obstruction.
◼ Postoperatively, bowel sounds
resume gradually depending on
the type of surgery. The small
intestine functions normally in the
first few hours postoperatively;
stomach emptying takes 24 to 48
hours to recover; and the colon
requires 3 to 5 days to recover
propulsive activity.
◼ Absent bowel sounds may be associated
with peritonitis or paralytic ileus. High-
pitched tinkling and rushes of high-pitched
sounds with abdominal cramping usually
indicate obstruction.
(the increasing pitch of bowel sounds is
most diagnostic of obstruction because it
signifies intestinal distention)
7. Auscultate for vascular
sounds and friction rubs.
VENUS HUM
◼ Using the bell of the stethoscope,
listen for a venous hum in the
epigastric and umbilical areas.
 BRUIT
◼ Use the bell of the stethoscope to listen
for bruits (low-pitched, murmur-like
sound) over the abdominal aorta and
renal, iliac, and femoral arteries.
 FRICTION RUB
◼ Auscultate friction rub over the liver and
spleen by listening over the right and left
lower rib cage with the diaphragm of the
stethoscope
 PERCUSSION
o 8.Percuss for tone.
o Abdominal percussion sequences
may proceed clockwise or up and
down over the abdomen.
◼ Percuss in all four quadrants (clockwise)
using proper technique: Inspect –
Auscultation – Percuss – Palpate.
◼ Categorize what you hear as tympanic or
dull. Tympany is normally present over
most of the abdomen in the supine
position. Unusual dullness may be a clue
to an underlying abdominal mass or full
bladder.
9. Percuss the liver.
◼Percuss the span or height of the liver by
determining its lower and upper borders.
◼The lower border of liver dullness is located
at the costal margin to 1 to 2 cm below.
◼If you cannot find the lower border of the
liver, keep in mind that the lower border of
liver dullness may be difficult to estimate when
obscured by intestinal gas
◼ To assess the lower border, begin in the
RLQ at the mid clavicular line (MCL) and
percuss upward toward the chest. Note
the change from tympany to dullness.
Mark this point. It is the lower border of
liver dullness.
◼ To assess the descent of the liver, ask the
client to take a deep breath, then repeat
the procedure. To assess the upper
border, percuss over the upper right chest
at the MCL and percuss downward, noting
the change from lung resonance to liver
dullness. Mark this point- it is the upper
border of liver dullness
◼ Measure the distance between the two
marks- this is the span of the liver
◼ 10.Perform the scratch test.
◼ If you cannot accurately percuss the liver
borders, perform the scratch test.
Auscultate over the liver, starting in the
RLQ, scratch lightly over the abdomen,
◼ Progressing upward toward the liver.
◼ The sound produced by scratching
becomes more intense over the liver.
◼ 11.Percuss the spleen.
◼ Begin posterior to the left mid-axillary
line(MAL) and percuss downward, noting
the change from lung resonance to splenic
dullness. ( results of splenic percussion
may be obscured by air in the stomach or
bowel)
◼ The spleen is an oval area of dullness
approximately 7cm wide near the left
tenth rib and slightly posterior to the MAL.
 Splenic Dullness
1. Percuss the lowest costal
interspace in the left
anterior axillary line. This
area is normally tympanic.
2. Ask the patient to take a
deep breath and percuss
this area again. Dullness in
this area is a sign of splenic
enlargement
◼ Splenomegaly is characterized by
an area of dullness greater than
7cm wide. The enlargement may
result from traumatic injury, portal
hypertension
◼ 12.Perform the blunt percussion
on the liver and the kidneys.
◼ To assess for tenderness in difficult-to-
palpate structures. Percuss the liver by
placing your left hand flat against the
lower right rib cage. Use the ulnar side of
your right fist to strike your left hand.
◼ Normally no tenderness or pain is elicited
or reported by the client. The examiner
senses only a dull thud.
◼ Tenderness or sharp pain elicited over
suggests kidney infection, renal calculi
13. Perform light palpation, noting
tenderness, or masses in all
quadrants
 GENERAL PALPATION
◼ 1. Begin with light palpation . At this point
you are mostly looking for areas of
tenderness. The most sensitive indicator of
tenderness is the patient's facial expression
(so watch the patient's face, not your
hands). Voluntary or involuntary guarding
may also be present.
◼ 2. Proceed to deep palpation after surveying
the abdomen lightly. Try to identify
abdominal masses or areas of deep
tenderness.
 Light Palpation
◼ Light palpation is used to identify areas of
tenderness and muscular resistance .
◼ Using the fingertips, begin palpation in a
non tender quadrant, and compress to a
depth of 1cm in a dipping motion.
◼ Then gently lift the fingers and move to
the next area
◼ To minimize the client’s voluntary guarding
(a tensing or rigidity of the abdominal
muscles usually involving the entire
abdomen)
◼ 2. Deeply palpate all quadrants to delineate
abdominal organs and detect subtle
masses.
Using the palmar surface of the fingers,
compress to a maximum depth (5 to
6cm). Perform bimanual palpation if you
encounter resistance or to assess deeper
structures
◼ Palpate for masses. Note their location,
size (cm), shape, consistency,
demarcation, pulsati, tenderness, and
mobility. Do not confuse a mass with a
normally palpated organ or structures.
◼ Normal (mild) tenderness is possible over
the xiphoid, aorta, cecum, sigmoid colon,
and ovaries with deep palpation.
◼ Severe tenderness or pain may be related
to trauma, peritonitis, infection, tumors, or
enlarged diseased organs.
◼ No palpable masses are present.
◼ A mass detected in any quadrant may be
due to a tumor, cyst, abscess, enlarged
organ, or adhesions.
Considerations
◼ 1. Avoid touching tender or painful areas
until last, and reassure the client of your
intentions.
◼ 2. Perform light palpation before deep
palpation to detect tenderness and
superficial masses.
◼ 3. Keep in mind that the normal
abdomen may be tender.
◼ 4. Overcome ticklishness and minimize
voluntary guarding by asking the client to
perform self-palpation.
◼ Place your hands over the client’s abdomen
After a while, let your fingers glide slowly
onto the abdomen while still resting mostly
on the client’s fingers. The same can be
done by using a warm stethoscope as a
palpating instrument, again letting your
fingers drift over the edge of the diaphragm
and palpate without promoting a ticklish
response.
5. Work with the client to promote relaxation
and minimize voluntary guarding. The
following techniques:
◼place a pillow under the client’s knees.
◼ask the client to take slow, deep breaths
through the mouth.
14. Perform deep palpation, noting
tenderness or masses in all
quadrants
15. Palpate the umbilicus and
surrounding area for swellings,
bulges, or masses.
◼ A soft center of the umbilicus can
be a potential for herniation.
Palpation of a hard nodule in or
round the umbilicus may indicate
metastatic nodes from an occult
gastrointestinal cancer.
16. Palpate the aorta.
◼ Use your thumb and first finger or
use two hands and palpate deeply
in the epigastrium. Slightly to the
left midline. Assess the pulsation
of the abdominal aorta.
◼ The normal aorta is approximately 2.5 to
3.0cm wide with a moderately strong and
regular pulse. Possibly mild tenderness
may be elicited.
◼ A wide bounding pulse may be felt with an
abdominal aortic aneurysm. A prominent,
laterally pulsating mass above the
umbilicus with an accompanying audible
bruit strongly suggests an aortic
aneurysm.
◼ Do not palpate pulsating middle mass it
may be a dissecting aneurysm that can
rupture from the pressure of palpation.
17. Palpate the liver, noting consistency
and tenderness.
◼ To palpate bimanually, stand at the
client’s right side and place your left
hand under the client’s back at the level
of the eleventh to twelfth ribs.
◼ Lay your right hand parallel to the right
costal margin (your fingertips
should point toward the client’s head).
Ask the client to inhale then compress
upward and inward with your fingers.
◼ Hooking Technique for liver palpation
◼ Curl (hook) the fingers
of both hands over the
edge of the right costal
margin.
◼ Ask the client to take a
deep breath
◼ gently but firmly pull
inward and upward
with your fingers.
◼ The liver is usually not palpable,
although it may be felt in some thin
clients. If the lower edge is felt, it should
be firm, smooth, and even. Mild
tenderness may be normal.
◼ A liver more than 1 to 3cm below the
costal margin is considered enlarged
(unless pressed down by the diaphragm.
◼ Enlargement may be due to hepatitis,
liver tumors
18. Palpate the spleen , noting consistency
and tenderness
◼ Start at the client’s right side, reach over the
abdomen with your left arm, and place your
hand under the posterior lower ribs.
◼ Pull up gently.
◼ Place your right hand below the left costal
margin with the fingers pointing toward the
client’s head.
◼ Ask the client to inhale and press inward
and upward as you provide support with
your other hand.
◼ Alternatively ask the client to turn onto the
right side may facilitate splenic palpation by
moving the spleen downward and forward.
◼ Document the size of the spleen in cm.
below the left costal margin.
◼ Also note consistency and tenderness.
◼ (be sure to palpate with your fingers below
the costal margin so you do not miss the
lower edge of an enlarged spleen).
◼ A palpable spleen suggests
enlargement (up to 3 times the
normal size), which may result
from trauma, and cancers.
caution: to avoid traumatizing and
possibly rupturing the organ, be
gentle when palpating an enlarged
spleen.
◼ The spleen feels soft with a
rounded edge when it is enlarged
from infection. It feels firm with a
sharp edge when it is enlarged
from chronic disease.
19. Palpate the kidneys.
◼ To palpate the right kidney,
support the right posterior flank
with your left hand and place your
right hand in the RUQ just below
the costal margin at the MCL.
◼ To capture the kidney, ask the
client to inhale. Then compress
your finger deeply during peak
inspiration.
◼ Ask the client to exhale and hold
the breath briefly. Gradually
release the pressure of your right
hand. If you have captured the
kidney, you will feel it slip beneath
your fingers.
◼ To palpate the left kidney, reverse
the procedure
◼ The kidneys are normally not
palpable. Sometimes the lower
pole of the right kidney may be
palpable by the capture method
because of its lower position. If
palpated, it should feel firm,
smooth, and rounded. The kidney
may o may not be slightly tender.
◼ An enlarged kidney may be due to
a cyst, tumor.
◼ 20.Palpate the urinary bladder.
◼ Palpate for a distended bladder when the
client’s history or other findings warrant
(e.g. dull percussion noted over the
symphysis pubis).
◼ Begin at the symphysis pubis and move
upward and outward to estimate bladder
borders.
◼ Normally the bladder is not
palpable.
◼ A distended bladder is palpated as
a smooth, round, and somewhat
firm mass extending as far as the
umbilicus. It may be further
validated by dull percussion tones.
21. Perform the test for shifting dullness.
This is a test for peritoneal fluid (ascites).
If you suspect that the client has ascites
because of a distended abdomen or
bulging flanks, perform this special
percussion technique.
◼ The client should remain supine, percuss
the flanks from the bed upward toward
the umbilicus. Note the change from
dullness to tympany, and mark this
point. Now help the client turn onto his
or her side. Percuss the abdomen from
the bed upward. Mark the level where
dullness changes to tympany.
◼22.Perform the fluid wave test
◼ Fluid wave test or fluid thrill test is a
test for ascites (free fluid in the
abdominal cavity). It is performed by
having the patient (or a colleague) push
their hands down on the midline of the
abdomen.
◼ The client should remain supine. You will
need assistance with this test. Ask the
client or an assistant to place the ulnar side
of the hand at the lateral side of the
forearm firmly along the midline of the
abdomen. Firmly place the palmar surface
of your fingers and hand against one side
of the client’s abdomen . Use your other
hand to tap the opposite side of the
abdominal wall.
◼ The examiner then taps one flank, while
feeling on the other flank for the tap.
The pressure on the midline prevents
vibrations through the abdominal wall
while the fluid allows the tap to be felt
on the other side. The result is
considered positive if tap can be felt on
the other side
◼ However, even with the midline
pressure, transmission through the skin
must be excluded. A positive fluid wave
test indicates that there is a free fluid
(ascites) in the abdomen. When one
side of the abdomen is pressed, the
other side may also be painful due to
the transfer of the fluid in it.
◼23.Perform the ballotment test.
◼ A Technique performed to identify
mass or enlarged organ within an
ascites abdomen. It can be
performed two different ways-
single handed or bi-manually.
Single-Hand Method
◼ Using a tapping or bouncing motion of
the fingerpad over the abdominal wall,
feel for a floating mass.
Bimanual Method
◼ Place one hand under the flank
(receiving/feeling hand),and push the
anterior abdominal wall with the other
hand.
 24. Perform test for
appendicitis.
a. Rebound tenderness/ Blumberg Sign
◼This is a test for peritoneal irritation. Warn
the patient what you are about to do.
◼1. Press deeply on the abdomen with your
hand.
◼2. After a moment, quickly release
pressure.
◼3. If it hurts more when you release, the
patient has rebound tenderness.
◼ b. Rovsing’s sign
◼ If palpation of the left lower quadrant of a
person's abdomen increases the pain felt
in the right lower quadrant, the patient is
said to have a positive Rovsing's sign and
may have appendicitis.
◼ c. Referred rebound tenderness
◼ Palpate deeply in the LLQ and quickly
release pressure
◼ Normal: No rebound pain
◼ Abnormal findings: Pain in RLQ during
pressure in the LLQ
d. Psoas sign
◼1. Place your hand above the patient's
right knee.
◼2. Ask the patient to flex the right hip
against resistance.
◼3. Increased abdominal pain indicates a
positive psoas sign.
e. Obturator Sign
◼1. Raise the patient's right leg with the knee
flexed.
◼2. Rotate the leg internally at the hip.
◼3. Increased abdominal pain indicates a
positive obturator sign.
◼4. Not used as much lately as there is a
question on how well it predicts appendicitis
◼ f. Hypersensitivity test
◼ Stroke the abdomen with a sharp object (
broken cotton applicator/ tongue blade or
grasp a fold of skin with your thumb and
index finger and quickly let go. Do this
several times along the abdominal wall
◼ Normal: client feels no pain/ no
exaggerated sensation
◼ Abnormal findings: Pain/ exaggerated
sensation felt in RLQ is a positive skin
hypersensitivity test and may indicate
appendicitis
◼ 25.Perform test for cholecystitis (Murphy’s
sign)

◼ To assess RLQ pain or tenderness, which

may signal inflammation of the
gallbladder, press your fingertips under the
liver border at the right costal margin and
ask the client to inhale deeply
ABDOMINAL DISTENTION
Ascites
Enlarged abdominal Organs