Gastrointestional Abdomen

1

• Gastrointestional- (Abdomen)
• Abdomen large oval cavity extending from the
  diaphragm down to the brim of the pelvis.
  
• Bordered in back by vertebral column and
  paravertebral muscles
  
• Bordered at sides and front by lower rib cage and
  abdominal muscles
  
• Abdominal wall divided by 4 quadrants by vertical
  and horizontal line bisecting the umbilicus
  
• Quadrants divided in right upper quadrant
• (RUQ)

2

• Left Upper Quadrant (LUQ)
• Right Lower Quadrant ( RLQ)
• Left Lower Quadrant (LLQ)
• RUQ- contains the Liver, Gallbladder, Duodenum,
  Head of Pancreas, Right Kidney and adrenal,
  
• Hepatic flexure of colon, Part of ascending and
  transverse colon
  
• LUQ- Stomach, Spleen, Left lobe of liver, Body
  of
  
• Pancreas, Left kidney and adrenal, Splenic
  flexure of colon, and Part of the transverse and
  descending colon
  
• RLQ- Cecum, Appendix, Right ovary and tube,
  Right ureter, right spermatic cord
  
• LLQ- Part of descending colon, Sigmoid colon, Left

3

• ovary and tube, Left ureter, Left spermatic
• cord
• Midline- Aorta, Uterus ( if enlarged), Bladder
  (if distended
  
• Gastrointestional Health Assessment
• Subjective questions need to ask client
• Appetite ( weight loss/gain)
• Dysphagia
• Food intolerance (allergies, reaction, use of
• antacids)
• Abdominal pain (explain, describe, point)
• Nausea/vomiting (frequency, color)
• Bowel habits ( consistency, changes)
• Past abdominal history

4

• Medications( what taking, alcohol)
• Nutritional assessment( how many meals, what
  eat for breakfast, lunch, dinner, snacks)
  
• Inspection
• Contour-stand on clients right side and look
  down abdomen. Contour describes nutritional
  state
  
• Flat
• Scaphoid
• Rounded
• Protuberant (see pg 571)
• Symmetry- should be symmetric bilaterally note
  any bulging, visible mass, or asymmetric shape
  

5

• Umbilicus- should be midline and inverted, no
  discoloration, inflammation or hernia
  
• Skin- smooth and even
• Striae- pigment change, (pink of blue) then turn
  silvery white, linear, jagged marks about 1-6cm
  long. Occurs with rapid or prolonged stretching
  as pregnancy
• Note- moles, scars
• Turgor- may occur with dehydration
• Pulsation or Movement-may see pulsation in
  epigastric area in thin person with good muscle
  tone
  
• Hair distribution- normally in diamond shape in
  males and inverted triangle in females

6

• Demeanor- if comfortable benign facial expression
  and slow even respirations
  
• Auscultation
• Auscultation done before percussion and palpation
  as it can increase peristalsis, which would be
  false interpretation or distortion of bowel
  sounds.
• Bowel sounds heard with the stethoscope are
  relatively high pitched. You begin in the RLQ as
  sounds are always present there normally
  
• Bowel sounds not character and frequency
• Originate from movement of air fluid through

7

• the small intestines
• Sounds are high pitched, gurgling, cascading
  sounds, occurring irregularly anywhere 5-30
  times/minute
  
• Borborygmus (borborygmi)-hyperactive bowel
  sounds/hyperperistalsis stomach growling
  
• Hyperacitve sounds- loud high pitched, rushing,
  tinkling sounds that signal increased motility
  
• Hypoactive sounds- have to listen carefully,
  usually occur after abdominal surgery, paralytic
  ileus, peritonitis, or bowel obstruction
  
• Vascular sounds-note presence of any vascular
  sounds or bruits
  

8

• Percussion
• Assess relative density of abdominal contents,
  locate organs and screen for abnormal fluid or
  masses
  
• General tympany- percuss lightly all 4 quadrants
  to determine tympany or dullnes.
  
• Tympany because air in intestines rise to surface
  when supine
  
• Dullness- over distended bladder, adipose tissue,
  fluid or mass
  
• Hyperresonance with gaseous distention
• Liver Span-measure boundaries of liver
• Begin at area of lung resonance and percuss down
  until sound changes to dull quality, Mark
  spotusually 5th intercostal

9

• space
• Find abdominal tympany and percuss to dull sound,
  normally right costal margin. Measure distance.
  Normal is 6-12 cm
  
• Hepatomegaly- enlarged liver
• Scratch Test- define liver border when abdomen is
  distended or abdominal muscle are tense.
  
• Splenic Dullness- locate by percussing for dull
  note from 9th to 11th intercostal space behind
  left midaxillary line. Normally dull.
  
• Enlarged spleen (trauma, mononucleosis,
  infection) is dull note forward of midaxillary
  line.
  

10

• Splenomegaly-percussion form tympany to dull
  sounds with full inspiration
  
• Costovertebral Angle tenderness-to assess kidney,
  place hand over 12th rib at costo- vertebral
  angle on back. Thump fist over hand percussion
  indirect, cause tissue to vibrate instead of
  producing sound. No pain
• Sharp pain occurs with inflammation of kidney or
  paranephric area
  
• Ascites- free fluid in the peritoneal cavity.
  Abdomen distended, bulging flanks, and umbilicus
  protruding displaced backwards.
  
• Fluid wave- test for ascites, see picture pg 577
  positivelarge amount of fluid

11

• Shifting Dullness- second test for ascites. In
  supine position, fluid settles in flanks,
  displacing airfilled bowel upward. As percuss
  downward sound changes for tympany to dull,
  ascites present.
• Ultrasound study more definitive
• Palpation
• To judge size, location and consistency of organs
  and detect abnormal mass or tenderness.
  
• Clients knees bent, palpate your hand low and
  parallel to abdomen, client breaths slowly
  
• Light palpation- begin first 4 fingers together,
  depress skin 1 cm, using rotary motion and

12

• sliding fingers and skin together
• Muscle guarding, rigidity, large masses and
  tenderness are abnormal
  
• Voluntary guarding- person cold, tense or
  ticklish
  
• Involuntary guarding- constant board like
  hardness is abnormal
  
• Deep palpation- same technique except 5-8 cm
  pushing down
  
• Tenderness is abnormal occurs with inflammation
  or peritoneum or underlying organs
  
• Mild tenderness when palpating sigmoid colon

13

• If ID mass need to check location, size, shape,
  consistency (soft, hard, firm), surface (smooth,
  nodular), mobility ( include movement with
  respirations), pulsatility, tenderness
• Liver- in RUQ, place left hand on clients back
  parallel to 11th 12 th ribs and lift to support
  abdominal contents, With right hand on RUQ
  fingers parallel to midline push deeply down and
  under right costal margin.
• Liver like firm regular ridge, often not
  palpable
  
• Hooking Technique- alternative method of
  palpating liver, see pg 583
  

14

• Spleen- normally not palpable, must be enlarged
• 3 times its normal size to be felt. Left hand
  over
  
• abdomen and behind left side at 11th and 12th
  ribs.
  
• Right hand oblique on LUQ, finger pointing to L
  axilla
  
• and just inferior to rib margin. Push hand deeply
  
  
• down and under L costal margin. Ask client to
  take
  
• Deep breaths.
• Spleen- feels nothing firm.
• Spleen enlarge with mononucleosis and trauma
• Kidney-R kidney, place hand together as
  duck-bill,
  
• on client R flank. Press 2 hands together
  firmly (deep
  
• Palpation), client takes deep breath. May feel
  lower
  
• Pole of R kidney as round, smooth mass slide.
• L kidney 1cm high than R kidney, not palpable
  normally.
  

15

• Enlarged kidney. Kidney mass
• Aorta- uses thumb an fingers, palpate aortic
  pulsation in upper abdomen slightly to L of
  midline normally. Is 2.5 to 4 cm wide and
  pulsates in an anterior direction.
• Abnormal- prominent lateral pulsation with aortic
  aneurysm
  
• Special procedures
• Rebound Tenderness- ( Blumbergs sign) hold hand
  at 90o, perpendicular to abdomen, push down
  
• slowly and deeply, lift hand quicklynormal or
  negative response no pain on release.
  
• If pain peritoneal inflammation.

16

• Inspiratory Arrest ( Murphys Sign) palpate the
  liver causes no pain If pain occurs, inflamed
  gallbladder.
  
• Iliopsoas Muscle Test- acute appendicitis is
  suspected
  
• Client is supine position, lift R leg straight
  up, flex from hip, push down over lower part of R
  thigh as client tries to hold leg up. Negative,
  feel no pain.
• Pain is felt on RLQ with inflamed or perforated
  appendix (AP)
  
• Obturator test- appendicitis is suspected. Supine
  position, left R leg, flex at hip and 90O at
  knee. Hold ankle rotate leg internally
  externally. No pain

17

• negative.
• Perforated appendix if producing pain.
• Abnormal Findings
• LiveHepatitis
• Esophagus Gastroesophageal reflux disease
  (GERD)
  
• GallbladderCholecystitis.
• Pancreas Pancreatitis
• Duodenum Duodenal ulcer
• Stomach Gastric Ulcer pain
• AppendixAppendicitis
• KidneyKidney stones
• Small Intestines- Gastroenteritis
• ColonIrritable bowel syndrome (IBS)

18

• Vocabulary
• Hypoactive Bowel Sounds- diminished or absent
  bowel sounds, decreased motility
  
• Hyperactive Bowel Sounds- loud, gurgling sounds,
  increased motility
  
• Ascites-free fluid in peritoneal cavity
• Hernia- protrusion of an organ through an
  abnormal opening in the muscle wall of a cavity
  that surrounds it.
  
• INFANT
• Inspect-contour of abdomen is protuberant because
  of immature abdominal musculature. Skin fine,
  superficial venous pattern.
  
• Umbilical cord- white and contain 2 umbilical

19

• arteries 1 vein surrounded by mucoid
• connective tissue. Stump dries, hardens,
  and falls off by 10 to 14 days.
  
• Umbilical hernia- appears 2 to 3 weeks,
  especially prominent when infant cries.
  Reaches maximum size at 1 month, usually
  disappears by 1 year.
• Auscultation-only bowel sounds, metallic
  tinkling no vascular sounds should heard
  
• Percussion-tympany over stomach( infant
  swallowing air with feeding), dullness over
  liver. Do not percuss spleen. Abdomen sounds
  tympanitic, over bladder dullness. Dullness
  extend up to umbilicus.

20

• Palpation-liver fills the RUQ. Feel Liver edge at
  right costal margin. May palpate tip of spleen
  
• tip both kidneys bladder. Palpate cecum in
  RLQ and sigmoid colon.
  
• Newborns first stoolsticky, greenish-black
  meconium stool within 24 hrs. 4th day breast fed
  babies golden-yellow pasty, smells like sour
  milk formula-fed stool is brown-yellow, firmer
  more fecal smelling stool
• Vocabulary
• Umbilical Hernia- soft, skin-covered mass, which
  is protrusion of the omentum or intestine through
  a weakness or incomplete closure in the umbilical
  ring.

21

• Incisional Hernia- bulge near an old operative
  scar
  
• Pyloric stenosis- projectile vomiting
• Pregnant female
• May have nausea vomiting (n/v)
• Morning sickness, starts between 1st 2ed missed
  period cause unknown
  
• Heartburn (pyrosis) caused by esophageal reflux

22

• Constipation decreased motility cause more water
  to be reabsorbed from colon.
  
• Hemorrhoids- caused by constipation and increased
  venous pressure in the lower pelvis
  
• Bowel sounds are diminished
• Appendix displaced upward to right
• Skin changes as Striae and linea nigra
• Older Adult
• Altered appearance of abdominal wall
• Males show fat deposits in abdominal area
  resulting in spare tire or bay window
  
• Adipose tissue redistributed away from face
  extremities to abdomen and hips
  

23

• Salivation decreased causing dry mouth and
  decreased sense of taste
  
• Esophageal emptying delayed, increased risk of
  aspiration
  
• Gastric acid secretion decreases, may cause
  pernicious anemia, iron deficiency and
  malabsorption of calcium
  
• Increased gallstones
• Liver size decreases
• Frequent constipation (causes by decreased
  physical activity, inadequate water intake,
  low-fiber diet, side effect of medications,
  irritable bowel syndrome, bowel obstruction,
  inadequate toilet facilities, possible lactose
  intolerance