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!

• Refer anything not sure of