ABDOMINAL ASSESSMENT

1. GATHER ALL EQUIPMENT

- Pillow, Centimeter Ruler, Stethoscope, Marking Pen

2. EXPLAINS PROCEDURE TO CLIENT

- Good morning, ma’am! I am Marianne Ladislao. A first year student nurse
from Lorma Colleges. So, today I am going to assess your abdomen so for
me to be able to do that, I am going to inspect, auscultate, percuss and
palpate your abdominal area. So I need your full cooperation po. Is that
okay with you, ma’am?

3. ASSIST CLIENT TO PUT ON A GOWN AND PUT A GLOVES

ABDOMEN (SUCSAm)

1. INSPECT THE SKIN ( noting the COLOR, VASCULARITY, STRIAE, SCARS,

LESIONS AND RASHES)
- The color of the skin is paler than your general skin tone
- There are visible scattered fine veins
- The striae is old, silvery, white and no stretch marks also
- Abdomen is free from scars, lesions and rashes also

2. INSPECTS THE UMBILICUS ( noting the COLOR, LOCATION AND CONTOUR)

- The umbilical skin tones are similar to skin tones
- It is in the midline at lateral line
- The contour is recessed and it is round

3. INSPECTS THE CONTOUR OF THE ABDOMEN.

- LOOKS ACROSS THE ABDOMEN AT EYE LEVEL FROM YOUR SIDE.
- The contour of your abdomen is flat po

4. INSPECTS THE SYMMETRY OF THE ABDOMEN

- Your abdomen is symmetrical
- Free from masses, hernia and bowel obstruction

5. INSPECTS ABDOMINAL MOVEMENT, AORTIC PULSATION, AND OR PERISTALTIC

WAVES
- Your chest and abdomen rise with respiration
- A slight pulsation of the aorta
- The peristaltic waves are not seen
 6. AUSCULTATE FOR BOWEL SOUNDS, NOTING INTENSITY, PITCH AND
FREQUENCY (4 quadrants - right, left, lower l, lower r) 1 min
- The sounds occur 5-15 times per minute
- The intensity is soft
- The pitch is low-pitched gurgling
- The frequency is normoactive

7. Auscultates for vascular sounds and friction rubs

Equipment: Stethoscope
Bruits Sound – Bell (Aorta, Renal, Iliac, Femoral)
Friction Rub – Diaphragm (liver and spleen)
Venous Hum – Bell (epigastric and umbilical areas)
- FINDINGS: No bruits. No friction rub over the liver or spleen.

1. PERCUSS THE ABDOMEN FOR TONE

- Tympany is loudest over the gastric bubble and intestines.

- Dullness is heard over liver, spleen, and distended bladder.

2. PERCUSS THE LIVER

○ The liver is within the standard size which is 6-12 cm for midclavicular and
4-8 cm for midsternal.
3. PERFORMS THE SCRATCH TEST
○ The inferior edge of the liver matches with the record in the percussion of the
liver.
4. PERCUSSES THE SPLEEN
○ The spleen is normal, the tympanic is on both expiration and inspiration which
does not indicate splenomegaly,
5. PERFORM THE BLUNT PERCUSSION ON THE LIVER AND THE KIDNEYS
- Ask patient if feel any pain, if none there is no tenderness which is normal.
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1. PERFORM LIGHTS PALPATION ( noting tenderness or masses in all quadrants)

○ The abdomen is normally tender
○ No palpable masses are present
2. PERFORMS DEEP PALPATION ( noting tenderness or masses in all quadrants)
○ Normal tenderness over the xiphoid, aorta, cecum, sigmoid colon and ovaries
○ No palpable masses are present
3. PALPATES THE UMBILICUS & SURROUNDING AREA FOR SWELLING, BULGES &
MASSES
○ There are no present swelling, bulging and masses
4. PALPATES THE AORTA
- The aortic pulsations is only visible when palpating deeply which is normal.

5. PALPATES THE LIVER ( noting the consistency and tenderness)

○ The consistency of the liver edge is smooth
○ There is no tenderness
6. PALPATES THE SPLEEN ( noting the consistency and tenderness)
- “Please take a deep breath sir. Do you feel any pain sir?”
- The spleen is not enlarged and is not tender as the patient said that there is no
pain.
7. PALPATES THE KIDNEYS
- “Can you please inhale sir. Do you feel any pain”
- The kidneys are normal and it is not enlarge nor does the patient feel any pain mean
there is no tenderness.
8. PALPATES THE URINARY BLADDER
- Ask the patient if they urinated earlier.
- The urinary bladder is not palpable because the patient urinated earlier.
9. PERFORM THE TEST FOR SHIFTING DULLNESS
- Side position
- FINDINGS: The borders between tympany and dullness remain relatively constant
throughout position changes.

10. PERFORMS THE FLUID WAVE TEST

- The fluid moves to the other side which is normal.

11. PERFORMS THE BALLOTTEMENT TEST*

- The patient does not show any free-floating object which is normal.
 1. PERFORMS THE FOLLOWING TEST FOR APPENDICITIS
A. REBOUND TENDERNESS
- Mas masakit po ba nong na-release ko na po?
- The patient did not feel any pain, there is no rebound tenderness.
B. ROVSINGS’S SIGNS
- May nararamdaman po ba kayong pain sa RIGHT lower abdomen ninyo?
- The patient did not feel any pain in the right quadrant and vice versa.
C. REFERRED REBOUND TENDERNESS
- Masakit po ba sa right lower abdomen ninyo?
- The patient did not feel any pain during release, there is no rebound
tenderness.
D. PSOAS SIGN (foot)
- May nararamdaman po ba kayong pain sa right lower abdomen nyo?
- There is no abdominal pain felt by the patient
E. OBTURATOR SIGN (knee)
- May nararamdaman po ba kayong pain sa right lower abdomen nyo?
- There is no pain felt by the patient
F. HYPERSENSITIVITY TEST
- The patient did not feel any pain.

- There is no exaggerated sensation.

2. PERFORMS TEST FOR CHOLECYSTITIS ( Murphy’s sign)

- The patient did not feel any pain.

ANALYSIS OF DATA
- The overall findings for the patient’s abdominal assessment is normal. Ma’am to
maintain a normal result, continue to eat healthily and a balanced diet. There is no need
for any necessary referrals because the patient is not at risk, or have any actual
problems.