ASSESSMENT OF DIGESTIVE SYSTEM OR GASTROINTESTINAL (Inspect, Auscultation, Percussion, Palpation) Position: Supine to reduce tension in abdominal muscles (Option:

Standing; never sitting which

can contract abdominal muscles)

Inspection: Expose only the abdominal area to avoid chilling and shivering w/c can tense or
contract abdominal muscles. Descriptive Terms: Shape or Contour of Abdomen 1. Flat 2. Schapoid (concave) Hollow, boat shaped 3. Globular or Rounded (convex) Presence of fluids or mass Presence of worms 3rd Trimester Pregnancy 4. Protuberant Common with the aged and sedentary (inactive) or overweight persons d/t subcutaneous fat or flaccid (flabby or sagging) abdomen

Related Descriptive Terms: Shape or Contour of Abdomen / Sounds or Contents of Abdomen 1. 2. 3. 4. 5. Ascites excessive fluid in peritoneal cavity Borborygmus audible bowel sound; or hyperactive peristalsis in <5 minutes Paralytic Ileus absence of bowel sound in > 5 minutes Abdominal Guarding involuntary rigidity (stiff & firm) of abdomen Rebound Tenderness deep pressure applied on the abdomen; (+) tenderness and pain when pressure is released.

Inspect Liver: Ask pt to take a deep breath and hold it (makes an enlarged liver or spleen more obvious) 8 Common Classic Surgical Incisions on the Abdomen 1. 2. 3. 4. 5. 6. 7. 8. Kocher right subcostal incision ex. Cholecystectomy Mc Burney short diagonal incision on RUQ ex. Appendicitis Pfannenstiel low caesarian section (bikini cut) Median or Midline Hypogastric vertical cut in CS; Hysterectomy Inguinal (Diagonal) R or L; parallel to inguinal line Paramedian (Vertical) R or L; parallel to midabdominal Median or Midline Epigastric common in Explore Lap Left Flank

When describing Surgical Incisions include the ff: 1. 2. 3. 4. 5. Location (4 quadrants, 9 regions) Direction Color (ex. silvery white if well healed) Length in cm (use tape measure) Condition well healed; unhealed; infected (with pus)

Examples: Well healed , 7 cm, midline abdominal surgical incision scar Infected Pfannenstiel incision Unhealed, well coaptated, 5cm, horizontal surgical incision in the right lumbar AUSCULTATION OF ABDOMINAL SOUNDS 1. Position Patient in Supine 2. Ask when the patient last ate (Shortly after or long due after eating, bowel sounds may normally increase. They are loudest when long overdue. 4 to 7 hours after eating, bowel sounds may be heard continuously over ileocecal valve while digestive contents from SI empty into LI) 3. Warm diaphragm and place on abdomen (cold stethoscope can contract abdominal muscles; diaphragm is most effective in high frequency sounds ) 4. Auscultate Bowel Sounds. Use diaphragm on 4 quadrants on the abdomen Check for gurgling sounds (peristaltic movement of the abdomen) for 5 minutes Best heard 2 3 inches away from the umbilicus right area Normal: 5 34 gurgling sounds / 5 mins. Main Ave: 12 17 gurgling sounds / 5 mins. Abnormal Bowel Sounds that can be heard in any quadrant: a. Hyperactive sounds (Borborygmus; unrelated to hunger) Possible causes: Hypermotility, Diarrhea, Laxative use, Early Intestinal Obstruction b. Hypoactive sounds then absent bowel sounds Possible causes: Hypomotility or true absence of intestinal motility, Paralytic Ileus, Peritonitis, Manipulation of bowel during surgery, Late Intestinal Obstruction c. High pitched tinkling sounds Possible cause: Intestinal fluid or air under tension in a dilated bowel. d. High pitched rushing sound w/ abdominal cramps Possible cause: Intestinal Obstruction

5. Check Vascular Sounds. Use BELL on the ff areas: a. Abdominal Aorta b. Renal Artery c. Inguinal Artery d. Femoral Artery Abnormal Vascular Bowel Sounds A. Systolic Bruits - Vascular BLOWING SOUND that resembles cardiac murmurs 1. Over Abdominal Aorta Possible Causes: Partial Arterial Obstruction OR Turbulent blood flow d/t narrowing of arteries 2. Over Renal Artery Possible Cause: Renal Stenosis 3. Over Inguinal Artery Possible Cause: Hepatomegaly (enlargement of liver) 4. Over Femoral Artery Possible Cause: Arterial insufficiency in Legs B. Venous Hum (rare) Location: Epigastric and Umbilical Regions Continuous, medium pitched tone d/t blood flow in a engorged vascular organ like LIVER Possible Cause: Liver Cirrhosis C. Friction Rub (RARE) Location: Liver and Spleen Harsh, grating sound like 2 sandpapers rubbed together Possible Causes: Inflammation of the peritoneal surface of liver (from tumor)OR spleen (from infarct) 5 Common Types of Abdominal Pain 1. 2. 3. 4. Burning PUD(Peptic Ulcer Disease); GERD (Gastro esophageal reflux disorder; >acid) Gnawing (hunger like pain) Hyperacidity, PUD, BPUD, GERD Stabbing Peritonitis, Cholecystisis Cramping Biliary Colic (gallbladder), Irritable Bowel Syndrome, Constipation, Diarrhea, Flatulence 5. Severe Cramping Crohns Disease, Appendicitis, Diverticulitis

PERCUSSION OF ABDOMEN

PALPATION OF ABDOMEN (FOUR QUADRANTS) Palpate using finger pads in a circular motion starting at the umbilical region (clockwise or counterclockwise) Check for tenderness, masses, abdominal guarding, and pain (see facial expression of patient) 1. Warm hands prior palpation (cold hands can tense or contract abdominal muscles) 2. Perform LIGHT PALPATION (systematically in 4 quadrants) 3. Perform DEEP PALPATION (sensitive areas last; normal tenderness may be present near xiphoid process, over cecum, and sigmoid colon) 4. Apply rebound tenderness to check if theres pain (can indicate peritoneal inflammation) 5. Palpate Liver Use bimanual method from top to bottom then bottom to top If liver is enlarged (palpable below costal margin) hook then measure mass in cm)