2 Abdomen Checklist 1

Republic of the Philippine
TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300
___________________________________________________________________________________________________
PERFORMANCE EVALUATION CHECKLIST
ASSESSMENT OF THE ABDOMEN
NAME: __________________________________________ SCORE: ____________________

YEAR \ SECTION: __________________________________ DATE: _____________________
Descriptive Interpretation for Actual Score:

2 – Outstanding 1 - Satisfactory 0- Needs Improvement/Repeat Performance
ACTUAL SCORE
PROCEDURAL STEPS
2 1 0
For All Assessment:
1. Hand wash and gather all equipment needed.
2. Identify the patient.
3. Addresses patient by proper name and conversation is therapeutic at all times.
4. Asks appropriate health questions.
 Is able to answer questions related to assessment?
5. Uses good body mechanics and position patient appropriately.
6. Prepare participant by telling them what you will be doing.
 Explain assessment process to the patient and secure consent.
7. Explain that you will be touching the client and instruct the client as needed.
8. Provide warmth, privacy and well lit-room.
SUBJECTIVE DATA
9. Current health status (Describe chief complaint, Pain, Ability to walk upright,
Nutritional Assessment, Indigestion, Heartburn, N/V, Stool)
10. Past health status (Allergies, smoking, medications, surgery, weakness)
11. Family health status (Colorectal CA, Polyps, Colitis)
GENERAL APPROACH
12. Instruct client to empty the bladder before placing to position.
13. Position in supine with pillow under head and knees.
 Full exposure of the abdomen from xyphoid process to groin.
 Arms should be held across chest or be at sides.
14. Have warm hands and stethoscopes.
15. Instruct the client to breathe normally.
INSPECTION OF THE ABDOMEN
Observe the following:
16. Contour and symmetry (flat, scaphoid, round, protuberant, distended);
17. Striae, scars, rashes, lesions and mass (location, length, color)
18. Umbilicus (contour, color) and signs of hernia
19. Peristalsis, dilated veins, blue discoloration
AUSCULTATION OF THE ABDOMEN
20. Listen to bowel sounds, note frequency, intensity, location, pitch and pattern
(absence, sluggish, hyperactive). Clicks and gurgles occur 5-30/min.
21. Determine borborygmi and vascular sounds (bruits, friction rub, venous hum) Note
bruits location and indication (abdominal, RUQ, iliac, renal, Femoral)
PERCUSSION OF THE ABDOMEN
22. Percuss in all sections to assess for tympany and dullness.
 Assess for gastric tympany, liver dullness, splenic dullness, suprapubic dullness.
23. Percuss the upper and lower border of the liver at the midclavicular and midsternal
lines.
 Normal limits:
Adult: 6-12 cm at midclavicular line; 4.4-8.2cm at midsternal line
Children; 5 yrs - 7 cm; 12 yrs - 9 cm
24. Hepatic enlargement suggests emphysema, mass or hepatitis.
25. Absence of liver dullness suggests perforation or cirrhosis
26. Percuss the flanks for shifting dullness (ascites).
PALPATION OF THE ABDOMEN
27. Light palpation (1-2cm). Note for consistency, guarding, tenderness
28. Deep palpation (4cm) Note the following:
 Masses (neoplasms, cysts, aneurysms, feces in bowel)
 Tenderness
 Rigidity (Voluntary and Involuntary rigidity)
PALPATE FOR ABDOMINAL PAIN
29. Visceral pain. Arises from within the abdominal organ. dull pain, poorly localized
(intestinal obstruction, pancreatic tumor)
30. Parietal (somatic) pain - inflammation of structure that is innervated by a somatic
sensory nerve. Pain is sharp and well localized (peritonitis, ruptured appendix)
31. McBurney Point - specialized tenderness in acute appendicitis between the umbilicus
and the right anterior superior iliac spine. Appendicitis pain starts in the umbilical area
and progresses down to the right lower quadrant.
PALPATE FOR REBOUND TENDERNESS
32. Press over region far away from the tender area and release pressure suddenly. Pain
will occur in area of disease.
33. Apply gentle pressure over tender area and have patient cough.
PALPATE THE SPLEEN
(Hyperplasia, congestion, neoplasms, fatty infiltration, systemic infections, and chronic
anemia).
34. Stand at patient's right
35. Place a supporting left hand under patient's left costovertebral angle and exert pressure
to push spleen anteriorly
36. At the same time, slide the fingers of your right hand gently upward beneath the
patient's left anterior costal margin
37. Ask patient to take a deep breath
38. If you suspect the spleen is enlarged but you cannot feel it while patient is in the supine
position, repeat the procedure while the patient is in the right lateral decubitus position.
A palpable spleen is always considered enlarged. A spleen must be enlarged 3-5 times
in order to be palpable.
39. Palpate over the suprapubic region for a large distended bladder. A bladder can distend
as far as the umbilicus.
PALPATE THE LIVER
40. Support posterior 11th and 12th rib, gently pressing upward with left hand.
41. Place right hand to the side of the rectus muscle and press upward.
42. Ask the patient to take a deep breath and feel the lower border of the descending liver
as it strikes the fingertips.
A palpable liver may be caused by:
 Abnormally large liver (neoplasms, hepatitis, early cirrhosis)
 A liver that is pushed downward by a low diaphragm
 A congenitally large right lobe
Note: Frequently palpable in children under age of 4 years
43. Describe edge of the liver:
 Nodular – neoplasm
 Soft - very hard liver indicated cirrhosis
 Smooth – normal
Tender - inflammation of the liver
PALPATE THE AORTA
44. Palpable pulsation in the midline of the abdomen (AAA)
 In a thin individual the normal aorta may be felt as a pulsatile structure.
The pulsations will displace the examining fingers laterally. Also pain in the abdomen
or back may be present.
PALPATE INGUINAL AND FEMOR
45. Found above and below inguinal ligament.
 The inguinal lymph nodes are frequently enlarged from superficial infections of
toes and feet.
 They are also enlarged in systematic viral infections, fungal parasitic or protozoal
infections or in lymphoma or leukemia
46. Palpation of femoral pulses. Also look for femoral hernia (more common in women)
.
AUSCULTATION OF THE POSTERIOR THORAX
47. Ask the client to breathe deeply through the mouth each time the stethoscope is placed
on a new spot. Tell the client to let you know if he or she is becoming tired or short of
breath and if so you will stop and allow time to rest.
FLUID WAVE TEST IN ASCITES
48. Use 2 people for this test. Assistant will place hand midline down abdomen.
49. Tap one flank and feel opposite flank for a delayed impulse transmitted throughout the
fluid. Seen with greater than 500cc of ascitic fluid
INTERPRETATION AND DOCUMENTATION OF FINDINGS
50. Refer or report abnormal findings and secure management.
51. Refer to the descriptions and interpretations of normal and adventitious breath sounds
52. Data for documentation:
 Date and time
 Procedure done and findings
 Abnormal findings and action taken.
 Patient’s response to the intervention/management.
SCORE
Evaluated by: Performed by:

______Regie S. Jimenez_________ ________________________________
(C.I.’s Signature over Printed Name) (Student’s Signature over Printed Name)

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Republic of the Philippine

TARLAC STATE UNIVERSITY

NAME: ______________________ SCORE:

Descriptive Interpretation for Actual Score:

Evaluated by: Performed by:

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