Abdomen

The upper gastrointestinal tract is largely inaccessible to the nurse; thus examination of the abdomen primarily involves assessment of lower gastrointestinal and genitourinary structures. Many common childhood disorders involve the gastrointestinal and genitourinary systems, and the function of these systems can also be altered by factors such as surgery, stress, medications, or the hygienic care that the child receives.

Ask the parent or child about a family history of gastrointestinal or genitourinary tract disorders and about the child’s prenatal history (maternal hydramnios is associated with intestinal atresia), mother’s lifestyle during pregnancy, and child’s growth. Inquire about whether the child had imperforate anus, failure to pass meconium, cleft palate or lip, difficulty in feeding, prolonged jaundice, or abdominal wall disorders (e.g., omphalocele or hernia) as a neonate. Ask if the child has had problems with feeding, such as anorexia, vomiting, or regurgitation, or if the child has engaged in fasting or dieting (see Chapter 7 and Chapter 24 for more information about assessment of eating disorders). If the child has had emesis or regurgitation, determine the time of occurrence, frequency, type (Table 17-1), amount, and force (nonprojectile or projectile). (See Table 17-2 for types of vomiting and associated etiologies). Inquire about whether the child has had pain (frequency, intensity, type, location; Table 17-3), itching (location), sleeplessness, swelling, tendency to bruise, thirst, dry mouth, unexplained fever, food allergies, sensitivity to diapers, or alterations in bowel movements or urinary elimination patterns. If there is a problem with bowel movements, inquire about the frequency, amount, consistency, quality, and color of stool (Table 17-4; Table 17-5); use of laxatives and enemas; recent camping trips; and presence of dogs, cats, or turtles. If there are alterations in the pattern of urinary elimination, determine what they are and when they began. If problems with urination or bowel movements occur in toddlers, explore what these problems mean to parents. In the school-age child who experiences recurrent abdominal pain, explore possible stressors and responses to stressors. Inquire about body piercings, tatoos, and environmental factors such as daycare, crowded living conditions, and sharing of utensils and other personal items. When making inquiries of parents regarding bowel habits and vomiting, it is important to avoid asking “Does your child vomit?” or “Does your child have constipation or diarrhea?” because studies suggest that understanding of these terms varies. There is a tendency, for example, with bowel movements, to define diarrhea and constipation by frequency, rather than by consistency of the stool.

It is important that the child be relaxed during abdominal examination, particularly during palpation. Having the child void, if possible, before the examination assists with comfort during the assessment. Flexing the child’s head or hips helps relax abdominal muscles. Asking the child to “suck in” or “puff out” the abdomen helps assess the degree of discomfort present before deeper probing. Flexing the child’s knees permits greater visibility of the anal area. If the toddler or preschooler is apprehensive, having the parent hold the child supine on the lap with legs flexed and dangling can be helpful in completing the assessment. Talking to and playing with the child also assists in examination. Most children are ticklish, so briefly place a hand flat on the abdomen before beginning the examination. A very ticklish child can be assisted by placing the child’s hand over the nurse’s during palpation. During palpation, observe for changes in vocalization (e.g., cry becomes high-pitched) or sudden protective movements that can indicate pain or tenderness.

Assessment	Findings
Inspection
Inspect the contour of the abdomen while the infant or child is standing and while he or she is lying supine.	A pot-bellied or prominent abdomen is normal until puberty, related to lordosis of the spine. The abdomen appears flat when the child is supine. Clinical Alert An especially protuberant abdomen can suggest fluid retention, tumor, organomegaly (enlarged organ), or ascites. A large abdomen, with thin limbs and wasted buttocks, suggests severe malnutrition and can be seen in children with celiac disease or cystic fibrosis. A depressed abdomen is indicative of dehydration or high abdominal obstruction. A midline protrusion from the xiphoid process to the umbilicus or the symphysis pubis indicates diastasis recti abdominis.

Assessment	Findings
With the child prone, inspect the buttocks and thighs. Examine the skin around the anal area for redness and rash.	Clinical Alert Asymmetry of the buttocks and thigh folds indicates congenital hip dysplasia. Redness and rash can indicate inadequate cleaning after bowel movements, infrequent changing of diapers, or irritation from diarrhea.
Examine the anus for marks, fissures (tears in the mucosa), hemorrhoids (dark protrusions), prolapse (moist tubelike protrusion), polyps (bright red protrusions), and skin tags.	The anus usually appears moist and hairless. Clinical Alert Scratch marks can indicate itching, which can indicate pinworm infestation. Fissures can indicate passage of hard stools. Defecation can be accompanied by bleeding if fissures are present. Bleeding can also accompany polyps, intussusception, gastric and peptic ulcers, esophageal varices, ulcerative colitis, infectious diseases, and Meckel’s diverticulum. Rectal prolapse indicates difficult defecation and often accompanies untreated cystic fibrosis. Skin tags can indicate polyps and are usually benign. Lacerations and bruises of anus can indicate abuse.
Stroke the anal area to elicit the anal reflex.	The anus should contract quickly. Clinical Alert A slow reflex can indicate a disorder of the pyramidal tract.