INSPECTION Inspection begins with noting lower chest wall integrity.

Because the last six ribs

lie over abdominal structures, distribution to this area may signal organ damage, specifically to the
liver, spleen, or diaphragm. The appearance of the abdomen should be described, The presence of
abrasions, contusions, lacerations, and surgical scars and the location, size, description, and
number of wounds should be documented. In patients who have been shot, an odd number of
wounds indicates the presence of a foreign object within the body. The nurse should resist the
temptation to categorize wounds as entrance and exit wounds. The abdominal contour, normally
flat or slightly rounded (or convex in a heavy patient), may be distended, which is indicative of an
accumulation of blood, other fluid, or gas resulting from perforation of hollow viscus, rupture of
or- gans (e.g., liver or spleen), abdomen. Repeated inspection by the nurse may reveal subtle signs
of distention, which, combined with absence of bowel sounds, may be indicative of an ileus,
peritonitis, or intra-abdominal bleeding. Involuntary guarding indicates injury to underlying struc-
tures. This may be less obvious or not present in patients with retroperitoneal injury. The presence
of discoloration, protu- berances, peristaltic movement, pulsations, abrasions, and old surgical
scars should be noted. Repeated inspection alerts the nurse to new discolorations or other changes
indicative of underlying injury. Dissection of blood into the abdominal wall from retroperitoneal
tissue (Grey Turner's sign) may oc cur several hours after the initial injury. Proper inspection
includes examining the patient's back and flank area and the anterior surface for the signs
mentioned. Obvious wounds or ecchymosis of the lumbar or flank areas may indicate damage to
retroperitoneal during diagnostic or reduced blood supply to the or abdominal organs.

AUSCULTATION Auscultation is often the most difficult part of the abdomi- nal examination
during resuscitative or critical care efforts simply because of the noise created by team members
per- forming lifesaving procedures. The presence or absence of bowel sounds on initial
examination is nonspecific informa- tion in patients with suspected abdominal injury. While
auscultating in all four quadrants, the nurse should be alert for the presence of bowel sounds in
unlikely locations, such as the chest cavity, which may indicate a diaphragmatic tear. In serial
auscultation, diminished or absent bowel sounds may indicate an ileus or peritonitis. The nurse
should listen for bruits, especially and iliac arteries, which may indicate partially obstructed over
the renal arteries, abdominal aorta, arterial blood flow.
PERCUSSION Percussion identifies the presence of air, fluid, or tissue. Tympanic sounds indicate
air-filled spaces such as stomach or gut, and a dull sound is present over organ structures such as
the liver or spleen. Dullness throughout the four quadrants indicates free fluid in the abdomen.
Fixed areas of dullness (Ballance's sign) in the LUQ may suggest a subcapsular or extracapsular
hematoma of the spleen or flank. Dullness that does not change with position suggests the presence
of retroperitoneal hematoma. Tympanic percussion may represent air in the abdominal cavity,
indicative of perforated viscus. A diaphrag- matic tear or hemothorax may be suspected if a dull
sound is elicited over the otherwise tympanic thoracic space.

PALPATION Abdominal tenderness is evaluated by using the whole hand over all four quadrants
and progressing from light to deep palpation. Tenderness is the most frequent and reliable sign of
intra-abdominal injury. Gentle palpation may elicit areas of increased tone or tenderness,
suggesting underlying in- jury. Abdominal wall injury produces focal tenderness, which increases
on exertion (tensing muscles). Deep palpation is used to elicit tenderness, guarding, and rebound
symptoms associated with peritoneal irritation.

A tender abdomen with guarding, distention, and signs of neritoneal irritation can indicate organ
rupture. RUQ ten- derness and guarding ribs may indicate liver damage. RUQ abdominal
tenderness may also be a sign of duodenal or elicited in the LUQ may indicate injury to the spleen,
stom- ach, or pancreas. Low abdominal or suprapubic discomfort may signal a potential for colon,
bladder, or urethral injuries and may be associated with pelvic fractures. The patient may have
referred pain. Most common among these is Kehr's sign, pain in the left shoulder from diaphrag-
matic irritation by blood after splenic rupture. Right shoul- der pain is often indicative of liver
injury. The patient must be lying flat or in Trendelenburg's position to elicit this type of shoulder
pain. Rectal examination includes testing for gross blood and anterior tenderness, which can
indicate bleeding or perito- neal irritation. Positive results may indicate lower gastroin- testinal
injury. or tenderness over the right lower six gallbladder injury. Pain 1O Diminished or absent
pulses in the femoral arteries may indicate common iliac artery thrombosis, dissecting aortic
aheurysm, or chronic vascular disease. Information about the quality and rate of pulses during the
initial assessment provides the clinician with good baseline information.
CONTINUING ASSESSMENT The four-step systematic physical examination continues during
all phases of care. Inspection includes the same as- sessment techniques; however, changes
detected in the ex- amination may be a result of the operative event, late signs of traumatic injury,
or sepsis. A chemical ileus caused by late pancreatic rupture or gastric repair leakage distends the
bowel and therefore the abdomen. Either the bowel sounds are obliterated or a auscultation.
hypertympanic sound is heard during Careful serial examination of the patient is the key to early
diagnosis of intra-abdominal injuries and prevention of