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    Emilio Aguinaldo College: School of Nursing

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    Grace Cabillo
    This document is an assessment form from the School of Nursing at Emilio Aguinaldo College in the Philippines. It provides instructions for students to assess a client's abdomen, including preparation, equipment needed, the performance of inspection, auscultation, percussion and palpation of the abdomen. The assessment is performed in 14 steps and is scored and evaluated by a faculty member.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Emilio Aguinaldo College: School of Nursing

    Uploaded by

    Grace Cabillo
    45 views3 pages
    This document is an assessment form from the School of Nursing at Emilio Aguinaldo College in the Philippines. It provides instructions for students to assess a client's abdomen, including preparation, equipment needed, the performance of inspection, auscultation, percussion and palpation of the abdomen. The assessment is performed in 14 steps and is scored and evaluated by a faculty member.

    Original Title

    ASSESSING-THE-ABDOMEN.

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    This document is an assessment form from the School of Nursing at Emilio Aguinaldo College in the Philippines. It provides instructions for students to assess a client's abdomen, including preparation, equipment needed, the performance of inspection, auscultation, percussion and palpation of the abdomen. The assessment is performed in 14 steps and is scored and evaluated by a faculty member.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    45 views3 pages

    Emilio Aguinaldo College: School of Nursing

    Uploaded by

    Grace Cabillo
    This document is an assessment form from the School of Nursing at Emilio Aguinaldo College in the Philippines. It provides instructions for students to assess a client's abdomen, including preparation, equipment needed, the performance of inspection, auscultation, percussion and palpation of the abdomen. The assessment is performed in 14 steps and is scored and evaluated by a faculty member.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    EMILIO AGUINALDO COLLEGE

    Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
    Tel. Nos. (046) 416-4339/41 www.eac.edu.ph
    ISO 9001:2015 CERTIFIED

    SCHOOL OF NURSING QUALITY MANAGEMENT SYSTEM

    ASSESSING THE ABDOMEN

    NAME: Cabillo, Ma. Grace F. ____________________________ SCORE: _____________________


    YR/SEC/GRP: BSN 1-6 _________________________________ DATE: April 12, 2021____________

    PERFORMED
    PREPARATION MASTERED COMMENTS
    YES NO
    1. Ask the client to urinate since an empty
    bladder makes the assessment more
    comfortable
    2. Ensure that the room is warm since the
    client will be exposed.
    EQUIPMENT
    Assemble all necessary equipment:
     Examining light
     Tape measure (metal or unstretchable cloth)
     Skin- marking pen
     Stethoscope
    PERFORMANCE
    1. Introduce self and verify the client’s identity
    using agency protocol. Explain to the client
    what you are going to do, why it is necessary
    and how the client can participate. Discuss
    how the results will be used in planning
    further care or treatments.
    2. Perform hand hygiene and observe other
    appropriate infection prevention procedures
    3. Provide for client privacy.
    4. Inquire if the client has any history of the
    following:
     Incidence of abdominal pain; its location,
    onset, sequence, and chronology; its quality
    (description); its frequency; associated
    symptoms (e.g. nausea, vomiting, diarrhea)
     Incidence of constipation or diarrhea (have
    client described what client means by these
    terms)
     Change in appetite, food tolerances, and
    foods ingested in past 24 hours
     Specific signs and symptoms (e.g. heartburn,
    flatulence, and/or belching, difficulty in
    swallowing, hematemesis [vomiting blood],
    blood or mucus in stools, and aggravating and
    alleviating factors)
     Previous problems and treatment (e.g.
    stomach ulcer, gallbladder surgery, history of
    jaundice).
    5. Assist the client to a supine position, with
    the arms placed comfortably at the sides.
    Place small pillows beneath the knees and
    the head to reduce tension in the abdominal
    muscles. Expose the client’s abdomen only
    from the chest line to the pubic area to avoid
    chilling and shivering, which can tense the
    abdominal muscles.
    INSPECTION OF THE ABDOMEN
    6. Inspect the abdomen for skin integrity

    • VIRTUE • EXCELLENCE • SERVICE


    7. Inspect the abdomen for contour and
    symmetry.
     Observe the abdominal contour (profile line
    from the rib margin to the pubic bone) while
    standing at the client’s side when the client is
    supine.
     Ask the client to take a deep breath and to
    hold it.
     Assess the symmetry if contour while
    standing at the foot of the bed.
     If distention is present, measure the
    abdominal girth by placing a tape around the
    abdomen at the level of the umbilicus. If girth
    will be measured repeatedly, use a skin-
    marking pen to outline the upper and lower
    margins of the tape placement for
    consistency of future measurements.
    8. Observe abdominal movements associated
    with respiration, peristalsis, or aortic
    pulsations.
    9. Observe the vascular pattern.
    AUSCULTATION OF THE ABDOMEN
    10. Auscultate the abdomen for bowel sounds,
    vascular sounds, and peritoneal friction rubs.
    Warm the hands and the stethoscope
    diaphragms
    For Bowel Sounds
     Use the flat-disk diaphragm
     Ask when the client last ate. 4 to 7 hours after
    a meal, bowel sounds may be heard
    continuously over the ileocecal valve area
    (right lower quadrant) while the digestive
    contents from the small intestine empty
    through the valve inti the large intestine.
     Place the diaphragm of the stethoscope in
    each of the four quadrants of the abdomen.
     Listen for active bowel sounds --- irregular
    gurgling noises occurring about every 5 to 20
    seconds. The duration of a single sound may
    range from less than a second to more than
    several seconds
    For Vascular Sounds
     Use the bell of the stethoscope over the
    aorta, renal arteries, iliac arteries, and
    femoral arteries.
     Listen for bruits.
    Peritoneal Friction Rubs
     Peritoneal friction rubs are rough, grating
    sounds like two pieces of leather rubbing
    together. Friction rubs may be cause by
    inflammation, infection, or abnormal growths.
    PERCUSSION OF THE ABDOMEN
    11. Percuss several areas in each of the four
    quadrants to determine the presence of
    tympany (sound indicating gas in stomach
    and intestines) and dullness (decrease,
    absence, or flatness of resonance over solid
    masses or fluid). Use a systematic pattern:
    begin in the lower right quadrant, proceed to
    the upper right quadrant, the upper left
    EMILIO AGUINALDO COLLEGE
    Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
    Tel. Nos. (046) 416-4339/41 www.eac.edu.ph
    ISO 9001:2015 CERTIFIED

    SCHOOL OF NURSING QUALITY MANAGEMENT SYSTEM

    quadrant, and the lower left quadrant.


    PALPATION OF THE ABDOMEN
    12. Perform light palpation first to detect areas of
    tenderness and/ or muscle guarding.
    Systematically explore all four quadrants.
    Ensure that the client’s position is appropriate
    for relaxation of the abdominal muscles, and
    warm the hands.
    Light Palpation
     Hold the palm of your hand slightly above the
    client’s abdomen, with your fingers parallel to
    the abdomen.
     Depress the abdominal wall lightly, about 1
    cm or to the depth of the subcutaneous
    tissue, with the pads of your fingers.
     Move the finger pads in a slight circular
    motion
     Note areas of tenderness or superficial pain,
    masses, and muscle guarding. To determine
    areas of tenderness, ask the client to tell you
    about them and watch for changes in the
    client’s facial expressions.
     If the client is excessively ticklish, begin by
    pressing your hand on top of the client’s hand
    while pressing lightly. Then slide your hand off
    the client’s and onto the abdomen to
    continue the examination.
    PALPATION OF THE BLADDER
    13. Palpate the area above the pubic symphysis
    if the client’s history indicates possible
    urinary retention.
    14. Document the irrigation and the client’s
    response in the client record using forms or
    checklists supplemented by narrative notes
    when appropriate. Electronic health records
    will use a designated wound/skin
    documentation sheet.
    TOTAL SCORE

    EVALUATED BY: CONFORME:

    _____________________________ ____________________________________
    Signature over Printed Name of the Faculty Signature over Printed Name of the Student

    • VIRTUE • EXCELLENCE • SERVICE

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