When examining the abdomen, two organ systems are con-cerned – the gastrointestinal and urinary systems.
All the important organs (liver, gallbladder, spleen and pancreas), related closely to the intestinal tract functionally are dealt with under gastrointestinal heading.
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Most common complaints and the important questions con-nected with them, required for an accurate diagnosis, are en-listed below.
Abdominal pain
One of the most common complaints, it is worth to clarify:
• location of pain (e.g. right hypochondrium – pain in the area of gall)
• direction of radiation (e.g. liver and gall pains radiate to the right scapula, in case of pancreatitis pain occurs belt-like in the vicinity of navel)
Figure 9 The mechanism of PF decrease and increase
Figure 10 Topographical percussion order of the lung
Figure 11 Comparative auscultation points of lung on the back
304 Textbook of Nursing Science Chapter 13 Introduction to Examination of Patients 305
• character of pain (burning, caustic, stabbing, spastic)
• duration of pain (long lasting, durable pain in the gallb-ladder caused by stones)
• relation of pain to having meals (pain in duodenal ulcer relieves when having meals)
• medication responsiveness of pain (taking antacid relie-ves complaints in case of gastric ulcer)
• other accompanying complaints (vomit, diarrhoea, bloo-dy stool)
• potential correlation with defecation
Appetite, lack of appetite, “repugnance “ to food
Lack of appetite is important, although it is not a symp-tom informative enough of gastrointestinal disease in several cases. On the one hand, it can be a general symptom of upper respiratory infection, on the other hand you can encounter decreasing appetite symptom in elderly people without any special reasons.
Nausea, regurgitation, vomit
Like in the previous case, nausea and vomitting can be ac-companying symptoms (mostly not a specific one) of several
clinical diseases. Regurgitation (flowing back) means that the abdominal content flows back into the oesophagus, though it does not empty out (remains in the body). It is important to emphasize the increased risk of aspiration and airway obstruc-tion in both cases (regurgitaobstruc-tion, vomitting). It has to be taken into account importantly in case of patients who suffer from mental confusion.
In case of vomiting the content of vomit is worth being inspected because fresh or digested blood in it can be an im-portant pathognomonic sign (symptom of disease).
Dysphagia (difficulty in swallowing), odynophagia (pain-ful swallowing)
Dysphagia occurs mostly as a subjective complaint of the patient, without any detectable reason (narrowing) in several cases.
Painful swallowing can appear in oesophageal diseases and often in cases of upper airway, larynx, pharynx inflamma-tions as well.
The gastrointestinal reasons of difficulty in swallowing and painful swallowing are similar: inflammation of oesophagus (oesophagitis), achalasia (spasm of the lower sphincter of
oesophagus), oesophageal-/cervical tumour, other external pressure, diaphragmatic hernia, pains of the nervous system and muscular pains.
Heartburn (pyrosis), hiccup (singultus)
In case of pyrosis the patient experiences burning pain be-hind the sternum and /or in epigastric region (cardiac orifice), which can radiate to the throat. Symptoms, similar to pyrosis, can be caused by angina pectoris or heart muscle infarction (myocardial infarction), it is advisable to obtain information about cardiac- like complaints.
In the course of hiccup diaphragm contracts abruptly, spontaneously, which is accompanied by specific sound. Be-hind hiccups there may be thoracic and abdominal organs, irritation of respiratory system but the reasons are not always known.
Distention, increased gas forming
Gas content is accumulated in the bowels, which is experi-enced as a subjective complaint, a sensation of being distend-ed (inflatdistend-ed) .Accumulatdistend-ed gases (mainly before significant narrowing) lead to tension of the smooth muscles of bowels, causing strong pain by this.
Components having an impact on gas formation and accumula-tion:
1. More gases are /are formed in the bowels because pa-tients swallow more (like an infant) or after consuming certain food more gases are formed.
2. Blood supply of the intestinal tract deteriorates, as a re-sult absorption of gases is slowed down (in the region of vena portae in case of congestion e.g. liver cirrhosis) 3. Emission of gastrointestinal gases is blocked mainly
be-cause of the deterioration of intestinal peristalsis.
Obstipation, diarrhoea, dyschezia, bloody stool, melaena Deceleration of peristalsis in case of obstipation or consti-pation generally leads to defecation less often and change in stool consistency (dry, solid). In case of diarrhoea the patient empties more fluid stool than usual, which is accompanied by defecation increased in frequency and quantity. Other in-dicators of obstipation and diarrhoea can be found in other chapters.
Most common reasons of painful defecation are inflam-mation of anus, fissure of anus-region, inflaminflam-mation of piles (haemorrhoids).
Melaena generally originates from a higher intestinal por-tion, it is black, creamy-like stool, which is partly digested and decomposed by bacteria. Bloody stool or melaena are highly suggestive of potential gastrointestinal tumours.
As far as other specialities of defecation are concerned, we refer to previous chapters.
Icterus (jaundice)
Jaundice can occur for several reasons. These can include the potential change in the systems, functions mentioned below:
• increased degradation of red blood cells, increased for-mation of bilirubin
• decreased bilirubin intake of the liver
• decreased capacity of liver to convert bilirubin
• blockage of the bile duct system in the liver or outside it, deceleration of excretion, discharge
In case of icterus, the colour and quality of urine and stool, the further inspection and examination of their com-ponents may play an important role in making a differential diagnosis.
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stablishinganamnEsisincasEofdisEasEsinurogEnitalsytEm
Diseases of the urogenital system are dealt with by specialists of several fields.
Complaints experienced during health problems in kidney, ureter, urinary bladder are described in this chapter.
Abdominal, lumbar region pain, pain occurring during urinating
In case of diseases of the urogenital system, as in case of gastrointestinal diseases, it is advisable to distinguish:
• distinctive features of pain (strong, dull – inflammation of the renal pelvis (pyelitis), convulsive)
• location (e.g. renal region, lumbar region - kidney)
• direction of radiation (radiating along the ureter - stone)
• duration of pain (when urinating - inflammation of uri-nary bladder)
• concomitant complaints (vomit, nausea, blood in the uri-ne)
Abnormalities in urination in frequency and urine quantity
Every patient must be interviewed about general com-plaints, including abnormalities of urination and urine.
To make an accurate assessment, it is necessary to know:
• how much liquid the patient has consumed (water, ref-reshments, soup etc. altogether)
• what other condition there is which leads to loss of li-quid in his case
• what medication he/ she takes (especially diuretics) After obtaining these details, it is advisable to assess abnor-malities of urination and urine.
It must be emphasized that the increase in frequency of urination does not necessarily mean the urination of bigger quantity urine (polyuria).
It is suggested to ask the patient who has complaints of frequent urination how much liquid they take in on a single occasion.
Small quantity of urination (oliguria) or anuria – taking into consideration the above mentioned- may indicate the pa-tient’s severe condition, so the cause reasons must be found quickly.
Normal sounds Alveolar sound Features:
• Created by airflow into the alveoli
• Can be heard only on inspiration Trachea-bronchial sound (tube sound) Features:
• Created by airflow in trachea and main bronchi.
• Can be heard through inspiration and expiration, (though it is stronger on expiration)
• Normally it is not transmitted to alveoli
• It can be heard best between the two scapulae, slightly on the right side of the spine Abnormal sounds
Pleural sounds Features:
• Can be heard on inspiration and expiration
• Can be heard better above lung base (its intensity is affected by breathing deviation)
• It sounds superficial, reminds of door creaking
• It can be heard above the affected pleura portion
• The intensity and character of murmur depends on fibrin and fluid content Bronchial sounds
Features:
• Its character depends on the diameter of bronchus, the quality of mucus, air content of lung vicinity
• Sticky discharge (mucus) causes ’dry’, more fluid ‘ moist’ rale
• If lung is infiltrated around dry rale can be heard louder as if pneumatised tissue surrounded it
• Generally can be heard on inspiration Table 1 Classification of breath sounds
Bloody urine (haematuria), abnormalities in urine colour and quality
Haematuria does not necessarily mean visible blood in urine (macroscopic haematuria), blood can often be detected only by laboratory tests (microscopic haematuria).As the pres-ence of blood can rarely be considered normal in urine (e.g.
during menstruation), the reason for it must be detected.
We refer to previous chapters for more on this matter.
Problems with voluntary control of urination
It comprises the whole spectrum from the inability to hold urine to urine retention. It is important to recognize the sever-ity of problems with voluntary control and to determine the problems behind the disease .Such causes may be:
• diseases of the nervous system/ systemic diseases affec-ted by the nervous system
• urogenital inflammation
• gynaecological diseases
• prostate diseases
• side effects of medication
As far as the other details are concerned, we refer to the previ-ous chapter, as well as the knowledge obtained in your further studies.
Before the examination of the abdomen, you should re-member the localization of abdominal organs and the posi-tion in accordance with each other. As several organs in the abdominal cavity overlap each other, in case of complaints it is more difficult to distinguish the affected organ.
It is useful to divide the abdomen into regions to make finding directions easier.
This division can be carried out in different ways. The sim-plest way is to divide the abdomen into 4 quadrants, by the help of the vertical line drawn in the median of the body and horizontal section placed on the navel (Fig.12/A).
According to another alternative, the abdomen is divided into 9 regions as displayed in the figure (12/B), the regions determined this way, can localize the potential abnormality more precisely.
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nspEctionIn general, abdomen is inspected on the patient lying on his back.
You ask the patient to make his abdomen free so that the whole abdomen and inguinal region can be determined easily.
The following are to be observed on the abdomen:
1. How high the abdomen is located in comparison with the chest level (it is located higher in case of e.g. ascites, meteorism, bigger tumour)
2. What abnormalities can be found on the skin (e.g. caput medusae, scars of previous operations)
3. If the navel or other portions of the abdominal wall are protruding (because of hernia)
4. If there is a region which does not take part in abdomi-nal breathing (circumscribed peritonitis)
5. If the abdomen is asymmetric.
6. If peristalsis can be observed on the abdomen (in case of thin individuals peristalsis can normally be seen).
It is easier to judge the more relaxed abdominal wall, the pres-ence of potential hidden hernia in a standing position.
Sometimes it is necessary to observe the anus and genital organs besides the abdomen to evaluate the gastrointestinal as well as urogenital system thoroughly.
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uscultationAuscultation provides several important details, mainly about the function of bowels. After inspection, examination must always be followed by auscultation. This must be done before palpation and percussion, as these treatments can change bowel sounds, so may provide false information for the examin-er (small video) (http://tamop.etk.pte.hu/apolastan/english.html).
Initially, sounds accompanying bowel functions must be observed in case of a patient in a lying position. Binaural stethoscope must be placed on navel region and abdomen must be listened to for a long time. As sounds are conducted relatively well in the abdomen, it is sufficient to listen to some places in the 4 quadrants of the abdomen.
Bowel functions are sometimes slowed down, so it may be necessary to perform auscultation for several minutes in order to be able to recognize the presence/the type of peristalsis.
As well as bowels the bigger vessels located in the abdo-men can be heard (abdominal aorta, renal femoral artery, ar-tery iliac, arar-tery (in inguinal fossa).
Auscultation points of arteries are indicated in Figure 13.
In case of a healthy individual healthy bowel function is indicated by bubbling sounds which accompany pe-ristalsis.
When listening over abdominal vessels, normally they cannot be heard, as blood flow in vessels is laminar, which is soundless. In pathological cases in case of narrowing of a spe-cific vascular portion (abdominal aorta, renal artery, common iliac artery) some “swishing” sounds can be heard.
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alpationAs well as auscultation, palpation is the other important ex-amining method of the abdomen.
Palpation has three main objectives in the course of ab-dominal examination:
• to assess muscular defence (defense musculaire) and compression sensitivity
• to assess other abdominal deviations (e.g. hernias)
• to look for pathological resistances
Before starting palpation, instruct the patient lying in the su-pine position to draw his legs flexed in knees, relax abdominal muscles, place arms at the sides.
If the patient identified pain localised on the abdomen when establishing anamnesis, then the identified area must be palpated last. So the patient’s further, painful mus-cular defence can be avoided. The examiner can perform palpation of the abdomen either by one or by two hands.
When palpating by both hands, hands can be held either next to each other or on each other. This is displayed in Figure 14.
In the course of examination take the position opposite the patient, standing on his right side. Palpate each quadrant of the
abdomen, keeping your fingers in stretched position. Palpation should be started from the left lower quadrant of the abdomen, as the patient is less likely to have complaints here. (small video) (http://tamop.etk.pte.hu/apolastan/english.html)
Light and deep palpation can be distinguished in perfor-mance.
Performing light palpation the following information can be obtained:
1. assessment of muscular defence (rigidity or guarding) 2. detection of painful regions
3. palpation of the upper layers of abdomen (skin, lesions in tissues underlying the skin, hernias)
In the course of deep palpation you try to obtain informa-tion about the organs lying deeper, their deviainforma-tions and abnormalities. In normal conditions the abdomen is tender, palpable, no pathogenic resistance and masses can be de-tected.
When palpating, it is important to know the borders of ab-dominal organs and their projection on the abab-dominal wall.
Pathogenic, reflexive, spontaneous consolidation of the abdominal muscle, so called “defense musculaire” is a sign of membrane inflammation.
It is important to distinguish if it is a diffuse or circum-scribed symptom when a lump/ compression sensitivity is experienced. Diffuse process refers to peritoneopathy, while the causes of circumscribed deviations can be different de-pendent on the abdominal regions.
• Right upper quadrant: gallstone, inflammation of gallb-ladder, liver diseases
• Epigastrium (cardia region): left lobe of liver (norm), pancreatic pseudocyst, gastric ulcer/tumour, oesopha-gus irritation, transverse colon tumour
• Left upper quadrant : enlargement of spleen/spleen di-sease, pancreatic cyst, inflammation/tumour of the spe-cific portion of large intestine
• Right lower quadrant: Crohn’s disease, appendicitis, di-sease of specific portion of large intestine, didi-sease of the ovaries/fallopian tubes
• Navel region: hernia, aorta aneurism, peritonitis
• Region above pubic: uterus, diseases of bladder
• Left lower quadrant: colonic diverticulum, sigmoid and colon descendent disease, disease of the ovaries/fallo-pian tubes
Palpation of the liver
It is recommended to perform the palpation of the liver after the complete, light and deep palpation of the abdo-men, as if the liver is enlarged, exceeds its normal size (it may exceed the right costal arch border by several centi-metres), then the following is not expected to be carried out.
If the border of the liver could not be palpated, then exami-nation is the following:
Figure 12 Picture A divides the abdomen into 4quadrants while Picture B shows the borders the abdomen divided into 9 regions
Figure 13 Auscultation points of abdominal veins
Figure 14 Two-handed abdominal palpation
308 Textbook of Nursing Science Chapter 13 Introduction to Examination of Patients 309 While standing opposite the patient in supine position
(lying on the back), place both your hands under the right costal arch then move them to the border of the costal arch, press them under the costal arch and try to reach the border of the liver. The border, the edge, the anterior surface of the liver can be determined more precisely if the patient is in-structed to take a deep breath when the liver moves down, so it can be reached more easily. On inspiration, the liver moving down falls over under your finger, while its edge can be felt.
The size of the liver must be measured on inspiration (how far it exceeds the costal arch in transverse fingers or centimetres) (small video – http://tamop.etk.pte.hu/apolastan/english.html)
When examining the liver, information must be obtained about the following:
Size of the liver, palpation, sensitivity, border, surface Enlarged liver with uneven surface (with nodules) may re-fer to cirrhosis, while enlarged liver with flat surface may rere-fer to fatty degeneration (steatosis). In case of liver enlargement, symptoms of increased pressure must be looked for within the system of portal vein, like caput medusae, pathogenic fluid effusion -accumulation (ascites).
Palpation of spleen
Normal size spleen can be palpated only in a special case (in very deep diaphragmatic position). Its examination is similar to that of the liver; only you try to reach under the left costal arch. If the patient takes a deep breath, it does not help to reach the spleen, so this manoeuvre is not applied frequently.
However, the spleen can be reached more easily if the pa-tient is examined turning on his right side.
Behind spleen enlargement several infectious-, or haema-topoietic, lymphatic diseases can be supposed.
Palpation of the kidneys
Kidneys can be palpated only in thin individuals. Palpation of kidneys is a difficult job and requires experience, so its ap-plication does not provide new information for the diagnosis in many cases.
During the examination you place one of your hands in the lumbocostal angle of the patient lying in supine position, while your other hand palpates from upwards (in accordance with the position of kidneys).You try to lift the kidneys by bal-lottements –slight pushes- with your lower hand, making them palpable between your two hands by doing so.
As kidneys generally cannot be palpated (with the excep-tion of thin patients), so if they become palpable, it may refer to enlarged kidneys, the presence of kidney cyst.
Palpation of the abdomen can be completed by rectal digital examination as well as by examination of external re-productive, genital organs, concerning their characteristics reference should be made to your further studies.
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ErcussionofthEabdomEnPercussion of the abdomen, as a physical examining method from among the others has more restricted importance. The region of the abdomen cavity, not covered by costal arches is mostly made up of bowels, which produces normal tympanic sounds when percussing. In normal conditions the size of pa-renchymal /compact organs (liver, spleen) as well as organs filled with fluid (urinary bladder) can be estimated simply, as their percussion sound is dull unlike the other regions of the abdomen. (http://tamop.etk.pte.hu/apolastan/english.html)
Percussion of the abdomen is also performed on the
Percussion of the abdomen is also performed on the