If you’re a newer nurse practitioner, chances are you may find documentation a challenge, especially if you don’t have an electronic medical records system prompting the input of your physical exam findings. Documentation is key to continuity of care for your patients, as well as to protecting yourself should questions arise about the patient
encounter. Given the importance of this foundational skill, we’re going to spend some time covering how to document a physical exam, system-by-system (in no particular order) over the next few weeks here on ThriveAP. Today, we’ll start with the abdominal exam because, well, it’s one of my favorites. The abdominal exam consists of a number of components, the most basic being inspection, auscultation for bowel sounds,
percussion, and palpation. The exam must be completed in this order as palpation before auscultation can lead to an inaccurate representation of bowel sounds. The patient should be lying supine for the exam with the abdomen exposed – examining over clothing doesn’t count! Why do these components matter?
Buzzwords to Know:There are a few physical exam tricks you can do to help you reach a diagnosis. Here are a few basic tests nurse practitioners should know:
Sample Normal Exam Documentation:Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted. Sample Abnormal Documentation:Note that the abdomen is divided into four quadrants, the right upper quadrant, the right lower quadrant, the left upper quadrant, and the left lower quadrant. The epigastric area (central abdomen) may also be used as a reference point in documentation. The more specific you can be about where an abnormality lies, the better. While you won’t use all of these elements in documenting an abnormal abdominal exam on the same patient, the following are examples of some abnormal abdominal physical exam findings you may need to note. Abnormals on an abdominal exam may include:
**Note: This is not meant to be a comprehensive guide. You are responsible for performing and appropriate physical exam and corresponding documentation on each and every patient you interact with. This content is based upon The Correctional Nurse Educator class entitled Abdominal Assessment: Basic Assessment for the Correctional Nurse. The physical examination of the patient begins with inspection. Unique to the sequence of the abdomen, the abdomen is then auscultated, percussed and finally, palpated. Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds. In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort. When completing the physical examination, it is helpful to divide the abdomen into regions in order to consider which organs are involved. A four-quadrant system – left upper quadrant, left lower quadrant, right upper quadrant and right lower quadrant provides a more general overview, and is acceptable in situations when there is no abdominal complaint. The nine-region system provides more specific information if the patient is complaining of discomfort or problems in a certain area. The nine regions include the following: right hypochondriac (upper) region, right lumbar (middle) region, right iliac (lower) region, left hypochondriac (upper) region, left lumbar (middle) region, left iliac (lower) region, epigastric region, umbilical region, and hypogastric (suprapubic) region.  INSPECTIONThe inspection of the abdomen includes looking for scars, striae, venous pattern, rashes, contour, symmetry, masses, peristalsis, and pulsations. Inspection is optimum with the patient lying flat on the examination table, breathing normally. As this is being done, note the comfort level of the patient. A patient that is shifting his/her position on the table, or moving frequently may be experiencing discomfort. A patient with a distended abdomen may have difficulty breathing when lying flat, as the abdominal contents may be pressing on the diaphragm. Normally, peristaltic movements are not visible. Some patients do have visible aortic pulsations, especially those with a thin body habitus. Ask the patient to raise his/her head and shoulders while the rest of the body remains supine to check for an umbilical and incisional hernia; if present, it will protrude during this maneuver. Abnormal findings that may be present on InspectionScars – indicate past surgery or trauma Striae – may indicate obesity, ascites, pregnancy, tumor, Cushing’s disease and steroid use Venous pattern – may be prominent in fair-skinned individuals or due to congested portal circulation Discoloration – may be due to jaundice, Addison’s disease, von Reckling-hausen’s disease, trauma, rashes or lesions Visible peristalsis – in an older adult, consider bowel obstruction. [PEARL: In newborns, upper abdominal peristalsis is diagnostic for pyloric stenosis.] Pulsations – visible aortic pulsations may be normal in thin individuals, but in others may indicate an aortic aneurysm Distention – for changes in contour or symmetry, consider the “Fs” of abdominal distention – fat, fluid, feces, fetus, flatus, fibroid, full bladder, fatal tumor, and false pregnancy. Be sure to return to the site next week, when we will add Auscultation to this continuing series on Abdominal Assessment. Which of the following is a normal finding in an abdominal assessment?Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
What is the normal contour of the abdomen?The normal contour of the abdomen is typically flat or rounded. A concave contour (inward curve of the abdomen that looks sunken in) is concerning because it can be associated with dehydration and malnutrition, and sometimes with anorexia nervosa and cancer.
When assessing a patient's abdomen which technique does the nurse use?Assessing your patient's abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.
What are the 4 parts in order for abdominal assessment?The abdominal examination consists of four basic components: inspection, palpation, percussion, and auscultation. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders.
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When inspecting a patients abdomen, which finding does the nurse note as normal
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