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clinical skills
Carol Cox is Professor of Patients present with a variety of abdominal approximately 27 feet long (Colbert et al, 2009;
Nursing, Advanced Clinical complaints and symptoms. Thus, it is important Marieb, 2009). It begins at the mouth and ends
Practice, and Martin Steggall is
to have an understanding of the underlying at the anus. Its function is to ingest and digest
Head of Department, Applied
Biological Sciences, School
problems that patients may have (Bickley and food, absorb nutrients, electrolytes and water,
of Community and Health Szilagyi, 2007). The ability to undertake and and excrete waste. Peristalsis moves food and
Sciences, City University, document a clear, concise and systematic the products of digestion under the control of
London assessment of a patient is an essential skill for the autonomic nervous system (Colbert et al,
gastrointestinal nurses. In this article, a model 2009; Marieb, 2009).
of assessment (McGrath, 2004) is described, A patient with abdominal problems or
which gastrointestinal nurses can use to readily disease may have a wide range of symptoms.
identify and prioritize patient care. Some problems may be dissociated from the
By undertaking a full and systematic assessment abdominal system directly but impact upon
of the abdomen, the gastrointestinal nurse is in organs in the abdomen, such as in diabetic
a unique position to act upon findings from the gastroparesis and anticholinergic drug therapy
assessment and ensure that appropriate medical in which the patient experiences unpleasant
or nursing intervention occurs. abdominal fullness after normal meals or early
In this article, abdominal examination – which satiety and therefore has an inability to eat
is the first part of a 2-part series – is presented. a full meal (Bickley and Szilagyi, 2007) or in
In part 2, digital rectal examination (DRE) is pregnancy when, in the third trimester, there
presented. DRE follows as the final element in is upward displacement of the stomach.
a comprehensive abdominal examination. In approximately 15–20% of pregnant women,
Key words the upper portion of the stomach herniates through
Background the diaphragm. This is more common in older,
■ Abdominal examination
■ Clinical skills For the purpose of review, the abdominal cavity obese and multiparous women after the seventh
■ Inspection is the centre for several of the body’s vital or eighth month of pregnancy (Seidel et al, 2006).
■ Palpation organs, including the liver, gallbladder, stomach, In addition, increased progesterone production
■ Percussion and auscultation pancreas, spleen, small intestine, cecum, appendix, causes a decrease in motility and tone of smooth
ascending, transverse, descending and sigmoid muscles. Therefore, there is a delayed emptying
This article has been subject to colon, kidneys, ureters, adrenal glands, abdominal time of the stomach (Seidel et al, 2006; Swartz,
double-blind peer review aorta, inferior vena cava, bladder and rectum 2006; Epstein et al, 2008).
(Colbert et al, 2009; Marieb, 2009). Conversely, there is a range of symptoms that
The alimentary tract, or gastrointestinal tube, is are associated with abdominal problems and/or
protected under the ribs, the lower half of the along the vein. Look to see in which direction the
chest must also be inspected. Assess abdominal vein refills. In inferior vena cava obstruction, the
symmetry, noting overall contour and skin condition blood flow below the umbilicus flows up towards
as well as the appearance of the umbilicus and the umbilicus, whereas in portal hypertension
any visible pulsations. Assess abdominal contour the blood flows downwards away from the
by standing at the feet of the patient first. Then umbilicus (McGrath, 2004).
move to the side of the patient and stoop so
that the abdomen is at eye level. Look at the Auscultation
abdominal profile. Is the abdomen fully rounded Auscultation follows inspection and provides
or distended? Is the umbilicus inverted or everted? valuable information about gastrointestinal
Is the abdomen scaphoid in appearance, or is motility and underlying abdominal vessels
it distended in the upper or lower half only? and organs. Sounds heard upon auscultation
Normally, the abdomen is concave, symmetrical can be characterized in the same fashion
and moves gently with respiration (Epstein et al, as in percussion (type of sound, pitch and
2008). A concave (scaphoid) abdominal contour location). It is preferable for the diaphragm of
may indicate malnutrition, whereas distension may the stethoscope to be used to hear normal as
indicate the presence of a tumour, ascites or the well as abnormal bowel sounds.
accumulation of air. In thin patients, the pulsation The diaphragm transmits high-pitched sounds
of the aorta may be seen in the midline epigastric and provides a broader area of sound whereas
area (Barkauskas et al, 2002; McGrath, 2004; Jarvis, the bell transmits softer sounds (Cox, 2004b).
2008). Aortic pulsations may be pronounced due When the bell is used, pressure on the bell will,
to increased intra-abdominal pressure related to by stretching the patient’s skin underneath the
the presence of a tumour or ascites. Peristalsis bell, create a diaphragm effect. Lightly place the
is not normally visible. Strong visible peristalsis stethoscope diaphragm on the abdominal skin
indicates intestinal obstruction. in all four quadrants of the abdomen. The four
Inspect the skin. It normally appears smooth quadrants of the abdomen (right lower quadrant,
and intact. Look for discolouration, striae, right upper quadrant, left upper quadrant, left
rashes, dilated veins, scars or other lesions. Skin lower quadrant) are divided horizontally and
abnormalities allude to underlying problems. vertically at the umbilicus. Take care not to put
Bulging around scars may indicate incisional pressure on the diaphragm as this may stimulate
hernias. Striae, in addition to resulting from peristalsis and subsequently mask the usual sounds
pregnancy or obesity, may reflect the presence that would be heard. A systematic approach
of an abdominal tumour or another disorder should be undertaken when listening.
such as Cushing’s syndrome. Cushing’s syndrome Before placing the diaphragm of the stethoscope
characteristically causes thin-looking skin and on the patient’s abdomen, warm your hands and
purple striae to occur, which is due to the excessive the diaphragm of the stethoscope in order to
secretion of cortisol (Seidel et al, 2006). prevent muscular contraction. Muscular contraction
Tortuous or dilated superficial abdominal veins can alter auscultation findings. Listen with the
may indicate inferior vena cava obstruction and diaphragm for friction rubs in the area of the
cutaneous angiomas may indicate liver disease. A liver and spleen. Friction rubs are high pitched
blue coloration around the umbilicus may be an and, although in the abdomen are rare, it may
early sign of intra-abdominal bleeding. Normally, indicate inflammation of the peritoneal surface
abdominal veins are not prominent. If abdominal of the organ from tumour, infection or infarction
veins are prominent, the direction of flow should (Seidel et al, 2006; Swartz, 2006).
be assessed. This can be readily undertaken by Listen for bowel sounds. Note their frequency
placing two fingers at one section of a vein and and character. Normally, bowel sounds occur
applying occlusive pressure. Move one of your irregularly and range 5–35 per minute. Borborygmi
fingers further along the length of the vein so is loud, prolonged gurgles, such as with diarrhoea.
that this section of vein is flattened (emptied). Increased sounds occur with gastroenteritis and
Then remove the finger that has been moved may indicate intestinal obstruction or hunger.
of the other hand is snapped downward and the Figure 2. Percussion sites and hand placement.
tip of the middle finger, which is being used as
the hammer, sharply taps the interphalangeal
joint of the finger that is pressing on the patient’s
abdomen (see Figure 3).
Refer to Table 4 for the classification of Percussion sites
percussion sounds of the abdomen and where Right upper Left upper
these may be heard. Remember, the quieter the quadrant quadrant
ring is soft in the centre, this suggests a hernia. Bickley L, Szilagyi P (2007) Bates’ Guide to Physical
Examination. 5th edn. Lippincott, Philadelphia
Specific structures, such as the liver, should be
palpated as well. The liver is difficult to assess Colbert B, Ankney J, Lee K, Steggall M, Dingle M (2009)
The gastrointestinal system: fuel for the trip. In: Colbert B,
because it lies under the eleventh and twelfth Ankney J, Lee K, Steggall M, Dingle M (eds). Anatomy and
ribs. To assess the liver, place your right hand Physiology for Nursing and Health Professionals. Pearson
Education, Harlow
on the patient’s abdomen with your fingers
pointing towards the patient’s head. Ask the Cox C (2004a) Assessment of Disability Including Care of
the Older adult, Physical Assessment for Nurses. Blackwell
patient to breathe regularly a few times and Publishing, Oxford
then to take a deep breath. As the patient takes Cox C (2004b) Examination of the Cardiovascular System,
a deep breath, try to feel the liver edge as the Physical Assessment for Nurses. Blackwell Publishing,
diaphragm pushes the liver down. Normally, the Oxford
liver is not palpable except in very thin people. Epstein O, Perkin G, de Bono D, Cookson J (2008) Clinical
Examination. 4th edn. Mosby, London
When a tumour or cirrhosis is present, the edge
Jarvis C (2008) Physical Examination & Health Assessment.
of the liver will feel hard and irregular.
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examination (excluding DRE) have been Marieb E (2009) Essentials of Human Anatomy and
Physiology. 9th edn. Benjamin Cummings, San Francisco
presented. The gastrointestinal nurse will find
the information related to the processes of Marsh AMA (2004) History and examination. Abdominal
Examination. 2nd edn. Mosby, Edinburgh: 119–36
inspection, auscultation, percussion and palpation
McGrath A (2004) Abdominal examination. In: Cox C
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occur or complications arise. Royal College of Nursing (2008) Advanced Nurse
Examination of the abdomen can tell the Practitioners: An RCN Guide to the Advanced Nurse
Practitioner Role, Competencies and Programme
gastrointestinal nurse much about the overall Accreditation. RCN, London
health status of the patient and provides a baseline
Royal College of Nursing (2003) Digital Rectal Examination
for diagnoses and treatment. In part 2, the process and Manual Removal of Faeces: Guidance for Nurses. 3rd
of undertaking a thorough DRE will be presented. edn. RCN, London
As with abdominal examination, DRE aids in the Seidel H, Ball J, Dains J, Benedict G (2006) Mosbys Guide to
Physical Examination. 6th edn. Mosby, St. Louis
identification of serious complications/pathology
that prompt further clinical investigation. ■ Swartz M (2006) Physical Diagnosis, History and
Examination. 5th edn. WB Saunders, London