Structure & Function:

Linea Alba

Structure & Function:

Viscera

Structure & Function:

Solid Viscera

Maintain a characteristic shape

Ex: Liver, pancreas, spleen, adrenal glands, kidneys, ovaries and uterus

Structure & Function:

Hollow Viscera

Depends on the contents

Ex: Stomach, gallbaldder, small intestine, colon, bladder

* Usually not palpable unelss distended with feces or bladder or inflammed

Structure & Function:

Where is the stomach? Gallbladder? Small Intestines?

Stomach: Below the diaphgragm, between the liver and spleen

Gallballder: Under the posterior surface of teh liver, lateral to right midclavicular line

Small Intestine: Located in all 4 Quadrants (Extends from stomach's pyloric valve to the ileocecal valve in the RLQ, where it joins in the colon)

Structure & Function:

Spleen

Where?

Spleen: Mass of Lymphatic tissue on the postlateral wall of the abdominal cativy, under the diaphgragm (LUQ) - 10th rib to the 11th rib

Normally not palpable -

If it becomes enlarged, its lower pole moves downward and toward the midline

Structure & Function:

Aorta

Location?

Left of midline in Upper abdomen

Behind the peritoneum and 2cm below the umbilicus

Bifurcates to right & left iliac arteries

Iliac arteries become Left & Right femoral - Pulsations are easily palpated halfway between the anterior superior iliac spine and symphysis pubis

Structure & Function:

Pancreas

Where?

Structure & Function:

Kidneys

Where?

Posterior to abdominal contents and peritoneal cavity

Protected by ribs

Structure & Function:

Costovertebral Angle

12th rib forms an angle with the verebral column

Left kidney lies right there

Left kidney is 1-2 cm higher then the right kidney 

Left kidney is not palpable

Structure & Function:

Four Quadrants: Right Upper Quadrant (RUQ)

Structure & Function:

Four Quadrants: Left Upper Quadrant (LUQ)

Stomach, Spleen, Pancrease, Left Lobe of Liver

Left Kidney and Adrenal

Structure & Function:

Four Quadrants: Right Lower Quadrant (RLQ)

Structure & Function:

Four Quadrants: Left Lower Quadrant (LLQ)

Structure & Function:

Four Quadrants: Midline

Aorta (Slightly to the Left)

Uterus (if enlarged)

Bladder (if distended)

Developmental Care:

Infants and Children

Differences in Liver?

Bladder?

Umbilicus?

Abdominal Wall?

Liver: More proportionate and more space in the abdomen then later in life

Bladder: Higher in abdomen then in adults

Umbilicus: Contains 2 arteries and 1 Vein

Abdominal Wall: Less muscular so organs are easier to palpate

Developmental Care:

Pregnant Female

Signs of Pregnancy

Nausea, Vomiting

Missed Periods: Due to hormonal changes such as the production of human chorionic gonadotropin (HcG)

Acid Indigestion or heartburn (pyrosis) caused by esophageal reflux

GI Motility decreases = prolongs gastric emptying time = causes more water to be reabsorbed from the colon = leads to constipation --> constipation increases venous pressure in lower pelvis which may led to hemorrhoids

Developmental Care:

Pregnant Female

Changes in Uterus, Bowel, Appendix, Skin

Enlarged uterus displaces intestines upward

Bowel sounds diminish

Appendix displaced upward and to the right

Skin changes in abdomen (Sriae and linea nigra)

Developmental Care:

Aging Adult Abdominal Normal Appearance Changes

Increased Fat

(Women due to decreased estrogen levels)

Adipose tissue redistributes away from face and extremities to the abdomen and hips

Developmental Care:

Aging Adult

Are GI Changes Significant in an adult? Yes/No

Developmental Care:

Aging Adult

Salivation decreases causing ...

Dry Mouth

Decreased sense of taste

Developmental Care:

Aging Adult

Esophageal emptying is ______

Developmental Care:

Aging Adult

Gastric Acid secretion Decreases with age, causing

Developmental Care:

Aging Adult

Liver size decreases causing liver function to

REMAIN NORMAL

Unless it is impaired by pharmacological treatments, alcoholism, liver disease, etc.

Cross Cultural Care

Lactose Intolerant

Lactase: Digestive enzyme necessary for absorption of carbs lactose (milk sugar)

Some racial groups, lactase is high at brith but declines in adulthood (called lactose intolerant)

Lactose intolerant have abdominal pain, bloatin and flaulence when milk is consumed

Appetite, Dysphagia (difficulty swallowing), Food intolerance, Abdominal Pain, Nausea, Vomiting, Bowel habits, Past Abdominal History, Medications, Nutritional Assessment

Infants and Children

Breast or Bottle feeding, Table foods introduced, Frequency of meals, Consitpation, Abdominal Pain, Overweight, Underweight

Adolescents

Regular meals, exercise, body requirements, activity patterns, over- or under- weight

Aging Adult

Acquire groceries, prepare snacks, eat alone, share meals, dificulty swallowing, bowel movements

Inspect the Abdomen:

Contour, Symmetry, Umbilicus

Look down at abdomen with light; Should be symmetrical, flat or rounded; Assess stomach during inspiration and expiration

Umbilicus shoudl be midline and inverted, no discoloration or inflammation

Inspect the Abdomen:

Symmetry abnormalities

Hernia

Inspect the Abdomen:

Umbilicus abnormal findings

Bluish periumbilical color occurs with ....

Inspect the Abdomen:

Umbilicus abnormal findings

Enlarged and enverted umbilicus with ...

Inspect the Abdomen:

Umbilicus abnormal findings

Deeply sunken umbilicus found with

Inspect the Abdomen:

Umbilicus abnormal findings

Everted (Outward appearance) of Umbilicus with ...

Inspect the Abdomen:

Skin inspection notes

* Good area to judge pigment because it is protected from sun

*Striae (Lineae albicants) - change in pigmant

*Note pigmented nevi (moles)

*Veins are not usually seen, except in thin persons

* Skin turgor reflects healthy nutrition

Cutaneous angiomas are .... ?

They occur with ... ?

Skin, benign tumors

Occur with portal hypertension or liver disease

Stillness, Resisting any movement

An inflammation of the peritonium. Peritonitis may be localised or generalised, and may result from an infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process.

Abnormal bowel sounds:

Hyperactive sounds

Abnormal bowel sounds:

Hypoactive/Absent Sounds

Type of hyperactive bowel sound (Common)

Stomach Growling

Vascular sounds

Bell

* Note any bruits

Aortic

Right & Left Renal Arteries

Right & Left Iliac Arteries

Right & Left Femoral Arteries

* House Shape *

Begin in the lung resonance area and percuss down the interspaces until the sound changes to dull quality. mark the spot.

Then find abdomen Tympany, Perucss upward and mark where the sound changes to dullness

Measure the distance between 2 marks: Normal liver span is 6-12 cm

Liver is direct correlation to persons actual height in a normal person with healthy liver functioning

Spleen is usually blocked by the stomach

Locate it by percussing from teh 9-11th intercostal space on the left side

How to determine splenomegaly?

What is splenomegaly?

If site changes to dullness instead of tympany during inspiration, sign of splenomegaly.

Splenomegaly is an enlargement of the spleen

Costovertebral Angle Tenderness - On the left side of back, by the 12 rib

Patients should feel a thud but no pain - if pain is present, represents inflammation of the kindeys or paranephric area.

Fluid Wave Test

Shifting Dullness Test

Stand on persons right side, place ulnder edge of patients hand firmly on abdomen midline; place your left hand on persons right flank. With right hand give the left flank a firm strike

If ascites is present: a fluid wave through the abdomen will occur (positive test)

If gas, not change will occur

Step 1: In supine position, fluid settles by gravity while air rises. Percuss the abdomen; if fluid is present, the note will change from tymphany to dull

Step 2: Turn the person towards you, fluid will gravitate; Percuss the upperside of abdomen and move downward, the sound changes from tymphany to dull as you reach fluid level; but this time the level of dullness is higher towards the umbilicus (shifiting level of dullness indicates presence of fluids)

* Note: Shifting dullness will not detect volumes less then 500 mL

Small circles about 1 cm deep over abdomen

Looking for muscle guarding, rigidty, large masses, tenderness

Voluntary Guarding: Occurs when the person is cold, tense or ticklish; bilater; you will feel msucles relax slightly during exhalation; use relaxation techniques to eliminate guarding or it will interfere with deep palpation

Involuntary Rigidity: Constant broadlike hardness of muscles; Protective mechanism accompanying acute inflammation of the peritoneum; could be unilateral; same area is painful when person increases pressure (ex: doing a sit up)

Push down 5 - 8 cm - Move counter clockwise & explore the abdoment

To overcome reistance of large abdomens, use a bimanual technique

Liver, Spleen, Kidneys

(Sometimes the Aorta as well)

1. Hooking Technique

2. Or place hand on persons back and push down deeply below the 11th and 12th ribs; Ask patient to take a deep breath; It is normal to feel the edge of the liver bump your fingertips as the diaphgragm pushes down during inhalation

Put left hand on the left side/back and lift body up slightly; Push your right hand obliquely on the LUQ with the fingers pointing toward the left axilla; Ask the person to take a deep breath

* Shoudl feel nothing firm

* If an enlarged spleen is felt, do not continue to palpate because an enlarged spleen is friable (easily crumbled) and can rupture easily with overpalpation

*Enlarged spleens are due to trauma or increased number of WBC

True or false:

The Left kidney is palpable, but not the right.

False

Right kidney is palpable becaue it sits 1-2 cm lower then the left kidney - the left kidney is up higher and surrounded more by the ribs

True or False

To palpate the Aorta, put your thumb and fingers slightly to the right of the midline.

Special Procedures & Findings:

Blumberg's Sign (Rebound tenderness)

Hod hand @ 90 deg perpendicular to abdomen, push down slowly, then life quickly;

Negative response is No Pain

*Pain or relase of pressure confirms rebound ternerness, which is a sign of peritoneal inflammation and/or appendicitis

Special Procedures & Findings:

Inspiratory Arrest (Murphy's Sign)

Special Procedures & Findings:

Iliopsoas Muscle Test

Perform when appendicitis is suspected; Lift leg straight up, flexing at the hip; push over the lower right thigh; the person should feel no pain

* When iliopsoas is inflamed (appendicitis), pain is felt in LRQ

Special Procedures & Findings:

Obturator Test

Performed when appenditis is expected; Lift the right leg, flex at hip and 90 deg at knee; Hold ankle and rotate the leg

Negative response is no pain

Positive response irritates the obturator muscle and produces pain (appendicitis)

Abnormalities on Palpation of Enlarged Organs:

Enlarged Gallbladder

Suggest acute cholecystitis (blockage of the cystic duct causing gallbaldder inflammation)

Felt behind the liver as smooth and firm mass (like a sausage); Difficult to palpate b/c of involuntary rigidty of abdominal muscles

Area is PAINFUL to percuss and Murphy's sign is present

Abnormalities on Palpation of Enlarged Organs:

Enlarged Spleen

Spleen enlarges downward and to midline because it is blocked by the diaphragm

Retains the splenic notch;

Splenomegaly occurs with acute infections (mononucleosis (too much WBC)); soft;

Chronic cause results in a firm, hard spleen with sharp edges

Enlarged spleens are not usually tender in palpations; only if the peritoneum is also inflammed

Abnormalities on Palpation of Enlarged Organs:

Enlarged Kidney

Enlarged with hydronephrosis (usually caused by obstruction of the free flow of urine from the kidney, leading to progressive atrophy of the kidney), cyst (closed sac having a distinct membrane and division on the nearby tissue. It may contain air, fluids, or semi-solid material) or neoplasm (new growth)

Difficult to distinguish between enlarged spleen and kidney; however, spleen has sharp edges whereas kidneys never do

Spleen retains splenic notch, where as the kidney has no palpable notch

Percussion over spleen is dull, where as over the kidney it is tympanitic b/c of the overriding bowel

Abnormalities on Palpation of Enlarged Organs:

Aortic Aneurysm

More then 95% are located below the renal arteries and extend to the umbilicus

80% are palapble during routine exam

Feel like a pulsating mass in upper abdomen to the left of the midline

Hear a bruit

Femoral pulses will decrease in strength

Abnormalities on Palpation of Enlarged Organs:

Enlarged Liver

Occurs with fatty infiltration, portal obstruction or cirrhosis (A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells. It can result from alcohol abuse, nutritional deprivation, or infection especially by the hepatitis virus), high obstruction of inferior vena cava and lymphocytic leukemia (type of leukemia affecting circulating lymphocyte cells).

Liver feels enlarged and smooth, but is tender to palpate with early CHF, acute hepatits or hepatic abscess

Abnormalities on Palpation of Enlarged Organs:

Enlarged Nodular Liver

Peritoneal Friction Rub

Liver vs. Spleen

Liver: Friction rub over Lower Right rib cage from abscess or metastict tumor

Spleen: Friction rub over lower left rib cage from abscess, infection or tumor

Venous Hum

(occurs rarely)

Heard in periumbilical region; originates from inferior vena cava;

Medium pitch, continuous sound, pressure on bell; occurs with portal hypertension and cirrhotic liver

Loud splash ausculated over the upper abdomen when the infant is rocked side to side

Indicates increased air and fluid in the stomach (pyloric obstruction or hiatus hernia (the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm))

Midline ridge, separation of abdominal rectus muscles

Ridge is revealed when intraabdominal pressure is increased by raising head while suppine

Occurs because of prolonged distention or a decrease in muscle tone

Not clinically significant

Small, Nodule at epigastrium in midline through the linea alba

One can feel rather then observe

Only palpable when standing