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Abdomen 2

abdomen assessment and anatomy

Abdomen Surface Landmarks Large oval cavity extending from the diaphragm down to the brim of the pelvis, Bordered in back by the vertebral column and paravertebral muscles, Bordered at the sides and front by the lower rib cage and abdominal muscles
Four layers of large, flat muscles form the ventral abdominal wall Linea alba - a tendinous seam joining the muscles midline
Rectus abdominis Forms a strip extending the length of the midline
Internal Anatomy All the internal organs are the viscera, Helpful to be able to visualize each organ that one listens to or palpates through the abdominal wall, The solid viscera are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kid
Solid Viscera (continued) The spleen is a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, immediately under the diaphragm , Lies obliquely with its long axis behind and parallel to the 10th rib, lateral to the midaxillary line,Its width extends fr
Solid Viscera (continued) The abdominal aorta is just to the left of midline in the upper part of the abdomen , It descends behind the peritoneum and at 2 cm below the umbilicus, it bifurcates into the right and left common iliac arteries opposite the 4th lumbar vertebra. You can
Solid Viscera (continued) The bean-shaped kidneys are retroperitoneal, or posterior to the abdominal contents , Well protected by the posterior ribs and musculature, The left kidney lies at the 11th and 12th ribs, Because of the placement of the liver, the right kidney rests 1 to
The costovertebral angle The 12th rib forms an angle with the vertebral column
The shape of the hollow viscera (stomach, gallbladder, small intestine, colon, and bladder) depends on the contents Usually are not palpable, The stomach is just below the diaphragm, between the liver and spleen, The gallbladder rests under the posterior surface of the liver just lateral to the right midclavicular line.
The small intestine is located in all four quadrants Extends from the stomach's pyloric valve to the ileocecal valve in the right lower quadrant (RLQ)
The abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting the umbilicus (blank)
The Aging Adult Aging alters the appearance of the abdominal wall, During and after middle age, some fat accumulates in the suprapubic area in females due to decreased estrogen levels, Males show some fat deposits in the abdominal area, resulting in the "spare tire," or
The Aging Adult Changes of aging occur in the gastrointestinal system but do not significantly affect function as long as no disease is present
The Aging Adult Salivation decreases causing the aging person to have a dry mouth and a decreased sense of taste
The Aging Adult Esophageal emptying is delayed, Increases risk of aspiration
The Aging Adult Gastric acid secretion decreases with aging, This may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium
The Aging Adult The incidence of gallstones increases with age, 10% to 20% of middle-aged and older adults, More common in females
The Aging Adult Liver size decreases with age, particularly after 80 years, although most liver function remains normal, Drug metabolism by the liver is impaired d/t blood flow through the liver decreased by 55% to 60% , Liver metabolism responsible for the enzymatic oxi
Constipation True constipation is having a bowel movement less often than every 3rd day, Constipation is often confused with the passage of hard or small stools, the feeling of , incomplete evacuation, or the need to strain at stool for constipation, Of those aging pe
Common causes of constipation: Decreased physical activity, Inadequate intake of water, Low-fiber diet, Side effects of medications, Irritable bowel syndrome, Bowel obstruction, Hypothyroidism, Inadequate toilet facilities (i.e., difficulty ambulating to the toilet may cause the perso
Lactose intolerant (or lactase deficiency) Lactase is the digestive enzyme necessary for the absorption of the carbohydrate lactose (milk sugar), Some racial groups, lactase activity is high at birth but declines to low levels by adulthood
Lactose intolerant (or lactase deficiency)Symptoms: Abdominal pain, Bloating, Flatulence, Incidence of lactose intolerance, 70% to 90% in blacks, Native Americans, Asians, and Mediterranean groups
Appetite Anorexia is a loss of appetite for food that occurs with gastrointestinal disease or as a side effect to some medications, with pregnancy, or with psychological disorders., Any change in appetite? Is this a loss of appetite?Any change in weight? How much
Dysphagia Any difficulty swallowing? When did you first notice this?Dysphagia occurs with disorders of the throat or esophagus
Food intolerance Example: lactase deficiency resulting in bloating or excessive gas after taking milk products.Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloating, indigestion? Do you use antacids? How ofte
Abdominal pain Any abdominal pain? Please point to it.Abdominal pain may be visceral from an internal organ (dull, general, poorly localized), Parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement), Referred from a disord
Referred Pain Liver Hepatitis may have mild-to-moderate, dull pain in right upper quadrant or epigastrium, along with anorexia, nausea, malaise, low-grade fever
Referred Pain Esophagus Gastroesophageal reflux disease (GERD) is a complex of symptoms of esophagitis, including burning pain in mid-epigastrium or behind lower sternum that radiates upward, or "heartburn." Occurs 30 to 60 minutes after eating; aggravated by lying down or bendi
Referred Pain Gallbladder Cholecystitis is biliary colic, sudden pain in right upper quadrant that may radiate to right or left scapula, and which builds over time, lasting 2 to 4 hours, following ingestion of fatty foods, alcohol, or caffeine. Associated with nausea and vomiting
Referred Pain Pancreas Pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting
Referred Pain Duodenum Duodenal ulcer typically has dull, aching, gnawing pain, does not radiate, may be relieved by food, and may awaken the person from sleep
Referred Pain Stomach Gastric ulcer pain is dull, aching, gnawing epigastric pain, usually brought on by food, radiates to back or substernal area. Pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders
Referred Pain Appendix Appendicitis typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney's point), Pain is aggravated by movement, coughing, deep breathing; associated with a
Referred Pain Kidney Kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain
Referred Pain Small intestine Gastroenteritis has diffuse, generalized abdominal pain, with nausea, diarrhea
Referred Pain Colon Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen, bloating. Irritable bowel syndrome (IBS) has sharp or burning, cramping pain over a wide area; does not radiate, Brought on by meals, relieved by bowel movement
Medications What medications are you currently taking? Peptic ulcer disease has risk factors that include frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, smoking, and Helicobacter pylori infection, How about alcohol—how much would you say you
Striae (lineae albicantes) -common pigment change Silvery white, linear, jagged marks about 1 to 6 cm long , Occur when elastic fibers in the reticular layer of the skin are broken following rapid or prolonged stretching, as in pregnancy or excessive weight gain, Recent striae are pink or blue; then the
Abnormal striae Ascites,Cushing's syndrome - striae look purple-blue with (excess adrenocortical hormone), Causes the skin to be fragile and easily broken from normal stretching
Aortic aneurysm— murmur is harsh, systolic, or continuous and accentuated with systole. Note in person with hypertension, Most aortic aneurysms (more than 95%) are located below the renal arteries and extend to the umbilicus, About 80% of these are palpable during routine
Renal artery stenosis— murmur is midline or toward flank, soft, low-to-medium pitch, Partial occlusion of femoral arteries
Venous hum— occurs rarely,Heard in periumbilical region, Originates from inferior vena cava, Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill, Occurs with portal hypertension and cirrhotic liver
Percuss for general tympany, Liver span, & Splenic Dullness Percuss to assess the relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses, First, percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness,
General tympany throughout is normal Tympany should predominate because air in the intestines rises to the surface when the person is supine, Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass ,Hyperresonance is present with gaseous distention
Liver Span Percuss to map out the boundaries of certain organs , Measure the height of the liver in the right midclavicular line. Begin in the area of lung resonance, and percuss down the interspaces until the sound changes to a dull quality, Mark the spot, usuall
Liver Span Clinical estimation of liver span is important to screen for hepatomegaly and to monitor changes in liver size, A gross estimate, Abnormal Findings,
Hepatomegaly Accurate detection of liver borders is confused by dullness above the fifth intercostal space, which occurs with lung disease, e.g., pleural effusion or consolidation (most common inaccuracy), Accurate detection at the lower border is confused when dulln
Splenic Dullness Locate the spleen by percussing for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line
Splenic Dullness The area of splenic dullness normally is not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble
Splenic Dullness A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection
Splenic Dullness Now percuss in the lowest interspace in the left anterior axillary line. Tympany should result. Ask the person to take a deep breath. Normally, tympany remains through full inspiration.
Splenic Dullness In this site, the anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign, indicating splenomegaly
Splenic Dullness This method will detect mild to moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria, or hepatic cirrhosis.
Costovertebral Angle Tenderness Indirect fist percussion causes the tissues to vibrate instead of producing a sound
Splenic Dullness To assess the kidney, place one hand over the 12th rib at the costovertebral angle on the back
Splenic Dullness Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. Sharp pain occurs with inflammation of the kidney or paranephric area
ascites (free fluid in the peritoneal cavity) Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer, Differentiate ascites from gaseous distention by performing two percussion tests
Fluid Wave Stand on the person's right side, Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline , This will stop transmission across the skin of the upcoming tap. Place your left hand on the person's right
Shifting Dullness In a supine person, ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel upward, You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid, Then percuss down
Shifting Dullness Now turn the person onto the right side (roll the person toward you)
Shifting Dullness The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward.
Shifting Dullness Begin percussing the upper side of the abdomen and move downward
Shifting Dullness The sound changes from tympany to a dull sound as you reach the fluid level, but this time the level of dullness is higher, upward toward the umbilicus.
Shifting Dullness This shifting level of dullness indicates the presence of fluid
Shifting Dullness Shifting dullness is positive with a large volume of ascitic fluid: It will not detect less than 500 ml of fluid
Palpate Surface and Deep Areas (blank)
Perform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness (blank)
Techniques for relaxing during palpation (blank)
Bend the person's knees. (blank)
Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up (blank)
Teach the person to breathe slowly (in through the nose, and out through the mouth) (blank)
Keep your own voice low and soothing. Conversation may relax the person (blank)
Techniques for relaxing during palpation (blank)
Try "emotive imagery." For example, you might say, "Now I want you to imagine you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax." (blank)
With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves (blank)
Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out w (blank)
Light and Deep Palpation (blank)
Begin with light palpation Depress the skin about 1 cm
Begin with light palpation Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen
Begin with light palpation The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature
Begin with light palpation Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination
Abnormal Finding Muscle guarding, Rigidity, Large masses, Tenderness
Light and Deep Palpation (blank)
Light palpation (continued) (blank)
Discriminate between voluntary muscle guarding and involuntary rigidity. (blank)
Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation
Involuntary rigidity is a constant board-like hardness of the muscles, It is a protective mechanism accompanying acute inflammation of the peritoneum, May be unilateral, Same area usually becomes painful when the person increases intraabdominal pressure by attempting a sit-u
Deep Palpation Push down about 5 to 8 cm (2 to 3 inches) , Moving clockwise, explore the entire abdomen, To overcome the resistance of a very large or obese abdomen, use a bimanual technique, Place your two hands on top of each other , The top hand does the pushing; th
Deep Palpation If a mass is identified distinguish it from a normally palpable structure or an enlarged organ (see previous slide). Then note the following: Location, Size, Shape, Consistency (soft, firm, hard), Surface (smooth, nodular), Mobility (including movement with respirations), Pulsatility, Tenderness
Liver (2 techniques) Place your left hand under the person's back parallel to the 11th and 12th ribs and lift up to support the abdominal contents.
Liver (2 techniques) Place your right hand on the RUQ, with fingers parallel to the midline. Push deeply down and under the right costal margin
Liver (2 techniques) Ask the person to take a deep breath. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation
Liver (2 techniques) It feels like a firm regular ridge. Often, the liver is not palpable and you feel nothing firm. Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is enlarged, Record the number of centimeters it descends
Hooking Technique An alternative method of palpating the liver is to stand up at the person's shoulder and swivel your body to the right so that you face the person's feet ,Hook your fingers over the costal margin from above. Ask the person to take a deep breath. Try to f
Spleen Normally, the spleen is not palpable and must be enlarged three times its normal size to be felt
Spleen To search for it, reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs
Spleen Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin.
Spleen Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. You should feel nothing firm.
Spleen Abnormal Findings The spleen enlarges with mononucleosis and trauma , If you feel an enlarged spleen do not continue to palpate it, An enlarged spleen is friable and can rupture easily with overpalpation, Describe the number of centimeters it extends below the left costal
Kidneys Search for the right kidney by placing your hands together in a "duck-bill" position at the person's right flank
Kidneys Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath
Kidneys Normal conditions:No change, Palpation of the lower pole of the right kidney as a round, smooth mass slide between your fingers
The left kidney Sits 1 cm higher than the right kidney and is not palpable normally
The left kidney Search for it by reaching your left hand across the abdomen and behind the left flank for support
The left kidney Push your right hand deep into the abdomen and ask the person to breathe deeply
The left kidney You should feel no change with the inhalation
Aorta ***Do not do this if you auscultated a bruit!***, Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline, Normally, it is 2.5 to 4 cm wide in the adult and pulsates in an anterior directio
Rebound Tenderness (Blumberg's Sign) Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation, Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen, Push down slowly and deeply; then lift
Rebound Tenderness (Blumberg's Sign) This makes structures that are indented by palpation rebound suddenly. A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination, because it can cause severe pain and muscle rigidity
Rebound Tenderness (Blumberg's Sign) Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation, Common finding with appendicitis
Inspiratory Arrest (Murphy's Sign) Normally, palpating the liver causes no pain, Pain occurs with inflammation of the gallbladder
Inspiratory Arrest (Murphy's Sign) Hold your fingers under the liver border
Inspiratory Arrest (Murphy's Sign) Ask the person to take a deep breath. A normal response is to complete the deep breath without pain
Inspiratory Arrest (Murphy's Sign) Positive Murphy’s sign: As the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway
Iliopsoas Muscle Test (Psoas Sign) Perform when the acute abdominal pain of appendicitis is suspected, With the person supine, lift the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold the leg up. When the test is
Positive Iliopsoas Sign: When the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant
Obturator Test. Performed when appendicitis is suspected , With the person supine, lift the right leg, flexing at the hip and 90 degrees at the knee , Hold the ankle and rotate the leg internally and externally. A negative or normal response is no pain., A perforated ap
Summary Checklist: Abdomen Exam (blank)
Inspection Contour, Symmetry, Umbilicus, Skin, Pulsation or movement, Hair distribution, Demeanor
Auscultation Bowel sounds, Note any vascular sounds
Percussion Percuss all four quadrants, Percuss borders of liver, spleen
Palpation Light palpation in all four quadrants, Deeper palpation in all four quadrants,Palpate for liver, spleen, kidneys
Created by: holtanmir