Chapter 23
Assessing Abdomen
Abdomen
Bordered superiorly by the costal margins
Bordered inferiorly by the symphysis pubis and
inguinal canals
Bordered laterally by the flanks
Divided into quadrants and regions
Abdominal wall muscles
Internal anatomy
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Quadrants #1
Quadrants:
o Right upper quadrant (RUQ)
o Right lower quadrant (RLQ)
o Left lower quadrant (LLQ)
o Left upper quadrant (LUQ)
Two imaginary lines:
o Vertical/midline
o Horizontal/lateral
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Quadrants #2
RUQ
o Ascending colon and transverse colon
o Duodenum
o Gallbladder
o Hepatic flexure of colon
o Liver
o Pancreatic head
o Pylorus
o Right adrenal gland
o Right kidney and right ureter
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Quadrants #3
RLQ
o Appendix
o Ascending colon
o Cecum
o Right kidney
o Right ovary and tube
o Right ureter
o Right spermatic cord
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Quadrants #4
LUQ
o Left adrenal gland
o Left kidney
o Left ureter
o Pancreas
o Spleen
o Stomach
o Transverse descending colon
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Quadrants #5
LLQ
o Left kidney
o Left ovary and tube
o Left ureter
o Left spermatic cord
o Descending and sigmoid colon
Midline
o Bladder
o Uterus
o Prostate gland
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Regions
Epigastric
Umbilical
Hypogastric
Right and left hypochondriac
Right and left lumbar
Right and left iliac (inguinal)
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Wall Muscles #1
Three layers from back, around flanks, to front:
o External abdominal oblique
o Internal abdominal oblique
o Transverse abdominis
Additional muscles: rectus abdominis
Additional structures: linea alba
Protect internal organs; allow normal compression of
internal organs during functional activities
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Wall Muscles #2
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Internal Anatomy #1
Abdominal viscera
Reprinted with permission from Hinkle, J., & Cheever, K. [2018]. Brunner & Suddarth’s textbook of medical-surgical
nursing [14th ed.]. Wolters Kluwer Health.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Internal Anatomy #2
Peritoneum
o Serous membrane that lines the abdominal
cavity (parietal peritoneum)
o Protective covering for most internal organs
(visceral peritoneum)
Different body systems:
o Gastrointestinal
o Reproductive (female)
o Lymphatic
o Urinary
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Internal Anatomy #3
Solid viscera: liver,
pancreas, spleen,
adrenal glands,
kidneys, ovaries,
uterus
Hollow viscera:
stomach, gallbladder,
small intestine, colon,
bladder
Palpation of abdominal
viscera depends on
location, structural
consistency, size
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Internal Anatomy #4
Viscera normally not
palpable:
o Pancreas, spleen,
stomach, gallbladder,
small intestine
Vascular structures:
o Abdominal aorta; right
and left iliac arteries
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Biologic (Genetic) and Cultural Behavior
Variations #1
In the United States, non-Hispanic Black, Hispanic,
Asian/Pacific Islander have 40% to 50% higher risk for
gastric cancer than Whites.
Cardia cancer rates 35% to 47% lower for Blacks,
Hispanics, Asian or Pacific Islanders, American Indian or
Alaska Natives; conversely, noncardia incidence rate
ratios were 1.7- to 3.9-fold higher for Blacks, Hispanics,
Asian or Pacific Islanders, and American Indian or Alaska
Natives.
Stomach cancer has association with Helicobacter pylori;
highest rates in Asia, Latin America, and Caribbean;
lowest rates in North America and Africa; countries with
highest incidence: Korea, Mongolia, Japan.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Biologic (Genetic) and Cultural Behavior
Variations #2
Esophageal adenocarcinoma risen rapidly in general
U.S. population; Asian Americans have low rates.
Esophageal squamous cell carcinoma rates in U.S.
general population has fallen; but extremely high for
Asians and Asian Americans.
Gallbladder disease and gallbladder cancer vary by
ethic group; Native Americans and Mexican
Americans have high rates.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Biologic (Genetic) and Cultural Behavior
Variations #3
Gallbladder disease included more women than
men; order of cases by ethnic group: Latinos,
Japanese Americans, Whites, African Americans,
Native Hawaiians.
Keloids: excess scar tissue, resulting from trauma or
surgery, more common in African Americans and
Asians.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Older Adult Considerations #1
Sensitivity to pain may diminish with aging, assess
carefully for acute abdominal conditions.
May experience decline in appetite from various
factors such as altered metabolism, decreased taste
sensation, decreased mobility, and depression; risk
for nutritional imbalance
At risk for potential complications with diarrhea
(fluid volume deficit, dehydration, electrolyte and
acid–base imbalances) because of higher fat-to-lean
muscle ratio
Prone to UTIs because activity of protective bacteria
in urinary tract declines with age
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Older Adult Considerations #2
Dilated superficial capillaries without a pattern may
be seen; more visible in sunlight.
The USPSTF recommends one-time screening for
abdominal aortic aneurysm for men between 65 and
75 years who have smoked; selectively for men 65
to 75 years who have never smoked; not
recommended for women.
If older than age 50 or has hypertension, assess
width of aorta.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #1
Is the following question true or false?
The abdominal wall allows normal compression during
functional activities such as childbirth.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #1
True
The abdominal wall allows normal compression during
functional activities such as childbirth.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Subjective Data: The Nursing
Health History #1
History of present health concern
o Abdominal pain
COLDSPA; character (dull, aching; burning,
gnawing; pressure; colicky; sharp, knifelike;
variable)
o Indigestion
o Nausea and vomiting
o Appetite
o Bowel elimination
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Subjective Data: The Nursing
Health History #2
Abdominal pain
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Subjective Data: The Nursing
Health History #3
Personal health history
Family history
Lifestyle and health practices
Copyright © 2022 Wolters Kluwer · All Rights Reserved
General Routine Screening
Observe the coloration, vascularization, scars,
rashes, and lesions of skin.
Observe umbilicus.
Observe abdominal contour and symmetry.
Observe for aortic pulsations and peristaltic waves.
Auscultate bowel sounds.
Percuss tones over four quadrants of abdomen.
Lightly palpate four quadrants of abdomen.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Focused Specialty Assessment #1
Auscultate for vascular sounds.
Percuss size of liver.
Percuss size of spleen.
Perform blunt percussion of liver and kidneys.
Deeply palpate four abdominal quadrants for organs
and masses.
Palpate aorta, liver, spleen, kidneys, urinary
bladder, or for shifting or dullness.
Perform fluid wave test.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Focused Specialty Assessment #2
Assess for rebound tenderness.
Test for referred rebound tenderness.
Assess for psoas sign.
Assess for obturator sign.
Perform hypersensitivity test.
Test for cholecystitis.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #1
Sequence for assessment differs from typical order
o Inspection, auscultation, percussion, palpation
Approach client from right side
Use tangential lighting
Explain every aspect to help client to relax and
avoid tensing abdominal muscles
Properly drape clients to protect privacy
Addressing ticklish client
Warm hands
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #2
Preparing the client
o Ask to empty bladder before starting.
o Remove clothes, put on gown.
o Help client into supine position with arms across
chest or at side, with flat pillow under head for
comfort, and slightly flex legs.
o Properly drape client.
o Instruct on proper breathing to relax muscles.
o Ask about painful areas and assess last.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #3
Equipment
o Small pillow or rolled blanket
o Centimeter ruler
o Stethoscope
o Marking pen
o Gown and drapes
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #4
Physical assessment
o Perform in correct order: inspection,
auscultation, percussion, palpation
o Common abnormal findings:
Abdominal edema
Abdominal masses
Unusual pulsations
Pain
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #5
Inspection
o Coloration of skin
o Vascularity of abdominal skin
o Note any striae
o Inspect for scars
o Assess for lesions and rashes
o Inspect umbilicus; location, contour
o Abdominal contour (see Assessment Guide 23-2,
Measuring Abdominal Girth)
o Assess symmetry
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #6
Inspection—(cont.)
o Abdominal movement when chest breathes
o Aortic pulsations
o Peristaltic waves
Auscultation
o Bowel sounds
o Vascular sounds
o Venous hums
o Friction rub over liver and spleen
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #7
Percussion
o Tone
o Span and height of liver
o Spleen
o Blunt percussion on liver and kidneys
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #8
Palpation
o Light palpation.
o Deeply palpate all quadrants.
o Palpate for masses.
o Palpate umbilicus and surrounding area for
swelling, bulges, or masses.
o Palpate aorta.
o Palpate liver, spleen, kidneys, and urinary
bladder.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #9
Test for ascites
o Test for shifting dullness.
o Perform fluid wave test.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #10
Tests for appendicitis/peritoneal irritation
o Assess for rebound tenderness.
o Test for referred rebound tenderness.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #11
Tests for appendicitis/peritoneal irritation—
(cont.)
o Assess for psoas sign.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #12
Tests for appendicitis/peritoneal irritation—
(cont.)
o Assess for obturator sign.
o Perform hypersensitivity test.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #13
Test for cholecystitis
o Assess RUQ pain or tenderness.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Collecting Objective Data: Physical
Examination #14
Abdominal signs
o Psoas sign: pain in RLQ when leg hyperextended
o Obturator sign: pain in RLQ when hip and knee
flexed and leg rotated internally and externally
o Murphy sign: pain when pressure applied under
liver border of right costal margin and client
inhales deeply
o Rovsing sign: pain in RLQ during pressure in LLQ
o Blumberg sign: pain or tenderness when tests for
rebound tenderness by palpating deeply at 90
degrees into abdomen between umbilicus and
anterior iliac crest
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Validating and Documenting Findings
Validate assessment data collected.
Necessary to verify data are reliable and accurate.
Document assessment data following health care
facility or agency policy:
o COLDSPA
o SBAR
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Analyzing Data to Make Clinical
Judgments
Selected client concerns
o Opportunity to improve client health
o Risk for client concerns
o Actual client concerns
Selected collaborative problems
o RC: Risk for Complications
Medical problems
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #2
Is the following statement true or false?
The correct order for conducting the physical
assessment techniques is inspection, percussion,
auscultation, and palpation.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #2
False
The correct order to perform the basic assessment
techniques when examining the abdomen is
inspection, auscultation, percussion, and palpation.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Peptic Ulcer Disease #1
An open sore that forms in the lining of the
esophagus, stomach, or small intestine
Can be quite painful and bleed
Wide variety of symptoms, from none until
advanced to pain, burning sensation, worse with
empty stomach, chest pain, fatigue, weight loss,
black or tarry stools, vomiting
Screening: no recommendations currently
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Peptic Ulcer Disease #2
Risk assessment
o Controllable factors:
Taking NSAIDs, especially if also taking
steroids, anticoagulants, low-dose aspirin,
SSRIs, alendronate, risedronate
Smoking or chewing tobacco
Having untreated stress
Eating spicy foods
Drinking alcohol
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Peptic Ulcer Disease #3
Risk assessment—(cont.)
o Noncontrollable factors:
Presence of H. pylori in GI tract
Hypersecretory condition
Personal or family history, possible genetic link
Radiation treatments
Zollinger–Ellison syndrome (rare tumor in
pancreas)
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Peptic Ulcer Disease #4
Client education
o Wash hands frequently.
o Eat foods cooked completely.
o Use all recommended cautions when taking pain
relievers.
o Avoid excessive alcohol intake.
o Avoid or stop smoking and chewing tobacco.
o If medications order, follow directions carefully
and report any continuing symptoms, symptoms
that worsen, or more serious symptoms occur.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #1
Stomach or gastric acids flow back into esophagus;
over time, causes irritation and can erode tissue,
leading to scarring and narrowing of esophagus,
Barrett esophagus or cancer
Symptoms: hoarseness, laryngitis, chronic dry
cough, asthma or worsening of asthma symptoms,
feeling as if lump in throat, sudden increase in
saliva, halitosis, earaches, and/or chest pain or
discomfort
Screening: none recommended
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #2
Risk factors
o Obesity
o Hiatal hernia
o Pregnancy
o Smoking
o Dry mouth
o Asthma
o Diabetes
o Delayed stomach emptying
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #3
Risk factors—(cont.)
o Eating large meals or late at night
o Connective tissue disorders such as scleroderma
o Alcohol consumption
o Dairy, spicy, and fried foods
o Some medications: aspirin, pain medications,
sedatives, antidepressants, medications for
asthma, hypertension, or allergies
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #4
Client education
o Avoid alcohol and tobacco intake.
o Assess foods that cause distress and avoid.
o Avoid foods that cause you to swallow air.
o Eat 5 to 6 small meals a day.
o Eat slowly and chew food well.
o Do not lie down after eating for at least 2 hours.
o Avoid late evening snacks.
o Avoid bending or stooping after eating.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #5
Client education—(cont.)
o Avoid lifting heavy objects.
o Avoid wearing tight clothes around waist, abdomen,
or stomach.
o Lose weight if overweight.
o Raise head of bed 6 to 8 in.
o Try sleeping on left side.
o Take medications exactly as prescribed.
o Tell health care provider you have GERD.
o Keep relaxed atmosphere when eating.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Gastroesophageal Reflux Disease #6
Client education—(cont.)
o Foods to avoid
Very hot or very cold; fatty or fried foods;
peppermint or spearmint, including flavoring;
coffee, tea, soft drinks containing caffeine;
spicy, highly seasoned foods; tomato-based
dishes; citrus fruits and juices; chocolate and
sweets if they cause symptoms
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Distention #1
Pregnancy (normal
finding) Fat
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Distention #2
Fibroids and other
Feces masses
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Distention #3
Flatus Ascitic fluid
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Bulges #1
Umbilical hernia Epigastric hernia
Reprinted with permission from Hawn, M. (2015).
Image provided by Stedman’s. Operative techniques in foregut surgery (Fig. 38-3).
Wolters Kluwer.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Abdominal Bulges #2
Diastasis recti Incisional hernia
Reprinted with permission from Corman, M., Nicholls, R. J., Fazio, V. W., & Bergamaschi, R. (2013). Corman’s colon and
rectal surgery (6th ed., Fig. 19-61). Wolters Kluwer.
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #1
Enlarged liver Enlarged nodular liver
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #2
Liver higher than
normal Liver lower than normal
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #3
Enlarged spleen Aortic aneurysm
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #4
Enlarged kidney Enlarged gallbladder
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #5
Palpating distended
Keloid bladder
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #6
Scaphoid abdominal Distended/protuberant
contour abdominal contour
(may be abnormal) (usually abnormal)
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Enlarged Abdominal Organs and Other
Abnormalities #7
Ascites: percussing for level of dullness with
client supine and lying on side
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Question #3
Which test should a nurse perform on a client with
ascites?
A. Fluid wave test
B. Murphy sign
C. Psoas sign
D. Obturator sign
Copyright © 2022 Wolters Kluwer · All Rights Reserved
Answer to Question #3
A. Fluid wave test
The nurse should perform the fluid wave test on a
client with ascites. Murphy sign is used to test for
cholecystitis, and the psoas sign and obturator signs
are performed to test for appendicitis.
Copyright © 2022 Wolters Kluwer · All Rights Reserved