Chapter (9) Assessment of the abdomen

1. Chapter (9) Assessment of the abdomen

2. Assessment of the abdomen • The largest body cavity" • Subjective data: ask the client about: - Nutritional history: appetite, weight loss or gain. - Gastro intestinal symptoms: dysphagia, nausea, vomiting, and indigestion. - Bowel habits: pattern, and stool characteristics. - Pain: location, quality, pattern, and relationship to ingestion of food. - Use of medications: Aspirin, Anti inflammatory drugs, and steroids. - Gastro intestinal diagnostic tests and surgeries.

3. Assessment of the abdomen cont.. • Client placed in the supine position, with small pillows under the head and knees. • Abdomen exposed from the breast to the symphysis pubis • Start assessment with inspection, palpation, auscultation, then percussion. • Stand at the client right side قف على يمين المريضand carry out assessment systematically, beginning with the left upper quadrant. • Bladder should be empty.

4. Assessment of the abdomen cont.. • Inspection: • Under source of light you see exactly changes in contours. • * Assess the presence or absence of symmetry, distention, masses, visible peristalticwaves &respiratorymovement. • Inspect the abdominal skin for pigmentatione.g. jaundice, lesions, striae scars, dehydration, general nutritional status and condition of umbilicus, this give information about general state health

5. Assessment of the abdomen cont.. • Contour of the normal abdomen is described as: flat, rounded, or scaphoid. N.B: contour is description of the profile line from the rib margin to the pubic bone. • Flat contour seen in the muscularly competent &well nourished individual. • Rounded abdomen: Normally in infant and toddler, but in the adult caused by poor muscle tone and excessive Subcutaneous fat deposition. • Scaphoid contour “Concave in horizontal line” seen in thin-clientsof all ages. • Inspect for respiratory movements especially for retraction of the abdominal wall on inspiration which is called "Czerny's sign “associated with some CNS diseases e.g.. Chorea”

6. Assessment of the abdomen cont.. • Auscultation : • Auscultate peristaltic sounds which are normallyhigh pitched. • Listen for at least "5" minutes before concluding that no bowel sounds are present. "Peristaltic sounds may be quite irregular". • Duration of single sound may be less than a second or more than it. • Stimulation of peristalsis may be achieved by flicking the abdominal wall with a finger “direct percussion

7. Assessment of the abdomen cont.. • Auscultate aortic soundsuperior to the umbilicus (Loud bruits), may indicate presence of aorticaneurysm. • Listen for Peritoneal friction rub over the area of liver and spleene.g. spleen infection, abscess or tumor: best heard over the lower rib cage in the anterior axillary line. (rough grating sound like sound of two pieces of leather being rubbed together).

8. Assessment of the abdomen cont.. Percussion: • To detecting fluid or gaseous distention/masses and assessing solid structures within the abdomen. • Percussion of one for each quadrant to assess areas of tympany and dullness. • Potentially painful areas are always Percusslast • Percussion allows you to identity borders of liver to detect organ enlargement. • N.B: Diseases e.g. cirrhosis, cancer, and hepatitis cause liver enlargement

9. Assessment of the abdomen cont.. • To detect liver size, start percussion at the right iliac crest and proceeds up ward on the right midclavicular line, when dullness occur this is the lower border of the liver. • To detect upper border of the liver percuss, down from the nipple along midclavicular line, then dullness occur “upper border” may be found in (5,6,7) intercostals space, distance between points lower and upper is (6-12cm). * Stomach position: • With percussion you can locate the tympanic air bubble of the stomach by percussion over the left lower anterior rib cage.

10. Assessment of the abdomen cont.. • * Kidney Tenderness: • In sitting or erect position, use direct or indirect percussion to assess for kidney inflammation. • Use ulnar surface of the partially closed fist and percuss the costovertebral angle at the scapular line. • If the kidneys are inflamed, client feels tenderness during percussion • Palpation: • * Detect abdominal tenderness and noting quality of abnormal distensions or masses. • Assess for muscular resistance, and superficial organs or masses.

11. Assessment of the abdomen cont.. • * Assess for bladder distention if client has inability to void. • Bladder lies normally belowumbilicus and above symphysis pubis). • In deep palpation depress hands (2.5-7.5 cm) 1-3 inch • N.B: Deep palpation never used over a surgical incision or tender organs, or masses. *If tenderness present, check for rebound tenderness, if it was positive indicated peritoneal irritation e.g. appendicitis

12. Assessment of the abdomen cont.. • Liver: • "Right upper quadrant under the rib cage": • * Place your left hand under client’s posterior thorax at the 11th and 12th ribs and by your right hand palpate in and up to feel the liver’s edge as the client inhales. • * G.B normally not felt ,if distended it felt under liver and may indicate cholecystitis. • Spleen: • Generally not palpable in normal adult person, but in case of spleen enlargement you can palpate it below costal margin.

13. * Assessment of the anus and rectosigmoid region, rectal exam is an important component of every comprehensive physical examination. * Events required rectal examination: • Abdominal pain. • Alternation in bowel habits. • Anal pain, anal spasm. • Anal itching or burning. • Black tary stool. • Rectal bleeding. * Positions for rectal examinations: • Left lateral or SEM's position. • Knee- chest position • Standing position, most common use for prostate gland examination. • Lithotomy position • Squatting position. • N.B.: in all positions, before examination wear two gloves.

14. Assessment of the anus and recto sigmoid region. Cont. Inspection: • Spread buttocks carefully with both hands to examine the anus and skin around it which is more pigmented, moist, and hairless. • Assess lesions, scars, or inflammation, peri-rectal abscess, fissures, piles, fistula opening, tumor and rectal prolapsed. • Ask the client to strain down ward as in defecation. • Inspect for Pilonidal sinus or cyst at the sacrococcygeal area, and give description .

15. Assessment of the anus and recto sigmoid region. Cont. Palpation: (PR examination) • Spread the buttocks apart with your non dominant hand. Gloved index gently placed against the anal verge, and with firm pressure in direction of umbilicus as the rectal sphincter relaxes. Ask client to tighten the sphincter around your finger to examine muscle strength. • Mucosa of the anal canal is palpated fro tumor or polyps. * Assess normal cervix in female which felt as small round mass during P.R examination.

16. * Variations from health which can be detected during rectal examination: • Pilonidal cyst or sinus. • Pruritus anus • Rectal tenesmus:. • Fecal impaction • Anal fissure: • Fistula in anus: • Hemorrhoids: External painful & internal painless unless complicated. • Rectal polyps: • Rectal prolapse: e.g. in case of internal hemorrhoids. • Anal incontinence. • Abscesses or masses e.g. Ischiorectal abscess, perirectal obstruction

17. Chapter (10) • Assessment of Musculoskeletal system • Subjective data: ask about: • Pain: at rest, with exercise, changes in shape or size of an extremity, changes in mobility to carry out activities of daily living, sports, and works. • Stiffness: time of day, relation to weight," bearing or exercise". • Sensations , decreased or altered or absent. • Redness or swelling of joints. • History of fractures and orthopedic surgery. • Occupational history.

18. Assessment of Musculoskeletal system.. cont. • Assessment of musculo-skeletal system done firstly when the client walks, moves in bed or performs any type of physical activity. • Determine Range of motion, muscle strength, tone, joint and muscle condition. • N.B: Muscle problems commonly manifestations of neurological disease, so you must do neurological assessment simultaneously. • Joints vary in their degree of mobility, range from freely movable e.g. knee, to slightly movable joints e.g. spinal vertebrae.

19. Assessment of Musculoskeletal system.. cont. • Assessment of muscle groups: assess muscle weakness, or swelling, and size, then compare between sides. • Joints should not be forced into painful positions. • Observer gait and posture as client walks into room. • Normally client walks with armsswinging freely at sides and head/faceleading the body.

20. Assessment of Musculoskeletal system.. cont. • Loss of height is frequently the first clinical sign of osteoporosis. • Small amount of heightloss expected with aging. • Ask client to put each joint through its full range of motion, if there is weakness, gently supporting & moving extremities through their Range of motion, to assess abnormalities. • Normal joints non tender, without swelling and move freely. • N.B: “You must assess these points”: In elderly joints often become swollen/stiff, with reduced Range of motion, resulting from cartilage erosion and fibrosis of synovial membranes.

21. Chapter 11 Assessment of Neurological system • You can assess this systemwhen doing physical examination e.g. cranial nerve function can be testing during the survey of head and neck. • Neurological assessment consists of six parts: (mental status, cranial nerves, sensory functions, motor function, cerebellar function, reflexes).

22. Assessment of Neurological system . Cont. • Subjective data: ask about: • Loss of consciousness, dizziness, and fainting. • Headache: precipitating factors and duration. • Numbness and tingling or paralysis or neuralgia. • Loss of memory, confusion, visual loss, blurring, and pain. • Facial pain, weakness, twitching, speech problems e.g. aphasia. • Swallowing problems and drooling. • Neck weakness or spasm

23. Assessment of Neurological system . Cont. • Mental and emotional status observed during nursing history collected, and by simply interacting with client, e.g. “Nursing care plan” • Consciousness level , which ranges from full a wakening, “alertness” to Non/unresponsiveness to any form of external stimuli. * Alert client responds to questions spontaneously. * You can assess Level of consciousness by using Glasgow coma scale.

24. Glasgow coma scale

25. Assessment of Neurological system . Cont. * Assessment of behavior and Appearance • Behavior, mood, hygiene, grooming and choice of dress reveal pertinent information about client’s mental status. • Appearance reflects how a client feels about the self. • Personal hygiene such as unkempt hair, a dirty body, or broken, dirty fingernails should be noted. • Language: Assess ability of individual to understand spoken or written words & how he speaks or writes.

26. Assessment of Neurological system . Cont. • Assess intellectual function, which includes: memory “recent, immediate, past”, knowledge, abstract thinking, association and judgment. • * Assess for sensory function: • - Assess sensitivity to light touch “cotton” • - Assess sensitivity to pain “pinprick” • - Assess sensitivity to vibrations “tuning fork” • - Assess sensitivity to positions. • Don’t forget comparing both sides of body

27. Chapter 12Assessment of the breast * Subjective data: ask about: • Tenderness, pain, swelling, or change in size of breasts. • Change in position of nipple or nipple discharge. • Presence of cysts, lumps, and lesions. • History of prior breast surgery

28. Female breast: • Inspection: with the client sitting, arms relaxed at sides. Inspect Areola and nipples for position, pigmentation, inversion, discharge, crusting & masses. • Assess breasttissue for size, shape, color, symmetry, surface, contour, &skin characteristics • Assess level of breasts, notes any retractions or dimpling of the skin. • Let client to elevate her hands over her head, repeat the observation. • Ask client to press her hands to her hips and repeat observation.

29. Palpation: Best done in recumbent position: * Raise the arm of client on the side of the breast being palpated above clients head. * Palpate the breast from less painful or less diseased area, use palmer aspects of the fingers in a rotating motion, compressing the breast tissue against the chest wall, this is done quadrant by until the entire breast has been palpated. *Note skin texture, moisture, temperature, or masses. *Gently squeeze the nipple and note any expressible discharge. "Normally not present in non lactating women". *Repeat examination on the opposite breast & compare findings. *N.B: If mass palpated, its location, size, shape, consistency, mobility and associated tenderness must reported

30. *Male Breast: • Examination of male breast can be brief and should never be omitted. • Observenipple & PalpateAreola for ulceration, nodules, swelling or discharge "normally not present" • Genitourinary and reproductive Assessment • you must focus you’re your questions on the following: • Any bulges or pain when straining or lifting heavy objects. • Unusual drainage. • Pain with urination or incontinence. • Lower abdominal pain.