Which sequence should the nurse follow when collecting data for an abdominal examination?

Overview

The patient should be exposed from the nipple line to the lower abdomen and lying supine. Flexing the knees slightly to relax the abdominal musculature is sometimes helpful. The abdomen can be divided into 4 quadrants, with vertical and horizontal lines intersecting at the umbilicus. The quadrants are then named in clockwise direction: right upper, left upper, left lower and right lower quadrants. Other anatomical landmarks such as epigastric, periumbilical, suprapubic, and McBurney point (1/3 of the distance from the right anterior superior iliac spine to the umbilicus) should be referenced to provide additional details. See images below.

All physical findings should be related to the area in which they are located. After the patient has been placed in the proper position, the examiner begins by observing the abdomen for any asymmetry and to detect any distension. The presence or absence of scars can provide clues and in certain cases may clarify the history if the patient is unclear or unable to provide accurate information. Bulging flanks suggest the presence of ascites or obesity. Signs of liver disease (tortuous abdominal vessels or jaundice) or pancreatic hemorrhage (Grey Turner and Cullen signs) may be evident. [12] See images below.

All physical signs must be interpreted with the patient’s age in mind because the differential may change drastically. For example, the presence of a scaphoid abdomen in a neonate with respiratory distress may indicate diaphragmatic hernia, but not in an older child. [13] Also in the newborn, the appearance or persistence of the umbilical stump may generate clues to a source of fever, to an underlying immunological disorder, or to liver or pancreatic disease. [13] A patient that is afraid of excessive movements may be experiencing peritoneal irritation. A young child or infant who experiences discomfort lying down may be experiencing gastroesophageal reflux. In an older child, a preference for sitting up can indicate retroperitoneal irritation, as in pancreatitis.

The next step should be auscultation (see image below) for the presence and quality of bowel sounds prior to any other form of manipulation. As these sounds are audible throughout the abdomen and peristaltic activity is never restricted to one portion of the abdomen, the practice of auscultating in all 4 quadrants provides little useful information. In the younger child, bowel sounds can appear to be referred and attempting to draw conclusions based on the apparent area of auscultation can be misleading. If bowel sounds are not immediately audible, a period of 30-60 seconds should be dedicated to listening as the establishment of absent bowel sounds has immediate implications and should be unequivocal. High-pitched, frequent bowel sounds are associated with small bowel obstruction. Abdominal bruits are associated with vascular, most commonly large arterial, pathology.

Initially, gentle palpation should determine the context for further examination by determining if peritoneal signs and exquisite tenderness exist and whether the pertinent findings are general or localized. The examiner should focus on the child’s face to detect nonverbal indicators of tenderness. [8] Palpation should always begin with light, soft, circular movements and should start in the area away from the suspected pathology. In this manner, the examiner can establish that portions of the abdomen are free from tenderness and apparent pathology.

As each region is examined, the contents and their potential for pathology should be sequentially palpated. For the solid organs of the abdomen, the liver, the spleen, and any masses, the perimeters of the structure should be defined and a quantitative estimate of the dimensions should be determined and recorded. Hepatomegaly without jaundice should prompt the consideration of storage rather than inflammatory liver disease. The surface should be repeatedly felt to establish whether the structure is homogenous and whether the surface is smooth, irregular, or nodular in addition to defining if it is tender. The qualitative and quantitative findings should be put into a well-defined, reproducible, anatomic context.

The span of the liver, for example, should be measured in the right midclavicular line. Presence of splenomegaly begins with gentle palpation from the umbilicus in an upward diagonal direction into the left upper quadrant. Support of the flank on the left may support and aid in projection of the spleen toward the examiners fingers. Enlarged or cystic kidneys may also be palpated with this maneuver. [1] It should be noted if the spleen, the liver, or both cross the midline.

Percussion of intercostals spaces is required to determine the cephalad border of the liver and of the spleen and thus to unequivocally establish the presence of organomegaly. Percussion is performed by tapping on the examiner’s hand with the second digit of the other hand. It may be an invaluable maneuver to determine size. The caregiver should be able to distinguish between hyperinflation of the lungs (as seen in asthma or cystic fibrosis or any obstructive pulmonary disease) from true hepatosplenomegaly. If the latter is present, the examiner should attempt to determine if the enlarged organs are firm and/or heterogeneous from an infiltrative process or have a normal consistency from congestion (see Table 2 in Preparation).

If determining the size of the liver is difficult, the scratch test may provide additional information. The diaphragm of the stethoscope is held over the liver, and the examiner listens for change in the quality of sound as the opposite hand gently scratches the abdomen moving in a semicircle around the stethoscope. [1]

Tenderness medial to McBurney’s point suggesting a Meckel diverticulum should be distinguished from typical appendicitis tenderness. The presence of dilated loops of bowel by palpation or percussion is an important finding that should be sought along with the degree of tenderness associated with the distended bowel. If tenderness is appreciated in an area of the abdomen that is unusual or does not match the history, then gentle pinching of the abdominal muscles should be performed to determine whether the pathology is actually musculoskeletal rather than abdominal. Regardless of the initial findings, all 4 quadrants, with particular attention to the liver, spleen, and any areas of fullness or symptoms, should be sequentially examined and the findings recorded.

Dullness along the flanks while in the supine position may indicate the presence of ascites. Various maneuvers can confirm this finding. [14] The examiner should percuss from the midline laterally and if ascites is present, a change from the tympany of bowel gas to the dullness of fluids should exist. The patient should then be positioned in a lateral position and the same sequence should be performed. If free-flowing ascitic fluid exists, the gravity will reposition it to the dependent side and a “shifting dullness” will be present.

The older, cooperative child or the parent can put the sides of their hands by the umbilicus, perpendicular to the abdomen, and apply gentle pressure. The examiner then gently pushes on one flank and determines if the “fluid wave” can be palpated on the opposite side. The “puddle sign” may also be used in children by first percussing the umbilicus while supine. As the child is moved to a prone position the ascitic fluid pools anteriorly, and the acoustic quality of percussion changes. The child may be placed in this position either by holding a very small child prone or by having them support themselves on their hands and knees.

Frequently, ancillary maneuvers are required to arrive at a diagnosis. Asking the patient to breathe in while gently pushing on the abdomen and then observing the response to rapid removal of the hands is an indication of rebound tenderness or peritoneal irritation. For a more anxious child, gently moving the feet or the bed may yield the same response. [8] If this finding is limited to the right upper quadrant (Murphy’s sign), it supports the presence of biliary disease. Eliciting pain by raising the right leg against pressure supplied by the examiner’s hand while in the supine position suggests psoas irritation. Besides providing the hallmark of appendicitis, it may suggest other, less common, retroperitoneal conditions (see Table 2 in Preparation).

Demonstrating pain with hopping, especially in a younger child, suggests peritoneal irritation. This may be an early sign of appendicitis, a diagnosis commonly missed in the young child. The most important of the ancillary maneuvers performed in conjunction with an abdominal examination is a rectal examination.

Inspection of the perineum for rashes, gluteal wasting, gluteal asymmetry, perianal disease, fistulas, areas of fluctuance, and fissures often yields important findings. If a digital examination is performed, anorectal stenoses, the presence and the consistency of stool, the presence and an estimation of the size of any polyps or other masses, stool guaiac, and tenderness should be recorded. If the patient has a history of constipation, a Valsalva should be performed to help address the contribution of dyschezia to the symptoms. If appendicitis is suspected, a bimanual examination should be performed during the rectal to assist in the diagnosis of retrocecal inflammation, which may otherwise be unappreciated. It has been suggested that abdominal pain with deep knee squats can also help to diagnose retrocecal appendicitis. [8]

If an abdominal examination is considered part of the art of medicine, it is becoming a lost art. Subtle pathology, such as hypertrophic pyloric stenosis, will usually require several minutes dedicated to gentle palpation with the baby in the mother’s lap in order to relax the abdominal muscles and appreciate the olive-shaped mass. Starting 10-15 years ago, experienced pediatric surgeons began to lament a substantially higher reliance on ultrasound rather than abdominal examination to diagnose this entity and reported the additional costs involved in this transition. [15] More recently, this trend has continued with reports on how efficiently pediatric surgeons can perform the diagnostic ultrasound themselves. [16]

At the conclusion of the examination, the practitioner should have a strong opinion on the urgency of the situation and have a clear idea on the progression of further diagnostic investigations that are required to reach a definitive diagnosis. If either of these parameters cannot be fulfilled, a more experienced clinician should be immediately called upon to avoid unnecessary delays. As the signs and symptoms of a surgical condition can be evolving over time, admission for serial examinations is an acceptable course of action. However, an objective, quantitative, or semi-quantitative (eg, moderate severe pain, 6/10 tenderness) assessment should be documented to allow for other care givers to participate in optimal sequential assessments. This is especially crucial if the patient is being moved between locations, ie, from the emergency room to the ward, from the ward to the intensive care unit, or from the recovery room to the inpatient observation ward.

After any abdominal surgery, serial physical examinations are mandatory to recognize the onset of complications. Although postoperative pain and analgesia are expected, subtle indicators of increasing pain or generalized peritoneal irritation should be sought in regular intervals. If discovered, early radiographic and laboratory investigations should be obtained to minimize morbidity and mortality.