King Saud University
Collage of Nursing
Medical Surgical Nursing depart
Application of Health Assessment
NUR 225
Module Seven
Physical examination of gastrointestinal and urinary system
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Abdominal Examination: Techniques and Findings, Study Guides, Projects, Research of Nursing
A comprehensive guide on performing an abdominal examination, including inspection, auscultation, percussion, and palpation techniques. It covers various abnormal findings, such as hernias, masses, tenderness, and signs of inflammation. The document also includes anatomical correlates of the quadrants of the abdomen and definitions of urinary abnormalities.
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King Saud University
Collage of Nursing
Medical Surgical Nursing depart
Application of Health Assessment
NUR 225
Module Seven
Physical examination of gastrointestinal and urinary system
Learning Outcomes:
At the end of the session, the student should be able to:
**1. Discuss the correct sequence of performing the abdominal examination.
- Describe the anatomic correlates of the quadrants and nine regions of the abdomen.
- Differentiate between normal and abnormal findings during application of abdominal**
examination.
**4. Perform a thorough physical assessment of the female urinary system.
- Differentiate normal and abnormal findings as an outcome of the examination**
performed;
Gastrointestinal examination
NORMAL RANGE OF FINDINGS ABNORMAL FINDINGS
I - Inspection:
Protruding caused by obesity , pregnancy or Ascities ( accumulation of fluid in peritoneal space)
Bulges , masses and asymmetric shape
Marked aortic pulsation
Marked visible peristalsis
Pink purple striae – Cushing’s syndrome Dilated veins – inferior vena cava obstruction Poor turgor.
Hernia ( protrusion of abdominal)
Inspect the abdomen for:
a) Shape and contour of abdomen
b) Symmetry
c) Pulsation from aorta beneath the skin in epigastric area
d) Peristalsis (wavelike motion)
Inspect skin of abdomen for color, scar, striae, Lesion & turgor
- Inspect umbilicus for shape, location, signs of inflammation, viscera through abnormal opening muscle wall
Presence of bulging or mass
Inspect kidney and bladder
- Inspect skin color, shape, swelling, lesions, bulging or mass, scars.
- Skin should be free of lesions and swelling
II. Auscultation
Listen for bowel sounds in all four quadrants
Use the diaphragm of the stethoscope and press lightly. Listen in a systematic progression, such as from (RLQ) to (RUQ) to (LUQ) to (LLQ) and finally
Auscultate the abdomen for bowel sounds.
Be sure to auscultate before palpating and percussing the abdomen so that the presence of bowel sound or pain is not altered.
Bowel sounds are heard as high pitched, gurgling, irregular sounds as fluid is moving away from one area to another.
Bowel sounds should be noted every 5 to 15 seconds. The duration of a single bowel sound may range from 1 second to several seconds. The sound are high pitched gurgles or clicks, although this varies greatly.
Audible sounds produced by hyperactive peristalsis is termed borborygmi, and create rumbling, gurgling, and high-pitched tinkling sounds. This can sometimes occur with diarrhea and after eating. Very high-pitched bowel sounds may be a sign of early bowel obstruction.
A bruit indicates a turbulent blood flow caused by narrowing of a blood vessel.
Bruits over the aorta suggest an aneurysm. Two sound patterns may indicate renal arterial stenosis: soft, medium-to low-pitched murmurs heard over the upper midline or toward the flank or epigastric bruits that radiate laterally.
Normal bowel sounds are harsh and high pitched occurring irregularly 5-34 times/minute.
Note the character and frequency of bowel sound. (Hyperactive, hypoactive, absent).
Hyperactive bowel sounds (Increased bowel sounds) can sometimes be heard even without a stethoscope. Hyperactive bowel sounds mean there is an increased in intestinal activity.
Hypoactive bowel sounds are normal during sleep and also occur normally for a short time after the use of certain medications and after abdominal surgery.
Decreased or absent bowel sounds occur with mechanical obstruction or paralytic ileus as well as with peritonitis and bowel obstruction.
Auscultate the abdomen for arterial and venous vascular sounds.
Listen with the bell of the stethoscope. Listen over aorta and renal, iliac and femoral arteries of bruits. They make “swishing sounds” occur during systole, and are continuous regardless of the client’s position.
Also listen with the bell over the epigastric region and around the umbilicus for a venous hum, a soft low – pitched and continuous sound.
Normally vascular sounds are not heard.
when the lower border of the liver exceeds 0.75 to 1.25 inches (2.3cm) below the costal margin, this indicates an enlarged liver (hepatomegaly), which is associated with cirrhosis and hepatitis.
when dullness extends above the 5th intercostal space, it indicating hepatomegaly.
clients with COPD (Chronic Obstructive Pulmonary Disease) may have flat diaghragm. Which
makes percussion of the upper border of the liver difficult.
Movement of dullness as the client shifts position reflects the shift of fluid in the peritoneal cavity (ascites).
- To assess the liver descent, as the client to take a deep breath and hold it, then percuss upward from the stomach to the RMCL.
Normally, The mid clavicular liver span is 2.5 to 4.5 inches ( to 12 cm).
Liver span correlates with body size and gender, large people and men tend to have larger spans.
The lower border of the liver should descend downward 0.75 to 1.25 inches (2-3 cm.).
C) Assess The Abdomen For Fluid.
If fluid is suspected within the abdomen, perform the following test:
Shifting fluid dullness:
This maneuver is performed with the patient supine, so that any fluid pools in the lateral (flank) area.
Percuss over the umbilical and directed to flanks, point the area transition from tympany to dullness noted.
The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.
Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.
Sharp pain occurs
D) Kidney Percussion:
Place the palm of your non-dominant hand over costovertebral angle. Strike the ball of that hand with the ulnar surface of your other hand. Ask the patient about pain
Patient will normally feel the thud but no pain
Full bladder produce dull sound
E) Bladder Percussion
Ask the patient to empty the bladder first.
Place patient in a supine position.
Start at the symphysis pubis and percuss upward toward the bladder and over it
You should hear tympanic sound
IV- Palpation of abdomen
Note any cutaneous tenderness of hypersensitivity.
Note any superficial masses or localized areas of rigidity or increased tension. Rigidity is associated with peritoneal irritation and may be diffuse or localized.
A. Light Palpation: Palpate the abdomen lightly for tenderness, muscle tone and surface characteristics.
- Palpate all quadrants of the abdomen. Use the Gentle horizontal dipping motion with pads of the fingertips to depress the abdomen 1 to 2 cm. Have the patient supine with knees slightly flexed.
- No tenderness should be present and the abdominal muscles should be relaxed.
- Note consistent tension as you move across the smooth surface.
- When the client has abdominal pain, palpate over the area of pain last.
B) Deep Palpation Palpate the abdomen deeply for tenderness, masses and aortic pulsation.
- Palpate all quadrants.
- Use either the distal flat portions of the finger pads and gradually and deeply 4 to 6 cm into the palpation area, or use a bimanual technique, with the lower hand resting lightly on the surface and
A palpable spleen will feel like a firm mass that bumps against the nurse’s fingers.
Spleen tenderness may indicate infection or trauma.
Ask the patient to take a deep breath.
The spleen is not normally palpable on most individuals.
Enlarged, hydronephrosis, cysts or tumors
Palpation of Kidney:
palpate for the right kidney by placing your nondominant hand below the client's right flank
place dominant hand above the kidney pole and apply pressure. Press the two hands together firmly and ask the person to take a deep breath
Repeat procedure over the left kidney
Normally You will feel the lower end of the right kidney as a smooth round mass
Mass or tumors
Palpation of Bladder:
If the bladder is full, you will feel it
Use the fingers of one hand to palpate the lower abdomen in a light dipping motion.
Normally A distended bladder will feel firm and smooth Rebound Tenderness
- It is performed if the client reports abdominal pain or if tenderness was detected during palpation
- This is a test for peritoneal irritation or peritonitis
- Choose a site away from the painful area , Press deeply with fingertips vertically on the abdomen and release pressure completely while keeping fingertips in contact with skin.
- Ask client about pain induced any area in the abdomen.
Pain in the hypogastric region is a positive Sign indicating irritation of the obturator muscle Which may be caused by a ruptured appendix or Pelvic abscess.
Obturator Sign
- This is a test for appendicitis. Increased abdominal pain indicates a positive obturator sign
- Raise the patient's right leg with the knee flexed.
- Rotate the leg internally at the hip.
Attachments
Box 1 – Anatomic Correlates of the Quadrants of the Abdomen
Right Upper Quadrant (RUQ)
Liver and gallbladder Pylorous Duodenum Head of pancreas Right adrenal gland Portion of right kidney Portions of ascending and transverse colon
Left Upper Quadrant (LUQ)
Left lobe of liver Spleen Stomach Body of pancreas Left adrenal gland Portion of left kidney Portions of transverse and descending colon
Right Lower Quadrant RLQ)
Lower pole of right kidney Cecum and appendix Portion of ascending colon Bladder (if distended) Right ureter Right ovary and salpinx Uterus (if enlarge) Right spermatic cord
Left Lower Quadrant (LLQ)
Lower pole of left kidney Sigmoid colon Portion of descending colon Bladder if distended Left ureter Left ovary and salpinx Uterus if enlarged Left spermatic cord
Box 2 – Anatomic Correlates of the Nine (9) Regions of the Abdomen
Right Hypochondriac
Right lobe of liver Portion of gallbladder Portion of duodenum Portion of right kidney Right adrenal gland
Epigastric
Pyloric end of stomach Duodenum Pancreas Portion of liver Portion of gallbladder
Left Hypochondriac
Stomach Spleen Tail of pancreas Upper pole of left kidney Left adrenal gland Right Lumbar
Ascending colon Lower half of right kidney Portion of duodenum and jejunum
Umbilical
Lower duodenum Jejunum and ileum Transverse colon
Left lumbar
Descending colon Lower half of left kidney Portion of jejunum and ileum
Right Iliac
Cecum Appendix Ileum (lower end) Right ureter Right spermatic cord Right ovary
Hypogastric
Ileum Bladder Uterus (in pregnancy
Left Iliac
Sigmoid colon Left ureter Left spermatic cord Left ovary
Box 3 – definitions of urinary Abnormal findings
Polyuria : Increase volume of urine voided more than 2,500 ml of urine daily. Oliguria : Urine out put less than 400ml/day Anuria : Urine out put less than 50ml/day - Urinary frequency: An increased urge to urinate more than every 3 hours
- urgency: Strong desire to urinate - Hesitancy: Delay or difficulty in initiating voiding. - Nocturia: Excessive urination at night, Dysuria : Painful or difficulty voiding Incontinence: Involuntary loss of urine Enuresis : Involuntary voiding during sleep - Hematuria: Red blood cells in the urine. Proteinuria : Abnormal amounts of protein in the urine Pyuria; Presence of pus in urine
Prepare required equipment.
Explain procedure.
Prepare Client The patient should have an empty bladder. The patient should be lying on supine position, knees bent or on pillow and arms at the sides. Expose the abdomen and drape the genitalia and female breast The examination room must be quiet and warm to perform adequate auscultation and percussion. Warm the stethoscope end piece and your hands to avoid abdominal tensing Keep your fingernail short Watch the patient's face for signs of discomfort during the examination Examine painful areas last to avoid any muscle guarding Instruct client appropriately
ABDOMINAL EXAMINATION
INSPECTION
- Scars, striae, stretch marks
- Rashes or lesions
- Umbilicus for shape, location , signs of inflammation, hernia
- Shape and contour
- Symmetry
- Peristalsis (wavelike motion)
- Pulsations from aorta beneath the skin in epigastric area.
- Inspect skin above the kidney and bladder For color, shape, swelling, lesions, bulding or mass, scars
AUSCUTATION
- Bowel sound by using diaphragm of stethoscope
- Bruits over the renal arteries, iliac arteries and aorta- by using diaphragm of stethoscope.
PERCUSSION
- Percuss the 4 quadrants
- Tympany (gastric bubble)
- Dullness (over) the liver and spleen or a mass)
- Measure liver size in the right midclavicular line (6-12 cm).
Bladder Percussion
- Ask the patient to empty the bladder first.
- Place patient in a supine position.
- Start at the symphysis pubis and percuss upward toward the bladder and over it.
Kidney Percussion:
- Assist client in a sitting position
- Place the palm of your non-dominant hand over costovertebral angle. Strike the ball of that hand with the ulnar surface of your other hand. Ask the patient about pain. PALPATION
- Light Palpation- to assess any superficial organs or masses or tenderness
- Deep Palpation- to assess any superficial organs or masses or tenderness
- Liver Palpation (Standard technique)
- Spleen Palpation
- Kidney palpation
- palpate for the right kidney by placing your nondominant hand below the client's right flank.
- place dominant hand above the kidney pole and apply pressure. Press the two hands together firmly and ask the person to take a deep breath.
- Repeat procedure over the left kidney