Abdominal Assessment
Abdominal Assessment
Abdominal complaints are found in frequent patient visits to nurse practitioners.
Remember...
•Be consistent with technique
•Thorough history-taking and physical examination may avoid unnecessary diagnostic tests.
Abdomen: General Overview
•Gastrointestinal System
–Stomach
–Small intestine
–Liver
–Gall bladder
–Pancreas
–Large intestine
–Appendix
•Urinary System
–Kidneys
–Ureters
–Bladder
–Urethra
•Reproductive System
–Prostate
–Uterus
–Ovaries
–Fallopian tubes
–Cervix
•Other
–Aorta/Vasculature
–Hernia
–Spleen
Types of Abdominal Pain
•Obstruction
•Peritoneal irritation
•Vascular disorders
•Mucosal ulceration or irritation
•Altered bowel motility
•Capsular expansion
•Metabolic disturbances
•Nerve injury
•Muscle wall diseases
•Referred pain
•Psychopathology
Abdominal Pain: Differential Diagnosis
•Appendicitis
•Cholecystitis
•Pancreatitis
•Perforated ulcer
•Diverticulitis
•Intestinal obstruction
•Volvulus
•Leaking abdominal aneurysm
•Biliary stones, colic
•Salpingitis
•Ectopic pregnancy
•Pelvic inflammatory disease (PID)
•Ruptured ovarian cyst
Common Symptoms of Abdominal Disease: Pain
•Origin of abdominal pain
–pain due to tension
–pain due to ischemia
–pain due to peritoneal irritation
•Onset
Onset of Pain: Immediate Onset
•Perforated ulcer
•Cholecystitis
•Pancreatitis
•Mesenteric infarction
•Intestinal obstruction
•Ruptured aneurysm
•Ureteral stone
•Diverticulitis
•Perforated colon
•Appendicitis
•Incarcerated hernia
•Ruptured ectopic pregnancy
Onset of Pain: Gradual Onset
•Urinary tract infection
•Appendicitis
•Low mechanical obstruction
•Hernia
Abdominal Disease: Nature of the Pain
•Burning (peptic ulcer)
•Cramping (biliary colic, gastroenteritis)
•Aching (appendiceal irritation)
•Knife-like (pancreatitis)
•Gradual onset (infection)
•Sudden onset (duodenal ulcer, acute pancreatitis, obstruction, perforation)
Common Symptoms of Abdominal Disease: Pain
•Location (referred pain)
•Associated symptoms
–Observation of the patient
–Presence of vomiting
–Signs of impending vascular collapse
–Pelvic and/or rectal exam
Other Common Symptoms of Abdominal Disease
•Nausea/vomiting
•Changes in bowel movements
•Rectal bleeding
•Jaundice
•Abdominal distention
•Mass
•Pruritis (elevated bilirubin?)
•Fever
Other History Components
•Past medical history
–If surgical history, think adhesions
–Check meds/OTC (NSAIDS - epigastric pain)
•Family history
•Psychosocial history
–money
–support systems
–alcohol/caffeine intake
Review of Systems
•Don’t forget….Date of LMP (include with ALL females of childbearing age)
Objective Assessment of the Client: Examination Components
•Complete set of vital signs (including wt.)
•Inspection
•Auscultation
•Percussion
•Palpation
–light (“scouting mission”)
–then deep
•Note: Stay on right side of patient
Inspection
•Landmarks
•Skin
–Scars
–Striae (purple with Cushing’s)
•Size/shape of abdomen (flat)
–If not flat, then one of the “Seven F’s” is the cause
The 7 F’s
•Fat
•Fibroids
•Flatus
•Fluid
•Fetus
•Feces
•Fatal (tumors)
Inspection
•Symmetry
–masses
–scoliosis
•Check for masses, pulsations, musculature, hernias
•Engorged vessels
•Visible peristalsis
Auscultation
•Where?
–4 quadrants and epigastric
•Bowel sounds
–Normal (5-34X/minute)
–Hyperactive
–Borborygmi
–Sluggish
–Absent
•Bruits
–abdominal aorta
–renal arteries
–iliac arteries
–femoral arteries
•Friction rubs
–with liver tumor, enlargement
Percussion
•Why and where?
•Percussion sounds
–Tympanic (gastric air bubble)
–Hyperresonant (base of left lung)
–Resonant (normal lung)
–Dull (liver, spleen)
–Flat (thigh)
Palpation
•Warm hands appreciated!
•Light
•Deep
–tenderness, voluntary guarding, rigidity
–rebound
–liver, spleen, kidneys, aorta, hernia
•How to tell if mass is in wall or below
Special Tests
•Iliopsoas test
–Pain elicited when supine patient attempts to flex thigh against resistance of examiner’s hand
•Obturator test
–Supine patient, flex thigh to 60 degrees
–Pain on rotation indicates inflamed obturator internus muscle due to perforated intrapelvic appendix
Other Examination Considerations
•Rectal exam
–every year after age 40
–occult after age 50
–sigmoidoscopy every 3 years after 50
–with poorly differentiated abdominal pain, may find retrocecal appendix
•Pelvic exam - with pain below the umbilicus (STD, PID)
•Prostate exam
Labs
•Urinalysis
•Urine HCG
•CBC
•Chemistries
•Amylase
Radiographs (x-rays)
•Flat plate
•Upright chest x-ray
How does the NP sort out all of this stuff?
If not normal, then...
•Acute Etiologies
–Surgically emergent
•appendicitis
•ectopic pregnancy
•intestinal obstruction
•acute cholecystitis
–Medically emergent
•acute pancreatitis
–Self-limiting (gastroenteritis)
If not normal, then...
•Chronic etiologies
–Cancer of stomach or pancreas
–Irritable bowel syndrome
–Hepatitis
–What to keep and what to REFER!