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.   

PERCUSSION

Percussion is done to determine the size and density of the structures and organs inside of the abdominal cavity, and to detect the presence of air or fluid.  While you may use direct percussion, indirect percussion enables better patient comfort (especially if he/she is presenting with a complaint of abdominal pain).  To perform indirect percussion, place your hand on the abdominal wall and sharply tap your middle finger with the index finger of the other hand.  Percussion is CONTRAINDICATED in patients with suspected aortic aneurysm, appendicitis, or those who have received abdominal organ transplants.  Just as you did with auscultation, divide the abdomen into regions and use percussion systematically, always remembering to keep a mental picture of the structures in that region.  Percussion sounds will change based upon what structure is below.  Solid structures, such as the liver, produce dull sounds.  Fluid-filled structures, such as a full urinary bladder, also produce dull sounds.  Air-filled structures, such as the stomach, produce tympany sounds.   The liver and spleen can be measured using percussion. 

Normal findings on percussion include tympany over the stomach, epigastric area, and upper midline, and dullness over the liver, a full bladder, a pregnant uterus and the left lower quadrant over the sigmoid colon (if the patient is ready to have a bowel movement). The typical upper and lower liver margins are 6 – 12 cm apart.  The spleen is typically located between the sixth and tenth rib.

TABLE OF NORMAL TONES THAT MAY BE PERCUSSED

Most Dense					Least Dense
AREA	Muscle, bone	Liver, Spleen	Lung	Emphysematous Lung	Gastric Air Bubble
TONE	Flat	Dull	Resonant	Hyper-resonant	Tympanic
INTENSITY	Soft	Medium	Loud	Very loud	Loud
PITCH	High	Medium	Low	very low	High
DURATION	Short	Medium	Long	very long	Medium

Be sure to return to the site next week, when we will add Palpation to our continuing series on Abdominal Assessment.