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Abdominal examination

Abdominal assessment uses all four of the basic assessment techniques – inspection, palpation, percussion, and auscultation. However, abdominal assessment is unique in that the order in which you implement these techniques differs. When assessing most body systems, the appropriate order is inspection, palpation, percussion, and auscultation. However, with the abdominal assessment, auscultate before you manipulate the abdomen with palpation and percussion. The rationale for this is that manipulation of the abdomen with palpation and percussion may stimulate peristalsis and thereby alter your examination findings. So the appropriate order for the abdominal examination is inspection, then auscultation, followed by palpation and percussion. However, when a child isnít cooperative during a physical examination, percussion cannot always be accomplished.

Inspection

To inspect the abdomen, position the patient supine and bare the skin from the xiphoid process down to the pubic symphysis. Observe the contour of the abdomen from more than one angle, for example, by looking from the side and also from the front. Is the abdomen scaphoid, flat, rounded, or protuberant? Do you find symmetry when comparing the right and the left sides? Is there a depression or bulging at midline above or below the umbilicus to indicate a separation in the rectus muscles? Note skin color and examine the skin for lesions and scars. Notice the location and configuration of the umbilicus as well. Is it centrally located? Inverted or everted? Is there an umbilical hernia present? Inspect the inguinal area for changes in contour or enlarged lymph nodes or masses.

Infants. The abdomen generally has a rounded, protruding appearance because of the immature musculature of the infant’s abdomen, and veins may be visible, especially in light-skinned children. You might note either or both of two small bulges. An umbilical hernia sometimes appears at about 2 to 3 weeks of age and is quite prominent when the infant cries. It usually disappears by about 1 year of age. The other is diastasis recti, which is a separation of the rectus muscles along the midline. This condition usually disappears by early childhood.

If the infant is in the first month of life, inspect the umbilical stump for bleeding, drainage, and odor. It should turn black, dry, and hard within a few days after birth and fall off in approximately 7 to 14 days. After the umbilical stump falls off, skin usually covers the area within 3 to 4 weeks.

Look for abdominal movements that correspond with breathing. Since infants and children up to 6 years of age breathe with the diaphragm, the abdomen should rise with inspiration and fall with expiration. You might also see occasional peristalsis, due to infants’ thin musculature.

Toddlers/Preschoolers/School-age children. Until about 4 years of age, the abdomen continues to protrude in both the supine and standing positions. After 4 years of age, the abdomen still protrudes with standing due to lumbar lordosis, but it is flat when the child is lying down. The abdomen still moves up and down with respirations until about 6 years of age.

Adolescents. By adolescence, the abdomen has lost its potbelly shape and has a slimmer appearance. An abdomen that is scaphoid, or sunken in, might be a sign of dehydration or malnutrition, warranting further evaluation. The abdomen should no longer move with inhalation and exhalation. At this stage, the chest moves with respiration.

Auscultation

Use the diaphragm of your stethoscope to auscultate bowel sounds in all four quadrants. You should be able to hear bowel sounds approximately every 10 to 30 seconds in all quadrants. Be sure to listen long enough to hear at least one bowel sound before moving to the next quadrant. As you move your stethoscope through all four quadrants, note the quality of the bowel sounds. Are they hypoactive, normal, or hyperactive? The absence of bowel signs, except in patients who have just had surgery, may indicate peritonitis or a paralytic ileus. Hyperactive bowel sounds, on the other hand, may indicate gastroenteritis or a bowel obstruction.

Infants. When auscultating the abdomen, bowel sounds should be the only sounds you hear. If the infant is hungry, you might hear loud gurgling sounds called borborygmi. You should not hear any vascular sounds.

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Toddlers/Preschoolers/School-age children. Bowel sounds should again be the only sounds you hear. After you listen for bowel sounds, turn the stethoscope head and use the bell to listen for vascular sounds over the abdominal aorta and the renal arteries. You should not hear any sounds.

Adolescents. Listen in all four quadrants for the high-pitched, tinkling sounds of peristalsis. Be sure to use light pressure when listening since applying too much pressure can stimulate more bowel sounds. The right lower quadrant is the best area to begin listening since bowel sounds are often more active in that quadrant. With the bell of the stethoscope, listen for a bruit over the abdominal aorta and renal arteries. You should not hear any sounds.

 

Percussion

Percussion is useful for estimating the density of tissues lying 2 to 3 inches (5 to 7 cm) below the surface of the skin. Practice percussing your own abdomen to develop a sense of the tones percussion generates. Abdominal percussion is useful for delineating the outlines of solid tissue, for example, the liver or the spleen, or of intra-abdominal masses such as tumors or fecal masses. The percussion tones that you are likely to hear when percussing the abdomen include dullness, tympany, and resonance. Dullness is heard over solid organs such as the liver and spleen. Tympany is commonly heard over areas that contain gas, such as the stomach and intestines. Resonance is heard over lung tissue.

Infants. You are likely to hear tympany over the stomach since infants tend to swallow some air during feedings. Dullness should be heard over the liver and is also normal over the bladder. You can probably percuss the upper edge of the liver near the fifth intercostal space at the midclavicular line and the lower edge about 1 inch (2 to 3 centimeters) below the right costal margin. The spleen is not generally percussed.

Toddlers/Preschoolers/School-age children. You are likely to hear tympany when percussing the abdomen and dullness over the bladder. As with the infant, percuss the lower edge of the liver about 1 inch below the right costal margin. The spleen is not generally percussed.

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Adolescents. Percussion sounds for this age group are the same as those of toddlers/preschoolers/school-age children. However, you can percuss the lower edge of the liver closer to the costal margin. Percussion over the costovertebral angles is often included as part of the abdominal examination of older children but is actually a test for kidney pain. This maneuver should not cause pain unless the patient has some inflammation in the kidney.

Palpation

The last part of the abdominal assessment is palpation, during which you use your fingertips to feel all over the abdomen systematically for rigidity, masses, and tenderness. Light palpation is done to determine how soft or hard the abdomen is. To perform light palpation, use one hand to depress the abdomen slightly. Deep palpation is done to feel for masses and identify any tenderness. To perform deep palpation, use one or both hands and the fingertips to depress the abdomen more deeply. Before palpating the abdomen, try to help your patient relax. If her abdominal muscles are contracted, her abdomen will be very firm and you will palpate little more than the rectus muscle. As part of the abdominal assessment, palpate the inguinal area for changes in contour or enlarged lymph nodes or masses.

Infants. To help relax the abdominal muscles, flex the infant’s knees with one hand and palpate with the other. If the infant is crying, try a pacifier. The liver fills the entire right upper quadrant; you can usually palpate the edge at the right costal margin. The tip of the spleen, both kidneys, and the bladder are also usually palpable. In the right lower quadrant, you can usually palpate the cecum and the sigmoid colon.

Toddlers/Preschoolers/School-age children. To help children relax for the abdominal examination, talk casually with them as you have them raise their knees. If your patient is ticklish, begin palpating with the child’s own fingers under yours, then switch positions so that your fingers are under the childís, and complete the examination that way. Also, since the abdominal muscles tend to be more relaxed when the child takes a deep breath, ask the child to take a deep breath each time you palpate the abdomen.

At this age, the liver is still easily palpable slightly below the right costal margin. The spleen is also easily palpable, with soft movable edges. Usually the tip of the left kidney is also palpable, as is a small part of the right kidney.

Adolescents. As with younger children, help your patient relax by talking with him as you have him raise his knees. If your patient is ticklish, begin palpating with the patient’s own fingers under yours, then switch positions so that your fingers are under his, and complete the examination that way. Also, ask him to take a deep breath each time you palpate the abdomen since this can also help with relaxing the abdominal muscles.

You might feel the edge of the liver as the patient takes a deep breath and the diaphragm pushes it down. The spleen is normally not palpable unless it is enlarged to approximately three times its normal size. The lower part of the right kidney may or not be palpable. If it is palpable, you will usually feel a round, smooth mass slide between your fingers. The left kidney sits approximately 1 centimeter higher than the right and is not normally palpable.

If the adolescent reports pain or you note pain with palpation, be sure to test for rebound tenderness. To do this, gently press over the painful area, gradually increasing pressure within your patient’s ability to tolerate the discomfort. Then quickly release the pressure. If releasing the pressure increases the pain, document that the patient has positive rebound tenderness, a common finding with appendicitis. Perform this test at the end of the examination as it can cause severe pain and the abdominal muscles can tighten.

 

References

Ball, J. W., & Bindler, R. C. (2003). Pediatric nursing: Caring for children (3rd ed.). Upper Saddle River, NJ: Pearson Education. Chapter 4.

Jarvis, C. (2004). Physical examination and health assessment (4th ed.). St. Louis, MO: Saunders. Unit 3.