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Normal Findings
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Deviation from Normal
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1.
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Inspect the abdomen for skin integrity.
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Unblemished skin;
Uniform color;
Silver-white striae (stretch marks) or surgical scars
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Presence of rash or other lesions;
Tense, glistening skin (may indicate ascites, edema)
Purple striae (associated with Cushing’s diseases)
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2.
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Inspect the abdomen for contour and symmetry.
• Observe the abdominal contour while standing at the client’s side when the client is supine.
• Ask the client to take a deep breath and to hold it.
• Assess the symmetry of contour while standing at the foot of the bed.
• If distention is present, measure the abdominal girth by placing a tape around the abdomen at the level of the umbilicus.
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Flat, rounded (convex), or scaphoid (concave)
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Distended
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3.
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Observe abdominal movements associated with respiration, peristalsis, or aortic pulsations.
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Symmetric movements caused by respiration;
Visible peristalsis in very lean people;
Aortic pulsation in thin persons at epigastric area
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Limited movement due to pain or disease process;
Visible peristalsis in nonlean-client (bowel obstruction);
Marked aortic pulsation
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4.
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Observe the vascular pattern.
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No visible vascular pattern
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Visible venous pattern (dilated veins) is associated with liver disease, ascites and venocaval obstruction
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5.
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Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs.
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Audible bowel sounds;
Absence of arterial bruits;
Absence of friction rub
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Absent, hypoactive, or hyperactive bowel sounds;
Loud bruit over aortic area (possible aneurysm);
Bruit over renal or iliac arteries
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6.
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Percuss several areas in each of the four quadrants to determine presence of tympany and dullness.
• Use a systematic pattern: Begin in the lower left quadrant, then proceed to the lower right quadrant, the upper right quadrant, and the upper left quadrant.
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Tympany over the stomach and gas-filled bowels; dullness specially over the liver and spleen, or a full bladder
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Large dull areas (associated with presence of fluid or tumor)
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7.
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Percuss the liver to determine its size.
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6 to 12 cm in the midclavicular line; 4 to 8 cm at the midsternal line
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Enlarged size
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8.
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Perform light palpation first to detect areas of tenderness and/or muscle guarding.
• Systematically explore all four quadrants.
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No tenderness; relaxed abdomen with smooth, consistent tension
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Tenderness and hypersensitivity;
Superficial masses;
Localized areas of increased tension
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9.
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Perform deep palpation overall four quadrants.
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Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon
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Generalized or localized areas of tenderness
Mobile or fixed masses
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10.
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Palpate the liver to detect enlargement and tenderness.
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May not be palpable
Border feels smooth
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Enlarged
Smooth but tender
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11.
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Palpate the area above the pubic symphysis if the client’s history indicates possible urinary retention.
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Not palpable
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Distended and palpable as smooth, round, tense mass
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