Abdomen: Anatomy and Physiology

After you have successfully completed this chapter, you should be able to:

Identify pertinent abdominal history questions

Obtain a pertinent abdominal history
Perform an abdominal physical assessment
Document abdominal assessment findings
Identify actual/potential health problems stated as nursing
diagnoses
Differentiate between normal and abnormal findings

The abdominal assessment provides information about a variety of systems

because every system, with the exception of the respiratory system, is found within
the abdomen. The stomach, small and large intestines, liver, gallbladder, pancreas,
spleen, kidneys, ureters, bladder, aortic vasculature, spine, uterus and ovaries, or
spermatic cord are all located in the abdomen. Not only does assessment of the
abdomen enable you to obtain valuable information about the functioning of the
gastrointestinal (GI), cardiovascular, reproductive, neuromuscular, and
genitourinary systems; it can also provide vital information about the health status
of every other system.
Anatomy and Physiology Review
Before you begin your assessment, an understanding of the anatomy and
physiology of abdominal structures is essential. You must be able to recognize
normal structures before you can identify abnormal findings. Recognizing the
structures will enable you to perform the assessment accurately, and understanding
the physiology will guide your assessment and allow you to interpret your findings.
Structures and Functions
The major system assessed in the abdominal examination is the GI or digestive
system. The digestive system is responsible for the ingestion and digestion of
food,absorption of nutrients, and elimination of waste products. The primary
structures of the digestive system (Fig. 17.1) include the mouth, pharynx,

esophagus, stomach, small intestines (duodenum, jejunum, and ileum), large

intestines (cecum, colon [ascending, transverse, descending, and sigmoid]), and
rectum.These main structures of the digestive system form a hollow tube that is
actually outside the internal environment of the body even though it is located
inside the body.This tube, referred to as the alimentary canal or
thegastrointestinal tract, begins at the mouth and ends at the anus. The digestive
system also contains accessory organs that aid in the digestion of food. The
accessory organs of the digestive system include the salivary glands (parotid,
submandibular, and sublingual), liver, gallbladder, and pancreas.

The Digestive Process

The digestive process consists of mechanical digestion, the breakdown of food
through chewing, peristalsis, and churning; and chemical digestion, the
breakdown of food through a series of metabolic reactions with enzymes. The
digestive process begins in the mouth, where food is taken in and masticated. The
bolus of food is then swallowed into the esophagus, where it is propelled slowly
via peristaltic contraction to the stomach. In the stomach, the food bolus is

churned, breaking it down further into smaller particles and mixing it with
digestive juices and hydrochloric acid that is produced by the stomach.The food
bolus becomes chyme and progresses down into the first portion of the small
intestine, called the duodenum. In the duodenum, pancreatic juices and bile are
secreted in the chyme. The food then enters the jejunum and ileum, where
nutrients are absorbed into the circulatory system. Food particles that are not
absorbed by the small intestines proceed into the large intestine, where they are
eventually excreted as feces.
Additional Abdominal Structures
Along with the organs of the digestive system, the abdomen also contains the
spleen; the urinary tract including the bladder, kidneys, and ureters; the uterus and
ovaries; the aorta; and the iliac, renal, and femoral arteries. The uterus and ovaries
are covered in Chapter 18,Assessing the Female Genitourinary System.The other
abdominal organs are shown in Figure 17.2. The abdominal cavity has a serous
membrane called the peritoneum, which covers the organs and holds them in
place.The peritoneum contains a parietal layer that lines the walls of the abdomen
and the visceral pleura, which coats the outer surface of the organs. A small amount
of fluid between these membranes allows them to move smoothly within the
cavity.

Interaction With Other Body Systems

The GI system requires the proper functioning of the nervous, endocrine,
respiratory, cardiovascular, integumentary, and musculoskeletal systems in order to
operate at its full capacity.
The Integumentary and Musculoskeletal Systems
The digestive system is protected and supported by the musculoskeletal and
integumentary systems.The musculoskeletal system also assists with ingestion,
mastication, deglutition (swallowing) of food,and eventual defecation of its
byproducts.
The Respiratory and Cardiovascular Systems
The respiratory and cardiovascular systems provide the oxygen needed for the
digestive organs to function.The respiratory system gets oxygen for the cells of the
body and rids the body of carbon dioxide. All the cells in the body, including those
of the digestive system, need oxygen to function appropriately.The cardiovascular
system circulates the oxygen-rich blood to all the cells in the body.Any decrease in

oxygen to the cells of the digestive system affects organ function. For example, if
blood flow to the bowel is disrupted,a bowel infarct can occur, causing the bowel
to stop functioning.
The Neurological System
The neurological system plays an important role in digestion. When the body is in
a parasympathetic response, or the rest and repair phase, the neurological system
releases acetylcholine, the neurotransmitter for the parasympathetic system. In
relation to the digestive system, acetylcholine stimulates the secretion of digestive
juices and increases peristalsis. The opposite is true for the sympathetic response.
The sympathetic system is stimulated at times of physical or psychological
stress.When this system is stimulated, a fight or flight response occurs, causing
the release of norepinephrine,which produces a decrease in peristalsis and secretion
of digestive juices.Therefore, the digestive system functions to its maximum
capacity when it receives parasympathetic responses from the peripheral nervous
system.
The Endocrine System
The secretion of digestive juices also depends on the proper functioning of the
pancreas, an organ that has both endocrine and exocrine functions. The endocrine
function is to release insulin, glucagon, and gastrin into the bloodstream to assist in
carbohydrate metabolism. The exocrine function is to secrete bicarbonate and
pancreatic enzymes into the duodenum to aid in the digestion of proteins, fats, and
carbohydrates.
Performing the Abdominal Assessment
Assessment of the abdomen involves obtaining a complete health history and
performing a physical examination. As you assess the patient, be watchful for signs
and symptoms of actual and potential problems involving the different organs and
structures in the abdomen.
Health History

The health history precedes the physical examination and involves interviewing the
patient about his or her perception of his or her health status.The health history
interview includes a broad range of questions so that possible problems associated
with each of the systems of the abdomen may be identified. Remember that
information collected as part of the health history may uncover problems related to
systems outside the abdomen (e.g., myocardial infarction [MI]). If time is an issue
and you are unable to perform a complete health history, perform a focused history
on the abdomen.

Biographical Data
Gathering biographical information can provide valuable insights about the
patients health status in several ways. Certain age groups are at greater risk for

problems in the GI system. For example, infants and toddlers have a higher
incidence of hernias than older children. Preschoolers are more likely to get
parasitic infections, and teenagers may have abdominal symptoms as a result of
pregnancy, sexually transmitted diseases (STDs),eating disorders like anorexia
nervosa or bulimia, and infectious mononucleosis. Appendicitis occurs more
frequently in children and teenagers than it does in adults. Older adults commonly
develop problems with digestion, absorption, metabolism, and elimination because
of changes caused by the aging process.Women aged 65 and over are commonly
diagnosed with hiatal hernia, constipation, and diverticulosis. Certain diseases
occur more frequently in some races and cultures (see previous section).You will
need to ask additional health history questions to determine whether symptoms of
these diseases are present so that appropriate screening measures can be
performed, if necessary. The potential for exposure to environmental and
occupational hazards can also be discovered in the biographical data. Where a
person lives or works may raise questions about environmental hazards such as
lead exposure in children (from inhalation of lead-based paint dust in older houses)
or occupational health hazards such as chemical exposure (arsenic, benzene).
Current Health Status
If your patient has an abdominal complaint, investigate this first. Common chief
complaints involving the body systems in the abdomen include:

Lymphatic: Swelling, lymph node tenderness.

Digestive: Anorexia, bruising, constipation, diarrhea, distension, dysphagia,

epigastric burning, gastric reflux, indigestion, jaundice, nausea, vomiting, pain,
weight changes.

Reproductive: Cramping,nausea,pain,vomiting,weight gain.

Neurological: Pain.

Cardiovascular: Pain.

Urinary: Edema, pain, problems with urination (burning, frequency).

The most common abdominal complaintspain, changes in weight, changes in
bowel habits (constipation, diarrhea), indigestion, nausea, and vomitingare
analyzed in the subsequent text,using the PQRST format. The nature and intensity
of the symptoms dictate the order and extent of questioning during the symptom
analysis.
Symptom Analysis

Symptom analysis tables for all the symptoms described in the following
paragraphs are available for viewing and printing on the compact disc that came
with the book.
Abdominal Pain
The most common complaint related to the abdomen, pain is often classified as
visceral, parietal, or referred.
Visceral pain results from distension of the intestines or stretching of the solid
organs. It is often described as burning, cramping, diffuse, and poorly localized.
Parietal pain results from inflammation of the parietal peritoneum. The pain is
usually severe, localized, and aggravated by movement.
Referred pain is felt at a site away from the site of origin. Impulses from the
internal organs and structures that share nerve pathways inside the central nervous
system explain the nature of referred pain. Acute abdominal pain (acute
abdomen) may indicate a life-threatening abdominal condition that requires
immediate medical intervention. In this situation, you should assess the patients
vital signs to determine whether she or he is in imminent danger.Vital signs
provide information about the possibility of cardiac irregularities and reveal
symptoms of shock and signs of an infectious process such as peritonitis. In
addition, you need to prioritize the symptom assessment questions to elicit the
most essential information.The order of symptom assessment becomes RTQSP.
Pain Location
The location of the pain is often diagnostically significant. Some disorders have
classic signs located in specific regions of the abdomen. For instance, pain in the
umbilical region may indicate an abdominal aortic aneurysm or early appendicitis.
Abdominal problems may also cause referred pain to the chest, so chest pain can
indicate either an abdominal problem or a cardiac event. Patients with a gastric
ulcer can have pain in the upper epigastric region left of midline, which is also the
location for angina and MI. Patients with gastroesophageal reflux disease (GERD)
may have chest pain that radiates to the back, neck, or jaw, which also mimics an
MI. Patients with a hiatal hernia may complain of substernal chest pain and
difficulty breathing, especially after a meal.
Note location of pain by quadrant or region:
Pain in shoulder: Ruptured spleen, ectopic pregnancy, Pancreatitis.

Pain in scapula: Cholelithiasis, MI, angina, biliary colic, pancreatitis.

Pain in thighs, genitals, lower back: Renal problems, ureteral colic.
Pain in lower and middle back: Abdominal aortic aneurysm. Recognizing the
relationship between the location of the pain and the possible health problem has
important implications for immediate nursing assessment and care of the patient.

Change in Bowel Patterns

Alterations in bowel movements are associated with a variety of GI disorders, such

as malabsorption disorders, irritable bowel syndrome, cancer, infections (viral,
bacterial, parasitic), food intolerance, and reactions to medications, as well as nonGI disorders.To determine whether a patient is having health problems that affects
bowel function, first establish a baseline by asking general questions about bowel
habits, such as: How often do you have bowel movements? Do you have any
problems with your bowels, such as straining, pain, constipation, or diarrhea?
Then ask more specific questions to help identify the origin of the problem.
Bowel patterns range from two movements per day to two or three per week.
Identify the color of the stool:
Black, tarry: Upper GI bleeding.
Red, bloody: Lower GI bleeding.
Clay colored: Increased bile in obstructive jaundice.
Weight Change
Weight change may indicate diseases in many body systems, reflect unhealthy
behaviors, or even reveal a normal state such as pregnancy. Weight changes can be
a sign of GI disease, cancer, congestive heart failure with fluid retention, metabolic
or endocrine disorders, unhealthy lifestyles, major depressive disorder, and eating
disorders. A careful analysis of this symptom provides data that allow the nurse to
distinguish between medical and behavioral problems causing the weight
change.Weight changes of 2 to 3 lb (1 to1.4 kg) within 48 hours result from fluid
changes. Unexplained weight loss in an adult should raise suspicions of underlying
malignancy.

Indigestion
Indigestionalso called dyspepsia or pyrosisis a frequent abdominal complaint
that is usually described as heartburn.This burning sensation is usually worse
after eating a meal. Acid from the stomach flows into the lower esophagus, causing
the burning sensation. GERD has heartburn as its chief symptom, but the epigastric
dis- tress occurs more frequently, lasts longer, and has more severe symptoms than
indigestion. Heartburn is also a common complaint in both gastric ulcer and
duodenal ulcer disease and gallbladder disease. Indigestion that increases when the
person is lying flat may indicate a hiatal hernia or GERD. Indigestion associated
with belching (eructation) and flatulence suggests cholecystitis
Nausea
Nausea is caused by stresses on the stomach wall or esophagus. Distension,
alterations in peristalsis, negative olfactory stimulation, inner ear problems, or
medications can also cause nausea. Many GI medical conditions have nausea as an
assessment finding.
Vomiting
During vomiting, peristalsis is reversed and the esophageal sphincter opens to
allow the contents of the stomach to be ejected.The involuntary emptying of
stomach contents is caused by irritation of the stomach lining caused by chemicals,
trauma, or distension; stimulation of the vomiting center in the brain (medulla);
and head injury. Some GI conditions that cause vomiting are intestinal obstruction,
peptic ulcer, viral or bacterial infection, and appendicitis.A person with repeated
vomiting is always at risk for fluid and electrolyte problems.
Past Health History
This section of the health history involves asking questions about childhood and
adult illnesses, injuries, hospitalizations, allergies, immunizations, and medications

that can affect the abdominal structures. Remember to document specific dates in
the patients record.

Family History
Questioning about diseases in the patients family enables you to identify those that
the patient may be at risk for because of genetic predisposition.Then you can help
the patient plan lifestyle changes that will help prevent those diseases and promote
health.

Review of Systems
A disruption in the systems contained in the abdominal cavity can cause problems
in many other areas of the body. The problem in another body system depends on
which organ of the abdomen is involved. For example, liver problems may cause
malaise, nausea and vomiting, bruising, jaundice, and fluid in the abdomen. This is
one reason why taking a careful review of systems (ROS) is so important. Another
reason is that the ROS might reveal that the primary health problem does not
originate in the abdomen.Instead,you may uncover medical illnesses that have
abdominal symptoms. So be sure to keep an open mind about the nature of the
patients health problem and not conclude that it lies in the GI system simply
because he or she has abdominal complaints. Instead, assess each system
methodically until you have collected all the data.

Psychosocial Profile
The psychosocial profile describes your patients lifestyle and habits. How your
patient eats, exercises, rests, and copes with the stresses of every day has an impact
on the health of the GI system.

Anatomical Mapping
Anatomical mapping helps pinpoint the location of findings during the abdominal
assessment. There are three ways to identify the location of these findings:
anatomical landmarks, the four-quadrant method,and the nine regions of the
abdomen.
Anatomical Landmarks
Anatomical structures are used as landmarks to help you describe abdominal
findings.The following landmarks are used: xiphoid process of the sternum; costal
margin; midline (down the center of the abdomen); umbilicus; anterior-superior
iliac spine; inguinal ligament (Pouparts); and superior margin of the pubic bone
(Figs. 17.3 and 17.4).

Four-Quadrant Method

Another way to mark the location of your findings is by the four-quadrant

method.To use this method,draw imaginary lines separating the abdomen into four
quadrants, with one line at the midline and the other horizontal at the
umbilicus.These lines should intersect at the umbilicus. The aorta and the spine are
located midline in the abdomen.The uterus and bladder,when enlarged,may be
palpable midline in the abdomen (Fig. 17.5).

Nine Regions of the Abdomen

The third way to document the location of your findings is to separate the abdomen
into nine regions, similar to a tic-tac-toe grid.The first two lines are vertical at the
right and left midclavicular lines to the middle of the inguinal ligaments.The
second two lines are horizontal beginning at the lower edge of the costal margin
and at the anterior- superior iliac spine of the iliac bones (Fig. 17.6).

Physical Assessment
Now that you have completed the subjective part of your examination,proceed to
the objective part.The purpose of the physical assessment is to identify normal
structures and functions as well as actual and potential health problems. Just as all
the organs of the body are interrelated,so are the assessments. Assessment findings
in other body areas can also indicate problems with abdominal organs. So your
assessment should begin with a general survey and a head-to-toe scan to detect
clues that may indicate an abdominal problem.
Approach

Perform the abdominal examination in a warm, private environment.Have your

patient empty her or his bladder before the examination, so that you do not mistake
a full bladder for a mass.Ask the patient to lie supine with her or his arms at the
sides.Warm both your stethoscope and your hands before proceeding with the
examination,and remember to work from the right side of your patient. Once your
patient is comfortable, expose the abdomen from the lower thorax to the iliac
crests.
Other things to remember include:
1.
Explain what you will be doing during the examination.
2.
Have adequate lighting so that you can visualize the abdomen without
difficulty.
3.
Observe the patients face for signs of discomfort.
4.
Perform the examination slowly and avoid quick movements.
5.
Make sure that your fingernails are short, to prevent injuring the patient
during palpation.
6.
Distract the patient with questions or conversation.
You will use all four techniques of physical assessment to examine the abdomen.
However, the sequence is inspection, auscultation, percussion, and palpation.
During an abdominal examination, it is important to auscultate before percussion
and palpation because the manipulation that occurs with these techniques may
increase the frequency of bowel sounds.
Performing a General Survey
Before physically assessing the abdomen, perform a general survey, observing the
patients overall appearance. Using your inspection skills, note nutritional status,
emotional status, body habitus, and any changes that might relate to the abdomen.
Begin by taking vital signs, height, and weight. Changes in vital signs may alert
you to a serious medical problem.
Vital sign changes and related abdominal problems include:

1.
Hypertension: Abdominal aortic aneurysm or dissection, renal infarction,
glomerulonephritis, vasculitis, or abdominal pain.
2.
Orthostatic hypotension: Hypovolemia (fluid or bloodloss).
3.
Fever: GI infection,peritonitis, pelvic infection,cholangitis.
4.
Pulse deficit: Aortic dissection or aneurysm.
5.
Hypotension/bradycardia: Hypotension may indicate shock associated with
ruptured abdominal aortic aneurysm.Vasovagal reaction is caused by bearing down
or straining with a bowel movement. The decrease in pulse and BP is a result of
decreased blood return to the heart and therefore decreased cardiac output. In
addition to taking vital signs, be alert for signs that may indicate underlying
abdominal problems. For example, note:
6.
Facial expression: Is it appropriate? If your patient complains of pain, does
her or his nonverbal behavior reflect this? For example, is she or he grimacing?
7.
Posture: Does your patient assume a particular posture for comfort? For
example, is he or she splinting a section of the abdomen, guarding an area of the
abdomen, or drawing the knees up to his or her chest? Patients with acute
appendicitis often flex their legs, because lying supine often increases the intensity
of pain. Does pain seem to increase with movement?
8.
Weight/nutritional status: Is your patient malnourished and underweight or
overweight? Severely thin patients may have an eating disorder. Overweight
patients may have underlying cardiovascular or renal disease as a result of fluid
retention. Gross abnormalities such as abdominal distension warrant further
investigation.
Performing a Head-to-Toe Physical Assessment