Overview of Abdomen
The abdomen is assessed using inspection, auscultation and palpation (White 2005). The abdomen is inspected for size and symmetry and is normally rounded, symmetric, protuberant, and soft because of weak abdominal musculature with a slightly greater diameter above the umbilicus than below. The subcutaneous blood vessels in the abdomen may appear distended and blue (Williams & Wilkins 2006).
Abdominal assessment is complex, largely because of the many vital organs and blood vessels within the cavity of abdomen and its life-sustaining functions, such as digestion and elimination that are performed here (Weber & Kelley 2009). The abdomen houses the several body structures– reproductive (female), gastrointestinal, urinary and lymphatic. Known as the solid or hollow abdominal viscera, these structures include the pancreas, liver, adrenal glands, spleen, ovaries, kidneys, and uterus (solid viscera) and the gallbladder, stomach, small intestine, bladder (hollow viscera) and colon.
During the abdominal assessment, the abdomen is first inspected for rashes and scars. The abdomen is observed for symmetry and visible signs of peristalsis or pulsations. Auscultations are the second component of the abdominal assessment of a client’s bowel status. A “bubbly-gurgly” sound, caused by peristalsis and movement of the intestinal contents, can be heard by placing the stethoscope on each quadrant of abdomen and listening for approximately 1 minute. These sounds should be present in all four quadrants of the abdomen, beginning in the right lower quadrant, and moving clockwise around the four quadrants. When approximately 5 to 20 bowel sounds are heard per minute, the bowel sounds are considered active (Weber 2009).
The absence of bowel sounds during 1 minute of auscultations in each quadrant is documented as absent bowel sounds. Percussion of abdomen is done in all four quadrants. The predominant abdominal percussion sound in tympany caused by precussing over the air-filled stomach and intensities. Light palpation of the abdomen is done to assess for muscle tone, masses, pulsations, or any signs of tenderness or discomfort.
A good knowledge of the normal function of the bladder and lower urinary tract is important to gather understanding the effects of abnormal functions. The bladder and lower urinary tract have two main functions, storage of urine at low pressures and periodic elimination of urine.
The bladder is a hollow muscular organ which lies in the anterior part of the pelvic cavity, behind the symphysis pubis. Bladder function comprises cycles of filling and emptying. Urine production by the kidneys is continuous and during the bladder filling phase the rugae flatten and bladder volume increases with very little change in internal pressure (Bartley 2007). This is termed compliance and is possible because the lining layers of transitional epithelial cells can overlap and slip over each other as the volume increases and because of the intrinsic ability of the smooth muscle to maintain constant tension over a wide range of stretch. The voiding phase is initiated voluntarily and can normally be delayed until appropriate circumstances are recognized. When a voiding dysfunction is suspected, or when there is no clear diagnosis, a diagnosis which is often missed is a post-voiding residual volume. All patience attending a continence clinic should have a routine pre and post-voiding bladder scan as part of standard care practice. PVR is the amount of urine left in bladder within 10-15 minutes after voiding and urinary retention is the inability or failure to empty the bladder completely with voiding.
Application to Surgical Ward
The assessment by nurses refers to the data collection, data analysis, and identification of the problem. Nurses are encouraged to obtain the clinical history of patient from the family members and patient which form the foundation of the assessment. The preliminary assessment is done using the interview technique followed by the physical check-up. The assessment is a process needs to be adopted both pre-operation and post-operation in the surgical ward. For the abdominal assessment pre-operation and post-operation is generalized and remains same, they will be discussed simultaneously. The abdominal assessment, both pre-operative and post-operative has their significance. A surgical pre-operative abdominal assessment is important to determine the presence of an abdominal aortic aneurysm (AAA), which is a potential contraindication of the use of an intra-aorta balloon pump. Abdominal palpitation to detect abnormal widening of an aortic pulsation is suggested to be the most effective method to determine presence of AAA (Elliot et al 2007). The width is compared with the intensity of aortic pulsation to establish the presence of an AAA. Findings from palpation, however, are limited in patients with abdominal obesity. Diagnostic evaluation with ultrasound may also be performed .
In recent times, recognizing the significance of the assessment by nurses, they are encouraged to identify the deficiency in their knowledge and to promote its application in their respective wards. Abdominal assessment by nurses in surgical ward both, preoperative and post operative has the potential to increase the comfort of patient along with accurate identification of the problem area. Surgical ward nurses play an important role in abdominal assessment preoperative and postoperative (O’Laughlen 2009). Nurses have to continuously observe and assess the patient’s condition closely. For an instance, in the case of non-catheterized patients, nurses should note the time when the patient first passes the urine after surgery. It is possible for retention of urine to occur, particularly in case of abdominal, genitourinary and gynecological surgery procedures have been undertaken. The patients of abdominal surgery are being examined for the palpation of the lower abdomen and the bladder is felt as full and rising up to the umbilicus. Relief of passing a catheter into the bladder and withdrawing it once the bladder is emptied may be required if the patient can’t be persuaded to pass urine normally. This all requires the nurse in the surgical ward to be attentive towards the patient and to possess the knowledge to identify this situation. The knowledge of nurses in assessing the abdomen of the patient is sometimes inadequate which may lead to the emergency situations. The skilled and trained nurses are efficient in recognizing the post-operative symptoms of discomfort in patients and to differentiate it from any abnormal symptoms.
The abdominal assessment port operation requires the nurse to carefully observe to ensure that the patient is capable of passing urine in the normal way as soon as possible (Hohenfellner & Santucci 2007). The certain area where the vigilant and trained nurses make a difference are for an instance, an assessment of patient’s level of comfort in terms of body temperature, pain and nausea can be made and, where appropriate, treated. Body temperature usually alters significantly as a result of exposure of tissue during surgery and the administration of cold intravenous fluids. Discomfort, pain and nausea are postoperative experiences which skilled nurses can help to significantly alleviate.
The observing nurse’s interpretation of the patient’s experience has an influence on the care given. Research indicates that some nurses overestimate the patient’s pain experience whilst others may underestimate the severity of pain. Harrison (1991) suggests that in order to accurately assess patient’s pain, nurses need to be self-aware of their own attitude towards the pain and adapt their care accordingly. Research has demonstrated that more experienced a nurse is, the more accurate is her description of the patients comfort level (Harrison 1991). This highlights the importance of the role played by nurses in identifying the accurate reason of discomfort to patient by physical assessment. In surgical ward, nurses with the training in abdominal assessment can increase the chances of speedy recovery of the patient postoperative and also can assess the exact organ of problem with their skills in abdominal assessment.
As the patient recovers from the immediate post-operative period, the nursing care required should be aimed to move the patient towards a maximum state of independence of medical and nursing interventions. Much of the nursing care in this period is still aimed at preventing complications by closely observing the patient’s condition so as to take immediate action should a complication occur (Crouch & Meurier 2005). In this period of time, nurses should support the patient in caring for his physical and mental well-being. Recent trends have seen an increasing use of non-operative care of patients with abdominal assessment of injury. In these patients, monitoring for deterioration is essential, as is the ability to activate surgery and care for patients accordingly.
With the high use of non-operative management techniques for solid organ injury, the role of monitoring the patients with abdominal injury is pivotal. Nurses must be cognizant of the clinical signs of abdominal injury, especially hemorrhage and act on these immediately (Pudner 2000). Specific aspects of nursing care for patients identified with trauma in abdominal assessment include pain monitoring, management and postoperative care. Abdominal assessment patients often experience severe pain, as both are the result of primary trauma and surgical intervention for repair (Sawyer 1988).
Vital sign monitoring is the mainstay of nursing management in patients with abdominal trauma, and all patients should have appropriate monitoring (Heath 1995). It is also essential that all patients should receive urinalysis after incurring abdominal trauma in order to assess the injury to the bladder and abdomen in general. Where the patient has undergone a trauma laparotomy, postoperative care is standard for any patient who has undergone an abdominal surgical procedure. The specific nursing care element depends on what organ has been injured and the surgical procedure that has been undertaken to repair the injury (Brooker & Nicole 2003). Careful attention must be paid to those general nursing care elements that all patients require.
It can be concluded by stating that abdominal assessment; both preoperative and postoperative are significant to ascertain the discomfort of the patient and also to identify minimal signs of upcoming problem. The problems which may appear post-operative can be avoided if the surgical ward nurses are trained in the abdominal assessment. The nursing staff in the surgical ward plays an important role in the correct diagnosis and identification of any abnormal symptoms. Nurses become pivotal in performing the assessment of the patients as they supervise and monitor the patient directly, both in pre-operative and post-operative cases. As demonstrated by several researches, nurses have the capability to perform accurate assessment, be it abdominal or respiratory once they are being provided the adequate training.
Various researchers have indicated the significance of the trained and skilled nurses in avoiding the last minute rush by identifying the abnormal or other than normal symptoms. Hence, it becomes vital for the nurses to be educated about the procedure of abdominal assessment and apply it in the surgical ward to improve the functionality of their role.
References
Anna T. Crouch & Clency Meurier (2005). Vital notes for nurses: health assessment. USA: Wiley-Blackwell. p147.
Christine Brooker & Maggie Nicol (2003). Nursing adults: the practice of caring. Australia: Elsevier Health Sciences. p235-236.
Doug Elliott, Leanne Aitken & Wendy Chaboyer (2007). ACCCN's Critical Care Nursing. Australia: Elsevier Australia. p567-679.
Harrison, A. (1991). Assessing Patient's Pain: identifying reasons for error. Journal of Advanced Nursing. 16 (1), p1018-1025.
Hazel B. M. Heath (1995). Potter and Perry's foundations in nursing theory and practice. Australia: Elsevier Health Sciences. p126.
Janet R Weber (2009). Nurses' Handbook of Health Assessment. UK: Lippincott Williams & Wilkins. p74-77.
Janet R Weber & Jane Kelley (2009). Lab Manual to Accompany Health Assessment in Nursing. UK: Lippincott Williams & Wilkins. p145-147.
Lippincott Williams & Wilkins (2006). Assessment. UK: Lippincott Williams & Wilkins. p68-79.
Lois White (2005). Foundations of nursing. London: Cengage Learning. p450-452.
Markus Hohenfellner & Richard A. Santucci (2007). Emergencies in Urology. USA: Springer. p323-367.
Marilynn K. Bartley. (2007). Acute abdominal pain: A diagnostic challenge. Advances in Nursing Science. 2 (6), p38-45.
Mary C. O'Laughlen. (2009). PEAK TECHNIQUE: Making sense of abdominal assessment. Advances in Nursing Science. 7 (5), p15-19.
Rosemary Pudner (2000). Nursing the surgical patient. Australia: Elsevier Health Sciences. p142-145.
Sawyer, J. (1988). On behalf of the patients. Nursing Times. 84 (41), p27-30.
