Abdominal Assessment for Nurses

When nurses are looking after a patient they are required to know the condition of the patient on a continuous basis. Each nurse, as a result of this responsibility, assesses every patient she is looking after at the start of the shift so that she can accurately evaluate any changes which may occur subsequently. She can use her initial assessment as a baseline for comparison.

Assessment done by nurses consists of a thorough “head to toe” examination. Nurses have considerable choice on the type of assessment and the amount of detail which is gathered.

Patients in the intensive care unit will be assessed in more detail than those in a retirement home. This does not mean that the patients in retirement homes are less important than those in the intensive care unit. It does mean that the condition of the patient in the ICU is different from those of the retirement home.

A patient in the ICU may need his blood gases monitored hourly because he may be on a breathing machine (ventilator) whereas a patient in a retirement home may need his dietary intake monitored. So, all assessments are geared to the needs of the patient. There is no “one assessment which fits all” for our purposes.

In the “head to toe assessment” the nurse starts the assessment from the head and assesses all the parts of the body. In the “body systems” approach the nurse begins her assessment from the central nervous system and evaluates all systems. These assessments are always documented. In this lecture we are going to learn how to do an assessment of the abdominal system. In order to put all the body sstems in perspective a general discussion of all the systems is included along with key observations.

For this learning exercise the following learner objectives were identified. The tasks which the lecturer will perform in order to communicate the contents of the lecture are identified and stated below. There are questions which each student must attempt. You are advised to answer the questions and then compare your answers with those provided.

Learner Objectives:

• Verbalize understanding of GIS’s anatomy and physiology. Complete labeling exercise.
• Able to identify the location of the stomach, liver, spleen, appendix, larger intestines and small intestines.
• Learners will be able to identify the four quadrants and then identify the organs lying below.
• Able to identify scars, stretch marks, and hernias.
• Students will understand that large abdomens are associated with obesity.
• Understand guarding, rebound tenderness are pathological symptoms.
• Able to verbalize physiology of peristalsis.
• Able to visualize and describe stomach. Large, small, flat, distended.
• Able to auscultate the stomach & hear abdominal sounds.
• Able to palpate the stomach.
• Understand conditions associated with GI system: nausea & vomiting, paralytic ileus, constipation, diarrhea, ascities.

Lecturer Objectives:

• Explain the normal gastrointestinal system’s anatomy and physiology, use power point presentation.
• Explain the location of the stomach, liver, spleen, appendix, larger intestines and small intestines with power point pictures.
• Lecturer will explain the location of four quadrants and then identify the organs lying below.
• Lecturer will identify scars, stretch marks, and hernias using power point presentations.
• Lecturer will explain that large abdomens are associated with obesity and higher incidence of MI.
• Lecturer will explain guarding, rebound tenderness.
• Lecturer will explain physiology of peristalsis. (stretch receptors).
• Lecturer will explain how to visually examine the stomach: Large, small, flat, distended.
• Lecturer will explain how to auscultate the stomach & hear abdominal sounds.
• Lecturer will explain how palpation is done, and differentiate between tympanic and dull sounds.
• Lecturer will explain common conditions of the GIS: nausea, vomiting, hematemesis, paralytic ileus, constipation, diarrhea, ascities.

Example of documenting using the “body systems approach”.

First entry: Date and Time, department:: Nursing: 18th. June 2007. 15.30hrs. In some institutions the recorder states the shift he or she is working. For example: 07.30 to 16.00hrs).

Question 1. Why is it important to document date, time, department and status of employee making the entry in the patient’s progress notes?

Second Entry: The Central Nervous System: This is the most complex system in the body. It is made up of many parts and pathways. The nervous system is divided into the central nervous system (CNS) and the peripheral nervous system (PNS). The spinal cord and the brain constitute the CNS. The main function of the CNS is to get the information from the environment (afferent pathway) and send out instructions (efferent pathways). The peripheral nervous system is made up of all of the nerves and the nerve connections. The PNS sends messages from the brain to the rest of the body via nerve cells.

Example: CNS: Mr. Jones is Alert, Conscious and orientated to time, person, place and situation. Both his pupils are equal and reactive to light, (3mm = bilaterally). No diplopia. This is often abbreviated to PERLA. This word means that the patient’s pupils are reacting, reactive to light and accommodation is present. He is able to move all limbs, equal strength bilaterally. Gait is steady. He scores 15/15 on the Glasgow coma scale.

Question 2: An entry reads, “Pupils are fixed and dilated”. What does this indicate?

Third entry: CVS: T-36.9, HR 88 regular. good volume, peripherally warm and well perfused, Blood Pressure 110/80 mm Hg. capillary refill >5 seconds, pedal and radial pulses present, no ankle edema.

Question 3. Identify the most significant abnormality in this patient”s CVS assessment.

Fourth Entry: Respiratory System: RR 12 breaths per minute, R=L (This is the abbreviated way of stating that the expansion of the right lung is the same as the left lung. Sternum central, equal expansion bilaterally, no adventitious sounds, saturating 100 % on Room Air. Has a productive cough which is getting worse! Suffers from SOB on exertion.

Question 4. Why is it important to observe the central location of the sternum?

Fifth Entry: Abdominal System / Gastrointestinal system:

History: Mr. Jones has not had any bowel activity for the last three days. Passing flatus.

Visual Inspection: His abdomen is large and rounded. There are scratch marks generalized, Abdominal girth is 84 cms at umbilicus (marked). No scars or hernias seen. Appears distended. Also describe skin color e.g . jaundice.

Palpation: No tenderness, no palpable masses, no guarding or rigidity.

Percussion: Resonant sound (underlying gas). Dull sounds = underlying fluid, solid structure, or consolidation.

Auscultation: Abdominal sounds were present but feint upon auscultation.

Question 5: What would you do if a patient you are caring for says, “Sister, I am constipated, I have not passed flatus, and my tummy feels bloated?”

Question 6: One of the most common post-operative complications following abdominal surgery is paralytic ileus. What is the most effective intervention to prevent this condition?

In Australia and UK Abdominal Assessment is done in the following order: Visual inspection, Auscultation, Percussion, Palpation (Q: What is the rationalization for doing the assessment in this order?

In USA: Abdominal assessment is done in the following order: Visual, Auscultation, Percussion, Palpation (Q: What is the rationalization for doing the assessment in this order?).

Sixth Entry: Renal System: This system consists of two kidneys which are essential regulatory organs. They maintain the volume and composition of body fluids by filtration of the blood and selective re-absorption and secretion of filtered solutes (essential products).

Example: Urinary output is more than adequate – if the output is more than half ml/kg of the patient’s weight. If urine is inadequate then you need to document as such and the most appropriate intervention is for you to notify the physician in charge of the treatment. Underlying cause must be treated. Patient has a Foley catheter in situ Size FR 14, silastic, In-line urometer, tolerating catheter well.

Describe the urine: Urine is clear / cloudy / hematuria (say if hematuria is microscopic or frank – visible to the naked eye.

The results of urinalysis must be recorded here and physician notified of abnormalities.

For more details on urinalysis see: healthmad.com

Question 7. What is the range of normal urine pH?

Seventh Entry: Metabolic system. This is the system which controls all the metabolic processes of the body: Chemical and physical changes of the body. An example is the metabolism of carbohydrates through the enzyme known as Insulin. To learn more about hormones and enzymes visit: users.rcn.com

This is a very complex system and will require close monitoring. If a patient is on insulin he/she must be observed closely. In less developed economies the blood sugar is monitored by testing the urine. In better of economies glucometers are used extensively to monitor blood glucose two to three times daily, depending upon the patient’s condition.

Example: Patient is a type I Diabetic (IDDM) he is on 6hrly BSL checks and on sliding scale insulin. His last blood sugar done at 0730hrs was 5.3 mmols pre-breakfast. He is a stable diabetic.

Question 8: What is normal BSL?

Eighth Entry: The integumentary system: This system is commonly called the skin system. It is one of the largest glands of the body. It has multiple functions. These include: protection, production of vitamin D in the presence of sunlight, thermo regulation, conduction of stimuli from the environment to the brain.

Example: The patient’s skin is clean and dry. There are no pressure sores, surgical scars or stretch marks. If there are then describe their location and condition.

If there are skin abnormalities like external bruising, cellulites, hematomas, sun burns, carpet burns, moles, spiders, ring worm etc describe then and specify their location.

Normal skin, when pinched, quickly returns to its normal state. If the patient is dehydrated the skin will maintain the pinched form for many seconds before returning to normal. The skin is innervated with millions of nerves which respond to touch, pressure and pain.

Ninth Entry: Musculo-skeletal Systems: The bony skeletal bones and contractile tissues known as muscles function together as the musculo-skeletal system. In some literature they are treated as two separate systems. The relationship between muscles, bones, tendons and cartilage is very interdependent and it is impossible for one to function without the other.

Description: Assess the patient’s strength or lack of it. Example: Patient is able to (or unable to) raise both hands against gravity. Patient is unable to move right leg.

Patient’s radius bone is not in alignment, appears fractured. Nurses must not diagnose unless they are specially trained to do so.

Tenth Entry: Lymphatic and Immune Systems: The human lymphatic system is made up of many organs, ducts, and nodes. These transport “lymph fluid” around the body, filter blood of bacteria and distribute immune cells, nutrients and hormones throughout the body. The lymphatic system consists of immune cells called lymphocytes. The lymphocytes protect the body against antigens (viruses, bacteria, fungi, pollens, foreign proteins etc.) which invade the body.

Description: The patient has enlarged lymph nodes in the neck and maxilla. These are painful upon touching. These have been increasing in size since September of last year.

Eleventh Entry: Excretory systems: The excretory systems of the body include the urinary system, the large intestine, the lungs, the skin, the liver and the Malphigian tubule systems. All these systems have been discussed elsewhere and will not normally be assessed independently.

Twelfth Entry: The Endocrine System: This system is made up of ductless glands sometimes called exocrine glands. These glands release hormones which influence other organs, cells, and body systems. It is instrumental in regulating metabolic rates (thyroxin), mood, and tissue functioning. Reproductive processes and sexual functioning is also regulated by hormones.

Exocrine glands: Made up of sweat and salivary glands. They release secretions in the skin or inside of the mouth. Endocrine glands, on the other hand, release more than 20 major hormones directly into the bloodstream where they can be transported to cells in other parts of the body.

Example: The patient is feeling tired and lethargic. His heart rate is normal, he normally sleeps seven to eight hours daily. Lately he has been sleeping more than 14 hours each day. He is known to be on thyroxine but he has not taken his medications because these were not available at the community pharmacy.

Final entry: You must sign and date your assessment. It is a legal document and no changes should be made after the entry. You can add addendums at different times if you have made an error or two.

Question 9: Name the parts labeled A to K and state the quadrant in which each part is located. Note: some parts are not located in the abdominal cavity. Answers are given at the end of these notes (picture by Sarjeet S. Gill).

Question 10: How would you describe this abdomen? Answer: VERY LARGE ABDOMEN. Children may call it “gynormous”.

Answers:

Answer to Q1: To be able to identify the employee and the event(s). Appropriate weight can be given to the information by subsequent care givers.

Answer to Q2. Fixed and dilated pupils are associated with cerebral hypoxia. In comatose patients fixed and dilated pupils are related to a poor prognosis. They are one of the confirming signs of brain death.

Answer to Q3. The most significant abnormality in this patient’s CVS assessment is the capillary refill. Normal capillary refill is less than 3 seconds.

Answer to Q4. It important to observe the central location of the sternum to rule out tension pneumo-thorax and major rib cage damage.

Answer to Q5. The most appropriate action would be to do an abdominal assessment and then to notify the physician of your findings. The goal here is to identify intestinal obstruction as soon as possible.

Answer to Q6. Early ambulation prevents this condition.

Answer to Q7. Normal urine pH value is from 4.5 to 8.0

Answer to Q8. Normal BSL is 3.5 to 8.0 mmols

Answers to Q9.

Answer to Q10. Very large rounded abdomen.

In conclusion it must stated that the human body is very complex and functions well as an entity. The subdivisions made by Nurses and Doctors are artificial. However, these divisions make it easier to understand study the body.