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Anatomy & Structure Overview USLO 1
Abdominal Quadrants — Organ Location
The abdomen is divided into 4 quadrants by vertical and horizontal lines bisecting the umbilicus. RUQ — RIGHT UPPER QUADRANT Liver & gallbladder Duodenum Head of pancreas Right kidney & adrenal
LUQ — LEFT UPPER QUADRANT
Stomach Spleen Le! lobe of liver Body of pancreas N S G 3 1 6 0 · H E A L T H A S S E S S M E N T · G A L E N C O L L E G E O F N U R S I N G
Chapter 22: Abdomen
Comprehensive Study Guide
Jarvis & Eckhardt (2024) · 9th Edition · pp. 537–564 · Exam 4 (Unit 9 content)
Unit 9 USLO 1 – Safe Assessment Techniques Unit 9 USLO 2 – Report Abnormal Findings Unit 9 USLO 3 – Documentation (SOAP) Unit 9 USLO 4 – Culture, Age & Ethnic Differences Unit 10 USLO 1 – CPE Comprehensive Assessment
Hepatic flexure of colon Part of ascending & transverse colon Le! kidney & adrenal Splenic flexure of colon RLQ — RIGHT LOWER QUADRANT Cecum & appendix Right ovary & tube Right ureter Right spermatic cord
LLQ — LEFT LOWER QUADRANT
Sigmoid colon Part of descending colon Le! ovary & tube Le! ureter Le! spermatic cord RATIONALE — MIDLINE STRUCTURES
Midline structures include the aorta, uterus (if enlarged), and bladder (if distended).
The costovertebral angle (12th rib + vertebral column) is the landmark for kidney
assessment via fist percussion.
Subjective Data — Health History USLO 1 & 3
9 Key History Questions + Rationales
1. APPETITE
Any change or loss of appetite? Weight changes? RATIONALE
Anorexia = loss of appetite from GI disease, medications, pregnancy, or mental
health disorders.
2. DYSPHAGIA
Difficulty swallowing? Pain, coughing, choking? Worse with liquids vs. solids?
6. BOWEL HABITS
Frequency? Color? Consistency? Diarrhea or constipation? Laxative use? RATIONALE
Black tarry = melena (upper GI bleed). Bright red = lower GI or hemorrhoids.
Gray = hepatitis. Diarrhea with fever + dehydration → risk for hypovolemic
shock.
7. PAST ABDOMINAL HISTORY
Ulcer, gallbladder, hepatitis, appendicitis, colitis, hernia, prior surgeries, x-rays?
8. MEDICATIONS Current medications? Alcohol use (how much, how o"en)? Smoking (packs/day)? RATIONALE
Peptic ulcer disease associated with NSAIDs, alcohol, smoking, and H. pylori
infection.
9. NUTRITIONAL ASSESSMENT
24-hour diet recall. Access to fresh food markets? RATIONALE
Many inner-city neighborhoods are food "deserts" — lacking produce but full
of fast-food, increasing risk for poor nutrition.
Developmental / Cultural Considerations USLO 4
Special Populations — History Questions + Rationales
Infants & Children Breastfeeding or bottle-feeding? Formula tolerance? New foods introduced? (Add one at a time — identifies allergies) Pica — eating non-foods (dirt, paint chips)? Should stop by age 2. Constipation (affects up to 30% of children — usually functional) Abdominal pain is hard to assess; children say "tummy hurts" for many conditions including otitis media Overweight child — age of onset, diet, family history, body image Adolescents Diet recall — skipping breakfast, junk food common Exercise pattern — boys need ~4000 cal/day Extremely thin? Screen for anorexia nervosa — voluntary starvation, purging, distorted body image Amenorrhea common with anorexia Anyone at risk → immediate referral to physician AND mental health Aging Adults How do they acquire groceries and prepare meals? (Limited access/mobility) Eat alone? (Social isolation → depression → poor nutrition) 24-hr recall may not be sufficient; consider week-long diary Constipation more common (2–3× more in women); Rome III criteria Liver size ↓ 25% between ages 20–70 → drug metabolism impaired → ↑ side effects Gallstones in 10–20% of middle-age/older adults GENETICS & ENVIRONMENT — LACTOSE INTOLERANCE
Lactase deficiency rates: 79% Native American · 75% Black · 51% Hispanic/Latino ·
21% White · 15–100% Asian. Affects calcium, vitamin D, B12 intake. Health providers
Step 1 — INSPECTION
NORMAL FINDINGS
ABNORMAL
FINDINGS
RATIONALE
Contour: Flat to rounded Scaphoid (caves in) =
dehydration/malnutrition.
Protuberant = distention
Reflects nutritional
state and fluid
balance
Symmetry: Bilaterally
symmetric
Bulges, masses, hernia.
Sister Mary Joseph
nodule = hard umbilical
nodule → metastatic
cancer (stomach, colon,
ovary, pancreas)
Shine light across
to highlight
shadows; check
from foot of table
too
Umbilicus: Midline,
inverted, no
discoloration/inflammation
Everted = ascites or mass.
Deeply sunken = obesity.
Cullen sign = bluish
periumbilical color →
intraperitoneal bleeding
Everts with
pregnancy or
underlying mass.
Piercing site should
NOT be red or
crusted.
Skin: Smooth, even,
homogeneous color.
Silvery-white striae (old
stretch marks) normal
Jaundice. Redness =
inflammation. Taut
glistening skin = ascites.
Purple-blue striae =
Cushing syndrome. Spider
angiomas = portal
HTN/liver disease.
Prominent dilated veins
( caput medusae ) = portal
HTN/cirrhosis
Recent striae =
pink/blue → turn
silvery white. Veins
normally NOT
visible (fine
network okay in
thin persons).
Pulsation: Aortic pulsation
visible in thin adults in
epigastric area. Respiratory
movement visible
(especially males).
Marked pulsation =
widened pulse pressure,
hypertension, aortic
aneurysm. Marked
visible peristalsis +
Waves of peristalsis
ripple slowly and
obliquely — normal
only in very thin
people
distention = intestinal
obstruction
Hair: Diamond-shaped in
males, inverted triangle in
females
Altered pattern =
endocrine/hormone
abnormality or chronic
liver disease
Demeanor: Relaxed
quietly, benign facial
expression, slow even
respirations
Restless, turning
constantly = colicky pain
(gastroenteritis, bowel
obstruction). Absolute
stillness, resisting
movement = peritonitis.
Knees flexed + grimacing
+ rapid respirations = pain
Patient's body
language is a key
clinical indicator of
pain type and
severity
Step 2 — AUSCULTATION (before percussion & palpation)
NORMAL FINDINGS
ABNORMAL
FINDINGS
RATIONALE
Bowel Sounds: High-
pitched, gurgling,
cascading. Irregular, 5–
times/min. Begin at RLQ
(ileocecal valve — always
present here). Use
diaphragm with light
pressure.
Hyperactive: Loud, high-
pitched, rushing, tinkling
= increased motility
(gastroenteritis, early
obstruction, diarrhea).
Hypoactive/Absent:
Follows abdominal
surgery or peritoneal
inflammation. Must listen
5 FULL minutes before
declaring absent.
Borborygmus =
stomach "growling" =
hyperperistalsis.
Bowel sounds alone
are not a reliable
indicator of bowel
function. Passage of
stool + tolerance of
oral intake are more
reliable post-op.
Vascular Sounds: Usually
absent. A systolic bruit
may be heard in 4–20% of
Systolic bruit = stenosis,
partial occlusion, or
aneurysm of aorta, renal,
Check over aorta,
renal arteries, iliac,
and femoral arteries
patient feels thud but NO
PAIN.
pyelonephritis) REPORT sound. Usually
performed with the
patient sitting during
thoracic assessment.
Step 4 — PALPATION
RELAXATION TIPS — CRITICAL FOR ACCURATE PALPATION (CPE)
Bend knees · Keep hand low and parallel · Have patient breathe in through nose,
out through mouth · Use emotive imagery · With ticklish patient: place patient's
hand under yours · Start with stethoscope to ease into touch · Examine painful
areas LAST
NORMAL FINDINGS
ABNORMAL
FINDINGS
RATIONALE
Light Palpation (1 cm):
Abdomen so", no
tenderness except mild
tenderness over sigmoid
colon (LLQ — normal).
Muscle guarding, rigidity,
large masses, tenderness.
Voluntary guarding =
bilateral, relaxes on
exhale. Can warm,
distract, or breathe
patient through it.
Deep Palpation (5–
cm): No abnormal
masses or tenderness.
Involuntary rigidity =
constant boardlike
hardness = peritoneal
inflammation. May be
unilateral. Tenderness =
local inflammation or
enlarged organ with
stretched capsule.
Bimanual technique
for obese/large
abdomen: top hand
pushes, bottom hand
senses. Note location,
size, shape,
consistency, surface,
mobility, pulsatility,
tenderness of any
mass.
Liver (RUQ): Firm regular
ridge palpated at costal
margin or just below
Liver >1–2 cm below right
costal margin = enlarged.
Firm/nodular = cirrhosis.
Le" hand supports
back at 11th–12th
ribs. Right hand
during inhalation. O"en
not palpable.
Enlarged + tender = early
heart failure, acute
hepatitis, hepatic
abscess. Enlarged +
nodular = metastatic
cancer, late portal
cirrhosis. REPORT
parallel to midline at
RUQ. Move up 1–2 cm
with each exhalation.
COPD = liver
displaced downward
by hyperinflated
lungs (may be normal
size overall).
Spleen (LUQ): Normally
NOT palpable (must be 3×
normal size to feel).
Enlarged with
mononucleosis, trauma,
leukemia, lymphoma,
portal HTN, HIV, malaria.
If enlarged — STOP
palpating immediately
(friable, can rupture).
REPORT
Roll patient to right
side to displace
spleen forward if
enlargement
suspected. Start
palpation low to
avoid missing
massive
enlargement.
Kidneys: Right kidney
occasionally palpable as
round smooth mass. Le"
kidney NOT normally
palpable (sits 1 cm
higher).
Enlarged kidney =
hydronephrosis, cyst,
neoplasm. REPORT
Duck-bill position
with both hands at
flank. Deep palpation
needed. No change
felt normally with
deep breath.
Aorta: 2.5–4 cm wide,
pulsates in anterior
direction, slightly le" of
midline in upper
abdomen.
Widened = abdominal
aortic aneurysm.
Prominent lateral
pulsation pushing fingers
apart. Bruit audible.
REPORT URGENTLY
Palpation may have
poor accuracy due to
adipose tissue and
retroperitoneal
location. Imaging is
definitive.
Special & Advanced Tests USLO 1 & 2
Ascites Tests Fluid Wave: Strike one flank, feel for wave in other hand. Positive = large amounts of ascitic fluid Shi!ing Dullness: Percuss supine → mark dullness → roll patient → dullness shi"s upward. Detects >500–1100 mL. Less reliable than fluid wave. Ultrasound is the definitive test for ascites. ALVARADO SCORE (MANTRELS) — APPENDICITIS PROBABILITY M Migration^ of pain to right iliac fossa^ 1 pt A Anorexia^ (or acetone in urine)^ 1 pt N Nausea and vomiting^ 1 pt T Tenderness RLQ^ (key finding — present in >90%)^ 2 pts R Rebound tenderness^ 1 pt E Elevation of temperature^ (oral^ ≥37.3°C)^ 1 pt L Leukocytosis^ (WBC >10,000/μL)^ 2 pts S Shi!^ to le!^ (>75% neutrophils)^ 1 pt Score ≤4 = significantly decreases probability of appendicitis | Score ≥7 = increases probability of appendicitis → refer for CT scan Normal vs. Abnormal Findings — Organ by Organ USLO 2
Abnormal Findings Reference (Jarvis Tables 22.1–22.7)
TABLE 22.1 — Abdominal Distention CONDITION KEY DISTINGUISHING SIGNS
Obesity Uniformly rounded. Umbilicus SUNKEN. Tympany with scattered
dullness over adipose. Normal bowel sounds.
Air/Gas Single round curve. Tympany over large area. Bowel sounds vary
(hyper in early obstruction, hypo with ileus).
Ascites Everted umbilicus. BULGING FLANKS supine. Taut, glistening skin.
Fluid wave + shi"ing dullness positive. Tympany at top (floating
bowel), dull over fluid.
Ovarian
Cyst
(large)
Curve in LOWER half toward midline. Transmits aortic pulsation (vs.
ascites which does not). Dull at top, intestines pushed superiorly.
Pregnancy Single curve. Umbilicus protruding. Engorged breasts. Fetal heart
tones. Fundus palpable. Fetal parts/movement.
Feces Localized distention. Plastic-like or rope-like mass. Scattered
dullness over fecal mass.
Tumor Localized distention. Dull over mass if reaches skin surface. Define
borders — distinguish from organ or normal structure.
TABLE 22.3 — Referred Pain Sites Organ/Condition Where Pain Is Felt Associated Symptoms Liver (hepatitis) RUQ or epigastrium Anorexia, nausea, malaise, low- grade fever GERD (esophagus) Mid-epigastrium or behind lower sternum, radiates upward Burning 30–60 min a"er eating; worse lying down Gallbladder (cholecystitis) RUQ, radiates to right or le" scapula Sudden pain a"er fatty foods/alcohol. Nausea, vomiting. Positive Murphy sign.
Bulge near old operative scar. Not visible supine but apparent with sit-up, standing,
or Valsalva maneuver.
EPIGASTRIC HERNIA
Small fatty nodule at epigastrium in midline through linea alba. Usually felt more
than seen. Palpable only when standing.
TABLE 22.5 — Abnormal Bowel Sounds HYPOACTIVE / ABSENT BOWEL SOUNDS
Decreased motility. Causes: peritonitis, paralytic ileus (post abdominal surgery),
late bowel obstruction, pneumonia. Must listen 5 full minutes to declare absent.
HYPERACTIVE BOWEL SOUNDS (BORBORYGMI)
Loud, gurgling sounds = increased motility. Causes: early mechanical bowel
obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, subsiding
paralytic ileus.
SUCCUSSION SPLASH (INFANT)
Very loud splash over upper abdomen when infant rocked side to side. Indicates
increased air and fluid in stomach — seen with pyloric obstruction or large hiatal
hernia. Pyloric stenosis: projectile vomiting in 2nd–3rd week of life. Peristaltic
waves cross le" to right a"er feeding → projectile vomiting → olive-size mass
palpable in RUQ. Refer promptly.
TABLE 22.6 — Friction Rubs & Vascular Sounds PERITONEAL FRICTION RUB
Rough, grating sound (like leather rubbing). Indicates peritoneal inflammation.
Rare. Over liver = abscess/metastatic tumor. Over spleen = abscess, infection, tumor.
AORTIC ANEURYSM BRUIT
>95% below renal arteries, extending to umbilicus. Focal bulging >5 cm palpable in
~80% of cases. Pulsating mass slightly le" of midline in upper abdomen. Bruit
present. Femoral pulses present but decreased.
Developmental Physical Exam Findings USLO 2 & 4
Age-Specific Normal & Abnormal Findings
Infant Normal: Protuberant abdomen (immature musculature) Fine superficial venous pattern (normal in lightly pigmented) Umbilical cord: 2 arteries + 1 vein + Wharton's jelly; dries in 1 week, falls off 10–14 days, covered by 3–4 weeks Umbilical hernia peaks at 1 month (up to 2.5 cm); usually gone by 1 year Meconium stool within first 24 hours of birth Liver palpable at costal margin or 1–2 cm below Spleen tip, both kidneys, bladder, cecum, sigmoid colon palpable Abnormal: Scaphoid = dehydration Only 1 umbilical artery = risk for congenital defects Umbilical hernia >2.5 cm = refer Marked peristalsis + projectile vomiting = pyloric stenosis Diastasis recti lasting >6 years = refer Child Normal: Protuberant when supine AND standing until age 4
Health Promotion & Patient Teaching USLO 3 & 4
Hepatitis B & C Screening — USPSTF Guidelines
HEPATITIS B SCREENING
Screen high-risk adolescents and adults. HBV transmitted perinatally and in
childhood (high-prevalence regions). Also high risk: persons born in US but not
vaccinated as infants with parents from high-risk countries, HIV+, injection drug
users, men who have sex with men, household contacts with HBV. Safe, effective
vaccine available. All infants should receive HBV vaccine.
HEPATITIS C SCREENING
Screen ALL adults ages 18–79. HCV transmitted by injection drug use. Chronic HCV:
high cure rate (>95%). HBV much harder to cure. HCV o"en asymptomatic early →
universal screening recommended. No vaccine for HCV yet. Secondary prevention:
antiviral treatment to prevent cirrhosis and liver cancer.
Documentation — SOAP Format USLO 3
Sample Charting — Normal Healthy Abdomen
S — SUBJECTIVE States appetite is good with no recent change, no dysphagia, no food intolerance, no pain, no nausea/vomiting. Has one formed BM/day. Takes OTC multivitamins, no other prescribed or OTC medications. No history of abdominal disease, injury, or surgery. O — OBJECTIVE
Inspection: Abdomen flat, symmetric, with no apparent masses. Skin smooth with no striae, scars, or lesions. Auscultation: Bowel sounds present, no bruits. Percussion: Tympany predominates in all 4 quadrants. Palpation: Abdomen soft, no organomegaly, no masses, no tenderness. A — ASSESSMENT Healthy abdomen; bowel sounds present.
Sample Charting — Acute Abdomen (Case Study 1 — Post-Gastric Bypass)
S — SUBJECTIVE "I feel terrible." Fever with chills, nausea, constant pain in back and shoulders, abdominal pain, and palpitations. 1 week post laparoscopic Roux-en-Y gastric bypass. Denied deviation from diet. O — OBJECTIVE Temp 102°F · Pulse 130 bpm · BP 90/56 mmHg (supine) Inspection: Lying on side with knees tucked. Abdomen uniformly round. Grimacing with movement. Auscultation: Hypoactive bowel sounds. No vascular sounds. Percussion: Tympany predominates. Tenderness with percussion. Palpation: EXTREME tenderness. Rebound tenderness present RLQ and LLQ. A — ASSESSMENT Acute abdomen · Possible anastomotic leak · Peritoneal inflammation · Risk for intra-abdominal infection
Sample Charting — Ascites (Case Study 2 — Metastatic Liver Cancer)
O — OBJECTIVE Weight gain 8 lb in 1 week. Abdomen distended with EVERTED umbilicus and BULGING FLANKS. Girth at umbilicus 85 cm. Prominent dilated venous pattern. Percussion: Tympany at dome, dullness over flanks — shifting dullness PRESENT. Fluid wave POSITIVE. Palpation: Liver 6 cm below right costal margin — firm, nodular, nontender. 4+ pitting edema bilateral ankles.
