Why is the abdominal assessment different than the rest?

[Dani_Sanchez777]

In class the other day we were going over the abdominal physical assessment. A student became frustrated and was asking the professor, “why is the abdominal assessment in a different order than the rest of the body? Why don’t they just make the rest of the systems the same order as the abdomen?”

All body systems except the abdomen: Inspect, Palpate, Percuss, Auscultate

Abdomen: Inspect, Auscultate, Palpate, Percuss

Does anybody have a good answer for this? I get why the order is the way that it is. But, the girl does have a point (Even though I’m not sure why it was making her mad...). Why don’t we do the rest of the body systems in the same order of the abdomen? ?

Thank you!

[Lunah, MSN, RN]

Because palpation can then produce bowel sounds that normally wouldn't be there and alter your assessment. You really want to assess bowel sounds in their true state.

Edit: Nevermind, I see your point!! LOL. When you are done with school, you can do them in the order you prefer, like the abdomen. I can't think of a good reason before coffee! ?

[Jedrnurse, BSN, RN]

8 hours ago, Pixie.RN said:

Because palpation can then produce bowel sounds that normally wouldn't be there and alter your assessment. You really want to assess bowel sounds in their true state.

Edit: Nevermind, I see your point!! LOL. When you are done with school, you can do them in the order you prefer, like the abdomen. I can't think of a good reason before coffee! ?

I think that your rationale is still sound; isn't it possible that percussion may have the same effect (stimulating bowel sounds) that palpation does?

OP: All caps is the online equivalent of shouting. Did you mean to scream out the title of your post?

[NurseBlaq]

8 hours ago, Pixie.RN said:

Because palpation can then produce bowel sounds that normally wouldn't be there and alter your assessment. You really want to assess bowel sounds in their true state.

This.

[Lunah, MSN, RN]

Yes, but she is asking why don't we just be consistent and auscultate everything first? At least that is how I read it (after re-reading, LOL).

[LibraNurse27, BSN, RN]

I think the shouting was to demonstrate the frustration with which her classmate kept asking the question ?Nursing school can cause a lot of emotional distress ?

[KatieMI, BSN, MSN, RN]

Because:

Everything else, we need to make sure the thing is really there and if we need to adjust our auscultation as appropriate. It doesn't make any sense to auscultate the heart if it is not where you think it is (happens more frequently than you might imagine). It doesn't make sense to auscultate the lung and write "no breathing sounds" and go into panic mode when the lung is not there for the last 15 years (which you would caught if you had your inspection done first as suggested and see the scar). It doesn't make sense to auscultate for bruit if you are not sure the pulse is even present.

Also, palpation/percussion prepares examiner to what he's going to hear and let him adjust the details. If you feel unusual thrill, it makes sense to establush the max point and listen over it in addition to everything else.

On the abdomen, we need to make sure that it is safe to palpate/percuss first. There are too many frequent conditions when palpation/percussion are directly contraindicated and "dead belly" may or may not be seen on inspection, especially on very obese or very sick patients. If by auscultation we confirm finding of absense of bowel sounds, intence bruit, pain even on stetoscope touch, etc. we need to halt the exam as every following action will bring no good.

Re. palpation before percussion, it is so because you will feel difference between "hollow" and "hard" and textures of the "hard" better if you first establish borders between organs. It is named "mental mapping".

P.S. please explain your students that physical exam rules are not the Ten Commandments. I'd seen more than one nurse who tried to do palpation/percussion before auscultation while during the code there was a question if the tube was where it was intended to be, and later tried to racionalize that "it was the correct order" or tried to proceed with auscultation of the abdomen for prescribed 3 to 5 min/point and happily reported "normal bowel sounds" when patient was bleeding to death in front of her. Please teach them thinking ?

[Dani_Sanchez777]

@LibraNurse27 @Jedrnurse Hahaha! No, I wasn't shouting. ? I must have hit ALL CAPS on my iPad keyboard when I wrote it. I wasn't paying attention ?. I'm not upset at all about this; I'm a good rule follower so this never bothered me.

What bothers me is that student was so mean and rude to our super sweet professor for not calling the board of nursing on the spot making the rules change! ?

I 100% get why we would not poke and move things around before listening with the abdomen. The other stuff, I'm fine with following the rules. Although my classmate does pose a good question/point... They're in that way for a reason ?

@Pixie.RN "Yes, but she is asking why don't we just be consistent and auscultate everything first? At least that is how I read it (after re-reading, LOL)." -- THIS is 100% correct! This is what the student was asking (which I do think is a good/fair question to ask). Just, minus the whole anger bit ?.

[Dani_Sanchez777]

@KatieMI Thank you for all of that!

I think it's fair to say that as students we LOVE a nice set of rules to go by (like they tell us we would). We do get drilled that you go in a specific order and if you don't, you don't pass the exam or check off, but we also are taught that as we progress through our program and out into our careers, that our intuition and experience will be vital in making decisions about our care for each patient and situation individually.

I love the point you made about these rules and comparing them to the Ten Commandments. It really puts it into perspective that nursing is NOT just a set of rules.. rules are necessary, but what I gained from everything that you said is that for school we do need to follow our set of rules; to learn, to pass , to understand the basics of what we are doing and why we are doing it. But out there in the real world, we will follow new sets of rules and we need to be able to think critically and focus on the situation at hand for each patient individually. ?