When performing the abdominal assessment for a client which assessment technique should the nurse perform first?

Abdominal assessment involves inspection, auscultation, palpation, and percussion. This order of physical assessment is important to preserve normal bowel sounds when auscultating. For example, pressing on the abdomen can modify bowel sounds by increasing peristalsis (wave-like contractions of the intestines).

Before beginning, ask the client to empty their bladder and bowel so that fullness will not influence the findings. 

This assessment is best accomplished in the supine position because this allows any air in the abdominal region to rise to the surface area. The client should lie flat with their head on a pillow. Some clients may find it difficult to lie completely flat; if so, you can slightly elevate the head of the bed (about 10 degrees). To ensure the abdominal musculature is relaxed, ask the client to have their arms resting beside their body and their knees bent with either their feet placed flat on the bed or a pillow placed under their knees. For a newborn or young child, you can ask someone (care partner, parent, healthcare provider) to hold them on their lap. 

Always do the assessment on bare skin.

Contextualizing Inclusivity – Discomfort in Exposing Abdomen

Some clients are uncomfortable exposing their abdomen. For example, they may feel uncomfortable because of body image issues associated with weight, modesty related to cultural or religious beliefs, or a new ostomy such as a colostomy or an ileostomy. Ostomies are surgically created openings onto the abdomen that allow stool to bypass a damaged/diseased part of the intestine and leave the body.

It is important that you create an inclusive environment that is judgment free and recognizes the client’s potential discomfort. For example, you may begin the assessment with the following: “I need to assess your abdomen on the bare skin. Is that okay?” (wait for the client to give consent).

Palpation of the abdomen provides information about the organs associated with the GI system. The palpation technique follows auscultation, so the abdomen is already exposed. Additionally, you should not palpate the abdomen if vascular bruits are present (e.g., aortic, renal, iliac, and femoral).

Remember, always palpate on bare skin.

Palpation of the abdomen involves the following steps (see Video 5.3):

1. If not already, ask the client to bend their needs up and ensure they are draped.

2. Use the pads of your four fingers to gently palpate the abdomen, keeping your fingers together and your wrist and forearm at about the same plane as the client’s body.

• Avoid a more angled position: this will create a feeling that you are poking the client in the abdominal region, which can be uncomfortable and also does not permit you to assess the area as well.
• Only the pads of your fingers should be touching the client during light palpation.

3. Begin in the right lower quadrant and proceed clockwise. If the client indicates they have pain in the right lower quadrant, begin in the right upper quadrant instead and palpate the area with pain last.

4. Press down about one to two centimeters (light palpation) and move your fingers together in a circular motion.

• Sometimes, you will notice voluntary guarding (tense abdominal muscles) as a result of nervousness, pain, cold room temperature or hands of the nurse, or ticklishness. The tenseness of the muscles usually covers the whole abdomen (i.e., bilateral). It can help to ask the client to take a deep breath when you palpate to help them relax the muscles. Remember to use light palpation and do the painful area last. Only expose the abdomen as long as needed so the client stays warm, and warm your hands by rubbing them together. If the client is ticklish, use a sandwich technique: put their hand on top of your palpating hand, and place your other hand over top of both to control the pressure.

5. Lift fingers up together and move on to the next location, ensuring that you palpate every square centimeter of the abdomen in all four quadrants.

6. Assess the following:

• Overall consistency (soft or firm) and associated pain/tenderness. The abdomen is usually soft upon palpation. Note the location of any firmness and any associated pain/tenderness. The consistency of the abdomen is influenced by the amount of adipose tissue or muscle, but these are symmetrical across the abdomen.
• Presence of masses. Describe any masses in terms of location, size (dimensions), shape, consistency (soft or firm), and associated pain/tenderness.
• Presence of swelling. Note the location of any swelling.
• Presence of pain. If the client feels pain/tenderness upon palpation, note the location and ask them to rate the severity on a scale of 0 to 10.
• Presence of rigidity and spasms. Rigidity is involuntary firmness/hardness of the abdominal muscles associated with peritoneal inflammation. This rigidity is felt over the inflamed area; it is not bilaterally symmetrical and not voluntary like guarding. You may also feel spasms which are muscle contractions that are often painful.

7. Note the findings.

• Normal findings might be documented as: “Abdomen soft to touch with no masses, swelling, pain, and rigidity.”
• Abnormal findings might be documented as: “Client noted generalized pain all over abdomen upon palpation, rating it 5/10. Abdomen firm to touch in all quadrants. Left lower quadrant mass, circular in shape, 5 x 5 cm.”

Video 5.3: Palpation of the abdomen

If a client has indicated pain/tenderness, palpate that area last. Palpating a painful area of the abdomen first will aggravate the pain and may affect the accuracy of your assessment.

Urgent surgical intervention is required when a client has appendicitis (inflammation of the appendix that is at risk of perforating). In these cases, client usually presents with an increasing level of pain in the right lower quadrant, often beginning in the periumbilical region. This can also be associated with lack of appetite, nausea, vomiting, fever, chills, and muscle rigidity. If you suspect appendicitis, notify the physician immediately. Continue to monitor the client, measure vital signs, do not allow the client to take anything by mouth, and begin an intravenous if there are standing orders. A physician or nurse practitioner may assess for rebound tenderness, which involves palpating in the right lower quadrant and quickly removing one’s hand. Positive rebound tenderness (pain when the assessor removes their hand) is often indicative of appendicitis.

All abnormal findings (e.g., masses, swelling, pain, rigidity) should be further investigated with a focused abdominal assessment. Report any new, worsening, or unexpected findings to the physician or nurse practitioner.

When performing an abdominal assessment which technique should the nurse perform first?

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Which assessment should the nurse Complete First abdominal assessment?

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