ABDOMINAL

ASSESSMENT
 ***In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles.

 Inspection of the abdomen

 Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).

 Contour (flat, rounded, scaphoid)

 Distension

 Respiratory movement.

 Visible peristalsis.

 Pulsations 
PROCEDURE

1. Divide the abdomen into 4 imaginary quadrants. Draw a vertical line from the
xiphoid process to the symphysis pubis and a horizontal line across the umbilicus.

2. These quadrants are labeled right upper quadrant (RUQ), left upper quadrant
(LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ).
3. Ask client if he needs to void. Drape the upper chest and legs.
4. Expose the abdomen from the xiphoid process to the symphisis pubis.
5. The client lies in supine position with arms down at the sides a small pillow
may be placed under the head.
Normal Findings:

 Skin color is uniform, no lesions.

 Some clients may have striae or scar.

 No venous engorgement.

 Contour may be flat, rounded or scaphoid

 Thin clients may have visible peristalsis.

 Aortic pulsation may be visible on thin clients.

Auscultation of the Abdomen

 This method precedes percussion because bowel motility, and thus bowel
sounds, may be increased by palpation or percussion.

 The stethoscope and the hands should be warmed; if they are cold, they may
initiate contraction of the abdominal muscles.
 Light pressure on the stethoscope is sufficient to detect bowel sounds and
bruits. Intestinal sounds are relatively high-pitched, the bell may be used in
exploring arterial murmurs and venous hum.
Peristaltic sounds

-sounds are produced by the movements of air and fluids through the gastrointestinal tract.
Peristalsis can provide diagnostic clues relevant to the motility of bowel.

 Listening to the bowel sounds (borborygmi) can be facilitated

by following these steps:
o Divide the abdomen into four quadrants.

o Listen over all auscultation sites, starting at the right lower quadrants, following the cross
pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that
we follow the direction of bowel movement.

o Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at
least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds
are present.
Normal bowel sounds

-are high-pitched, gurgling noises that occur

approximately every 5 – 15 seconds.
-Itis suggested that the number of bowel sound may
be as low as 3 to as high as 20 per minute, or
roughly, one bowel sound for each breath sound.
Some factors that affect bowel sound:

 Presence of food in the GI tract.

 State of digestion.
 Pathologic conditions of the bowel (inflammation, Gangrene,
paralytic ileus, peritonitis).
 Bowel surgery
 Constipation or Diarrhea.
 Electrolyte imbalances.
Bowel obstruction.
Percussion of the abdomen

-is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and
masses, and in assessing solid structures within the abdomen.

 The direction of abdominal percussion follows the auscultation site at each abdominal
guardant.

 The entire abdomen should be percussed lightly or a general picture of the areas of
tympany and dullness.

 Tympany -presence of gas in the small and large bowel.

 Dull- Solid masses, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or
at the midaxillary line on the left side.
 Percussion in the abdomen can also be used in assessing the liver span and size of the
spleen.
Percussion of the liver

 The palms of the left hand are placed over the region of liver dullness.

 The area is strucked lightly with a fisted right hand.

NORMAL- no tenderness

Tenderness -is usually a result of hepatitis or cholecystitis.

Renal Percussion

 Can be done by either indirect or direct method.

 Percussion is done over the costovertebral junction.

Tenderness -suggests renal inflammation.

Palpation of the Abdomen

 Light palpation

 It is a gentle exploration performed while the client is in supine

position. With the examiner’s hands parallel to the floor.
 The fingers depress the abdominal wall, at each quadrant, by
approximately 1 cm without digging, but gently palpating with
slow circular motion.
 This method is used for eliciting slight tenderness, large masses,
and muscles, and muscle guarding.
Tensing of abdominal musculature
may occur because of:

o The examiner’s hands are too cold or are

pressed to vigorously or deep into the abdomen.
o The client is ticklish or guards involuntarily.
o Presence of subjacent pathologic condition.
Normal Findings:

 No tenderness noted.

 With smooth and consistent tension.

 No muscles guarding.
Deep Palpation

 It is the indentation of the abdomen performed by pressing the distal half of

the palmar surfaces of the fingers into the abdominal wall.

 The abdominal wall may slide back and forth while the fingers move back and
forth over the organ being examined.

 Deeper structures, like the liver, and retroperitoneal organs, like the kidneys, or
masses may be felt with this method.

 In the absence of disease, pressure produced by deep palpation may produce

tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation

 2 types of bimanual palpation

 1. Superimposition of the right hand over the
left hand.
 Ask the patient to take 3 normal breaths.
o Then ask the client to breathe deeply and hold. This would
push the liver down to facilitate palpation.
o Press hand deeply over the RUQ
The second method:

o The examiner’s left hand is placed beneath the client at the level of the right 11th
and 12th ribs.

o Place the examiner’s right hands parallel to the costal margin or the RUQ.

o An upward pressure is placed beneath the client to push the liver towards the
examining right hand, while the right hand is pressing into the abdominal wall.

o Ask the client to breathe deeply.

o As the client inspires, the liver maybe felt to slip beneath the examining fingers.
Normal Findings:

 The liver usually cannot be palpated in a normal

adult. However, in extremely thin but otherwise
well individuals, it may be felt the coastal margins.
 When the normal liver margin is palpated, it must
be smooth, regular in contour, firm and non-
tender.
 
PELVIC EXAMINATION
Pelvic examination 
-is the physical examination of the external and internal female pelvic organs.
-is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive
and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma (e.g. sexual
assault)
-can also be used assess a patient's anatomy in preparation for procedures.
-can be done awake in the clinic and emergency department, or under anesthesia in the operating
room.
Most commonly performed:

1) External exam- to evaluate the external genitalia

2) Internal exam with Palpation
-commonly called the bimanual exam
-to examine the uterus, ovaries, and fallopian tubes
3) Internal exam using the speculum
- to visualize the vaginal walls and cervix.
Preparation
1. Examiners should ask the patient if they have had a pelvic exam in the past and
whether they have any questions or concerns about the exam.
2. The examiner should offer to show the patient models or diagrams of the pelvic
anatomy and any instruments that will be used during the exam. The examiner should
explain each step of the exam and its purpose, should address and normalize any
concerns.
3. Relaxation of the pelvic muscles can reduce discomfort during the exam. Rather than
telling the patient to "relax", which can trigger strong emotions for patients who are
survivors of assault, patients can be told to breathe slowly and deeply into their
abdomens, which is a more instructive way of describing how to relax the pelvic muscles.
4. Careful preparation is helpful for an efficient and comfortable exam. Prior to asking the
patient to position themselves on the exam table, the examiner should collect all the
instruments needed for the exam and any planned procedures, including the speculum,
light source, lubricant, gloves, drapes, and specimen collection media. Warming the
speculum with warm tap water can also increase comfort. The patient should be given
the opportunity to have a chaperone or support person in the room during the exam. In
general, male examiners should always be accompanied by a female chaperone.
External Examination

1. Explain the procedure.

2. The patient is asked to put on an examination gown, get on the examination
table, lay on her back with her feet in stirrups.
3. Sliding down toward the end of the table is the best position for the
clinician to do a visual examination.
4. A pelvic exam begins with an assessment of the reproductive organs that
can be seen without the use of a speculum.

The clinician may want to perform pelvic examination and assessment of the
vagina because there are unexplained symptoms of vaginal discharge, pelvic
pain, unexpected bleeding, or urinary problems.
Externally inspect for the:
1. Pubic hair
-for pubic lice and hair growth patterns.
-Sparse hair patterns can exist in older and in some Asian women.
2. Labia majora
-position and symmetry are assessed.
-expected finding in older women can be thinner and smaller.
-look for ulcers, inflammation, warts and rashes. If drainage is present from these structures, its color,
location and other characteristics are noted.
3. Labia minora
-should appear moist, smooth in texture and pink.
-presence of tearing, inflammation and swelling is noted.
-thinner and smaller labia minora are an expected finding in older women.
4. Clitoris
-assessed for size, position, symmetry, and inflammation.
5. Urethral opening
- No urine should leak when the woman is asked to cough.
-Urine leakage may indicate stress incontinence and the weakening of pelvic structures.
-The opening should be midline, pink, and smooth.
-The presence of inflammation, or discharge which may indicate an infection.
-Excoriation can be present in obese women due to urinary incontinence.
6. Vaginal opening
-inspected for position, presence of the hymen, and shape.
-the presence of bruising, tearing, inflammation and discharge.
-When the woman is requested to ‘bear down’, the presence of prolapsed structures such as the bladder
(cystocele), rectum (rectocele) or uterus are documented.
7. Perineum
-the space between the vagina and the anus.
-should be smooth, firm, and free of disease.
-Scars from episiotomies are visible on women who have had the procedure during childbirth.
8. Anus
-assessed for lesions, inflammation or trauma.
-It should appear dark, continuous and moist.
NOTE:

Pelvic examinations are usually procedures that are designed to obtain objective,
measurable descriptions of what is observed. If sexual abuse is suspected,
questions regarding this is discussed after the examination and not during it.
Internal Examination

Before inserting the speculum, the vaginal

wall, urethra, Skene's glands and Bartholin's
glands are palpated through the vaginal wall.
During the internal exam, the examiner
describes the procedure while doing the
assessment, making sure that the woman can
anticipate where she will feel the palpations.
Internally assess thru PALPATION

1. Vagina and vaginal walls

-The woman is first informed that the examiner will insert their finger into the vagina.
-should feel smooth, consistent and soft.
-rugae can also be assessed by palpation.
-The woman is again asked to bear down while the examiner continues the internal examination.
The presence of bulging is assessed.
2. Urethra
-position is assessed by palpation with a finger through the vaginal wall.
3. Skene's glands
-located on each side of the urethra are palpated to produce secretion from the glands.
4. Bartholin glands
-assessed by gently squeezing them with one finger placed externally, on the posterior labia
majora and the other finger in the vagina.
Assessment using the SPECULUM:

-to visualize other internal structures: the cervix, uterus, and ovaries.

 The appropriate sized speculum is selected.

 The speculum is slowly inserted in its collapsed state at a forty-five degree
angle to match the slope of the vagina.
 The blades are then expanded until the cervix comes into view. If the
speculum is transparent, the vaginal walls can be seen.
VAGINAL SPECULUM
Assessment using the SPECULUM:

1. Cervix
-it should look moist, round, pink, and centered to the
middle. - -the secretions of the cervix should be clear or
whitish with no odor.
-the presence or absence of polyps, ulcers, and
inflammation are noted.
-A swab or cytobrush will be used to collect or scrape
cervical cells off of the surface of the cervix to be evaluated
for changes. Other vaginal swabs can be taken at this time to
test for sexually transmitted diseases.
BIMANUAL PALPATION

-Begins after the speculum is removed.

-the examiner informs and explains this part of the exam.
-two fingers are used to palpate the cervix.
BIMANUALLY PALPATE:

1. Cervix and fornices

-assessed for mobility and the presence of lumps.
2. Uterus
-palpated and evaluated to determine its position by leaving the fingers of one hand in the vagina while
pressure to the abdomen is applied with the other hand.
-If the body tissue is too thick due to obesity, an ultrasound may be performed instead.
-If the examiner can feel the fallopian tubes, this is not a normal finding.
3. Rectum
-The examiner removes their hands and puts on clean gloves to assess the rectum, and explains this
part of the exam to the woman.
-assessed by having one finger in the vagina and the other in the rectum. The rectum should be smooth.

 The examiner removes their fingers, discards their gloves, washes their hands and helps the women get
into an upright position. Any deviations from what is considered normal will be discussed.
BREAST EXAMINATION
Inspection of the Breast
There are 4 major sitting position of the client used for clinical breast examination. Every client
should be examined in each position.
1. The client is seated with her arms on her side.
2. The client is seated with her arms abducted over the head.
o 3. The client is seated and is pushing her hands into her hips, simultaneously eliciting
contraction of the pectoral muscles.
-specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory
ligaments.
4. The client is seated and is learning over while the examiner assists in supporting and
balancing her.
• While the client is performing these
maneuvers, the breasts are carefully
observed for symmetry, bulging, retraction,
and fixation.
• An abnormality may not be apparent in the
breasts at rest a mass may cause the breasts,
through invasion of the suspensory ligaments,
to fix, preventing them from upward
movement in position 2 and 4.
Normal Findings:

• The overlying the breast should be even.

• May or may not be completely symmetrical at rest.
• The areola is rounded or oval, with same color, (Color varies
from light pink to dark brown depending on race).
• Nipples are rounded, everted, same size and equal in color.
• No “orange peel” skin is noted which is present in edema.
• The veins may be visible but not engorge and prominent.
• No obvious mass noted.
• Not fixated and moves bilaterally when hands are abducted
over the head, or is leaning forward.
• No retractions or dimpling.
Palpation of the Breast


• Palpate the breast along imaginary concentric
circles, following a clockwise rotary motion, from the
periphery to the center going to the nipples. Be sure
that the breast is adequately surveyed. Breast
examination is best done 1-week post menses.
• Each areolar areas are carefully palpated to
determine the presence of underlying masses.
• Each nipple is gently compressed to assess for the
presence of masses or discharge.
Normal Findings:

No lumps or masses are palpable.
•

• No tenderness upon palpation.

• No discharges from the nipples.

• NOTE: The male breasts are observed by

adapting the techniques used for female clients.
However, the various sitting position used for
woman is unnecessary.
BREAST SELF EXAMINATON
BEST TIME:
-Few days after your monthly menstrual cycle ends.

-Hormonal changes can affect the size and feel of your

breasts, so it is best to perform the exam when your
breasts are in their normal state.
**Women who do not menstruate should choose a certain
day to perform the exam, such as the first of each month.
**Keep a journal of your self-exams. This will help you
track and record any changes you have noticed in your
breasts.
PROCEDURE:
1.Start by standing topless in front of a mirror
with your hands at your sides. Visually
inspect your breasts for the following:
• changes in size, shape, or symmetry
• dimpling
• inverted nipples
• puckering
• asymmetrical ridges at the bottom
2.Check for these signs with your hands at your sides. Then, with
your arms over your head, and again when lifting one breast at a
time.
3. Using the pads of your fingers, not the tips, inspect your
breasts while lying down and again in the shower. The water and
soap in the shower will allow your fingers to glide easily over your
skin.
4. Using varying pressure and taking your time, massage your
fingers over your breasts in a spiral pattern starting at the nipple.
Make your way up to the top of your breast near the collarbone,
to the center by your breastbone, and to the sides near your
armpits. Do this by putting one arm over your head while
massaging your breast with the other hand.
5. Lastly, gently squeeze your nipples to check for discharge.
 TESTICULAR
EXAMINATION
Risk Factors for Testicular Cancer
 1. Age 20-34 (15-35)
 2. History of undescended testes
 3. Early puberty
 4. Family history
 5. White race
 6. Higher social class
 7. Obesity
 8. Never married or late marriage
 9. Maternal use of oral contraceptives or diethylstilbestrol during early pregnancy
 10. Maternal abdominal/pelvic x-ray during pregnancy
 11. Mother or sisters with breast cancer
Warning Signs for Cancer of the Testicle

 1. A small, hard, painless lump-about the size of a pea

 2. Feeling of heaviness in the testicle
 3. Enlargement of the testicle
 4. Change in how the testicle feels to the touch
 5. Sudden accumulation of fluid/blood in the scrotum
 6. Dull ache in the groin
 7. Swelling or tenderness in other parts of the body (groin, breast, neck)
TESTICULAR SELF EXAMINATION

1. Perform after a warm bath/shower

2. Use both hands and start on right testicle
3. Place index and middle finger underneath testicle
4. Place thumb on top of testicle
5. GENTLY roll the testicle between thumbs and fingers
6. Check all sides of the right testicle and repeat procedure on left testicle
7. Find the epididymis on the top and back of each testicle.
8. Examine the testes in mirror while standing. Look for unusual contours and swelling of testes
(noting that one usually hangs lower than the other)