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E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to the normal
● Pursue more specific tests and assessments regarding abnormal
findings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● Gait and posture and symmetry of joints, muscles, and extrem-
ity length.
● Note the joint’s range of motion and the extent to which it
can be moved. Record and report any abnormalities found.
● Note in the patient’s record the muscle tone and strength
that were observed and report any abnormalities found.

PROCEDURE 4.9
Assessing the Abdomen
OVERVIEW
● The abdominal assessment is routine in a physical examination and
is performed on patients of all ages.
● The abdominal cavity contains several of the body’s vital organs and

can provide valuable clues as to the patient’s diagnosis and condition.

P R E PA R AT I O N
● Landmarks help the nurse map out the abdominal region.
● Assessment involves examination of organs and tissues anteriorly
and posteriorly.
● Patients must be relaxed, warm, and provided privacy for the exami-

nation.
● Adequate light is essential for inspection and visualization during

examination.
● Nurse must begin with inspection then follow with auscultation.

Special Considerations
• The nurse must begin with inspection and then follow with
auscultation.
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P r o c e d u r e 4 . 9 Assessing the Abdomen 101

• Palpation and percussion may alter the frequency and character of

bowel sounds.
• During auscultation, the nurse asks the patient to refrain from talk-
ing. If the patient has a nasogastric tube or an orogastric tube con-
nected to suction, it should be turned off so that the sound from
the suction will not obscure the bowel sounds.

R E L E VA N T N U R S I N G D I A G N O S E S
● Nutrition, altered related to infection
● Pain related to injury

EXPECTED OUTCOMES
● Assessment completed while maintaining patient’s privacy and
comfort
● Awareness of cultural and traditional health practices

EQUIPMENT/SUPPLIES
Stethoscope
Ruler or nonstretchable measuring tape
Marking pen

I M P L E M E N TAT I O N
➧ Wash hands.
Reduces transmission of microorganisms.
➧ Explain procedure to patient.
Explanation reduces the patient’s anxiety.
➧ Position the patient supine with arms down at sides, and place a
small pillow beneath the knees.
Supine position facilitates the examination of the entire abdomen. Pillow
supports the patient’s back.
➧ Provide adequate cover for the patient.
This helps to reserve the patient’s privacy and provide warmth before pro-
ceeding with rest of the assessment.
➧ The nurse must stand on the patient’s right side and sit in a position
to look across the abdomen’s surface.
Standing helps detect abnormal shadows and movement. Sitting position
provides horizontal view that allows detection of abnormal protuberances
and contours.
➧ Divide the abdomen into four quadrants.
Landmarks help the nurse map out the abdominal regions.
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102 C h a p t e r 4 Physical Assessment

Inspection
➧ Inspection.
Examiner needs to make sure the patient is disrobed and provide privacy
with adequate covers and warmth of the examination room.
➧ Inspection of skin.
The location of scars, venous patterns, rashes, lesions, pigmentation
changes, and stretch marks are noted. This can help identify previous
surgeries or trauma and show if skin has been stretched from obesity
or pregnancy. Striations can also signal possible adrenal problems.
➧ Inspection of umbilicus.
Normally the umbilicus is flat. You may notice a different shape or color,
which could indicate pathology.
Underlying masses may displace the umbilicus, and an everted umbilicus
indicates distention.
Watch for umbilical discharge; this is an abnormal sign.
➧ Inspect contour and symmetry.
The presence of a mass or masses on one side may indicate a problem.
Intestinal gas, tumor, or fluid in the abdomen may cause distention.
Do not confuse distention with obesity.
● Observe the abdomen while asking the patient to take a deep
breath.
This moves the diaphragm downward and decreases the size of the abdomi-
nal cavity; any enlarged organs may cause a bulge.
● Observe the abdomen while the patient raises his or her hands
over the head.
This helps to evaluate the abdominal musculature. Any hernias, masses,
and muscle separation will become more apparent.
➧ Inspect for movement and pulsations.
With pain, respiratory movement is diminished, and the patient may guard
against the pain by tightening the abdominal muscles. (Women breathe
costally, and men breath more abdominally.)
Looking across the abdomen, the nurse may see peristaltic movement and
aortic pulsations (midline, above the umbilicus).
Auscultation
➧ Auscultation.
Auscultation comes next in the physical examination.
The examiner should listen to bowel sounds before palpating or percussing.
These actions will stimulate bowel action and provide unreliable data for the
examiner.
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P r o c e d u r e 4 . 9 Assessing the Abdomen 103

➧ Warm the diaphragm of the stethoscope, and with light pressure

auscultate in all four quadrants to detect normal, high-pitched
bowel sounds.
Sounds are normally described as
Normal
Audible
Absent—absence of gastrointestinal motility and a late stage of bowel
obstruction
Hyperactive or hypoactive—Hyperactive sounds indicate hypermotility
caused by inflammation of the bowel, anxiety, diarrhea, bleeding, excess
ingestion of laxatives, and reaction of the intestine to certain foods.
You must listen 5 to 15 seconds in each quadrant.
➧ Place the bell of the stethoscope diaphragm over the epigastrium
to auscultate for bruits, which manifests as a whooshing or blowing
sound. Renal-artery bruits can be heard by placing the stethoscope
over each upper quadrant anteriorly or over the costovertebral angle
posteriorly.
If a bruit is heard, it is not normal and should be reported to a physician
immediately.
➧ Place bell of the stethoscope above the liver and spleen and listen
for a friction rub.
An inflamed liver or spleen may rub against the peritoneum during inspira-
tion, creating a grating sound.
Percussion
➧ Percussion.
Percussion allows the examiner to determine borders of the spleen, liver, and
other major organs in the abdomen. It also provides information regarding
presence of fluid in the abdominal cavity.
➧ Systematically percuss each quadrant to assess areas of tympany
and dullness.
Tympany is percussed when there is air in the stomach or intestine. Dull
percussion is heard over solid masses as in an enlarged liver, spleen, tumor,
or a full bladder.
➧ Percuss to identify the liver border by starting at the iliac crest and
proceeding upward on the right midclavicular line. As you percuss
upward, the percussion note changes from tympanic to dull at the
liver’s lower border. (Mark the point.) The upper border is found by
percussing downward from the nipple along the midclavicular line.
When the note changes from resonance to dull, make a mark. The
distance between the points should be 6 to 12 cm.
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104 C h a p t e r 4 Physical Assessment

Percussion allows the nurse to identify borders of the liver and to detect any
organ enlargement. Diseases such as cirrhosis, cancer, and hepatitis can
cause this liver enlargement.

➧ Percuss for the gastric air bubble in the left lower anterior rib cage
and left epigastric area.
Note: The tympany heard when percussing the gastric bubble is lower in
pitch than the tympany of the intestines.

➧ Have the patient sit or stand erect to assess for kidney inflammation.
With the ulnar surface of a partially closed fist, percuss the costover-
tebral angle at the scapular line.
If the kidneys are inflamed, the patient will feel tenderness during percussion.

Palpation
➧ Palpation.
Palpation is the last process of the abdominal examination and provides the
examiner with data concerning areas of tenderness and presence of fluid,
masses.

➧ Hold the palm of your hand and forearm horizontally and lightly
palpate each quadrant.

FIGURE 4.9 Light palpation.

● Superficial palpation (1 cm)

● Deep palpation (2.5 to 7.5 cm). If you are experienced, you may
do this.
You are palpating for muscular resistance, distention, tenderness, and
superficial organs or masses.

➧ Wash hands.
Reduces transmission of microorganisms, which could cause infection.
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P r o c e d u r e 4 . 1 0 Assessing the Neurologic System 105

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Pursue more specific tests and assessment regarding abnormal
findings if warranted

KEY POINTS FOR REPORTING AND RECORDING

● If patient has abdominal or lower back pain, record the pain
in detail (location, onset, frequency, severity, precipitating fac-
tors, aggravating factors).
● Assess normal bowel habits and any history of changes.
● Determine if patient has had abdominal surgery or trauma to
the abdomen in the past.
● Assess for difficulty swallowing, heartburn, black or tarry
stools, diarrhea, or constipation.
● Determine if patient is pregnant, and note last menstrual
period.
● Ask patient about history of alcohol or aspirin intake.

PROCEDURE 4.10
Assessing the Neurologic System
OVERVIEW
● To determine alteration in neurologic functions such as initiation
and coordination of movement, reception and perception of sensory
stimuli, organization of thought processes, control of speech, and
storage of memory.
● To determine a cause for level of consciousness (LOC), mental/emo-

tional status, and to determine if there are any alterations in central

or peripheral nervous system. Identification of specific patterns may
aid in the diagnosis of a pathologic condition.

P R E PA R AT I O N
● Neurologic assessment can be time consuming, and the examiner
must not rush through the assessment process.
● An efficient nurse can integrate neurologic measurements with

other parts of a physical examination. Example: While taking the his-

tory, the nurse can note the patient’s mental and emotional status.