Goal: The assessments are completed without causing the patient to experience anxiety or discomfort, the findings are documented, and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.
1. Perform hand hygiene and put on PPE, if indicated.
2. Identify the patient.
3. Close curtains around bed and close the door to the room, if possible. Explain the purpose of the abdominal examination and what you are going to do. Answer any
questions.
4. Help the patient undress, if needed, and provide a patient gown. Assist the patient to a supine position and expose the abdomen. Use the bath blanket to cover any exposed area other than the one being assessed.
5. Inspect the abdomen for skin color, contour, pulsations, the umbilicus, and other surface characteristics (rashes, lesions, masses, scars).
6. Auscultate all four quadrants of the abdomen for bowel sounds by using the diaphragm of the stethoscope. Use a systematic method.
7. Auscultate the abdomen for vascular sounds by using the bell of the stethoscope.
8. Percuss the abdomen for tones.
9. Palpate the abdomen lightly in all four quadrants and then palpate using deep palpation technique. If the patient complains of pain or discomfort in a particular area of the abdomen, palpate that area last.
10. Palpate for the kidneys on each side of the abdomen. Palpate the liver at the right costal border. Palpate for the spleen at the left costal border.
11. Assess for rebound tenderness last if the patient reports pain by pressing deeply and gently into the abdomen with the hand and fingers downward and then withdrawing the hand rapidly.
12. Palpate and then auscultate the femoral pulses in the groin.
13. Assist the patient in replacing the gown. Remove PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate, or indicated. Initiate appropriate referral to other healthcare practitioners for further evaluation, as indicated.
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