Christian University of Thailand

Christian University of ThailandCollege of NursingINUR3302: Nursing Process and Basic Health Assessment

Performing Abdominal Assessment

1. ID No. .... Name. Score ...

2 = Performed satisfactorily1 = Needs practice0 = No Performance

ProcedureRationaleEvaluation

1. Identify the patient.Identification of the patient ensures that the assessment will be performed on the right patient.

2. Explain the purpose of the abdominal examination and answer any questions.Explanation helps to alleviate anxiety, promotes cooperation, and facilitates the examination.

3. Perform hand hygiene.Hand hygiene deters the risk of microorganism transmission.

4. Help the patient undress if needed and provide a patient gown. Assist the patient to a supine position and expose the abdomen.Having the patient wear a gown facilitates examination of the abdomen.

5. Inspect the abdomen for skin color, contour, pulsations, the umbilicus, and other surface characteristics ( rashes, lesions, masses, scars).The umbilicus should be centrally located and may be flat, rounded, or concave.The abdomen should be evenly rounded or symmetric,without visible peristalsis. In thin people, an upper midline pulsation may normally be visible.

6. Auscultate all four quadrants of the abdomen for bowel sounds by using the diaphragm of the stethoscope.Use a systematic method.Performing auscultation before percussion or palpation prevents percussion and palpation techniques from interferring with findings. Auscultation detects the presence of bowel sounds, which indicate peristalsis.

7. Auscultate the abdomen for vascular sounds by using the bell of the stethoscope.A bruiit on auscultation suggests an aneurysm or arterial stenosis.

8. Percuss the abdomen for tones.Persussion assesses for the density of the abdominal contents, organs, or possible masses. Tympany over more air-filled regions and dullness over a solid organ are the predominant tones elicited. Percussion on the right side helps to evaluate the spleen;percussion over the symphysis pubis helps to evaluate the bladder for fullness.

9. Palpate the abdomen lightly in all four quadrants and then palpate using deep palpation technique.Palpation provides information about the location, size, tenderness, and condition of the underlying structures.

10. Palpate for the kidneys on each side of the abdomen. Palpate the liver at the right costal boarder. Palpate for the spleen at the left costal border.A normal liver, spleen, and kidneys are often not palpable. Palpation helps detect enlarged organs.

11. Assess for rebound tenderness last if the patient reports pain by pressing deeply and gently into the abdomen with the hand and fingers downward and then withdrawing the hand rapidly.Rebound tenderness indicates peritioneal irritation, such as from appendicitis. This assessment is performed last because it can causepain and muscle spasm that could interfere with the rest of the examination. Continues palpation for rebound tenderness could lead to rupture of the appendix.

12. Palpate and then auscultate the femoral pulses in the groin.This technique assesses vascular patency.

13. Replace the patients gown and assist the patient to a comfortable position.This ensures the patients comfort.

14. Perform hand hygiene.This deters the spread of microorganisms.

15. Document findings and the procedure done.Documentation prevents clinical errors during the practice

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Instructor..././.