This content is based upon The Correctional Nurse Educator class entitled Abdominal Assessment: Basic Assessment for the Correctional Nurse.
The physical examination of the patient begins with inspection. Unique to the sequence of the abdomen, the abdomen is then auscultated, percussed and finally, palpated. Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds. In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort. When completing the physical examination, it is helpful to divide the abdomen into regions in order to consider which organs are involved. A four-quadrant system – left upper quadrant, left lower quadrant, right upper quadrant and right lower quadrant provides a more general overview, and is acceptable in situations when there is no abdominal complaint. The nine-region system provides more specific information if the patient is complaining of discomfort or problems in a certain area. The nine regions include the following: right hypochondriac (upper) region, right lumbar (middle) region, right iliac (lower) region, left hypochondriac (upper) region, left lumbar (middle) region, left iliac (lower) region, epigastric region, umbilical region, and hypogastric (suprapubic) region.
Perform auscultation before percussion and palpation because manipulating the abdominal wall may increase bowel sounds or produce sounds that are not usually present. Make sure that your hands and the stethoscope are warm so that the abdominal muscles do not contract on contact. Auscultation should be performed systematically by quadrant. Using the diaphragm of the stethoscope will allow you to hear high-pitched sounds. Normal bowel sounds are not constant, and so it is important to listen for about a minute over each quadrant. In order to conclude that bowel sounds are absent, one must listen for three to five minutes (and hear nothing). Be sure to pick up the stethoscope as you move from quadrant to quadrant (do not drag it across the abdomen). Remember that the thickness of the abdominal wall may affect auscultation, and so the bowel sounds of an obese person may be more difficult to hear. Once all quadrants are auscultated with the diaphragm, use the bell to auscultate vascular sounds, bruits and friction rubs. To do this, listen over the aorta, and the iliac, femoral and renal arteries.
Expected sounds include peristaltic, high-pitched, gurgling noises about every five to fifteen seconds in an irregular pattern. They may be loud if the patient is hungry or has missed a meal.
Abnormal findings that may be present on Auscultation
Bruits – a swishing sound heard over the aortic, renal, iliac, and femoral arteries, indicating narrowing or aneurysm
Pops/tinkles – high-pitched sounds suggesting intestinal fluid and air under pressure, as in early obstruction
Rushes – rushes of high pitch sounds that coincide with cramping suggest intestinal obstruction
Borborygmi – increased, prolonged gurgles occur with gastroenteritis, early intestinal obstruction, and hunger
Rubs – grating sounds that vary with respiration. Indicate inflammation of the peritoneal surface of an organ from tumor, infection, or splenic infarct
Venus hum – A soft humming noise heard in hepatic cirrhosis that is caused by increased collateral circulation between portal and systemic venous systems
Decreased/absent sounds – Occurs with peritonitis or paralytic ileus
Be sure to return to the site next week, when we will add Percussion to our continuing series on Abdominal Assessment.