1. Abdominal Assessment Created by: Nicole Anderson MN, NP Presented by: Jennifer Burgess RN, GNC(C)

2. Objectives Overview of anatomy Abdominal assessment technique Interpretation of findings Constipation, fecal impaction, and bowel obstruction When to report findings

3. Overview Of Anatomy

4. Abdominal quadrants Landmarks/surface anatomy Abdominal muscles Abdominal vasculature Internal organs

5. Abdominal Quadrants

7. Dividing the abdomen into 4 quadrants will aid during assessment and will allow for appropriate documentation of findings. • Understanding which organs are relevant to each quadrant will help you to determine etiology of signs/symptoms found during assessment.

8. Landmarks and Surface Anatomy

12. Understanding landmarks and surface anatomy will enhance your documentation skills and will allow for more efficient reporting of symptoms.

13. Abdominal Muscles

16. Function to support abdominal cavity and protect organs • Weakness in these muscles may lead to hernias, inability to cough effectively, increased risk of falls, abdominal distension, postural problems, and back pain.

17. Abdominal Vasculature

19. Internal Organs

21. Liver: bile production, controls levels of fats/amino acids/proteins in the blood, immune function, detoxification, metabolizes drugs, blood clotting, store sugars, etc. Gallbladder: aids in fat digestion and concentrates/stores bile produced by the liver. Pancreas: produces digestive enzymes, secretes insulin/glucagon/somatostatin to control blood sugar levels Spleen: stores and produces lymphocytes

22. Small intestine: digestion and absorption of nutrients, approximately 21 feet long. Large intestine: absorption of water, lubrication of contents, neutralization of acids, decomposition by live bacteria, approximately 4.5-5 feet long and 2.5 inches in diameter.

23. Organs Per Quadrant RUQ: liver, gallbladder, duodenum, hepatic flexure of colon, head of pancreas, right kidney/ureter, part of ascending and transverse colon RLQ: cecum, appendix, small intestine, right ureter, right ovary/fallopian tube, right spermatic cord

24. LUQ: stomach, spleen, splenic flexure of colon, tail of pancreas, left kidney/ureter, part of transverse and descending colon LLQ: sigmoid colon, small intestine, part of descending colon, left ovary/fallopian tube, left spermatic cord

25. Abdominal Assessment Technique

26. Preparation Resident should be calm and supine Bring a stethoscope An understanding of health history or reported symptoms is useful Obtain relevant history from resident

27. Technique Inspection Auscultation Percussion Palpation

28. Inspection Observe resident’s abdomen from foot of bed for peristalsis, asymmetry, and abdominal distension Observe umbilicus for deviation Assess skin of abdomen Measure abdominal girth if relevant

29. Auscultation Start in RLQ and listen to each quadrant for 2-5 minutes for bowel sounds Normal sounds are high-pitched and gurgling in small intestine and low-pitched and rumbling in the colon Normally occur at a rate of 5-35/min

30. Percussion Percuss all quadrants for dullness Percuss for tympany Percuss for hyperresonance Percuss for bladder volume

31. Palpation With warm hands lightly palpate all 4 quadrants- palpate any area of pain last Use pads of fingers depressing abdomen 1cm Moderate palpation may be done to assess musculature and deeper structure

32. Interpretation of Findings

33. Inspection Asymmetry: enlarge spleen or liver Distension: fat, flatus, stool, fluid, tumor Bruising at umbilicus: acute necrotizing pancreatitis Flank bruising: intra-abdominal or retroperitoneal hemorrhage, or injury to pancreas

35. Periumbilical and flank ecchymosis

36. Auscultation Very loud bowel sounds: hyperperistalsis caused by diarrhea or early intestinal obstruction. High-pitched tinkles and rushes: bowel obstruction Absence or decreased: paralytic ileus, peritonitis, or acute abdomen

37. Percussion Dullness: normal over liver and spleen, but abnormal in mid abdomen and may be due to organ distension or mass Pain: inflammation Tympany: high-pitched tympany suggests distension Hyperresonance: normal at umbilicus, but anywhere else suggests distended vasculature or aneurysms

38. Palpation Crepitus: subcutaneous emphysema suggests abscess, diverticulitis, or organ perforation. Pain: many causes such as peritonitis, inflammation, abscess Mass/Ridge: depending on the area, could mean tumor, aneurysm, abscess.

39. Constipation, Fecal Impaction, and Bowel Obstruction

40. Constipation Infrequent or difficult passage of stool, hard stool, or a feeling of incomplete evacuation

42. Signs and Symptoms • Difficulty passing stool • Hardened stool • Complaints of rectal fullness • Self disimpaction • hemorrhoids • Symptoms are often un-noticed in the older adult and frequency of stools may not change

43. Red Flags • Distended tympanic abdomen • Vomiting • Blood in stool • Weight loss • Severe constipation of recent onset/worsening in older adults

44. Fecal Impaction A large lump of hard dry stool that remains stuck in the rectum, often due to chronic constipation

46. Signs and Symptoms • Abdominal cramping and bloating • Leakage of liquid from rectum or diarrhea in a resident with chronic constipation • Rectal bleeding • Small, semi-formed stools • Difficulty passing stool and/or straining

47. Red Flags • Nausea and vomiting • Tachypnea • Tachycardia • Abdominal distension with tympanic, absent and/or high-pitched bowel sounds

48. Bowel Obstruction Significant mechanical impairment for complete blockage of contents through the intestine. Mechanical obstruction can effect either the small or large intestine.

49. Signs and Symptoms • Small bowel obstruction: • Cramping around umbilicus or epigastrium • Vomiting • Obstipation • Hyperactive, high-pitched bowel sounds with rushes • Diarrhea in partial obstruction