PHYSICAL ASSESSMENT: ABDOMEN

Presented by: Anne Marjorie I. Futalan, RN

ANATOMY The Four Quadrants

Right Upper Quadrant Organs: Liver Right Kidney Duodenum Head of pancreas Left Upper Quadrant Organs: Stomach Spleen Left Kidney Body of pancreas Right Lower Quadrant Organs: Appendix Cecum Rt Ovary or Spermatic cord Rt Ureter Left Lower Quadrant Organs: Sigmoid colon Lt. Ovary or Spermatic cord Lt Ureter

ANATOMY

The Nine Regions

EQUIPMENT
Small pillow or rolled blanket Centimeter Ruler Stethoscope (warm the diaphragm and bell) Marking pen

ABDOMEN
Assessment Procedure INSPECTION Observe the coloration of the skin. Normal Findings Abdominal skin may be paler than the general skin tone because this skin is so seldom exposed to the natural elements. Abnormal Findings
Purple discoloration at the flanks (Grey Turner sign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis. The yellow hue of jaundice may be more apparent on the abdomen. Pale, taut skin may be seen with ascites (significant abdominal swelling indicating fluid accumulation in the abdominal cavity. Redness may indicate inflammation. Bruises or areas of local discoloration are also abnormal.

Assessment Procedure INSPECTION Note the vascularity of the abdominal skin.

Normal Findings Scattered fine veins may be visible. Blood in the veins located above the umbilicus flows toward the head; blood in the veins located below the umbilicus flows towards the lower body. O: Dilated superficial capillaries without a pattern may be seen in older clients. They are more visible in sunlight.

Abnormal Findings Dilated veins may be seen with cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascites. Dilated surface arterioles and capillaries with a central star (spider angioma) may be seen with liver disease or portal hypertension.

Assessment Procedure INSPECTION Note any striae.

Normal Findings

Abnormal Findings

Old, silvery, white striae or stretch marks from past pregnancies or weight gain are normal.

Dark bluish-pink striae are associated with Cushings syndrome.

Striae may also be caused by ascites, which stretches the skin. Ascites usually results from failure or liver disease.

Inspect for scars. Ask about the source of a scar, and use a centimeter ruler to measure the scars length. Document the location by quadrant and reference lines, shape, length, and specific characteristics. With experience, many examiners can estimate the length of a scar visually without a ruler.

Pale, smooth, Nonhealing scars, redness, minimally raised old inflammation. Deep irregular scars may be seen. scars may result from burns. Scarring should be Keloids (excess scar tissue) an alert for possible result from trauma or durgery internal adhesions. and are more common in African Americans and Asians.

Assessment Procedure INSPECTION Assess for lesions and rashes

Normal Findings

Abnormal Findings

Abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent.

Changes in moles including size, color, and border symmetry. Any bleeding moles or petechiae (reddish or purple lesions) may also be abnormal. Bluish or purple discoloration around the umbilicus (Cullens sign) indicates intra-abdominal bleeding. A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue. An everted umbilicus is seen with abdominal distention. An enlarged, everted umbilicus suggests umbilical hernia.

Inspect the umbilicus. Umbilical skin tones are Note the color of the similar to surrounding umbilical area. abdominal skin tones or even pinkish. Observe umbilical location Umbilicus is midline at lateral line.

Assess contour of umbilicus.

It is recessed (inverted) or protruding no more than 0.5 cm and is round or conical.

Assessment Procedure INSPECTION Inspect abdominal contour. Look across the abdomen at eye level from the clients side, from behind the clients head, and from the foot of the bed. Measure abdominal girth as indicated

Normal Findings

Abnormal Findings

Abdomen is flat, rounded, or scaphoid (usually seen in thin adults). Abdomen should be evenly rounded.

A generalized protuberant or distended abdomen may be due to obesity, air (gas), or fluid accumulation. Distention below the umbilicus may be due to a full bladder, uterine enlargement, or an ovarian tumor or cyst. Distention of the upper abdomen may be seen with masses of the pancreas or gastric dilation. The major causes of abdominal distention are sometimes referred to as the 6 Fs: Fat, feces, fetus, fibroids, flatulence, and fluid. A scaphoid (sunken) abdomen may be seen with severe weight loss or cachexia related to starvation or terminal illness)

Assessment Procedure INSPECTION Assess abdominal symmetry. Look at the clients abdomen as she lies in a relaxed supine position. To further assess the abdomen for herniation or diastasis recti or to differentiate a mass within the abdominal wall from one below it, ask the client to raise the head.

Normal Findings Abdomen is symmetric.

Abnormal Findings

Asymmetry may be seen with organ enlargement, large masses, hernia, diastasis recti, or bowel obstruction.

Abdomen does not bulge when client raises head.

A hernia (protrusion of the bowel through the abdominal wall) is seen as a bulging in the abdominal wall. Diastasis recti appears as a bulging between a vertical midline separation of the abdominis rectus muscles. This condition is of little significance. An incisional hernia may occur when a defect develops in the abdominal muscles because of a surgical incision. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured.

Assessment Procedure INSPECTION Inspect abdominal movement when the client breathes (respiratory movements). Observe aortic pulsations.

Normal Findings Abdominal respiratory movement may be seen, especially in male clients.

Abnormal Findings Diminished abdominal respiration or change to the thoracic breathing in male clients may reflect peritoneal irritation.

A slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people. Normally, peristaltic waves are not seen although they may be visible in very thin people as slight ripples on the abdominal wall.

Vigorous, wide, exaggerated pulsations may be seen with abdominal aortic aneurysm.

Observe for peristaltic waves.

Peristaltic waves are increased and progress in a ripple-like fashion from the LUQ to the RLQ with intestinal obstruction (especially small intestine). In addition, abdominal distention typically is present with intestinal wall obstruction.

Assessment Procedure AUSCULTATION Auscultate for bowel sounds. Use the diaphragm of the stethoscope and make sure that it is warm before you place it on the clients abdomen. Apply light pressure or simply rest the stethoscope on a tender abdomen. Begin in the RLQ and proceed clockwise, covering all quadrants.

Normal Findings

Abnormal Findings

A series of intermittent, soft clicks and gurgles are heard at a rate of 5 to 30 per minute. Hyperactive bowel sounds that may be heard normally are the loud, prolonged gurgles characteristic of stomach growling. These hyperactive bowel sounds are called borborygmi.
Postoperatively, bowel sounds resume gradually depending on the type of surgery. The small intestine functions normally in the first few hours postoperatively;

Hypoactive bowel sounds indicate diminished bowel motility. Common causes include abdominal surgery or late bowel obstruction.
Hyperactive bowel sounds indicate increased bowel motility. Common causes include diarrhea, gastroenteritis, or early bowel obstruction. Decreased or absent bowel sounds signify the absence of bowel motility, which constitutes an emergency requiring immediate referral.

Bowel sounds may be more active over the ileocecal valve in the RLQ.

Assessment Procedure Confirm bowel sounds in each quadrant. Listen for up to 5 minutes (minimum of 1 minute per quadrant) to confirm the absence of bowel sounds.

Normal Findings stomach emptying takes 24 to 48 hours to recover; and the colon requires 3 to 5 days to recover propulsive activity.

Abnormal Findings Absent bowel sounds may be associated with peritonitis or paralytic ileus. High-pitched tinkling and rushes of highpitched sounds with abdominal cramping usually indicate intestinal obstruction.

Bowel sounds normally occur every 5 to 15 seconds. An easy way to remember is to equate one bowel sound to one breath sound.
Note the intensity, pitch, and frequency of the sounds.

The increasing pitch of bowel sounds is most diagnostic of obstruction because it signifies intestinal distention.

Assessment Procedure
AUSCULTATION Auscultate for vascular sounds. Use the bell of the stethoscope to listen for bruits (low-pitched, murmurlike sound) over the abdominal aorta and renal, iliac, and femoral arteries. Auscultating for vascular sounds is especially important if the client has hypertension or if you suspect arterial insufficiency to the legs.

Normal Findings
Bruits are not normally heard over abdominal aorta or renal, iliac, or femoral arteries. However, bruits confined to systole may be normal in some clients depending on other differentiating factors.

Abnormal Findings
A bruit with both systolic and diastolic components occurs when blood flow in an artery is turbulent or obstructed. This usually indicates aneurysm or arterial stenosis. If the client has hypertension and you auscultate a renal artery bruit with both systolic and diastolic components, suspect renal artery stenosis as the cause.

Assessment Procedure Using the bell of the stethoscope, listen for a venous hum in the epigastric and umbilical areas.

Normal Findings Venous hum is not normally heard over the epigastric and umbilical areas.

Abnormal Findings Venous hums are rare. However, an accentuated venous hum heard in the epigastric or umbilical areas suggests increased collateral circulation between the portal and systemic venous systems, as in cirrhosis of the liver.

Assessment Procedure AUSCULTATION Auscultate for friction rub over the liver and spleen. Listen over the right and left lower rib cage with the diaphragm of the stethoscope.

Normal Findings No friction rub over liver or spleen is present.

Abnormal Findings Friction rubs are rare. If heard, they have a high-pitched, rough, grating sound produced when the large surface area of the liver or spleen rubs the peritoneum. They are heard in association with respiration. A friction rub heard over the lower right costal area is associated with hepatic abscess or metastatses. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor.

Assessment Procedure PERCUSSION Percuss for tone. Lightly and systematically percuss all quadrants (clockwise or up and down).

Normal Findings Generalized tympany predominates over the abdomen because of air in the stomach and intestines. Normal dullness is heard over the liver and spleen. Dullness may also be elicited over a nonevacuated descending colon.

Abnormal Findings Accentuated tympany or hyperresonance is heard over a gaseous distended abdomen. An enlarged area of dullness is heard over an enlarged liver or spleen. Abnormal dullness is heard over a distended bladder, large masses, or ascites. If you suspect ascites, perform the shifting dullness and fluid wave tests.

Assessment Procedure PERCUSSION Percuss the span or height of the liver by determining its lower and upper borders.

Normal Findings

Abnormal Findings

The lower border of liver dullness is located at the costal margin to 1 to 2 cm below.

If you cannot find the lower border of the liver, keep in mind that the lower border of liver dullness may be difficult to estimate when obscured by intestinal gas.

To assess the lower border, begin in the RLQ at the mid-clavicular line (MCL) and percuss upward. Note the change from tympany to dullness. Mark this point: it is the lower border of liver dullness.

Assessment Procedure

Normal Findings

Abnormal Findings

To assess the descent of the liver, ask the client to take a deep breath then repeat the procedure. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness. Mark this point; it is the upper border of liver dullness.
Measure the distance between the two marks; this is the span of the liver.

On deep inspiration, the lower border of liver dullness may descend from 1 to 4 cm below the costal margin. The upper border of liver dullness is located between the left fifth and seventh intercostal spaces.

The upper border of liver dullness may be difficult to estimate if obscured by pleural fluid or lung consolidation.

The normal liver span at the MCL is 6 to 12 cm (greater in men and taller clients, less in shorter clients). Normally liver size decreases after age 50.

Hepatomegaly, a liver span that exceeds normal limits (enlarged), is characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement. Atrophy of the liver is indicated by a decreased span.

Assessment Procedure

Normal Findings

Abnormal Findings

A liver in a lower position than normal may be caused by emphysema, whereas a liver in an higher position than normal may be caused by an abdominal mass, ascites, or a paralyzed diaphragm. A liver in lower or higher position should have a normal span.
Repeat percussion of the The normal liver span at liver at the midsternal the MSL is 4 to 8 cm. line (MSL). If you cannot accurately percuss the liver borders, perform the scratch test. Auscultate over the liver and, starting in the RLQ, scratch lightly over the abdomen, progressing upward toward the liver. An enlarged liver may be roughly estimated (not accurately) when more intense sounds outline a liver span or The sound produced by borders outside the normal scratching becomes more range. intense over the liver.

Assessment Procedure PERCUSSION Percuss the spleen. Begin posterior to the left mid-axillary line (MAL) and percuss downward, noting the change from lung resonance to splenic dullness. Results of splenic percussion may be obscured by the air in the stomach or bowel. A second method for detecting splenic enlargement is to percuss the last left interspace at the anterior axillary line (AAL) while the client takes a deep breath. Other sources of dullness (e.g., full stomach or feces in the colon) must be ruled out before confirming splenomegaly.

Normal Findings The spleen is an oval area of dullness approximately 7 cm wide near the left tenth rib and slightly posterior to the MAL.

Abnormal Findings Splenomegaly is characterized by an area of dullness greater than 7 cm wide. The enlargement may result from traumatic injury, portal hypertension, and mononucleosis.

Normally tympany (or resonance) is heard at the last left insterspace.

On inspiration, dullness at the last left interspace at the AAL suggests an enlarged spleen.

Assessment Procedure

Normal Findings

Abnormal Findings Tenderness elicited over the liver may be associated with inflammation or infection (e.g., hepatitis or cholecystitis).

PERCUSSION Perform blunt percussion on the Normally no liver. This is to assess for tenderness is tenderness in difficult-to-palpate elicited. structures. Percuss the liver by placing your left hand flat against the lower rib cage. Use the ulnar side of your right fist to strike your left hand. Perform blunt percussion on the kidneys at the costovertebral angles (CVA) over the twelfth rib. This technique requires that the client sit with his or her back to you. Therefore, it may be best to incorporate blunt percussion of the kidneys with your thoracic assessment because the client will already be in this position. Normally no tenderness or pain is elicited or reported by the client. The examiner senses only a dull thud.

Tenderness or sharp pain elicited over the CVA suggests kidney infection (pyelonephritis), renal calculi, or hydronephrosis.

Assessment Procedure PALPATION Perform light palpation. Light palpation is used to identify areas of tenderness and muscular resistance. Using the fingertips, begin palpation in a nontender quadrant, and compress to a depth of 1 cm in a dipping motion. Then gently lift the fingers and move to the next area. Keep in mind that the rectus abdominis muscle relaxes on expiration.

Normal Findings

Abnormal Findings

Abdomen is nontender and soft. There is no guarding.

Involuntary reflex guarding is serious and reflects peritoneal irritation. The abdomen is rigid and the rectus muscle fails to relax with palpation when the client exhales. It can involve all or part of the abdomen but is usually seen on the side (i.e., right vs. left rather than upper or lower) because of nerve tract patterns. Right-sided guarding may be due to cholecystitis.

Assessment Procedure
PALPATION Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses. Using the palmar surface of the fingers, compress to a maximum depth (5 to 6cm). Perform bimanual palpation if you encounter resistance or to assess deeper structures.

Normal Findings
Normal (mild) tenderness is possible over the xiphoid, aorta, cecum, sigmoid colon, and ovaries with deep palpation.

Abnormal Findings

Severe tenderness or pain may be related to trauma, peritonitis, infection, tumors, or enlarged or diseased organs.

Palpate for masses. Note their location, size (cm), shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a mass with a normally palpated organ or structure. Palpate the umbilicus and surrounding area for swelling, bulges, or masses.

No palpable masses are present.

A mass detected in any quadrant may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.

Umbilicus and surrounding area are free of swellings, bulges, or masses.

A soft center of the umbilicus can be a potential for herniation. Palpation of a hard nodule in or around the umbilicus may indicate metastatic nodes from an occult gastrointestinal cancer.

Assessment Procedure PALPATION Palpate the aorta. Use your thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline. Assess the pulsation of the abdominal area.

Normal Findings The normal aorta is approximately 2.5 to 3.0 cm wide with a moderately strong and regular pulse. Possibly mild tenderness may be elicited.

Abnormal Findings A wide, bounding pulse may be felt with an abdominal aortic aneurysm. A prominent, laterally pulsating mass above the umbilicus with an accompanying audible bruit strongly suggests an aortic aneurysm.

If the client is older than age 50 or has hypertension, assess the width of the aorta.
Do not palpate a pulsating midline mass; it may be a dissecting aneurysm that can rupture from the pressure of palpation. Also avoid deep palpation over tender organs as in the case of polycystic kidneys, Wilms tumor, transplantation, or suspected splenic trauma.

Assessment Procedure PALPATION Palpate the liver. Note consistency and tenderness. To palpate bimanually, stand at the clients right side and place your left hand under the clients back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin (your fingertips should pint toward the clients head). Ask the client to inhale then compress upward and inward with your fingers.

Normal Findings The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal.

Abnormal Findings A hard, firm liver may indicate cancer. Nodularity may occur with tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may be from vascular engorgement (e.g., congestive heart failure), acute hepatitis or abscess. A liver more than 1 to 3 cm below the costal margin is considered enlarged (unless pressed down by the diaphragm). Enlargement may be due to hepatitis, liver tumors, cirrhosis, and vascular engorgement.

To palpate by hooking, stand to the right side of the clients chest. Curl (hook) the fingers of both hands over the edge of the right costal margin. Ask the client to take a deep breath and gently but firmly pull inward and upward with your fingers.

Assessment Procedure
PALPATION Palpate the spleen. Stand at the clients right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the clients head. Ask the client to inhale and press inward and upward as you provide support with your other hand. Alternatively asking the client to turn onto the right side may facilitate splenic palpation by moving the spleen downward and forward. Document the size of the spleen in centimeters below the left costal margin. Also note consistency and tenderness.

Normal Findings The spleen is seldom palpable at the left costal margin; rarely, the tip is palpable in the presence of a low, flat diaphragm (e.g., chronic obstructive lung disease) or with deep diaphragmatic descent on inspiration. If the edge of the spleen can be palpated, it should be soft and nontender.

Abnormal Findings A palpable spleen suggests enlargement (up to three times the normal size), which may result from trauma, mononucleosis, chronic blood disorders, and cancers. The splenic notch may be felt, which is an indication of splenic enlargement.
Caution: To avoid traumatizing and possibly rupturing the organ, be gentle when palpating an enlarged spleen.

Assessment Procedure

Normal Findings

Abnormal Findings The spleen feels soft with a rounded edge when it is enlarged from infection. It feels firm with a sharp edge when it is enlarged from a chronic disease. Tenderness accompanied by peritoneal inflammation or capsular stretching is associated with splenic enlargement.

Assessment Procedure PALPATION Palpate the kidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL.
To capture the kidney, ask the client to inhale. Then compress your fingers deeply during peak inspiration. Ask the client to exhale and hold the breath briefly. Gradually release the pressure of your right hand. If you have captured the kidney, you will feel it slip beneath your fingers. To palpate the left kidney, reverse the procedure.

Normal Findings
The kidneys are normally not palpable. Sometimes the lower pole of the right kidney may be palpable by the capture method because of its lower position. If palpated, it should feel firm, smooth, and rounded. The kidney may or may not be slightly tender.

Abnormal Findings
An enlarged kidney may be due to a cyst, tumor, or hydronephrosis. It can be differentiated from splenomegaly by its smooth rather than sharp edge, absence of a notch, and overlying tympany on percussion.

Assessment Procedure

Normal Findings

Abnormal Findings A distended bladder is palpated as a smooth, round, and somewhat firm mass extending as far as the umbilicus. It may be further validated by dull percussion tones.

PALPATION Palpate the urinary Normally, the bladder bladder. Palpate for a is not palpable. distended bladder when the clients history or other findings warrant (e.g., dull percussion noted over the symphysis pubis). Begin at the symphysis pubis and move upward and outward to estimate bladder borders.

SPECIAL ABDOMINAL TESTS

Assessment Procedure Test for ASCITES Test for shifting dullness. If you suspect that the client has ascites because of a distended abdomen or bulging flanks, perform this special percussion technique. The client should remain supine. Percuss the flanks from the bed toward the umbilicus. Note the change from dullness to tympany and mark this point. Now help the client turn onto his or her side. Percuss the abdomen from the bed upward, Mark the level where dullness changes to tympany. Normal Findings The borders between tympany and dullness remain relatively constant throughout position changes. Abnormal Findings When ascites is present and the client is supine, the fluid assumes a dependent position and produces a dull percussion tone around the flanks. Air rises to the top and tympany is percussed around the umbilicus. When the client turns to one side and ascites is present, the fluid assumes a dependent position and air rises to the top. There is a marked increase in the height of the dullness. This test is not always reliable and definitive testing by ultrasound is necessary.

SHIFTING DULLNESS

Assessment Procedure

Normal Findings

Abnormal Findings Movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites). Because test is not completely reliable, definitive testing by ultrasound is needed.

Test for ASCITES Perform the fluid wave test. No fluid wave is The client should remain transmitted. supine. You will need assistance with this test. Ask the client or an assistant to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Firmly place the palmar surface of your fingers and hand against one side of the clients abdomen. Use your other hand to tap the opposite side of the abdominal wall.

Assessment Procedure Test for ASCITES Use ballottement technique. Ballottement is a palpation technique performed to identify a mass or enlarged organ within an ascitic abdomen. It can be performed two different ways:

Normal Findings No palpable mass or masses are present.

Abnormal Findings In the client with ascites, you can feel a freely movable mass moving upward (floats). It can be felt at the fingertips. A floating mass can be palpated for size.

Single-Hand Method: Using a tapping or bouncing motion of the fingerpads over the abdominal wall, feel for a floating mass. Bimanual Method: Place one hand under the flank (receiving/feeling hand) and push the anterior abdominal wall with the other hand.

Assessment Procedure

Normal Findings

Abnormal Findings The client has rebound tenderness when he or she perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumbergs sign). It suggests peritoneal irritation (as from appendicitis). If the client feels pain at an area other than where you were assessing for rebound tenderness, consider that area as the source of the pain.

Test for APPENDICITIS Assess for rebound No rebound tenderness and Rovsings tenderness is sign. Abdominal pain and present. tenderness may indicate peritoneal irritation. To assess this possibility, test for rebound tenderness. Palpate deeply in the abdomen where the client has pain then suddenly release pressure. Listen and watch for the clients expression of pain. Ask the client to describe which hurt more the pressing in or the releasing and where on the abdomen the pain occurred.

Assessment Procedure

Normal Findings

Abnormal Findings

Test for APPENDICITIS

Test for rebound tenderness should always be performed at the end of the examination because a positive response produces pain and muscle spasm that can interfere with the remaining examination.

Palpate deeply in the LLQ.

No pain is elicited. Pain in the RLQ during pressure in the LLQ is a positive Rovsings sign. It suggests acute appendicitis. No rebound pain is elicited. Pain in the RLQ during pressure in the LLQ (referred rebound tenderness) suggests appendicitis.
Avoid continued palpation when test findings are positive for appendicitis because of the danger of rupturing the appendix.

Test for referred rebound tenderness. Palpate deeply in the LLQ and, quickly release pressure.

Assessment Procedure

Normal Findings No abdominal pain is present.

Abnormal Findings Pain in the RLQ (Psoas sign) is associated with irritation of the iliopsoas muscle due to an appendicitis (an inflamed appendix).

Test for APPENDICITIS Assess for Psoas sign. Raise the clients right leg from the hip and place your hand on the lower thigh. Ask the client to try to keep the leg elevated as you apply pressure downward against the lower thigh.

Assess for Obturator sign. No abdominal Support the clients right knee pain is present. and ankle. Flex the hip and knee and rotate the leg internally and externally.

Pain in the RLQ indicates irritation of the obturator muscle due to an appendicitis or a perforated appendix.

Assessment Procedure

Normal Findings The client feels no pain and no exaggerated sensation.

Abnormal Findings Pain or an exaggerated sensation felt in the RLQ is a positive skin hypersensitivity test and may indicate appendicitis.

Test for APPENDICITIS Perform hypersensitivity test. Stroke the abdomen with a sharp object (e.g., broken cotton tipped applicator or tongue blade) or grasp a fold of skin with your thumb and index finger and quickly let go. Do this several times along the abdominal wall.

Assessment Procedure

Normal Findings

Abnormal Findings

Test for CHOLECYSTITIS

Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder. Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply. No increase in pain is present. Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphys sign and is associated with acute cholecystitis.

SAMPLE OBJECTIVE DATA

Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is flat and recessed with no bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when client raises head. Slight respiratory movements and aortic pulsations noted. No peristaltic waves seen. Soft clicks and gurgles heard at a rate of 15 per minute. No bruits, venous, or friction rubs auscultated.

Percussion reveals generalized tympany over all four quadrants with dullness over the liver, spleen, and descending colon. Percussion of liver span reveals MCL=8 cm and MSL=6 cm. Percussion over spleen discloses a dull oval area approximately 7 cm wide near left tenth rib posterior to MAL. No tenderness elicited with blunt percussion over liver and kidneys. No tenderness or guarding in any quadrant with light palpation. Mild tenderness elicited over xiphoid, aorta, cecum, and sigmoid colon with deep palpation.

No masses palpated. Umbilicus and surrounding area free of masses, swelling, and bulges. Aortic pulsation moderately string, regular, and approximately 3.0 cm wide. Liver, spleen, kidneys, and urinary bladder not palpable. Test for shifting dullness reveals constant borders between tympany and dullness throughout position changes. No fluid wave transmitted during fluid wave test. No mass palpated during ballottement test. All test findings for appendicitis are negative as is test finding for cholecystitis.

REFERENCE
Weber, Janet & Jane Kelley. (2007). Health Assessment in Nursing, 3rd Ed. Philadelphia, PA: Lippincott Williams & Wilkins.