17-2 Key Points Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 17: Abdomen Key Points This review discusses examination of the abdomen. Before the exam, gather the necessary equipment: stethoscope, centimeter ruler, non-stretch tape measure, and marking pen. To inspect the abdomen, perform the following. Using tangential lighting, inspect the abdomen for four surface characteristics.First, observe the skin color. It may vary greatly but should have no jaundice, cyanosis, redness, bruises, or discoloration. Second, check for nodules and other lesions, which should not be present. Third, note any scars and draw their location, configuration, and relative size on an illustration of the abdomen. Fourth, assess the venous return. Above the umbilicus, venous return should be toward the head. Below the umbilicus, it should be toward the feet.Next, inspect the abdominal contour and symmetry.The contour is the abdominal profile from the rib margin to the pubis. It normally may be flat, rounded, or scaphoid. The umbilicus should be centrally located and may be inverted or may protrude slightly. Contralateral areas of the abdomen should be symmetrical in appearance and contour and should have no distention or bulges.To elicit hidden masses or bulges, have the patient take a deep breath and hold it. The abdomen should remain smooth and symmetrical. Next, have the supine patient raise their head from the table as you inspect the abdomen. Note any masses, hernia, or muscle separation.With the patient’s head at rest, observe for three types of abdominal movement.First, inspect for smooth, even movement with respiration. Second, assess for surface motion from peristalsis. In a thin patient, it normally may be visible. Otherwise, it may signal an intestinal obstruction. Third, note any aorticpulsation in the upper midline. Although pulsations may be visible in a thin patient, marked pulsations suggest a disorder. To auscultate the abdomen, perform the following. Remember to auscultate before you percuss or palpate because these techniques can alter bowel sounds. Using the diaphragm of a warmed stethoscope, listen for bowel sounds and note their frequency and character.Expect to hear clicks and gurgles at a rate of 5 to 35 per minute.Note unexpected findings, such as increased or decreased bowel sounds or high-pitched tinkling sounds.Auscultate for three additional sounds.First, use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen. Second, use the stethoscope bell to check for bruits over the aortic, renal, iliac, and femoral arteries. Third, use the stethoscope bell to assess for a soft, continuous, low-pitched venous hum in the epigastric area and around the umbilicus. To percuss the abdomen, perform the following. Systematically percuss for tone in all abdominal quadrants.Tympany is ...

1. 17-2
Key Points
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 17: Abdomen
Key Points
This review discusses examination of the abdomen.
Before the exam, gather the necessary equipment: stethoscope,
centimeter ruler, non-stretch tape measure, and marking pen.
To inspect the abdomen, perform the following.
Using tangential lighting, inspect the abdomen for four surface
characteristics.First, observe the skin color. It may vary greatly
but should have no jaundice, cyanosis, redness, bruises, or
discoloration.
Second, check for nodules and other lesions, which should not
be present.
Third, note any scars and draw their location, configuration, and
relative size on an illustration of the abdomen.
Fourth, assess the venous return. Above the umbilicus, venous
return should be toward the head. Below the umbilicus, it
should be toward the feet.Next, inspect the abdominal contour
and symmetry.The contour is the abdominal profile from the rib
margin to the pubis. It normally may be flat, rounded, or
scaphoid. The umbilicus should be centrally located and may be
inverted or may protrude slightly.
Contralateral areas of the abdomen should be symmetrical in

2. appearance and contour and should have no distention or
bulges.To elicit hidden masses or bulges, have the patient take a
deep breath and hold it. The abdomen should remain smooth and
symmetrical. Next, have the supine patient raise their head from
the table as you inspect the abdomen. Note any masses, hernia,
or muscle separation.With the patient’s head at rest, observe for
three types of abdominal movement.First, inspect for smooth,
even movement with respiration.
Second, assess for surface motion from peristalsis. In a thin
patient, it normally may be visible. Otherwise, it may signal an
intestinal obstruction.
Third, note any aorticpulsation in the upper midline. Although
pulsations may be visible in a thin patient, marked pulsations
suggest a disorder.
To auscultate the abdomen, perform the following.
Remember to auscultate before you percuss or palpate because
these techniques can alter bowel sounds. Using the diaphragm
of a warmed stethoscope, listen for bowel sounds and note their
frequency and character.Expect to hear clicks and gurgles at a
rate of 5 to 35 per minute.Note unexpected findings, such as
increased or decreased bowel sounds or high-pitched tinkling
sounds.Auscultate for three additional sounds.First, use the
stethoscope diaphragm to detect high-pitched friction rubs over
the liver and spleen.
Second, use the stethoscope bell to check for bruits over the
aortic, renal, iliac, and femoral arteries.
Third, use the stethoscope bell to assess for a soft, continuo us,
low-pitched venous hum in the epigastric area and around the
umbilicus.
To percuss the abdomen, perform the following.
Systematically percuss for tone in all abdominal
quadrants.Tympany is heard over the stomach and
intestines.Dullness is heard over organs and solid
masses.Percussto estimate the liver span, using three steps.First,

3. determine the lower border of the liver by percussing up from
an area of tympany along the right midclavicular line. Mark the
point where tympany changes to dullness, which usually occurs
at or slightly below the costal margin.
Second, determine the upper border of the liver by percussing
down from an area of resonance along the right midclavicular
line. Mark the point where resonance changes to dullness, which
usually is in the fifth intercostal space.
Third, measure the distance between the marks. The vertical
liver span usually ranges from 6 to 12 cm.To assess liver
descent, ask the patient to take a deep breath and hold it while
you percuss the lower border again. With this maneuver, the
area of dullness at the lower border should shift down 2 to 3
cm.Percuss the spleen just posterior to the midaxillary line on
the left side, beginning in areas of lung resonance and moving
in several directions. You normally may hear a small area of
splenic dullness from the sixth to ninth rib. Percuss the lowest
intercostal space in the left anterior axillary line before and
after the patient takes a deep breath. Tympany should remain in
this area.Percuss for the gastric air bubble in the l eft lower
anterior rib cage and left epigastric region. Gastric bubble
tympany is lower in pitch than intestinal tympany.
With the patient seated, percuss the kidneys, following two
steps.First, place the palm of your hand over the right
costovertebral angle and strike it with the side of the fist of
your other hand.
Second, repeat this action on the left costovertebral angle. In
both locations, the patient should feel a thud but no pain.
To palpate the abdomen, perform the following.
Using light palpation, systematically assess all quadrants. But
first, try to relax the abdominal muscles. For example, place a
small pillow under the patient’s head and slightly flexed knees,
warm your hands, take a slow and gentle approach, and save any
tender areas for last. For light palpation, press in no more than
1 cm with the palmar surface of your fingers.Expect the

4. abdomen to feel smoothand soft.
Note any resistanceor tenderness. And watch for guarding,
which should alert you to proceed with caution.
Using moderate palpation, systematically assess all quadrants in
two ways.First, palpate with the palmar surface of your fingers.
This may elicit tenderness that was not produced by light
palpation.
Second, palpate with the side of your hand throughout the
respiratory cycle. As the patient inhales, you may feel the liver
and spleen bump gently against your hand.Using deep palpation,
systematically assess all quadrants with the palmar surface of
your fingers. If a patient’s obesity or muscular resistance makes
deep palpation difficult, try bimanual palpation with one hand
on top of the other. With either technique, feel for the rectus
abdominis muscles, aorta, and portions of the colon. Note any
tenderness.
If you detect a mass, evaluate its location, size, shape,
consistency, tenderness, pulsation, mobility, and movement with
respiration. To see if the mass is superficial or intraabdominal,
palpate as the patient lifts his or her head off the table. A
superficial mass will remain palpable; an intraabdominal mass
will not.
Palpate the umbilical ringand periumbilical area. The umbilical
ring should feel round and regular. The area should have no
bulges, nodules, or granulation.Palpate for specific abdominal
structures.For the liver, press in and feel for its edge at the right
costal margin as the patient takes a deep breath. If palpable, the
liver should feel firm, smooth, even, and nontender.
For the gallbladder, palpate below the liver margin at the lateral
border of the rectus abdominus muscle. A healthy gallbladder is
not palpable.
For the spleen, press in over the left costal margin as the patient
takes a deep breath. The spleen is not usually palpable.
For the kidneys, assess the right and left organs separately,
placing one hand on the flank and the other hand on the costal
margin. As the patient inhales deeply, lift the flank and palpate

5. deeply. The right kidney is more commonly palpable than the
left kidney.
For the aorta, palpate deeply for the aortic pulsation slightly
left of the midline. If the pulsation is prominent, try to
determine its direction.
For the bladder, palpate above the symphysis pubis. If the
bladder is distended with urine, it feels like a smooth, round,
tense mass.
To assess the abdomen further, perform the following.
If you suspect ascites,percuss the supine patient’s abdomen for
dullness in the dependent parts and tympany in the upper parts.
Also assess for shifting dullness or fluid wave.If the patient
reports abdominal pain, assess it thoroughly, especially its
quality and location. When examining the abdomen, be sure to
watch the patient’s face for clues to pain. If needed, assess for
rebound tenderness and perform the iliopsoas muscle and
obturator muscle tests.
If you suspect a freely movable abdominal mass, perform
ballottement.
17-2
Student Checklist
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
Copyright © 2015 by Mosby, an imprint of Elsevier Inc.
Ball: Seidel’s Guide to Physical Examination, 8th Edition
Chapter 17: Abdomen
Student Checklist

6. Assessed Appropriately by Student?
Yes
No
Comments
I. Inspection of the abdomen (patient supine, pillow under head,
arms at sides)
A. Skin characteristics, venous return patterns, symmetry,
surface motion
B. Abdominal muscles (as patient raises head) for masses,
hernia, or separation
II. Auscultation of all quadrants
A. Bowel sounds and frequency
B. Arteries (bruits)
III. Percussion of all quadrants

7. A. Tone
B. Estimation of liver size
C. Splenic dullness
D. Gastric air bubble
IV. Light palpation of all quadrants for muscle resistance,
tenderness, masses
V. Deep palpation of all quadrants
A. Umbilicus and umbilical ring (bulges, masses)
B. Liver border
C. Gallbladder

8. D. Spleen
E. Kidneys
F. Aortic pulsations
G. Other masses
VI. With patient seated, percuss the costovertebral angles for
kidney tenderness
NURS 6512 Midterm Exam Review (Week 1-6)
Building A Complete Health History
· Communication techniques used to obtain a patient’s health
history
· Recording and documenting patient information
· SOAP note documentation
· Subjective vs objective information when documenting
· Ethical decision making and beneficence

9. Diversity and Health Assessments
· Cultural awareness and diversity
· Socioeconomic, spiritual, and lifestyle factors affecting
diverse populations
· Functional assessments
Assessment Tools and Diagnostic Tests in Adults and Children
· Growth, Development, and Measurements in children and
adults
· Nutritional assessment to include recommended water intake
and energy requirements
· Macronutrients vs Micronutrients
· Significance of a food diary
· BMI measurements for normal, overweight, obesity, morbid
obesity
· Pernicious Anemia
· Examination techniques and equipment
· Diagnostic Assessment tools and tests to include tuning forks,
BP monitoring, use of stethoscope, otoscope, ophthalmoscope
Assessment of the Skin, Hair, and Nails
· Skin lesion characteristics
· Documenting skin lesions using “ABCD” rule
· Anatomy and physiology of skin layers
· Abnormal nail findings in older adults
· Psoriatic skin lesions
· Vesicular skin characteristics
· Normal vs abnormal hair distribution during aging
· Characteristics of hair distribution
Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
· Cranial Nerves associated with the HEENT system
· Normal assessment findings of an adolescent’s nose and throat
· Normal examination findings of an infant’s fontanelles
· Examination findings of a patient with hypothyroid and
hyperthyroid
· Techniques for examining the HEENT systems

10. · Examination findings for a patient with sinus symptoms
· Appropriate tuning fork frequencies to approximate vocal
frequencies
· Examining the oral mucosa
· Hearing loss findings when examining the elderly patient
· Examination techniques used to examine the trachea and
thyroid
Assessment of the Abdomen and Gastrointestinal System
· Organs involved in the alimentary tract
· Correct assessment order for examining the abdomen
· Examination technique and findings of the liver
· Examination findings associated with appendicitis
· Examining McBurney’s sign
· Assessment of abdominal pain in women
· Landmarks for abdominal examination
· Characteristics of bowel sounds heard during auscultation
© 2019 Walden University
Page 2 of 2