St.

Paul College of Ilocos Sur

( Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 14

Assessing Abdomen

Melanio P. Rojas Jr, MAN

Clinical Instructor

2023

ABDOMEN 1
 Module No. 14
Assessing Abdomen

Learning Objectives:

After completing this module, the students will be able to:

1. Describe the function and structure of the abdomen

2. Perform a physical assessment of the abdomen using the correct techniques of

inspection, auscultation, palpation and percussion.

ABDOMEN 2
 ANATOMY AND PHYSIOLOGY OF THE ABDOMEN

 The gastrointestinal system is composed of the following structures:

 MOUTH
- Digestion starts from the mouth
- Mechanical digestion occurs through mastication (chewing)
- Chemical digestion occurs through the action of salivary amylase ( ptyalin)
which breaks down starches to maltose
- Deglutition ( swallowing) occurs, once the food is broken down into small
pieces and well mixed with saliva ( food bolus)
 ESPOHAGUS
- It serves as passage for food bolus from mouth to stomach by peristalsis
- The distal end of the esophagus is guarded by lower esophageal sphincter
(LES). It also known as cardiac sphincter. It prevents gastric reflux
 STOMACH
- It is located in the left upper quadrant of the abdomen. It has an
approximately capacity of 1,500 mls.
- The stomach has the following regions: cardiac region, fundus, body and
antrum or pyloric region. It has a lesser greater curvature.
- FUNCTIONS:
1. Mechanical digestion: storage, mixing and liquefaction of bolus and
food into a semisolid mixture called chyme: The rugae liquefy solid
food particles through grinding motion.
2. Secretion: 1500 to 3000 mls. of gastric juice is secreted by the glands
in the gastric mucosa. The gastric juice is composed of mucus, HCL,
pepsinogen, and water. Gastrin ( a hormone) is secreted directly into
the blood stream.
3. Chemical digestion. Digestion of protein starts in the stomach through
the action of pepsin, which converts protein into polypeptides,
o Amylase from the salivary glands is inactivated by the acidity
in the stomach so carbohydrate digestion stops
o Pepsinogen ( inactive enzymes) is converted into pepsin
( active form) in the presence of HCL
4. Protection: The acid medium also responsible for the reduced activity
of harmful bacteria that may have been taken with food. It also
provides a favorable medium for the absorption of calcium and other
minerals.
5. Absorption. Minimal water, alcohol, glucose, and some drugs are
absorbed through the gastric mucosa.
6. Control passage of chyme into duodenum. Though peristaltic waves,
carbohydrates are emptied within 1 to 2 hours, proteins within 3 to 4
hours, fats within 4 to 6 hours. Once acidic chyme is formed, slow
peristaltic waves travel from the fundus to the pylorus. Pressure builds
up and pyloric sphincter opens

ABDOMEN 3
 SMALL INTESTINE
- The small intestine is about 6 meters long (20 to 22 feet). It extends from the
pyloric sphincter to the ileocecal valve.
- It is divided into three parts: duodenum, jejunum and ileum
- Majority of the digestive process is completed into the duodenum and
absorption of foods occur primarily in the small intestine.

 The function of the small intestine are as follows:

1. Mucus secretion.
o Goblet cells and duodenal’s (Brunner’s) glands secrete mucus to
protect the mucosa.
2. Secretion of enzymes
o Brush border cells secrete sucrose, maltase, and enterokinase which
act on disaccharides (carbohydrates)
o Peptidase acts on polypeptides ( proteins)
o Enterokinsase activates trypsinogen from the pancreas
3. Secretion of hormones
o Endocrine cells secrete cholecystokinin, secretin, and enterogastrone
that regulate the secretion of bile, pancreatic juice and gastric juice
4. Chemical digestion
o In the presence of carbohydrates, fats and protein stimulate secretion
of pancreozymin. This enzymes stimulates enzyme secretion of
pancreatic amylase, lipase and trypsin. Amylase completes digestion
of carbohydrates, lipase completes digestion of fats and trypsin
completes digestion of protein.
o In the presence of fats in the acidic chyme, the duodenum secretes,
cholecystokinin, which causes contraction of the gallbladder,
relaxation of sphincter of Oddi, thereby releasing bile.
- The bile emulsifies fats, thereby enabling pancreatic lipase to
complete digestion of fats
- The bile and pancreatic juice are alkaline, therefore they
neutralize the acidic chyme
5. Absorption. Nutrient and water move from the lumen of the small intestine into
the blood capillaries and lacteals in the villi. Absorption is by active transport,
by osmosis and by diffusion.
6. Motor Activities. Mixing (segmental) movements and peristalsis proper chyme
through the small intestine. The chyme remains in the small intestine for 3 to
10 hours. The residue move into the large intestine.

 LARGE INTESTINE
 The large intestine extends from the ileocecal valve to the anus. It is
approximately 1.5 meters (5 to 6 feet long)
 It is divided into the following parts: cecum, colon, rectum and anus
 The vermiform appendix is attached to the cecum
 The colon is divided into: ascending, transverse, descending and sigmoid
sections
 The final segments of the large intestine are the rectum and the anus.

ABDOMEN 4
  The FUNCTIONS of the large intestine are as follows:
1. Motor activities: haustral chuming and peristalsis
2. Secretion: the mucus protects the mucosa from injury, binds fecal particles into a
formed mass, lubricates and allows passage of fecal residual and counteracts the
effects of acid- forming bacteria.
3. Absorption of water, sodium, and chloride. Approximately 800 to 1000 mls. of water
is absorbed in the large intestine
4. Vitamin synthesis. Colonic bacteria flora synthesizes vitamin K, thiamine, riboflavin,
vitamin b12, folic acid, biotin and nicotinic acid.
5. Formation of feces. Fecal material is ¾ water and ¼ solid material
6. Defecation. The act of expelling feces from the body.

Locating Abdominal Structures by Quadrants

Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ)

1. Ascending and transverse colon 1. Left adrenal gland
2. Duodenum 2. Left kidney (upper pole)
3. Gallbladder 3. Left ureter
4. Hepatic flexure of colon 4. Pancreas (body and tail)
5. Liver 5. Splenic flexure of colon
6. Pancreas (head) 6. Stomach
7. Pylorus (the small bowel ileum-transverse 7. Transverse descending colon
all quadrants
8. Right adrenal gland
9. Right kidney ( upper mole)
10. Right ureter
Right Lower Quadrant ( RLQ) Left Lower Quadrant (LLQ)
1. Appendix 1. Left kidney ( lower pole)
2. Ascending colon 2. Left ovary and tube
3. Cecum 3. Left ureter
4. Right kidney ( lower pole) 4. Left spermatic cord
5. Right ovary and tube 5. Descending and sigmoid colon
6. Right ureter
7. Right spermatic cord

Abdominal Regions

Right hypochondriac region Epigastric region Left hypochondriac

region

Right lumbar region Umbilical region Left lumbar region

Right iliac Hypogastric region Left iliac

(Inguinal region) (inguinal region)

ABDOMEN 5
MECHANISM AND SOURCES OF ABDOMINAL PAIN

Types of Pain

1. Visceral pain occurs when hollow abdominal organs such as intestines-become

distended or contract forcefully, or when the capsules of organs such as the liver and
spleen are stretched. Poorly defined or localized and intermittently timed, this type of
pain is often characterized as dull, aching, burning, cramping or colicky pain.
2. Parietal pain occurs when the parietal becomes inflamed, as in appendicitis or
peritonitis.
3. Referred pain occurs at distant sites that are innervated at approximately the same
levels as the disrupted abdominal organ. This type of pain travels, or refers from the
primary site and becomes highly localized at the distant site.

MECHANISM AND SOURCES OF ABDOMINAL PAIN

1. Dull, aching- Appendicitis, acute hepatitis, biliary colic, cholecystitis, cystitis, dyspepsia,
glomerulonephritis, incarcerated or strangulated hernia, irritable bowel syndrome,
hepatocellular cancer, pancreatitis, pancreatic cancer, perforated gastric or duodenal
ulcer, peritonitis, peptic ulcer disease, and prostatitis.
2. Burning, Gnawing- Dyspepsia, peptic ulcer disease, cramping, acute mechanical
obstruction, appendicitis, colitis, diverticulitis, and gastroesophageal reflux disease.
3. Pressure- Benign prostatic hypertrophy, prostate cancer, prostitis, and urinary retention.
4. Colicky- Colon cancer
5. Sharp, Knifelike- Splenic abscess, splenic rupture, renal colic, renal tumor, ureteral colic,
vascular liver tumor
6. Variable- Stomach cancer

ABDOMINAL SIGNS

NAME DESCRIPTION CAUSE

1. Psoas sign Pain in RLQ when leg is hyperextended. Irritation of the iliopsoas muscle due
to appendicitis (an inflamed appendix)
2. Obturator Pain in the RLQ when hip and knee are Irritation of the obturator muscle due
sign flexed and leg is rotated internally and to appendicitis of a perforated
externally. appendix.
3. Murphy Pain elicited when pressure is applied Inflammation of the gallbladder.
sign under the liver border at the right costal
margin and client inhales deeply.
4. Rovsing Pain in the RLQ during pressure in the Acute appendicitis
sign LLQ.
5. Blumberg Abdominal pain or tenderness Peritoneal irritation
sign experienced when examiners, tests, for
rebound tenderness by palpating deeply
at 90 degrees into the abdomen one-
half between umbilicus and the anterior

ABDOMEN 6
 iliac crest (McBurney point)

ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS

PROCEDURE
INSPECTION
Observe the Abdominal skin may be paler than Purple discoloration at the
coloration of the skin. the general skin tone because this flans (Grey-Turner sign)
skin is so seldom exposed to the indicates bleeding within the
natural elements. 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.

Pale, taut skin may be seen

with ascites (significant
abdominal wall swelling)
indicating fluid accumulation
in the abdominal cavity.

Redness may indicate

inflammation.

Bruises or areas of local

discoloration are also
abdomen.

Note the vascularity Scattered fine veins may be visible. Dilate veins may be seen
of the abdominal skin. Blood in the veins located above with cirrhosis of the liver,
the umbilicus flows toward the obstruction of the inferior
head; blood in the veins located vena cava, portal
below the umbilicus flows toward hypertension, or ascites.
the lower body.
Dilated surface arterioles and
capillaries with central (spider
angioma) may be seen with
liver disease or portal
hypertension.
Note any striae. New striae are pink or bluish in Dark bluish-pink striae are
(Stretch marks) due to color, old striae are silvery, white associated with Cushing
past stretching of the linear, and uneven stretch marks syndrome.
reticular skin layers due from past pregnancies or weight
to fast or prolonged gain. Striae may also be caused by
stretching. ascites, which stretches the
skin. Ascites usually results
from liver failure or liver

ABDOMEN 7
 disease.

Inspect for scars. Ask Pale, smooth, minimally Nonhealing wounds, redness,
about the source of a scar, raised old scars may be inflammation. Deep irregular
and use a centimeter ruler seen. scars may result from burns.
to measure the scar’s
length. Document the
location by quadrant and
references lines, shape,
length, and any specific
characteristics (e.g., 3 cm
vertical scar in RLQ 4 cm
below the umbilicus and 5
cm left of the midline). With
experience, many
examiners can estimate the
length of a scar visually
without a ruler.
Assess for lesions and Abdominal is free of lesions Changes in moles including
rashes. or rashes. Flat raised brown size, color, and border
moles, however, are normal symmetry. Bleeding moles or
and may be apparent. petechiae (reddish or purple
lesions) may also be abnormal.
Inspect the umbilicus. Umbilical skin tones are Cullen sign: A bluish or purple
Note the color of the similar to surrounding discoloration around the
umbilical area. abdominal skin tones or umbilicus (periumbilical
even pinkish. ecchymosis) indicates intra-
abdominal bleeding. Grey-
Turner sign: bluish of purplish
discoloration on the abdominal
flanks.
Observe umbilical Umbilicus is midline at A deviated umbilicus may be
location. lateral line. caused by pressure from a
mass, enlarged organs, hernia,
fluid, or scar.
Assess contour of It is recessed (inverted) or An everted umbilicus is seen
umbilicus. protruding no more than 0.5 with abdominal distention. An
cm and is round or conical. enlarged, everted suggests
umbilical hernia.
Inspect abdominal Abdomen is flat, rounded, A generalized protuberant or
contour. Sitting at the or scaphoid usually seen in distended abdomen may be due
client’s side, look across the thin adults. Abdomen to obesity, air (gas) or fluid
abdomen at a level slightly should be evenly rounded. accumulation. Distention below
higher than the client’s the umbilicus may be due to a
abdomen. Inspect the area full bladder, uterine
between the lower ribs and enlargement, or an ovarian
pubic bone. Measure tumor or cyst. Distention of the
abdominal girth as indicated upper abdomen may be seen

ABDOMEN 8
in assessment. with masses of the pancreas or
gastric dilatation.

The major causes of abdominal

distention are sometimes
referred to as the “6” Fs Fat,
Feces, Fetus, Fibroids,
Flatulence, and Fluid.

A scaphoid (sunken) abdomen

may be seen with severe weight
loss or cachexia related to
starvation or terminal illness.

Assess abdominal Abdomen is symmetric. Asymmetry may be seen with

symmetry. Look at the organ enlargement large
abdomen as the client lies masses, hernia, diastasis recti
in a relaxed supine or bowel obstruction.
position.

Further assessment: To
further assess the abdomen Abdomen does not bulge A hernia (protrusion of the bowel
for herniation a mass within when the client raises head. through the abdominal wall) is
the abdominal wall from one seen as a bulge in the
below it, ask the client to abdominal wall. Diastasis recti
raise the head. appears as a bulge between a
vertical midline separation of the
abdominal rectus muscles. This
condition is of little significance.
An incisional hernia may occur
when a defect develops on the
abdominal muscles because of
a surgical incision. A mass
within the abdominal wall is
more prominent when the head
is raised whereas a mass below
the abdominal wall is obscured.

Inspect abdominal Abdominal respiratory Diminished abdominal

movement when the client movement may be seen, respiration or change to thoracic
breathes especially in male clients. breathing in male clients may
(respiratory movements). reflect peritoneal irritation.

ABDOMEN 9
Observe aortic pulsations. A slight pulsation of the Vigorous, wide, exaggerated
Ultrasound has high sensitivity abdominal aorta, which pulsations may be seen with
and specificity and is the is visible in the abdominal aortic aneurysm.
preferred screening modality. epigastrium extends
Abdominal palpation has poor full length in thin
accuracy and is not people.
recommended for screening.

Observe for peristaltic waves. Normally, peristaltic Peristaltic waves are increased
waves are not seen, and progress in a ripple-like
although that may be fashion from the LUQ to the RLQ
visible in very thin with intestinal obstruction
people as slight ripples (especially small intestine). In
on the abdominal wall. addition, abdominal distention
typically is present with intestinal
wall obstruction.

Auscultate for bowel sounds. A series of intermittent, “Hyperactive” bowel sounds that
Use the diaphragm of the soft clicks and gurgles are rushing, tinkling, and high
stethoscope and make sure that are heard at a rate of pitched may be abnormal
is warm before you place it on 5-30 per minute. indicating very rapid motility heard
the client’s abdomen. Apply light Hyperactive bowel in early bowel obstruction,
pressure or simply rest the sounds referred to as gastroenteritis, diarrhea, or with
stethoscope on a tender “borborygmus” may use of laxatives. Hypoactive
abdomen. Begin in the RLQ and also be heard. These bowel sounds indicate diminished
proceed clockwise, covering all are the loud, prolonged bowel motility. Common causes
quadrants. gurgles characteristic include paralytic ileus following
of one’s stomach abdominal surgery, inflammation
Listen for at least 5 minutes growling.” of the peritoneum, or late bowel
before determining that no obstruction. May also occur in
bowel sounds are present and pneumonia.
that the bowel sounds are silent.

Clinical Tip: Bowel sounds may Clinical tip: postoperative, Decreased or absent bowel
be more active over the bowel sounds resume sounds signify the absence of
ileocecal valve in the RLQ. gradually depending on bowel motility, which constitutes
the surgery. The small an emergency requiring
intestine functions
immediate referral.
normally in the first few
hours postoperatively;
stomach emptying take
24-48 hours to resume;
and colon requires 3-5
days to recover

ABDOMEN 10
 propulsive activity.

Confirm bowel sounds in each Absent bowel sounds may be

quadrant. Listen for up to 5 associated with peritonitis or
minutes (minimum of 1 minute paralytic ileus. High-pitched
per quadrants) to confirm the tinkling and rushes of high-
absence of bowel sounds. pitched sounds with abdominal
cramping usually indicate
Clinical tip: Bowel sounds
normally occur 5-15 seconds. obstruction.
An easy way to remember is to
equate one bowel sound to one
breath.

Note the intensity, pitch, and Clinical tip: The increasing pitch
frequency of the sounds of bowel sounds is most
diagnostic of obstruction because
it signifies intestinal distention.

Auscultate for vascular Bruits are not normally A bruit with systolic and diastolic
sounds. Use the bell of the heard over abdominal components occurs when blood
stethoscope to listen for bruits aorta or renal Iliac, or flow in an artery is turbulent or
(low-pitched, murmur-like sound, femoral arteries. obstructed. This may indicate an
pronounced BROO-ee) over the However, bruits aneurysm or renal arterial
abdominal aorta and renal iliac, confined to systole may stenosis. When blood flows
femoral arteries. be normal in some through a narrow vessel, it makes
clients depending on a whooshing sound called a bruit.
other differentiating However, the absence of this
factors. sound does not exclude the
possibility RAS.

Clinical tip: Auscultating for

For a more accurate diagnosis, an
vascular sounds is especially
ultrasound or an angiogram is
important if the client has
needed.
hypertension or if you suspect
arterial insufficiency to the legs.

Listen for venous hum. Using Venous hum is not Venus hums are rare, however an
the bell of the stethoscope listen normally heard over accentuated hum heard in the
for a venous hum in the the epigastric and epigastric pain or umbilical areas
epigastric and umbilical areas. umbilical areas. suggests increased collateral
circulation between the portal and
systematic venous systems, as in
cirrhosis of the liver.

ABDOMEN 11
Auscultate for a friction rub No friction rub over Friction rubs are rare. If heard,
over the liver and spleen. liver or spleen is they have a high-pitched, rough,
Listen over the right and lower present. grating sound produced when the
rib cage with the diaphragm of large surface area of the liver or
the stethoscope. spleen rubs the peritoneum. They
are heard in association with
respiration.

A friction rub heard over the lower

right costal area is associated
with hepatic abscess or
metastases.

A rub heard at the anterior axillary

line in the lower left costal area is
associated with splenic infarction,
abscess, infection or tumor.

Percussion for tone. Lightly Generalized tympany Accentuated tympany or

and systematically percuss all predominates over the hyperresonance is heard over a
quadrants. abdomen because of gaseous distended abdomen.
air in the stomach and
intestines. Dullness is
heard over the liver
and spleen.
An enlarged area of dullness is
Dullness may also be heard over an enlarged liver or
elicited over a non- spleen.
evacuated descending
colon. Abnormal dullness is heard a
distended bladder, large masses
or ascites.

If you suspect ascites, perform

the shifting dullness and fluid
wave tests.

Percuss the span on height of The lower border of Clinical tip: if you cannot find the
the liver by determining its liver dullness is located lower border if the liver, keep in
lower and upper borders. at the costal margin to mind that the lower border of liver
1-2 cm below. dullness may be difficult to
estimate when obscured by
intestinal gas.

ABDOMEN 12
To assess the lower border, begin On deep inspiration, the
in the RLQ at the mid-clavicular line lower border of liver
(MCL) and percuss upward. Note dullness may descend
the change from tympany to from 1 to 4 cm below the
dullness. Mark this point: it is the costal margin.
lower border of liver dullness. To
assess the descent of the liver, ask
the client to take a deep breath and
hold; then repeat the procedure.
Remind the client to exhale after
percussing.

To assess the upper border,

percuss over the upper right chest
The upper border of liver
at the MCL and percuss downward, The upper border of liver dullness
dullness is located
noting the change from lung may be difficult to estimate if
between the left fifth and
resonance to liver dullness. Mark obscured by pleural fluid of lung
seventh intercostal
this point; it is the upper border of consolidation.
spaces.
liver dullness.

Measure the distance between the The normal liver span at Hepatomegaly, a liver span that
two marks: this is the span of the the MCL is 6-12 cm exceeds normal limits (enlarged) is
liver. (greater in men and taller characteristic of liver tumors,
clients, less in shorter cirrhosis, abscess, and vascular
clients). engorgement.

Atrophy of the liver is indicated by a

decreased span

A liver in a lower position than normal

may be caused by emphysema,
whereas a liver in a higher position
than normal may be caused by an
abdominal mass, ascites, or
paralyzed diaphragm. A liver in a
slower or higher position should have
a normal span, but an enlarged liver
may be higher, lower or both.

Repeat percussion of the liver at The normal liver span at An enlarged liver may be roughly
the midsternal line (MSL). the MSL is 4-8 cm. estimated (not accurately) when
more intense sounds outline a liver
span or borders outside the normal
range.

The scratch test is a The normal liver span An enlarged liver may be roughly

ABDOMEN 13
technique that can be used to at the MSL is 4-8 cm. estimated (not accurately) when
ascertain the location and size more intense sounds outline a
of the liver and spleen. This test liver span or borders outside the
can be particularly useful if the normal range.
abdomen is tense (rigid or
guarded), distended, obese, or
too tender to palpate.

To perform the scratch test,

place the diaphgram of your
stethoscope at the 2nd to last
intercostal space, MCL.

Use one finger to very lightly

stroke the skin horizontally,
starting at the umbilicus.
Continue to stroke the skin,
moving toward the lower costal
margin. The sound will suddenly
be transmitted though the
stethoscope and increase in
intensity. This indicates the
lower border of the liver.

Percuss the spleen. Begin The spleen is an oval Splenomegaly is characterized by

posterior to the left mid-axillary area of dullness an area of dullness greater than 7
line (MAL), and percuss approximately 7 cm cm wide. The enlargement may
downward, noting the change wide near the left tenth result from traumatic injury, portal
from lung resonance to splenic rib and slightly hypertension and mononucleosis.
dullness. posterior to the MAL.

A second method for Normally, tympany (or On inspiration, dullness at the left
detecting splenic enlargement resonance) is heard at interspace at the AAL suggests
is to percuss the last left the left interspace. an enlarged spleen.
interspace at the anterior axillary
line (AAL) while the client takes
a deep breath.

Perform blunt percussion on Normally, no Tenderness elicited over the liver

the liver and the kidneys. This tenderness is elicited. may be associated with
is to assess for tenderness in inflammation or infection
difficult-to-palpate structures. (hepatitis or cholecystitis).
Percuss the liver by placing your
left hand against the lower right
anterior rib cage. Use the ulnar
side of your right fist to strike
ABDOMEN 14
your left hand.

Perform blunt percussion on the Normally, no Tenderness or sharp pain elicited

kidneys at the costovertebral tenderness or pain is over the CVA suggests kidney
angles (CVA) over the 12 rib. elicited or reported by infection
the client. The ( pyelonephritis) renal calculi or
examiner senses only hydronephrosis.
This technique requires that the a dull thud.
client sit with his or her back to
you. Therefore, it may be best to
incorporate blunt percussion of
the kidneys with your thoracic
assessment because the client
will already be in this position.

Perform light palpation. Abdomen is nontender Involuntary reflex guarding is

Provides considerations for and soft. There is no serious and reflects peritoneal
palpation. Light palpation is guarding. irritation. The abdomen is rigid
used to identify areas of and the rectus muscles fails to
tenderness and muscular relax with palpation when the
resistance. Use the fingertips, client exhales. It can involve all or
begin palpation in a nontender part of the abdomen but is usually
quadrant and compress to a seen on the side. (i.e., right vs left
depth 1 cm in a dipping motion. rather than upper or lower)
Then gently lift the fingers and because of nerve tract patterns.
move to the next area. For Right-sided guarding may be due
techniques to minimize the to cholecystitis.
client’s voluntary guarding (a
tense or rigidity of the abdominal
muscles usually involving the
entire abdomen. Keep in mind
that the rectus abdominis
muscle relaxes on expiration.

Deeply palpate all quadrants to Normal (mild) Severe tenderness or pain may
delineate abdominal organs tenderness is possible be related to trauma, peritonitis,
and detect subtle masses. over the xiphoid, aorta, infection, tumors or enlarged or
Using the palmar surface of the cecum, sigmoid, colon, diseased organs.
fingers, compress to a maximum and ovaries with deep
depth (5-6cm). Perform bimanual palpation.
palpation if you encounter
resistance or to assess deeper
structures.

ABDOMEN 15
Palpate for masses. Note their No palpable masses A mass detected in any quadrant
location, size (cm) shape, are present. may be due to a tumor, cyst,
consistency, demarcation, abscess, enlarged organ,
pulsatility, tenderness, and aneurysm or adhesions.
mobility. Do not confuse a mass
with an organ or structure.

Palpate the umbilicus and Umbilicus and A soft center of the umbilicus can
surrounding areas for surrounding area are be potential for herniation.
swelling, bulges or masses. free of swellings, Palpation of a hard nodule in or
bulges or masses. around the umbilicus may indicate
metastatic nodes from an occult
gastrointestinal cancer.

Palpate the aorta. Use your The aorta is A wide, bounding pulse may be
thumb and first finger or use two approximately 2.5-3.0 felt with an abdominal aortic
hands and palpate deeply in cm wide with a aneurysm. A prominent, laterally
epigastrium, slightly to the left of moderately strong and pulsating mass above the
midline. Assess the pulsation of regular pulse. Possibly umbilicus with an accompanying
the abdominal aorta. mild tenderness may audible bruit strongly suggests an
be elicited. aortic aneurysm.

Palpate the liver. Note The liver is usually not A hard firm may indicate cancer.
consistency and tenderness. To palpable, although it Nodularity may occur with tumors,
palpate bimanually, stand at the may be felt in some metastatic cancer, late cirrhosis or
client’s right side and place your thin clients. If the lower syphilis. Tenderness may be from
left hand under the client’s back edge is felt, it should vascular engorgement (e.g.,
at the level of the 11th and 12th be firm, smooth, and congestive heart failure) acute
ribs. Lay your right hand parallel even. Mild tenderness hepatitis or abscess.
to the right costal margin (your may be normal.
fingers should point toward the
client’s head).

Ask the client to inhale, then A liver more than 1-3 cm below
compress upward and inward the costal margin is considered
with your fingers. Have the client enlarged (unless displaced by the
exhale and hold your hand in diaphragm).
place as the client inhales a
second time. With deep
inhalation the edge of the liver is
more easily palpated.

To palpate by hooking, stand the

right of the client’s chest. Curl
ABDOMEN 16
(hook) the fingers of both hands Enlargement may be due to
over the edge of the right hepatitis, liver, tumors, cirrhosis,
coastal margin. Ask the client to and vascular engorgement.
take deep breath and gently but
firmly pull inward and upward
with your fingers.

Palpate the spleen. Stand at The spleen is seldom A palpable spleen suggests
the client’s right side, reach over palpable at the left enlargement (up to three times
the abdomen with your left arm, costal margin. Rarely, the normal size), which may result
and place your hand under the tip is palpable in from infections, trauma,
posterior lower ribs. Pull up the presence of a low, mononucleosis, chronic blood
gently. Place your right hand flat diaphragm (e.g., disorders, and cancers.
below the left costal margin with chronic obstructive
fingers pointing toward the lung disease) or with The splenic notch may be felt,
client’s head. Ask the client to deep diaphragmatic which an indication of splenic
inhale and press inward and descent on inspiration. enlargement. Splenic
upward as you provide support If the edge of the enlargement may not always be
with your other hand. spleen can be pathologic.
palpated, it should be Caution: To avoid traumatizing
soft and nontender. and possibly rupturing the organ,
be gentle when palpating an
enlarged spleen.

Alternatively, asking the client

too turn onto the right side may The spleen feels soft with a
facilitate splenic palpation by rounded edge when it is enlarged
moving the spleen downward from infection. It feels firm with a
and forward. Document the size sharp edge when enlarged from
of the spleen in centimeters chronic disease.
below the left costal margin.
Also note consistency and
tenderness.

Clinical tip: Be sure to palpate Tenderness accompanied by

with your fingers below the peritoneal inflammation or
costal margin so you do not capsular stretching is associated
miss the lower edge of an with splenic enlargement.
enlarged spleen.

Palpate the kidneys. To The kidneys are An enlarged kidney may be due to
palpate the right kidney, support usually not palpable. cyst, tumor, or hydronephrosis. It
the right posterior flank with your Sometimes the lower can be differentiated from
left hand and place your right pole of the right kidney splenomegaly by its smooth

ABDOMEN 17
hand in the RUQ just below the may be palpable by the rather than sharp edge, absence
costal margin at the MCL. capture method of a notch, and overlapping
because of its lower tympany on percussion.
position. If palpated, it
should feel firm,
smooth, and rounded.
The kidney may or may
not be slightly tender.

To capture the kidneys, ask the

client to inhale. Then compress
your fingers deeply during peak
of 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.

Palpate the urinary bladder. An empty bladder is A distended bladder is palpated

Palpate for a distended bladder neither palpable nor as a smooth, round, and
when the client’s history or other tender. somewhat firm mass extending as
things warrant (e.g., percussion far as the umbilicus. It may be
noted over the symphysis further validated by dull
pubis). Begin at the symphysis percussion tones.
pubis and move upward and
outward to estimate bladder
borders.

TEST FOR ASCITES NORMAL FINDINGS ABNORMAL FINDINGS

Test for shifting dullness. If The borders between When ascites is present and the
you suspect that the client has tympany and dullness client is supine, the fluid assumes

ABDOMEN 18
ascites because of a distended remain relatively a dependent position and
abdomen or bulging flanks, constant throughout procedures a dull percussion tone
perform this special percussion position changes. around the flanks. Air rises to the
technique. The client should top and tympany is percussed
remain supine. Percuss the around the umbilicus. When the
flanks from the bed upward client turns onto one side and
toward the umbilicus. ascites is present, the fluid
assumes a dependent position
and air rises to the top.

There is a marked increase in the

height of the dullness. This test is
Note the change from dullness
not always reliable, thus definitive
to tympany and mark this point.
testing by ultrasound is
Now help the client turn onto the
necessary.
side. Percuss the abdomen from
the bed upward. Mark the level Ascites often is a sign of severe
where dullness changes to liver disease due to portal
tympany. hypertension (high pressure in the
blood vessels of the liver and low
albumin levels).

Perform the fluid wave test. A No fluid wave is Movement of a fluid wave against
second technique to detect transmitted. the resting hand suggests large
ascites is the fluid wave test. amounts of fluid are present
The client should remain supine. (ascites).
You will need assistance with
this test. Ask the client or an Because of this test is not
assistant to place the ulnar side completely reliable, definite
of the hand and the lateral side testing by ultrasound is needed.
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.

TEST FOR NORMAL FINDINGS ABNORMAL FINDINGS

APPENDICITIS/PERITONEAL
IRRITATION

ABDOMEN 19
Assess for rebound No rebound tenderness The client has rebound
tenderness. If the client has is present. tenderness when the client
abdominal pain or tenderness, perceives sharp, stabbing pain as
test for rebound tenderness by the examiner release pressure
palpating deeply at 90 degrees from the abdomen (Blumberg
into the abdomen halfway sign). It suggests peritoneal
between the umbilicus and the irritation (as from appendicitis.
anterior iliac crest. (McBurney’s
point). Then suddenly release
pressure. If the client feels pain at an area
Listen and watch for the client’s other than where you were
expression of pain. Ask the assessing for rebound
client to describe which hurt tenderness, consider that area as
more- the pressing in or the the source of the pain.
releasing-and where on the
abdomen the pain occurred.

Clinical tip: test for rebound

tenderness should always be
performed at the end of the
examination because a positive
response produces pain and
muscle spasm that can interfere
with the remaining examination.

Test for referred rebound Pain in the RLQ during pressure

tenderness. Palpate deeply in No rebound pain is in the LLQ is a positive Rovsing
the LLQ and quickly release elicited. sign. It suggests acute
pressure. appendicitis.

Safety tip: Avoid continued

palpation when test findings are
positive for appendicitis because
of the danger of rupturing the
appendix.
Assess for psoas sign. No abdominal pain is Pain in the RLQ (psoas) is
Ask the client to lie on the left present. associated with irritation of the
side. Hyperextended the client’s iliopsoas muscle due to
right leg.
appendicitis (an inflamed
appendix).

Assess for obturator. Support No abdominal pain is Pain in the RLQ indicates of the
the client’s right knee and ankle. present. obturator muscle due to

ABDOMEN 20
Flex the hip and knee, and appendicitis or a perforated
rotate the leg internally and appendix.
externally.

Perform hypersensitivity test. The client feels no pain Pain or an exaggerated sensation
Stroke the abdomen with a and no exaggerated felt in the RLQ is a positive skin
sharp object (e.g., broken tipped sensation. hypersensitivity test and may
applicator or tongue blade) or indicate appendicitis.
grasp a fold of skin with your
thumb and index finger and
quickly let go. Do this several
times along the abdominal wall.

TEST FOR CHOLECYSTITIS NORMAL FINDINGS ABNORMAL FINDINGS

Assess RUQ or tenderness No increase in pain is Accentuated sharp pain that

which may signal cholecystitis present. causes the client to hold his or her
(inflammation of the breath (inspiratory arrest) is a
gallbladder). Press your positive Murphy sign and is
fingertips under the liver border associated with acute
at the right costal margin and cholecystitis.
ask the client to inhale deeply.

ABDOMEN 21
ABDOMEN 22