27.2: Physical Assessment

Learning Objectives

By the end of this section, you will be able to:

• Analyze how to perform a comprehensive abdominal assessment
• Describe abnormalities identified during the assessment of the abdomen
• Recall proper documentation of the abdominal assessment

A thorough assessment of the abdomen provides valuable information regarding the function of a patient’s GI and GU systems. Understanding how to properly assess the abdomen and recognizing both normal and abnormal assessment findings will allow the nurse to provide high-quality care to the patient.

This unit discusses how to complete a comprehensive abdominal assessment using subjective and objective data. Abnormalities are discussed, as well as how to properly validate and document findings.

Comprehensive Abdominal Assessment

The GI system is responsible for the ingestion of food and the absorption of nutrients. Additionally, the GI and GU systems are responsible for the elimination of waste products. Therefore, during assessment of these systems, the nurse collects subjective and objective data regarding the underlying structures of the abdomen, as well as the normal functioning of the GI and GU systems.

Clinical Safety and Procedures (QSEN): QSEN Competency: Performing an Abdominal Assessment

See the competency checklist for Performing an Abdominal Assessment. You can find the checklists on the Student resources tab of your book page on openstax.org.

Subjective Data

During focused GI and GU subjective assessments, the nurse collects data about the signs and symptoms of GI and GU diseases, including any digestive or nutritional issues, relevant medical or family history of GI and GU diseases, and any current treatment for related issues (Table 27.6). Information gained from the interview process is used to tailor the subsequent physical assessment and create a plan for patient care and education.

Table 27.6: Interview Questions for Subjective Assessment of GI and GU Systems

Interview Questions	Follow-Up
Have you ever been diagnosed with a gastrointestinal, kidney, pancreas, liver, gallbladder, or bladder condition?	Please describe the conditions and treatments.
Have you ever had abdominal surgery?	Please describe the surgery and if you experienced any complications.
Are you currently taking any medications, herbs, or supplements?	Please describe.
Do you have any abdominal pain?	Are there any associated symptoms with the pain such as fever, nausea, vomiting, or change in bowel pattern? Are you having bloody stools (hematochezia); dark, tarry stools (melena); abdominal distention; or vomiting of blood (hematemesis)? When did the pain start to occur? (Onset) Where is the pain? (Location) When it occurs, how long does the pain last? (Duration) Can you describe what the pain feels like? (Characteristics) What brings on the pain? (Aggravating factors) What relieves the pain? (Alleviating factors) Does the pain radiate anywhere? (Radiation) What have you used to treat the pain? (Treatment) What effect has the pain had on you? (Effects) How severe is the pain, on a scale from 0 to 10, with 10 being the worst, when it occurs? (Severity) Where is the pain located? What makes the pain better? Have you had this pain before?
Have you had any issues with nausea, vomiting, food intolerance, heartburn, ulcers, change in appetite, or weight?	Please describe. What treatment did you use for these symptoms? What is your typical diet in a 24-hour period?
Do you have any difficulty swallowing food or liquids (dysphagia)?	Please describe. Have you ever been diagnosed with a stroke or transient ischemic attack?
When was your last bowel movement?	Have there been any changes in pattern or consistency of your stool? Are you passing any gas?
Have you had any issues with constipation or diarrhea?	Please describe. How long have you had these issues? What treatment did you use for these symptoms? If constipation: Has constipation been a problem for you throughout your life? How frequently do you usually have a bowel movement? If diarrhea: Are your stools watery or is there some form to them? How many episodes of diarrhea have you had in the past 24 hours?
Do you experience any pain or discomfort with urination (dysuria)?	Please describe. If you have discomfort while urinating, is the discomfort internal or external? Do you use any treatment for these symptoms?
Do you experience frequent urination (urinary frequency)?	Please describe. Does the frequency occur during daytime or nighttime hours?
Do you ever experience a strong urge to urinate that makes it difficult to reach the bathroom in time (urinary urgency)?	Does this strong urge ever result in a leakage of urine? Does the urge come and go or is it continuous?
Do you have any involuntary leakage of urine when you cough, sneeze, or jump (urinary incontinence)? Do you have difficulty starting the flow of urine?	Have you tried any treatment for this issue?

Abdominal pain should be explored just like any pain in any other body system. When discussing pain with the patient, follow questions in the sequence PQRST for the assessment, as follows:

• Provocation: What started the pain?
• Quality: What does the pain feel like?
• Region (or radiation): make sure you note the location using the quadrants
• Severity or scale: use the numerical pain scale 0–10 or use a pain scale to match the patient’s developmental stage or situation
• Timing: Is the pain worse at certain times of the day, after eating, better with stooling?

The location and the pain elicited will guide the diagnostics steps. For example, pain upon palpation of the LRQ often is associated with referred pain from appendicitis. More examples of pain related to the quadrant system are as follows: pain felt in the RUQ may be from cholecystitis (inflammation of the gallbladder), pain in the LUQ could indicate gastritis (stomach inflammation), pain in the LLQ could indicate colitis (inflammation of the colon). Diagnostic studies to rule out appendicitis like an ultrasound or computed tomography (CT) scan may be ordered.

Objective Data

Physical examination of the abdomen includes inspection, auscultation, palpation, and percussion. Note that the order of physical assessment differs for the abdominal system compared to other systems. Palpation should occur after the auscultation of bowel sounds so that accurate, undisturbed bowel sounds can be assessed. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper, and left lower (Figure 27.6). When assessing the abdomen, consider the organs located in the quadrant you are examining.

Figure 27.6: It is helpful to correlate the anatomic location of the organs within the abdomen in quadrants when completing an abdominal assessment. (credit: modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

In preparation for the physical assessment, the nurse should create an environment in which the patient will be comfortable. Encourage the patient to empty their bladder prior to the assessment. Warm the room and stethoscope (by rubbing with hands) to decrease the likelihood of the patient tensing during the assessment.

Clinical Safety and Procedures (QSEN): QSEN Competency: Preparing for the Abdominal Exam

1. Perform hand hygiene and properly don personal protective equipment, if needed.
2. Introduce yourself to the patient.
3. Verify the patient’s information using name and date of birth.
4. Explain to the patient the steps of the abdominal exam and obtain consent.
5. Position the patient supine. If needed, a small pillow to support the head and underneath the knees may be used.
6. Expose the patient from nipple to lower abdomen, maintaining modesty by using a blanket or gown.
7. Begin the assessment by systematically using the process of “look, listen, and feel.”

Inspection

The abdomen is inspected by positioning the patient supine on an examining table or bed. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The patient’s arms should be at their side and not folded behind the head, because doing so tenses the abdominal wall. Ensure the patient is covered adequately to maintain privacy while still exposing the abdomen as needed for a thorough assessment. Visually examine the abdomen for overall shape, masses, skin abnormalities, and any abnormal movements.

• Observe the general contour and symmetry of the entire abdominal wall. The contour of the abdomen is often described as flat, rounded, scaphoid (sunken), or protuberant (convex or bulging).
• Assess for distention. Generalized distention of the abdomen can be caused by obesity, bowel distention from gas or liquid, or fluid buildup.
• Assess for masses or bulges, which may indicate structural deformities like hernias (abdominal bulges) or be related to disorders in abdominal organs.
• Assess the patient’s skin for uniformity of color, integrity, scarring, or striae. Striae are white or silvery elongated marks that occur when the skin stretches, especially during pregnancy or excessive weight gain.
• Note the shape of the umbilicus; it should be inverted and midline.
• Carefully note any scars and correlate these scars with the patient’s recollection of previous surgeries or injury.
• Document any abnormal movement or pulsations. Visible intestinal peristalsis can be caused by intestinal obstruction. Pulsations may be seen in the epigastric area of patients who are especially thin, but otherwise should not be observed.

Auscultation

Listening with a stethoscope to the abdomen, or auscultation, is done after inspection for more accurate assessment of bowel sounds. Use a warmed stethoscope to assess the frequency and characteristics of the patient’s bowel sounds, which are also referred to as peristaltic murmurs.

Begin your assessment by gently placing the diaphragm of your stethoscope on the skin of the RLQ, because bowel sounds are consistently heard in that area. Bowel sounds are generally high-pitched, gurgling sounds that are heard irregularly. If you do not hear any bowel sounds, continue to listen for 5 minutes within that quadrant before moving on to the next quadrant. Move your stethoscope to the next quadrant (RUQ) in a clockwise motion around the abdominal wall. Listen for 1 full minute per quadrant. Normally, bowel sounds are heard in all four quadrants.

It is not recommended to count abdominal sounds, because the activity of normal bowel sounds may cycle with peak-to-peak periods as long as 50 to 60 minutes. Instead, bowel sounds should be described as normal, hyperactive, or hypoactive. The majority of peristaltic murmurs are produced by the stomach, with the remainder from the large intestine and a small contribution from the small intestine. Because the conduction of peristaltic murmur is heard throughout all parts of the abdomen, the source of peristaltic murmur is not always at the site where it is heard. If the conduction of peristaltic sounds is good, auscultation at a single location is considered adequate.

Auscultation revealing hyperactive bowel sounds may indicate bowel obstruction or gastroenteritis. Sometimes you may be able to hear a patient’s bowel sounds without a stethoscope; this often is described as “stomach growling” or borborygmus. This is a common example of hyperactive sounds. With constipation, after abdominal surgery, peritonitis, or paralytic ileus, there may be hypoactive bowel sounds. As you auscultate the abdomen, you should not hear vascular sounds. If heard, this finding should be reported to the healthcare provider because it could indicate aortic aneurism or renal artery stenosis (Mealie et al., 2022).

Link to Learning

This video on palpating the abdomen reviews this important step of the abdominal assessment. Review how to properly perform both light and deep palpation.

Palpation and Percussion

The term palpation refers to touching of the abdomen using the flat of the hand and fingers (not the fingertips) to detect palpable organs, abnormal masses, or tenderness (Figure 27.7). When palpating the abdomen of a patient reporting abdominal pain, the nurse should palpate the painful area last. Light palpation is primarily used by bedside nurses to assess for musculature, abnormal masses, and tenderness. Deep palpation is a technique used by advanced practice clinicians to assess for enlarged organs.

Encourage the patient to empty their bladder prior to palpation. When palpating the abdomen, ask the patient to bend their knees when lying in a supine position to enhance relaxation of abdominal muscles. Lightly palpate the abdomen by pressing into the skin about 0.5 in. (~1 cm) beginning in the RLQ. Continue to move around the abdomen in a clockwise direction.

Figure 27.7: The correct way to palpate an abdomen is by using the flat part of the fingers. (credit: “DSC 2286 -1024x678 .jpg” by British Columbia Institute of Technology, CC BY 4.0)

Palpate the bladder for distention. Palpate gently from umbilicus down toward the pelvis feeling for a full bladder. The bladder is not normally palpable, but a distended bladder may reach the umbilicus. A full bladder presents as a pelvis mass that is typically regular, smooth, firm, and oval shaped. It arises in the midline. Note the patient’s response to palpation, such as pain, guarding, rigidity, or rebound tenderness. The term voluntary guarding refers to voluntary contraction of the abdominal wall musculature, usually due to fear, anxiety, or the touch of cold hands. Involuntary guarding is the reflexive contraction of overlying abdominal muscles as the result of peritoneal inflammation. Involuntary contraction of the abdominal musculature in response to peritoneal inflammation is called rigidity, a reflex the patient cannot control. And rebound tenderness is another sign of peritoneal inflammation or peritonitis. To elicit rebound tenderness, the clinician maintains pressure over an area of tenderness and then withdraws the hand abruptly. If the patient winces with pain upon withdrawal of the hand, the test is positive.

You may observe advanced practice nurses and other healthcare providers percussing the abdomen to obtain additional data. Percussing can be used to assess the liver and spleen or to determine if costovertebral angle tenderness is present, which is related to inflammation of the kidney.

Abnormalities of the Abdominal Assessment

While assessing the abdomen, it is important not only to recognize normal findings but to recognize abnormalities as well (Table 27.7).

Table 27.7: Abnormal Findings During Abdominal Assessment

Finding	Possible Indications
Caput medusae (distended veins that extend from the umbilicus)	Liver cirrhosis, portal hypertension
Cullen sign (ecchymosis, or bruising, in the subcutaneous fatty tissue below the umbilicus) (credit: “Cullen’s sign” by Herbert L. Fred/Wikimedia Commons, CC BY 2.0)	Hemorrhagic pancreatitis
Distention (credit: “F1: Preoperative appearance of the patient showing abdominal distention” by World Journal of Surgical Oncology/National Library of Medicine, CC BY 2.0)	Constipation, obesity, irritable bowel syndrome, ascites, ovarian cancer, hepatosplenomegaly, intestinal obstruction, ascites, intestinal gas, ulcerative colitis gallstones, food intolerance, pregnancy
Grey Turner sign (ecchymosis along the flank) (credit: modification of “Hemorrhagic pancreatitis – Grey Turner’s sign” by Herbert L. Fred/ Wikimedia Commons, CC BY 2.0)	Intra-abdominal hemorrhage associated with acute necrotizing pancreatitis
Soft abdominal protrusion (credit: “Umbilical hernia 01” by "Saltanat"/Wikimedia Commons, Public Domain)	Hernia (an abdominal organ, usually the intestine, pushes through the muscle of the abdominal wall)

Real RN Stories: Abdominal Pain

Nurse: Sarah, RN
Clinical setting: Emergency department
Years in practice: 8
Facility location: Fort Worth, Texas

I was working in the pediatric emergency department and an 18-year-old patient came in with his mom with a chief complaint of intermittent abdominal pain and diarrhea for the past 2 days. The patient had gone to his primary care doctor the day before for evaluation. Mom reported that the provider evaluated the young man and diagnosed him with a stomach virus. Mom said that at the time of the visit with the doctor, her son was eating and drinking and seemed like he was back to normal. Overnight, the young man woke up with unbearable abdominal pain that caused him to double over and new onset vomiting, which brought him to the emergency department. When I triaged him, it was evident that his pain level was high, and initial assessment showed abdominal distension, hypoactive bowel sounds, and pain on palpation. He also had a fever of 102.4°F (39°C) and was extremely anxious. I alerted the provider immediately to assess the patient. The patient was quickly assessed and sent for imaging, which revealed he had peritonitis caused by intussusception (when the intestine folds into itself). He was sent emergently for surgery. Honestly, I thought it was an appendicitis because that’s what you learn about. Looking back at this history, I realized that his feeling fine on and off but then crying out in pain was from the telescoping of the intestine.

Ascites

Ascites is characterized by abnormal accumulation of fluid in the abdominal cavity. Fluid buildup can be the result of liver disease, heart failure, kidney disease, or cancer. When fluid accumulates in the abdominal cavity, the abdomen will appear swollen and distended (Figure 27.8). The patient often feels discomfort and may have a difficult time breathing. A technique to determine ascites is to check for a fluid wave. Have the patient lie flat with their hands down on the midline of the abdomen. Tap on one side of the flank while holding your palm flat on the other side of the flank. If the tap is felt by the other hand, that means there is free fluid or ascites in the abdominal cavity. If the tap is not felt, the distention may be caused by be caused by other conditions, such as dilated loops of bowel or fat.

Figure 27.8: A patient with ascites. The presence of fluid in the peritoneal cavity causes the abdomen to be distended. A tube is placed to drain the fluid. (credit: “Draining ascites, secondary to hepatic cirrhosis” by John Campbell/Flickr, Public Domain)

Link to Learning

See how a fluid wave test is performed.

Impaired Elimination

Common alterations in bowel elimination include constipation, diarrhea, and bowel incontinence. These alterations are common signs and symptoms in several diseases and conditions of the GI system. Urinary tract infection, urinary incontinence, and urinary retention are common alterations in urinary elimination. See Table 27.8 for a comparison of expected versus unexpected findings when assessing the abdomen.

Table 27.8: Expected Versus Unexpected Gastrointestinal and Genitourinary Assessment Findings

Assessment	Expected Findings	Unexpected Findings (document and notify the provider of any new findings*)
Inspection	Flat or rounded contour (protuberant in children until age 4 years) Intact skin No visible lesions Symmetry of shape and color	Asymmetry Distension Pulsations Scars Skin breakdown Visible peristalsis Wounds
Auscultation	Presence of normal bowel sounds	Absent bowel sounds Hyperactive bowel sounds Hypoactive bowel sounds
Palpation	Absence of masses Absence of pain or tenderness Voluntary guarding	Involuntary guarding Masses noted that are not previously documented Pain on palpation Rebound tenderness Rigidity
Genitourinary	Absence of pain, urgency, frequency, or retention Clear, pale-yellow urine Nondistended bladder	Dark or bloody urine, foul odor, or sediment present Dysuria Urinary frequency Urinary retention, indicated by distended bladder and/or tenderness on palpation Urinary urgency
*CRITICAL CONDITIONS to report immediately		Bloody stools Hematemesis New or worsening melena Signs of dehydration associated with diarrhea and vomiting, such as <30 mL/h urine

Validating and Documenting Findings

After completing the abdominal exam, it is important to validate that objective data found on physical exam is in line with the subjective data gathered during patient interview. If there are discrepancies or inconsistences in the findings, it may be necessary to repeat parts of the exam or clarify questions in the patient interview before formulating the diagnosis. This is crucial because if there are gaps or irregularities and a diagnosis is made on the basis of those incorrect findings, the treatment plan may not address the patient’s chief complaint. For example, if a patient reports profuse vomiting during the patient interview, the patient exam should also reflect that. The patient exam should reflect this to validate the data.

Documentation should be described using the quadrants as a reference. For example, “Rebound tenderness felt with light palpation in the right lower quadrant (RLQ).” Documentation should include results of the following:

• auscultation: description of bowel sounds (normal bowel sounds, hyperactive, hypoactive or absent), bruits
• inspection: shape and contour, skin coloring, visible veins, evidence of bruising, any medical devices such as ostomy bags or gastronomy tubes
• palpation: Both light and deep palpation findings should be documented. Note any masses felt and location on the abdomen. Tenderness and rebound tenderness should also be documented.
• percussion: Sounds heard over each quadrant with percussion may include tympanic sounds over air- and fluid-filled spaces, or dullness over solid organs.