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Assessment of Abdomen, anus & rectum

This document provides guidance on assessing the abdomen, anus, and rectum. It discusses obtaining a relevant health history, performing a physical examination of the abdomen, and documenting findings. Key points covered include dividing the abdomen into quadrants or regions, asking about symptoms, medications, and risk factors. Guidance is provided on examining specific areas like the urinary tract and evaluating signs of potential conditions.

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Assessment of Abdomen, Anus & Rectum Ms. Gulshan Umbreen PhD Scholar (Epidemiology & Public Health) Lecturer, SNC
Learning Objectives • Discuss the pertinent health history questions necessary to perform the assessment of Abdomen, Anus and Rectum. • Describe the specific assessment to be made during the physical examination of the abdomen. • Discuss components of a rectal examination. • Document findings. • List the changes in abdomen that are characteristics of aging process.
Anatomy of Abdomen
• The nurse locate and describes abdominal findings using two common methods of subdividing the abdomen Quadrants and Regions • To divide the abdomen into quadrants, The nurse imagine two lines • A vertical line from the xiphoid process to the pubic symphysis • A horizontal line across the umbilicus
Four Quadrants • Right upper quadrant • Left upper quadrant • Right lower quadrant • Left lower quadrant
Regions • Using second method, division into nine regions. • Two vertical lines that extend superiorly from the midpoints of the inguinal ligaments • Two horizontal lines, one at the level of the edges of the lower ribs and other at the left of the iliac crest
Obtaining Health History If patient has GI problem, he will usually complain abdominal or chest pain, belching, cramping, heartburn, nausea, vomiting, or altered bowel habits. To investigate these and other signs and symptoms ask him about the location, quality, onset, duration, frequency and severity of each. Also ask him/her what relieves or worsens his symptoms
Asking about Current Health • Ask the patient if he taking any medications. Several drugs especially aspirin, non steroid anti inflammatory drugs, antibiotics, and opioid analgesics can cause nausea, vomiting, diarrhea, constipation and other GI signs and symptoms. • Be sure to ask about laxative use, habitual use may cause constipation. Ask about enema, suppository use. Don’t forget to ask the patient if they have allergies to medications, food. Such allergies may cause GI symptoms.
• In addition, ask the patient about changes in appetite, difficulty chewing or swallowing, and changes in he bowel habits. Does he has excessive belching. Has he noticed a change in color, amount, frequency and appearance of his stool. Has he ever seen blood in stool
• Travel plans • If the patient’s reason for seeking care is diarrhea, find out if he has recently traveled abroad, where he traveled. Diarrhea, Hepatitis and parasitic infections can result from ingesting contaminated food or water.
HISTORY OF PRESENT HEALTH CONCERN Abdominal Pain Are you experiencing abdominal pain? Abdominal pain occurs when specific digestive organs or structures are affected by chemical or mechanical factors such as inflammation, infection, distention, stretching, pressure, obstruction, or trauma. How would you describe the pain? How bad is the pain (severity) on a scale of 1 to 10, with 10 being the worst? The quality or character of the pain may suggest its origin. The client’s perception of pain provides data on his or her response and tolerance with pain.
How did (does) the pain begin? The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis produces sudden onset of pain, whereas the pain of pancreatic cancer may be gradual or recurrent. Where is the pain located? Does it move or has it changed from the original location? Location helps to determine the pain source and whether it is primary or referred When does the pain occur (timing and relation to particular events such as eating, exercise, bedtime)? Timing and the relationship of particular events may be a clue to origin of pain (e.g., the pain of a duodenal ulcer may awaken the client at night).
What seems to bring on the pain (precipitating factors), make it worse (exacerbating factors), or make it better (alleviating factors)? Various factors can precipitate or exacerbate abdominal pain such as alcohol ingestion with pancreatitis or supine position with Gastro esophageal reflux disease. Lifestyle and stress factors may be implicated in certain digestive disorders such as peptic ulcer disease Is the pain associated with any other symptoms such as nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or skin? Associated signs and symptoms may provide diagnostic evidence to support or rule out a particular origin of pain. For example, epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer.
PATTERNS AND MECHANISMS OF ABDOMINAL PAIN • Be familiar with three broad categories: Visceral pain • occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. • May be difficult to localize • Varies in quality; may be gnawing (dull, Constant Pain) , burning, cramping, or aching
• Parietal pain from inflammation of the parietal peritoneum. • Steady, aching • Usually more severe • Usually more precisely localized
• Referred pain • Pain felt in a part of the body other than its actual source. • Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree—to the right shoulder or right posterior chest. • Pain from the chest, spine, or pelvis may be referred to the abdomen.
Upper Abdominal Pain, Discomfort, or Heartburn • Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. • Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn. • Find out just what your patient means. Possibilities include:
• Bloating from excessive gas, especially with frequent belching, abdominal distention, or flatus, the passage of gas by rectum • Nausea and vomiting • Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal • Heartburn Suggests gastroesophageal reflux • disease (GERD)
Lower Abdominal Pain or Discomfort—Acute and Chronic. If acute, is the pain sharp and continuous or intermittent and cramping? Right lower quadrant (RLQ) pain, or pain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy Left lower quadrant (LLQ) pain in diverticulitis If chronic, is there a change in bowel habits? Alternating diarrhea and constipation? Colon cancer; irritable bowel syndrome
Other GI Symptoms Anorexia Liver disease, pregnancy, diabetic ketoacidosis, adrenal insufficiency, uremia, anorexia nervosa Dysphagia or difficulty swallowing If solids and liquids, neuromuscular disorders affecting motility. If only solids, consider structural conditions like Zenker’sdiverticulum, Schatzki’s ring, etc Odynophagia, or painful swallowing Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV Diarrhea, acute (<2 weeks) and chronic Acute infection (viral, salmonella, shigella, etc.); chronic in Crohn’s disease, ulcerative colitis; oily diarrhea (steatorrhea)
Zenker's diverticulum. • When a pouch forms at the junction of the pharynx and the esophagus, it is called Zenker's diverticulum. • The pharynx is located at the back of your throat, behind your nasal cavity and mouth. • Zenker's diverticulum typically appears in the hypo pharynx. • A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.
Constipation Medications, especially anticholinergic agents and opioids; colon cancer Melena, or black tarry stools GI bleed Jaundice from increased levels of bilirubin: Impaired excretion of conjugated bilirubin in viral hepatitis, cirrhosis, primary biliary cirrhosis, drug induced cholestasis Ask about the color of the urine and stool. Dark urine from increased conjugated bilirubin excreted in urine; clay-colored stool when excretion of bilirubin into intestine is obstructed
THE URINARY TRACT Ask about pain on urination, usually a burning sensation, sometimes termed dysuria (also refers to difficulty voiding). Bladder infection Also, consider bladder stones, foreign bodies, tumors, and acute prostatitis. In women, internal burning in urethritis, external burning in vulvovaginitis Other associated symptoms include: ● Urgency, an unusually intense and immediate desire to void May lead to urge incontinence Urinary frequency, or abnormally frequent voiding ● Fever or chills; blood in the urine
Any pain in the abdomen, flank, or back Dull, steady pain in pyelonephritis; severe colicky pain in ureteral obstruction from renal stone Assess any: ● Polyuria, a significant increase in 24-hour urine volume Diabetes mellitus, diabetes insipidus Nocturia, urinary frequency at night Bladder obstruction Urinary incontinence, involuntary loss of urine: From coughing, sneezing, lifting ● From urge to void Stress incontinence (poor urethral sphincter tone) Urge incontinence (detrusor overactivity)
Asking a Past History • To determine if your patient’s problem is new or recurring ask about past GI illnesses, such as ulcer, liver, pancreas, or gallbladder disease, inflammatory bowel disease, rectal or GI bleeding, hiatal hernia, Irritable bowel syndrome, diverticulitis, gastro-esophageal reflux disease or cancer. Also ask if he has had abdominal surgery or trauma/ accidents, blood transfusion
PAST HEALTH HISTORY Have you ever had any of the following gastrointestinal disorders: ulcers, gastroesophageal reflux, inflammatory or obstructive bowel disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis? Presenting the client with a list of the more common disorders may help the client to identify any that he has or has had. Have you had any urinary tract disease such as infections, kidney disease or nephritis, or kidney stones? Urinary tract infections may become recurrent and chronic. Moreover, resistance to drugs used to treat infection must be evaluated. Chronic kidney infection may lead to permanent kidney damage.
Have you ever had viral hepatitis (type A, B, or C)? Have you ever been exposed to viral hepatitis? Various populations (e.g., school and health care personnel) are at increased risk for exposure to hepatitis viruses. Any type of viral hepatitis may cause liver damage. Have you ever had abdominal surgery or trauma to the abdomen? Prior abdominal surgery or trauma may cause abdominal adhesions, thereby predisposing the client to future complications or disorders. What prescription or over-the-counter medications do you take? Medications may produce side effects that adversely affect he gastrointestinal tract. For example, aspirin, ibuprofen, and steroids may cause gastric bleeding. Chronic use of antacids or histamine-2 blockers may mask the symptoms of more serious stomach disorders. Overuse of laxatives may decrease intestinal tone and promote dependency. High iron intake may lead to chronic constipation
Asking about Family Health • Some GI disorders are hereditary, ask the patient whether anyone in his family had a GI disorder. • Disorders with familial link include • Ulcerative colitis • Colorectal cancer • Peptic Ulcer • Gastric cancer • Alcoholism • Crohn’s disease
FAMILY HISTORY Is there a history of any of the following diseases or disorders in your family: colon, stomach, pancreatic, liver, kidney, or bladder cancer; liver disease; gallbladder disease; kidney disease? Family history of certain disorders increases the client’s risk for those disorders. Genetic testing can now identify the risk for certain cancers (colon, pancreatic, and prostate) and other diseases. Client awareness of family history can serve as a motivation for health screening and positive health promotion behaviors.
Asking about psychosocial Health • Inquire about parent occupation, home life, financial situation, stress level and recent life changes. • Be sure to ask about alcohol, caffeine and tobacco use as well as food and fluid, exercise habits and oral hygiene. Ask about sleep pattern, how many hours of sleep does he felt he needs? How many does he get?
LIFESTYLE AND HEALTH PRACTICES Do you drink alcohol? How much? How often? Alcohol ingestion can affect the gastrointestinal tract through immediate and long-term effects on such organs as the stomach, pancreas, and liver. Alcohol-related disorders include gastritis, esophageal varices, pancreatitis, and liver cirrhosis. What types of foods and how much food do you typically consume each day? How much non caffeinated fluid do you consume each day? How much caffeine do you think you consume each day (e.g., in tea, coffee, chocolate, and soft drinks)? A baseline dietary and fluid survey helps to determine nutritional and fluid adequacy and risk factors for altered nutrition, constipation, diarrhea, and diseases such as cancer.
How much and how often do you exercise? Describe your activities during the day. Regular exercise promotes peristalsis and thus regular bowel movements. In addition, exercise may help to reduce risk factors for various diseases such as cancer and hypertension What kind of stress do you have in your life? How does it affect your eating or elimination habits? Lifestyle and associated stress and psychological factors can affect gastrointestinal function through effects on secretion, tone, and motility. If you have a gastrointestinal disorder, how does it affect your lifestyle and how you feel about yourself? Certain gastrointestinal disorders and their effects (e.g., weight loss) or treatment (e.g., drugs, surgery) may produce physiologic or anatomic effects that affect the client’s perception of self, body image, social interaction and intimacy, and life goals and expectations.
Assessment • With abdominal assessment, you inspect first, then auscultate, percuss, and palpate. • This order is different from the rest of the body systems, for which you inspect, then percuss, palpate, and auscultate. Auscultation is done before palpation and percussion
General Considerations • Provide privacy • Good lighting/appropriate temp in room • Expose the abdomen • Empty bladder • Position pt supine, arms by side & head on pillow with knees slightly bent or on a pillow • Warm stethoscope & hands • Painful areas last. 4/15/2020 Ms. Fazeelat Tahira 38
Cont… • Patient needs to be exposed from above the xiphoid process to the symphysis pubis. • Also, make sure your patient does not have a full bladder. • Place patient in a supine position: pillow under the head and knees. • Helps to relax abdominal muscles. 4/15/2020 Ms. Fazeelat Tahira 39
• Have patient point out any areas of pain or tenderness. • Examine these last. • During exam continue to monitor your patient’s facial expression for pain and discomfort. • Use inspection, auscultation, percussion, and palpation to perform the exam. • Always auscultate before percussing or palpating. • because palpation or percussion cause movement or stimulation of the bowel, which can increases bowel motility and thus heighten bowel sounds, creating false results. 4/15/2020 Ms. Fazeelat Tahira 40
Landmarks • Anatomical structures are used as landmarks to help you describe abdominal findings. The following landmarks are used: xiphoid process of the sternum; costal margin; midline (down the center of the abdomen); umbilicus; anterior- superior iliac spine; inguinal ligament and superior margin of the pubic bone
Inspection • Observe the abdomen for color and symmetry, checking for bumps, bulges, lesions, scars, rashes or masses. A bulge may indicate distension or hernias • Abdominal shape • Contour • Umbilicus • Skin of abdomen
• Striae • Stretch marks • Abdominal movements or pulsations
Normal Findings • Abdomen flat to rounded in people of average weight. • A slender person may have a slightly concave abdomen. • A protruding abdomen may be caused by obesity, pregnancy, ascites or abd. distension
• Umbilicus inverted and located midline of abdomen • Conditions such as pregnancy, ascites or an underlying mass can cause the umbilicus to protrude. • Have the patient raise his head and shoulders. If his umbilicus protrudes, he may have an umbilical hernia • Waves of peristalsis not seen. • In thin patients, pulsation of aorta is visible in epigastric area.
Auscultation • Assess all four quadrants • Listen for at least 5 minutes before concluding bowel sounds are absent. Ms. Fazeelat Tahira
Auscultation • Normal findings – Bowel sounds are heard in all quadrants – Usually sounds are high pitched – Occur 5 to 15 times per minute. – Borborygmus or stomach growling is the loud, gurgling, splashing bowel sound heard over the large intestine as gas passes through it. Ms. Fazeelat Tahira
Auscultation • Abnormal findings: absent, hypoactive or hyperactive bowel sounds • Pathophysiological indications – Absent and hypoactive bowel sounds may indicate decreased motility and possible obstruction – Hyperactive bowel sounds indicate increased motility and possible diarrhea, gastroenteritis Ms. Fazeelat Tahira
listen for Bruits (venous hum) over aorta, renal artery, iliac artery, and femoral artery • listen for friction rub over liver and spleen
Percussion • Direct or indirect percussion is used to detect the size and location of abdominal organs and to detect air or fluid in the abdomen, stomach, or bowel. • For direct percussion, strike your hand or finger directly against the patient’s abdomen. • For indirect percussion, use the middle finger of your dominant hand or a percussion hammer to strike a finger resting on the patient’s abdomen.
• Begin percussion in the RLQ and proceed clockwise, covering all four quadrants. Note where percussed sound change from tympany to dullness • Don’t percuss if the patient has an abdominal aortic aneurysm or a transplanted abdominal organ. Doing so can precipitate a rupture or organ rejection.
Normal Findings • Tympany heard over air-filled areas, such as stomach and intestines • Dullness heard over solid areas, such as liver, spleen, or a distended bladder • No tenderness elicited over kidneys and liver • Empty bladder is not percussable above the symphysis pubis
• Identify the upper border of liver dullness in the mid-clavicular line by lightly percussing from lung resonance down toward liver. • Starting at a level below the umbilicus in the right mid-clavicular line, lightly percuss upward toward the liver. Ascertain the lower border of liver dullness.
Findings • Liver span: commonly clinically under estimated. • Midclavicular line: normally 6-12cm. • Midsternal line: normally 4-8cm
Percussing the Spleen • The spleen is located at about the level of the 10th rib, in the left midaxillary line. Percussion may produce a small area of dullness, generally 7” (17.8cm) or less in adults. However, the spleen usually can’t be percussed because tympany from the colon masks the dullness of the spleen
• Percuss the lowest intercostal space in the left anterior auxiliary line, percussion notes should be tympanic. • Ask the patient to take a deep breath, then percuss this area again. If the spleen is normal in size, the area will remain tympanic. If the tympanic percussion note changes on inspiration to dullness, the spleen is probably enlarged. • To estimate spleen size, outline the spleen’s edges by percussing in several directions from areas of tympany to areas of dullness.
• Perform blunt percussion on the kidneys. • Use the ulnar side of your right fist to strike your left hand. Perform blunt percussion on the kidneys • at the costovertebral angles (CVA) over the twelfth rib. • Normally no tenderness or pain is elicited or reported by the client. The examiner senses only a dull thud.
Assessing Bladder Size • To percuss the bladder for distension, begin at the symphysis pubis and percuss upward to the umbilicus, noting any dullness. Normally, an empty bladder does not rise above the symphysis pubis
Palpation • To perform light palpation • Put the fingers of one hand close together. • Depress the skin about ½ (1.5cm) with your fingertips and make gentle, rotating movements. Avoid short, quick jabs. • To perform deep Palpation • Push the abdomen down 2” to 3” (5-7.5cm) in an obese patient, put one hand on top of the other and push
Light & Deep Palpation
• Palpate the entire abdomen in a clockwise direction, checking for tenderness, pulsation, organ enlargement, and masses. • The abdomen should be soft and nontender. As you palpate the four quadrants, note organs, masses, area of fluid accumulation, and areas of tenderness or increased resistance. • Determine whether resistance is due to the
• Patient’s being cold, tense or ticklish, or if it’s due to involuntary guarding or rigidity from muscle spams or peritoneal inflammation. • Don’t palpate a rigid abdomen. Peritoneal inflammation may be present, in which case palpation cause pain, or rupture an inflamed organs.
Palpating the Liver • Palpating the liver by two methods • Standard Method • Hooking the liver
Standard Method • Place the patient in supine position. Standing his right, place your left hand under his back at the approximate location of the liver. • Place your right hand slightly below the mark at the liver’s upper border that u made during percussion. Point the fingers of your right hand toward the patient’s head just under the right costal margin. • As the patient inhale deeply, gently press in and up on the abdomen until the liver brushes under your right hand. The edge should be smooth, firm and somewhat round. Note any tenderness.
Standard Method
Hooking the Liver • Stand next to the patient’s right shoulder, facing his feet. Place your hand side by side, and hook your fingertips over the right costal margin, below the lower mark of dullness. • Ask the patient to take deep breath as you push your fingertip in and up. If the liver is palpable, you may feel its edges as it slides down in the abdomen as he breathe in.
Hooking the Liver
Palpating the spleen • To detect tenderness and enlargement. Splenic tenderness may result from infections. • With the patient in a supine position and you at his right side, reach across him to support the posterior lower rib cage with your left hand. • Place your right hand below the left costal margin and press inward.
• Instruct the patient to take a deep breathe. The spleen normally shouldn’t descend on deep inspiration below the 9th or 10th intercostal space in the posterior midaxillary line. • Normally the spleen is not palpable. If the spleen is enlarged, you will feel its rigid border. If you do feel the spleen, stop palpating immediately because an enlarged spleen can easily ruptured.
Palpating the spleen
• Palpate the kidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL. • To capture the kidney, ask the client to inhale. Then compress your fingers deeply during peak inspiration. Ask the client to exhale and hold the breath briefly. Gradually release the pressure of your right hand. If you have captured the kidney, you will feel it slip beneath your fingers. To palpate the left kidney, reverse the procedure
Palpating the right kidney (A) and the left kidney (B).
Checking for ascites • Have an assistant place the ulnar edge of her hand firmly on the patient’s abdomen at its midline. • As you stand facing the patient’s head, place the place the palm of your left hand against the patient’s right flank. • Give the left abdomen a firm tap with your right hand. If ascites is present, you may see and feel a fluid wave ripple across the abdomen
• If detect ascites, use a tape measure to measure the fullest part of the abdomen. Mark the point on the patient’s abdomen with a felt tip pen so you will be sure to measure it consistently. This measurement is important, especially if fluid removal or paracentesis is performed.
• Shifting Dullness To perform the shifting dullness test, place the patient in the supine position, percuss the entire abdominal region, and mark the dullness-tympany transition point (left figure). Then place the patient in the right lateral decubitus position, wait 30 to 60 seconds, repeat the percussion, and again mark the dullness-tympany transition point (right figure). A positive shifting dullness test is indicated by a shifting of the transition point
Eliciting Abdominal pain • Rebound Tenderness / Blumberg's sign • Help the patient into supine position • Place hands gently on the RLQ at McBurney’s (located about midway between the umbilicus and the anterior superior iliac spine). • Slowly and deeply dip fingers into area then release the pressure in a quick, smooth motion. • Pain on release rebound tenderness is a positive sign
Ilieopsoas Sign • Help the patient into a supine position with his legs straight. • Instruct him to raise his right leg upward as you exert slight downward pressure with your hand on his right thigh. • Repeat the maneuver with the left leg. • When testing either leg, increased abdominal pain is a positive result, indicating irritation of psoas muscle.
Obturator Sign • Help the patient into supine position with his right leg flexed 90 degrees at the hip and knee. • Hold the leg just above the knee and at the ankle then rotate the leg laterally and medially. • Pain in the hypogatric region is a positive sign, indicating irritation of obturator muscles
Examining the rectum and Anus • Inspection • Put on gloves and spread the buttocks to expose the anus and surrounding tissues • The skin in the perineal area is normally somewhat darker than that of the surrounding tissues. • Check for fissures, lesions, scars, inflammation, discharge, hemorrhoids. Then ask the client to strain as if he’s having bowel movements. This action may reveal internal hemorrhoids or fissures.
Palpation • Apply water soluble lubricant to your gloved index finger • Tell the patient to relax and warm him that he’II feel some pressure. • Ask the patient to bear down. • As the sphincter opens, gently insert finger into rectum toward the umbilicus. • To palpate as much of the rectal wall as possible, rotate finger clockwise and then counterwise. • The rectal walls should feel soft and smooth, without masses, fecal impaction or tenderness.
• Remove finger from rectum and inspect the gloves for stool, blood and mucus. • Test fecal matter adhering to the glove for occult blood using a guaiac test.
Abnormal finding • Abdominal Distension • Distension may result from gas, a tumor, or colon filled with feces. • It may also caused by an incisional hernia, which may protrude when he patient lifts his head and shoulder
Abdominal Pain • Abdominal pain may indicate ulcers, intestinal obstruction, appendicitis, cholecystitis, peritonitis etc. Types of abdominal pain • Burning peptic ulcer, GERD • Cramping Diarrhea, constipation • Severe cramping Appendicitis, Crohn disease • Stabbing pancreatitis, cholecystitis
Abdominal pain origin Affected organ Visceral pain Parietal pain Referred pain Stomach midepigastrium Midepigastriu m and LUQ Shoulder Appendix Periumbilical area RLQ RLQ Small intestine Periumbilical area Over affected site Midback (rare)
Abnormal abdominal sounds • Altered bowel sounds • Hyperactive sounds in any quadrant • Hypoactive in any quadrant • High pitched tinkling sound • High pitched rushing sound • Systolic bruits over abd aorta, renal & iliac artery • Resembling cardiac murmur • Venous hum epigastric and umbilical region • Friction rub over liver & spleen
Abnormal finding Spider angiomas
• Bloody stool • Constipation • Diarrhea • Hepatomegly • Splenomegaly
Changes in abdomen that are characteristics of aging process • As we age, the digestive process becomes less efficient: • In the mouth, food may not be properly broken down due to missing teeth or gum problems as well as lowered saliva production • The lower sphincter that regulates the flow of food from the esophagus into the stomach, can weaken resulting in reflux, a back flowing of food or acid (heartburn)
• Loss of muscle tone causes food to move more slowly along the digestive tract • The stomach becomes less elastic and cannot hold as much food • The production of acids and enzymes declines. A decline in the production of lactase, an enzyme that digests dairy products can lead to lactose intolerance, a condition that causes bloating and gas when milk products are consumed
Reference • Rushforth, H. (2010). Assessment made incredibly easy!(2nd edition). Wolters Kluwer • Janet R. Weber & Jane H. Kelley (2013). Health Assessment in Nursing (4th ed). : Lippincott Williams & Wilkins • Video link • https://www.youtube.com/watch?v=j8GEIIEY71c • https://www.youtube.com/watch?v=PrlTdsJ7lWg • https://www.youtube.com/watch?v=j_zDaCzW08k • https://www.youtube.com/watch?v=D0G7353qfY w
Assessment of Abdomen, anus & rectum

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Assessment of Abdomen, anus & rectum

  • 1.
    Assessment of Abdomen,Anus & Rectum Ms. Gulshan Umbreen PhD Scholar (Epidemiology & Public Health) Lecturer, SNC
  • 2.
    Learning Objectives • Discussthe pertinent health history questions necessary to perform the assessment of Abdomen, Anus and Rectum. • Describe the specific assessment to be made during the physical examination of the abdomen. • Discuss components of a rectal examination. • Document findings. • List the changes in abdomen that are characteristics of aging process.
  • 3.
  • 4.
    • The nurselocate and describes abdominal findings using two common methods of subdividing the abdomen Quadrants and Regions • To divide the abdomen into quadrants, The nurse imagine two lines • A vertical line from the xiphoid process to the pubic symphysis • A horizontal line across the umbilicus
  • 5.
    Four Quadrants • Rightupper quadrant • Left upper quadrant • Right lower quadrant • Left lower quadrant
  • 8.
    Regions • Using secondmethod, division into nine regions. • Two vertical lines that extend superiorly from the midpoints of the inguinal ligaments • Two horizontal lines, one at the level of the edges of the lower ribs and other at the left of the iliac crest
  • 11.
    Obtaining Health History Ifpatient has GI problem, he will usually complain abdominal or chest pain, belching, cramping, heartburn, nausea, vomiting, or altered bowel habits. To investigate these and other signs and symptoms ask him about the location, quality, onset, duration, frequency and severity of each. Also ask him/her what relieves or worsens his symptoms
  • 12.
    Asking about CurrentHealth • Ask the patient if he taking any medications. Several drugs especially aspirin, non steroid anti inflammatory drugs, antibiotics, and opioid analgesics can cause nausea, vomiting, diarrhea, constipation and other GI signs and symptoms. • Be sure to ask about laxative use, habitual use may cause constipation. Ask about enema, suppository use. Don’t forget to ask the patient if they have allergies to medications, food. Such allergies may cause GI symptoms.
  • 13.
    • In addition,ask the patient about changes in appetite, difficulty chewing or swallowing, and changes in he bowel habits. Does he has excessive belching. Has he noticed a change in color, amount, frequency and appearance of his stool. Has he ever seen blood in stool
  • 14.
    • Travel plans •If the patient’s reason for seeking care is diarrhea, find out if he has recently traveled abroad, where he traveled. Diarrhea, Hepatitis and parasitic infections can result from ingesting contaminated food or water.
  • 15.
    HISTORY OF PRESENTHEALTH CONCERN Abdominal Pain Are you experiencing abdominal pain? Abdominal pain occurs when specific digestive organs or structures are affected by chemical or mechanical factors such as inflammation, infection, distention, stretching, pressure, obstruction, or trauma. How would you describe the pain? How bad is the pain (severity) on a scale of 1 to 10, with 10 being the worst? The quality or character of the pain may suggest its origin. The client’s perception of pain provides data on his or her response and tolerance with pain.
  • 16.
    How did (does)the pain begin? The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis produces sudden onset of pain, whereas the pain of pancreatic cancer may be gradual or recurrent. Where is the pain located? Does it move or has it changed from the original location? Location helps to determine the pain source and whether it is primary or referred When does the pain occur (timing and relation to particular events such as eating, exercise, bedtime)? Timing and the relationship of particular events may be a clue to origin of pain (e.g., the pain of a duodenal ulcer may awaken the client at night).
  • 17.
    What seems tobring on the pain (precipitating factors), make it worse (exacerbating factors), or make it better (alleviating factors)? Various factors can precipitate or exacerbate abdominal pain such as alcohol ingestion with pancreatitis or supine position with Gastro esophageal reflux disease. Lifestyle and stress factors may be implicated in certain digestive disorders such as peptic ulcer disease Is the pain associated with any other symptoms such as nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or skin? Associated signs and symptoms may provide diagnostic evidence to support or rule out a particular origin of pain. For example, epigastric pain accompanied by tarry stools suggests a gastric or duodenal ulcer.
  • 18.
    PATTERNS AND MECHANISMSOF ABDOMINAL PAIN • Be familiar with three broad categories: Visceral pain • occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. • May be difficult to localize • Varies in quality; may be gnawing (dull, Constant Pain) , burning, cramping, or aching
  • 19.
    • Parietal pain frominflammation of the parietal peritoneum. • Steady, aching • Usually more severe • Usually more precisely localized
  • 20.
    • Referred pain •Pain felt in a part of the body other than its actual source. • Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree—to the right shoulder or right posterior chest. • Pain from the chest, spine, or pelvis may be referred to the abdomen.
  • 21.
    Upper Abdominal Pain, Discomfort,or Heartburn • Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. • Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn. • Find out just what your patient means. Possibilities include:
  • 22.
    • Bloating fromexcessive gas, especially with frequent belching, abdominal distention, or flatus, the passage of gas by rectum • Nausea and vomiting • Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal • Heartburn Suggests gastroesophageal reflux • disease (GERD)
  • 23.
    Lower Abdominal Pain orDiscomfort—Acute and Chronic. If acute, is the pain sharp and continuous or intermittent and cramping? Right lower quadrant (RLQ) pain, or pain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy Left lower quadrant (LLQ) pain in diverticulitis If chronic, is there a change in bowel habits? Alternating diarrhea and constipation? Colon cancer; irritable bowel syndrome
  • 24.
    Other GI Symptoms AnorexiaLiver disease, pregnancy, diabetic ketoacidosis, adrenal insufficiency, uremia, anorexia nervosa Dysphagia or difficulty swallowing If solids and liquids, neuromuscular disorders affecting motility. If only solids, consider structural conditions like Zenker’sdiverticulum, Schatzki’s ring, etc Odynophagia, or painful swallowing Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV Diarrhea, acute (<2 weeks) and chronic Acute infection (viral, salmonella, shigella, etc.); chronic in Crohn’s disease, ulcerative colitis; oily diarrhea (steatorrhea)
  • 25.
    Zenker's diverticulum. • Whena pouch forms at the junction of the pharynx and the esophagus, it is called Zenker's diverticulum. • The pharynx is located at the back of your throat, behind your nasal cavity and mouth. • Zenker's diverticulum typically appears in the hypo pharynx. • A Schatzki ring or Schatzki–Gary ring is a narrowing of the lower esophagus that can cause difficulty swallowing (dysphagia). The narrowing is caused by a ring of mucosal tissue (which lines the esophagus) or muscular tissue.
  • 26.
    Constipation Medications, especiallyanticholinergic agents and opioids; colon cancer Melena, or black tarry stools GI bleed Jaundice from increased levels of bilirubin: Impaired excretion of conjugated bilirubin in viral hepatitis, cirrhosis, primary biliary cirrhosis, drug induced cholestasis Ask about the color of the urine and stool. Dark urine from increased conjugated bilirubin excreted in urine; clay-colored stool when excretion of bilirubin into intestine is obstructed
  • 27.
    THE URINARY TRACT Askabout pain on urination, usually a burning sensation, sometimes termed dysuria (also refers to difficulty voiding). Bladder infection Also, consider bladder stones, foreign bodies, tumors, and acute prostatitis. In women, internal burning in urethritis, external burning in vulvovaginitis Other associated symptoms include: ● Urgency, an unusually intense and immediate desire to void May lead to urge incontinence Urinary frequency, or abnormally frequent voiding ● Fever or chills; blood in the urine
  • 28.
    Any pain inthe abdomen, flank, or back Dull, steady pain in pyelonephritis; severe colicky pain in ureteral obstruction from renal stone Assess any: ● Polyuria, a significant increase in 24-hour urine volume Diabetes mellitus, diabetes insipidus Nocturia, urinary frequency at night Bladder obstruction Urinary incontinence, involuntary loss of urine: From coughing, sneezing, lifting ● From urge to void Stress incontinence (poor urethral sphincter tone) Urge incontinence (detrusor overactivity)
  • 29.
    Asking a PastHistory • To determine if your patient’s problem is new or recurring ask about past GI illnesses, such as ulcer, liver, pancreas, or gallbladder disease, inflammatory bowel disease, rectal or GI bleeding, hiatal hernia, Irritable bowel syndrome, diverticulitis, gastro-esophageal reflux disease or cancer. Also ask if he has had abdominal surgery or trauma/ accidents, blood transfusion
  • 30.
    PAST HEALTH HISTORY Haveyou ever had any of the following gastrointestinal disorders: ulcers, gastroesophageal reflux, inflammatory or obstructive bowel disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis? Presenting the client with a list of the more common disorders may help the client to identify any that he has or has had. Have you had any urinary tract disease such as infections, kidney disease or nephritis, or kidney stones? Urinary tract infections may become recurrent and chronic. Moreover, resistance to drugs used to treat infection must be evaluated. Chronic kidney infection may lead to permanent kidney damage.
  • 31.
    Have you everhad viral hepatitis (type A, B, or C)? Have you ever been exposed to viral hepatitis? Various populations (e.g., school and health care personnel) are at increased risk for exposure to hepatitis viruses. Any type of viral hepatitis may cause liver damage. Have you ever had abdominal surgery or trauma to the abdomen? Prior abdominal surgery or trauma may cause abdominal adhesions, thereby predisposing the client to future complications or disorders. What prescription or over-the-counter medications do you take? Medications may produce side effects that adversely affect he gastrointestinal tract. For example, aspirin, ibuprofen, and steroids may cause gastric bleeding. Chronic use of antacids or histamine-2 blockers may mask the symptoms of more serious stomach disorders. Overuse of laxatives may decrease intestinal tone and promote dependency. High iron intake may lead to chronic constipation
  • 32.
    Asking about FamilyHealth • Some GI disorders are hereditary, ask the patient whether anyone in his family had a GI disorder. • Disorders with familial link include • Ulcerative colitis • Colorectal cancer • Peptic Ulcer • Gastric cancer • Alcoholism • Crohn’s disease
  • 33.
    FAMILY HISTORY Is therea history of any of the following diseases or disorders in your family: colon, stomach, pancreatic, liver, kidney, or bladder cancer; liver disease; gallbladder disease; kidney disease? Family history of certain disorders increases the client’s risk for those disorders. Genetic testing can now identify the risk for certain cancers (colon, pancreatic, and prostate) and other diseases. Client awareness of family history can serve as a motivation for health screening and positive health promotion behaviors.
  • 34.
    Asking about psychosocialHealth • Inquire about parent occupation, home life, financial situation, stress level and recent life changes. • Be sure to ask about alcohol, caffeine and tobacco use as well as food and fluid, exercise habits and oral hygiene. Ask about sleep pattern, how many hours of sleep does he felt he needs? How many does he get?
  • 35.
    LIFESTYLE AND HEALTHPRACTICES Do you drink alcohol? How much? How often? Alcohol ingestion can affect the gastrointestinal tract through immediate and long-term effects on such organs as the stomach, pancreas, and liver. Alcohol-related disorders include gastritis, esophageal varices, pancreatitis, and liver cirrhosis. What types of foods and how much food do you typically consume each day? How much non caffeinated fluid do you consume each day? How much caffeine do you think you consume each day (e.g., in tea, coffee, chocolate, and soft drinks)? A baseline dietary and fluid survey helps to determine nutritional and fluid adequacy and risk factors for altered nutrition, constipation, diarrhea, and diseases such as cancer.
  • 36.
    How much andhow often do you exercise? Describe your activities during the day. Regular exercise promotes peristalsis and thus regular bowel movements. In addition, exercise may help to reduce risk factors for various diseases such as cancer and hypertension What kind of stress do you have in your life? How does it affect your eating or elimination habits? Lifestyle and associated stress and psychological factors can affect gastrointestinal function through effects on secretion, tone, and motility. If you have a gastrointestinal disorder, how does it affect your lifestyle and how you feel about yourself? Certain gastrointestinal disorders and their effects (e.g., weight loss) or treatment (e.g., drugs, surgery) may produce physiologic or anatomic effects that affect the client’s perception of self, body image, social interaction and intimacy, and life goals and expectations.
  • 37.
    Assessment • With abdominalassessment, you inspect first, then auscultate, percuss, and palpate. • This order is different from the rest of the body systems, for which you inspect, then percuss, palpate, and auscultate. Auscultation is done before palpation and percussion
  • 38.
    General Considerations • Provideprivacy • Good lighting/appropriate temp in room • Expose the abdomen • Empty bladder • Position pt supine, arms by side & head on pillow with knees slightly bent or on a pillow • Warm stethoscope & hands • Painful areas last. 4/15/2020 Ms. Fazeelat Tahira 38
  • 39.
    Cont… • Patient needsto be exposed from above the xiphoid process to the symphysis pubis. • Also, make sure your patient does not have a full bladder. • Place patient in a supine position: pillow under the head and knees. • Helps to relax abdominal muscles. 4/15/2020 Ms. Fazeelat Tahira 39
  • 40.
    • Have patientpoint out any areas of pain or tenderness. • Examine these last. • During exam continue to monitor your patient’s facial expression for pain and discomfort. • Use inspection, auscultation, percussion, and palpation to perform the exam. • Always auscultate before percussing or palpating. • because palpation or percussion cause movement or stimulation of the bowel, which can increases bowel motility and thus heighten bowel sounds, creating false results. 4/15/2020 Ms. Fazeelat Tahira 40
  • 41.
    Landmarks • Anatomical structuresare used as landmarks to help you describe abdominal findings. The following landmarks are used: xiphoid process of the sternum; costal margin; midline (down the center of the abdomen); umbilicus; anterior- superior iliac spine; inguinal ligament and superior margin of the pubic bone
  • 43.
    Inspection • Observe theabdomen for color and symmetry, checking for bumps, bulges, lesions, scars, rashes or masses. A bulge may indicate distension or hernias • Abdominal shape • Contour • Umbilicus • Skin of abdomen
  • 44.
    • Striae • Stretchmarks • Abdominal movements or pulsations
  • 45.
    Normal Findings • Abdomenflat to rounded in people of average weight. • A slender person may have a slightly concave abdomen. • A protruding abdomen may be caused by obesity, pregnancy, ascites or abd. distension
  • 46.
    • Umbilicus invertedand located midline of abdomen • Conditions such as pregnancy, ascites or an underlying mass can cause the umbilicus to protrude. • Have the patient raise his head and shoulders. If his umbilicus protrudes, he may have an umbilical hernia • Waves of peristalsis not seen. • In thin patients, pulsation of aorta is visible in epigastric area.
  • 47.
    Auscultation • Assess allfour quadrants • Listen for at least 5 minutes before concluding bowel sounds are absent. Ms. Fazeelat Tahira
  • 48.
    Auscultation • Normal findings –Bowel sounds are heard in all quadrants – Usually sounds are high pitched – Occur 5 to 15 times per minute. – Borborygmus or stomach growling is the loud, gurgling, splashing bowel sound heard over the large intestine as gas passes through it. Ms. Fazeelat Tahira
  • 49.
    Auscultation • Abnormal findings:absent, hypoactive or hyperactive bowel sounds • Pathophysiological indications – Absent and hypoactive bowel sounds may indicate decreased motility and possible obstruction – Hyperactive bowel sounds indicate increased motility and possible diarrhea, gastroenteritis Ms. Fazeelat Tahira
  • 51.
    listen for Bruits(venous hum) over aorta, renal artery, iliac artery, and femoral artery • listen for friction rub over liver and spleen
  • 52.
    Percussion • Direct orindirect percussion is used to detect the size and location of abdominal organs and to detect air or fluid in the abdomen, stomach, or bowel. • For direct percussion, strike your hand or finger directly against the patient’s abdomen. • For indirect percussion, use the middle finger of your dominant hand or a percussion hammer to strike a finger resting on the patient’s abdomen.
  • 53.
    • Begin percussionin the RLQ and proceed clockwise, covering all four quadrants. Note where percussed sound change from tympany to dullness • Don’t percuss if the patient has an abdominal aortic aneurysm or a transplanted abdominal organ. Doing so can precipitate a rupture or organ rejection.
  • 54.
    Normal Findings • Tympanyheard over air-filled areas, such as stomach and intestines • Dullness heard over solid areas, such as liver, spleen, or a distended bladder • No tenderness elicited over kidneys and liver • Empty bladder is not percussable above the symphysis pubis
  • 55.
    • Identify theupper border of liver dullness in the mid-clavicular line by lightly percussing from lung resonance down toward liver. • Starting at a level below the umbilicus in the right mid-clavicular line, lightly percuss upward toward the liver. Ascertain the lower border of liver dullness.
  • 57.
    Findings • Liver span:commonly clinically under estimated. • Midclavicular line: normally 6-12cm. • Midsternal line: normally 4-8cm
  • 58.
    Percussing the Spleen •The spleen is located at about the level of the 10th rib, in the left midaxillary line. Percussion may produce a small area of dullness, generally 7” (17.8cm) or less in adults. However, the spleen usually can’t be percussed because tympany from the colon masks the dullness of the spleen
  • 59.
    • Percuss thelowest intercostal space in the left anterior auxiliary line, percussion notes should be tympanic. • Ask the patient to take a deep breath, then percuss this area again. If the spleen is normal in size, the area will remain tympanic. If the tympanic percussion note changes on inspiration to dullness, the spleen is probably enlarged. • To estimate spleen size, outline the spleen’s edges by percussing in several directions from areas of tympany to areas of dullness.
  • 60.
    • Perform bluntpercussion on the kidneys. • Use the ulnar side of your right fist to strike your left hand. Perform blunt percussion on the kidneys • at the costovertebral angles (CVA) over the twelfth rib. • Normally no tenderness or pain is elicited or reported by the client. The examiner senses only a dull thud.
  • 62.
    Assessing Bladder Size •To percuss the bladder for distension, begin at the symphysis pubis and percuss upward to the umbilicus, noting any dullness. Normally, an empty bladder does not rise above the symphysis pubis
  • 63.
    Palpation • To performlight palpation • Put the fingers of one hand close together. • Depress the skin about ½ (1.5cm) with your fingertips and make gentle, rotating movements. Avoid short, quick jabs. • To perform deep Palpation • Push the abdomen down 2” to 3” (5-7.5cm) in an obese patient, put one hand on top of the other and push
  • 64.
    Light & DeepPalpation
  • 65.
    • Palpate theentire abdomen in a clockwise direction, checking for tenderness, pulsation, organ enlargement, and masses. • The abdomen should be soft and nontender. As you palpate the four quadrants, note organs, masses, area of fluid accumulation, and areas of tenderness or increased resistance. • Determine whether resistance is due to the
  • 66.
    • Patient’s beingcold, tense or ticklish, or if it’s due to involuntary guarding or rigidity from muscle spams or peritoneal inflammation. • Don’t palpate a rigid abdomen. Peritoneal inflammation may be present, in which case palpation cause pain, or rupture an inflamed organs.
  • 67.
    Palpating the Liver •Palpating the liver by two methods • Standard Method • Hooking the liver
  • 68.
    Standard Method • Placethe patient in supine position. Standing his right, place your left hand under his back at the approximate location of the liver. • Place your right hand slightly below the mark at the liver’s upper border that u made during percussion. Point the fingers of your right hand toward the patient’s head just under the right costal margin. • As the patient inhale deeply, gently press in and up on the abdomen until the liver brushes under your right hand. The edge should be smooth, firm and somewhat round. Note any tenderness.
  • 69.
  • 70.
    Hooking the Liver •Stand next to the patient’s right shoulder, facing his feet. Place your hand side by side, and hook your fingertips over the right costal margin, below the lower mark of dullness. • Ask the patient to take deep breath as you push your fingertip in and up. If the liver is palpable, you may feel its edges as it slides down in the abdomen as he breathe in.
  • 71.
  • 72.
    Palpating the spleen •To detect tenderness and enlargement. Splenic tenderness may result from infections. • With the patient in a supine position and you at his right side, reach across him to support the posterior lower rib cage with your left hand. • Place your right hand below the left costal margin and press inward.
  • 73.
    • Instruct thepatient to take a deep breathe. The spleen normally shouldn’t descend on deep inspiration below the 9th or 10th intercostal space in the posterior midaxillary line. • Normally the spleen is not palpable. If the spleen is enlarged, you will feel its rigid border. If you do feel the spleen, stop palpating immediately because an enlarged spleen can easily ruptured.
  • 74.
  • 76.
    • Palpate thekidneys. To palpate the right kidney, support the right posterior flank with your left hand and place your right hand in the RUQ just below the costal margin at the MCL. • To capture the kidney, ask the client to inhale. Then compress your fingers deeply during peak inspiration. Ask the client to exhale and hold the breath briefly. Gradually release the pressure of your right hand. If you have captured the kidney, you will feel it slip beneath your fingers. To palpate the left kidney, reverse the procedure
  • 77.
    Palpating the rightkidney (A) and the left kidney (B).
  • 78.
    Checking for ascites •Have an assistant place the ulnar edge of her hand firmly on the patient’s abdomen at its midline. • As you stand facing the patient’s head, place the place the palm of your left hand against the patient’s right flank. • Give the left abdomen a firm tap with your right hand. If ascites is present, you may see and feel a fluid wave ripple across the abdomen
  • 79.
    • If detectascites, use a tape measure to measure the fullest part of the abdomen. Mark the point on the patient’s abdomen with a felt tip pen so you will be sure to measure it consistently. This measurement is important, especially if fluid removal or paracentesis is performed.
  • 80.
    • Shifting Dullness Toperform the shifting dullness test, place the patient in the supine position, percuss the entire abdominal region, and mark the dullness-tympany transition point (left figure). Then place the patient in the right lateral decubitus position, wait 30 to 60 seconds, repeat the percussion, and again mark the dullness-tympany transition point (right figure). A positive shifting dullness test is indicated by a shifting of the transition point
  • 83.
    Eliciting Abdominal pain •Rebound Tenderness / Blumberg's sign • Help the patient into supine position • Place hands gently on the RLQ at McBurney’s (located about midway between the umbilicus and the anterior superior iliac spine). • Slowly and deeply dip fingers into area then release the pressure in a quick, smooth motion. • Pain on release rebound tenderness is a positive sign
  • 85.
    Ilieopsoas Sign • Helpthe patient into a supine position with his legs straight. • Instruct him to raise his right leg upward as you exert slight downward pressure with your hand on his right thigh. • Repeat the maneuver with the left leg. • When testing either leg, increased abdominal pain is a positive result, indicating irritation of psoas muscle.
  • 87.
    Obturator Sign • Helpthe patient into supine position with his right leg flexed 90 degrees at the hip and knee. • Hold the leg just above the knee and at the ankle then rotate the leg laterally and medially. • Pain in the hypogatric region is a positive sign, indicating irritation of obturator muscles
  • 89.
    Examining the rectumand Anus • Inspection • Put on gloves and spread the buttocks to expose the anus and surrounding tissues • The skin in the perineal area is normally somewhat darker than that of the surrounding tissues. • Check for fissures, lesions, scars, inflammation, discharge, hemorrhoids. Then ask the client to strain as if he’s having bowel movements. This action may reveal internal hemorrhoids or fissures.
  • 90.
    Palpation • Apply watersoluble lubricant to your gloved index finger • Tell the patient to relax and warm him that he’II feel some pressure. • Ask the patient to bear down. • As the sphincter opens, gently insert finger into rectum toward the umbilicus. • To palpate as much of the rectal wall as possible, rotate finger clockwise and then counterwise. • The rectal walls should feel soft and smooth, without masses, fecal impaction or tenderness.
  • 91.
    • Remove fingerfrom rectum and inspect the gloves for stool, blood and mucus. • Test fecal matter adhering to the glove for occult blood using a guaiac test.
  • 92.
    Abnormal finding • AbdominalDistension • Distension may result from gas, a tumor, or colon filled with feces. • It may also caused by an incisional hernia, which may protrude when he patient lifts his head and shoulder
  • 93.
    Abdominal Pain • Abdominalpain may indicate ulcers, intestinal obstruction, appendicitis, cholecystitis, peritonitis etc. Types of abdominal pain • Burning peptic ulcer, GERD • Cramping Diarrhea, constipation • Severe cramping Appendicitis, Crohn disease • Stabbing pancreatitis, cholecystitis
  • 94.
    Abdominal pain origin Affected organ Visceralpain Parietal pain Referred pain Stomach midepigastrium Midepigastriu m and LUQ Shoulder Appendix Periumbilical area RLQ RLQ Small intestine Periumbilical area Over affected site Midback (rare)
  • 95.
    Abnormal abdominal sounds •Altered bowel sounds • Hyperactive sounds in any quadrant • Hypoactive in any quadrant • High pitched tinkling sound • High pitched rushing sound • Systolic bruits over abd aorta, renal & iliac artery • Resembling cardiac murmur • Venous hum epigastric and umbilical region • Friction rub over liver & spleen
  • 96.
  • 97.
    • Bloody stool •Constipation • Diarrhea • Hepatomegly • Splenomegaly
  • 98.
    Changes in abdomenthat are characteristics of aging process • As we age, the digestive process becomes less efficient: • In the mouth, food may not be properly broken down due to missing teeth or gum problems as well as lowered saliva production • The lower sphincter that regulates the flow of food from the esophagus into the stomach, can weaken resulting in reflux, a back flowing of food or acid (heartburn)
  • 99.
    • Loss ofmuscle tone causes food to move more slowly along the digestive tract • The stomach becomes less elastic and cannot hold as much food • The production of acids and enzymes declines. A decline in the production of lactase, an enzyme that digests dairy products can lead to lactose intolerance, a condition that causes bloating and gas when milk products are consumed
  • 100.
    Reference • Rushforth, H.(2010). Assessment made incredibly easy!(2nd edition). Wolters Kluwer • Janet R. Weber & Jane H. Kelley (2013). Health Assessment in Nursing (4th ed). : Lippincott Williams & Wilkins • Video link • https://www.youtube.com/watch?v=j8GEIIEY71c • https://www.youtube.com/watch?v=PrlTdsJ7lWg • https://www.youtube.com/watch?v=j_zDaCzW08k • https://www.youtube.com/watch?v=D0G7353qfY w