More Than Bowel Sounds: Abdominal Assessment

Assessment of the abdomen is important for nursing students, new grads, and veteran nurses alike. For the newer nurses, the skill has to be repeated consistently to ensure that it becomes a routine. For veteran nurses, they may forget some of the nuances of the skill, depending on how many times they are called to do it. It may be easy to overlook inspection and percussion, especially if you are in a hurry or the patient doesn't seem to have any abdominal problems.

The belly of your patient can tell you a great deal about their health, and that is why it is important to know the intricacies of this assessment. No, you will not always need to percuss, but if you suspect something GI, then you want to know how to do it. These skills are hard to learn and easy to forget, and a full abdominal assessment can alert you to a problem long before it becomes critical. Learn to inspect, auscultate, palpate, and percuss the abdomen for the best patient outcomes.

Inspection

It is easy to overlook inspection, especially if you are busy. Of course, looking at the abdomen is obvious, but how closely do you actually look at it? The patient needs to be supine, their knees supported by pillows, and their arms at their sides. This ensures that the musculature of the abdomen is in a relaxed state. Look at the general contour of the region. Are their any masses, protuberances, pulsations, or uneven sections? Sometimes it is easier to see a mass than to feel one, but the patient has to be laying flat with adequate lighting. For a thorough inspection, you should spend at least 30 seconds looking over the stomach. You may notice things that slip the eye otherwise.

Another important point to look for is the color of the skin. Is it grey, yellow, blue, or red? Are their stretch marks or pulsing veins that stand out on the skin? In some cases, it helps to shine a light across the abdomen to pick out issues that are not seen by direct lighting. Pulsations of the abdomen can sometimes indicate a bowel obstruction. Also look at how the abdomen moves while the patient is breathing. It should move toward the head on inhalation and subside on exhalation. When parts of the stomach do not move naturally according to breath, then you may have some interruption in peristalsis to investigate.

Auscultation

When most nurses think of abdominal assessment, they think of auscultation. Whip out the stethoscope, listen in four random places, and move on. Actually, it is a little more involved than that when done correctly. The patient should be in the same position they were in when you inspected the abdomen. You want to place the diaphragm of your stethoscope lightly over the skin, and listen carefully at each of the four quadrants. You will hear gurgling when the bowel sounds are active.

If you don't hear anything, then you have a duty to listen until you do. Most nurses will balk at listening over a quadrant for at least three minutes, but that is the only way to fully assess that there are no bowel sounds in that quadrant. For patients at risk of an ileus, this may be an important assessment finding. You can even pinpoint the place where the peristalsis stops. Before the blockage, you may hear high pitched, very active bowel sounds and then nothing further on. When working with a GI patient, it is more than just a quick listening over the quadrants. You need to take your time to really listen to the quality and positioning of the sounds.

Palpation

Like the other methods of assessment, you should not rush through palpation. It is important to leave palpation until after auscultation because it can affect what you hear. Some nurses press here and there, then they are on to the next task. Again, this will not help you to fully determine if a patient is having abdominal pain. It is important to position them so they are laying flat. Many nurses palpate while the patient is sitting up in bed, and this can interfere with how the patient responds. You want to palpate to the four quadrants and under the diaphragm, or epigastric region. The first level of palpation is superficial. You only feel the top portion of the tissue to determine if there are any gross masses or fluid shifts.

Next, deep palpation may be called for. You use two hands, one set of fingers over the other, to press into the tissue. Notice how the patient reacts by observing their face, but also pay attention to what you feel under your fingers. Are the patient's muscles contracting? Is the patient wincing in pain when you palpate deep? Are they pulling away? Do they feel pain when you let go of the tissue, indicating rebound tenderness? If the patient has a particular part of the abdomen that hurts, please don't perform deep palpation there. Otherwise, deep palpate to the four quadrants and notice what you feel.

Percussion

Most nurses don't have the time or the need for percussion. Honestly, this is more for a physician or advanced practice nurse to venture into. However, even the bedside nurse can use this technique for different reasons. On the whole, the technique, when used on the abdomen, tends to help delineate the margins of the liver. Not many nurses need to know that. You can use it over the quadrants, though, to hear if there is anything in the intestines that could not be felt any other way. It should sound hollow, like beating on a drum.

Masses and fluid will sound dull. There is some concern over how to properly percuss. It is definitely a skill that requires practice, and it seems everyone has a different way of doing it. One is to curl the first finger of your non-dominant hand and place the knuckle over the place for percussion. Use your dominant hand's first finger to tap on the knuckle and listen to the sound. With practice, you will be able to hear the difference between different types of tissues in the abdomen.

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Reference

Clinical Methods: The History, Physical, and Laboratory Examinations; Charles M. Ferguson. Accessed February 27, 2015