"Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with Suggests peritonitis from possible increased tenderness, guarding, and rebound in the right midquadrant. appendicitis (see pp. 347-348 and

Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen pp. 363-364) and kidneys not felt. No CVA tenderness.

For a good abdominal examination you need (1) good light, (2) a relaxed patient, and (3) full exposure of the abdomen from above the xiphoid process to the symphysis pubis. The groin should be visible. The genitalia should remain draped. The abdominal muscles should be relaxed to enhance all aspects of the examination, but especially palpation.

Steps for Enhancing Examination of the Abdomen

■ The patient should have an empty bladder.

■ Make the patient comfortable in a supine position, with a pillow for the head and perhaps another under the knees. Slide your hand under the low back to see if the patient is relaxed and flat on the table.

■ Have the patient keep arms at the sides or folded across the chest. Often patients raise their arms over their heads, but this stretches and tightens the abdominal wall, making palpation difficult.

■ Before you begin palpation, ask the patient to point to any areas of pain and examine these areas last.

■ Warm your hands and stethoscope, and avoid long fingernails. You may need to rub your hands together or warm them up with hot water; you can also begin palpation through the patient's gown to absorb warmth from the patient's body before exposing the abdomen properly. Anxiety may make the hands cool, a problem that decreases over time.

■ Approach slowly and avoid quick unexpected movements. Watch the patient's face closely for any signs of pain or discomfort.

■ Distract the patient if necessary with conversation or questions. If the patient is frightened or ticklish, begin palpation with the patient's hand under yours. After a few moments, slip your hand underneath to palpate directly.

An arched back thrusts the abdomen forward, thus tightening the abdominal muscles.

Visualize each organ in the region you are examining. Stand at the patient's right side and proceed in an orderly fashion with inspection, auscultation, percussion, and palpation. Assess the liver, spleen, kidneys, and aorta.

H The Abdomen_

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