Chapter 17. Abdomen
Lower bowel sounds can be affected by manual manipulation; thus the order of assessment is inspection, auscultation, percussion, and palpation. Because it is sometimes performed as part of the abdominal assessment, assessment of the anus is included in this chapter.
Rationale
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.
Anatomy and Physiology
Gastrointestinal System
The primary functions of the gastrointestinal tract are the digestion and absorption of nutrients and water, elimination of waste products, and secretion of various substances required for digestion.
The liver, located in the right upper quadrant of the abdomen, has several important functions, including biosynthesis of protein; production of blood clotting factors; metabolism of fat, protein, and carbohydrates; production of bile; metabolism of bilirubin; and detoxification.
A primitive gut develops from the endoderm by the third week of gestation. This developing midgut grows so rapidly that by the fourth week of gestation it is too large for the abdominal cavity. Failure of the midgut to rotate and reenter the abdominal cavity at 10 weeks of gestation can produce a variety of disorders, such as omphalocele, and susceptibility to intussusception and bowel obstruction.
Despite the development of the digestive tract in utero, the exchange of nutrients and waste is the function of the placenta. At birth the gastrointestinal tract is still immature and does not fully mature for the first 2 years. Because of this immaturity, many differences exist between the digestive tract of the infant or child and that of the adult. For example, the muscle tone of the lower esophageal sphincter does not assume adult levels until 1 month of age. This lax sphincter muscle tone explains why young infants frequently regurgitate after feedings. Intestinal peristalsis in children is rapid, with emptying time being 2½ to 3 hours in the newborn infant and 3 to 6 hours in older infants and children. Stomach capacity is 10 to 20 ml (0.3 to 0.7 oz) in the neonate, compared with 10 to 200 ml (0.3 to 7 oz) in the 2-month-old infant, 1500 ml (50 oz) in the 16-year-old adolescent, and 2000 to 3000 ml (68 to 101 oz) in the adult. The stomach is round and lies somewhat horizontally until 2 years of age. The parietal cells of the stomach do not produce adult levels of hydrochloric acid until 6 months. The gastrocolic reflex, or movement of the contents toward the colon, is rapid in young infants, as evidenced by the frequency of stools. The intestine, which underwent rapid growth in utero, undergoes further growth spurts when the child is 1 to 3 years of age and again at 15 to 16 years. After birth the musculature of the anus develops as the infant becomes more upright. The child then becomes able to voluntarily control defecation.
Genitourinary System
The kidneys lie posteriorly within the upper quadrants of the abdomen. The kidneys regulate fluid and electrolyte levels in the body through filtration, reabsorption, and secretion of water and electrolytes. Water is excreted in the form of urine. The bladder, located below the symphysis pubis, collects the urine for elimination.
The development of the kidneys begins early in gestation but is not complete until near the end of the first year of life. Until the epithelial cells of the nephrons assume a mature flat shape, filtration and absorption are poor. The loop of Henle gradually elongates, which increases the infant’s ability to concentrate urine, as seen by fewer wet diapers near the first year of life. Increasing bladder capacity also contributes to decreased frequency of voiding. The infant’s bladder capacity is 15 to 20 ml (0.5 to 0.7 oz), compared with 600 to 800 ml (20 to 27 oz) in the adult. The size of the kidneys varies with size and age. The kidneys of infants and children are relatively large in comparison with those of adults and are more susceptible to trauma because of their size.
Equipment for Assessment of Abdomen
▪ Warm stethoscope
▪ Warm hands
▪ Short fingernails
Preparation
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.
| Type of Emesis | Related Findings |
|---|---|
| Undigested formula or food | Rapid expulsion of stomach contents before digestion has occurred. |
| Yellow; might smell acidic | Contents originated in stomach. |
| Dark green (bile-stained) | Contents originated below the ampulla of Vater. |
| Dark brown, foul odor | Emesis produced by intestinal obstruction. |
| Bright red/dark red | Bright red signifies fresh bleeding. Dark red signifies old blood or blood altered by gastric secretions. |
| Description of Vomiting | Associated Symptoms | Possible Etiology |
|---|---|---|
| Acute vomiting |
Diarrhea
Fever
Abdominal pain or cramping (except with cholera infections)
Nausea
Meningeal symptoms (Shigella and
Salmonella groups)
Upper respiratory symptoms (found with Rotavirus)
|
Infections (e.g., Rotavirus, Norwalk virus,Salmonella, Shigella, Escherichia coli, Giardia lamblia, Vibrio cholerae—cholera) |
| Acute vomiting |
Fever
Irritability
Poor feeding (infants and young children) and anorexia
Pulling at the ear
Complaint of earache
Red, bulging eardrum
|
Acute otitis media |
| Acute vomiting |
Fever
Headache
Irritability
Photophobia
Nuchal rigidity
Positive Kernig’s sign
Positive Brudzinski’s sign
Lethargy
Failure to feed (infants)
High-pitched cry (infants)
Tense or bulging fontanel (infants)
Macular or petechial rash
|
Bacterial meningitis |
| Acute Vomiting |
Periumbilical pain that moves to the right iliac fossa
Fever
Rebound tenderness
|
Appendicitis |
| Acute Vomiting |
Disorientation
Ataxia
Nystagmus
Drowsiness
Hypotension
Dysarthria
|
Alcohol poisoning |
| Vomiting |
Episodic colicky pain
Pallor
Infant/child draws up legs
Red currant-jelly stools
Palpable mass in the line of the colon
Peak incidence in infants between 5 and 7 months
|
Intussusception |
| Persistent vomiting |
Effortless regurgitation or emesis
Frequently found in infants younger than 6 months but also occurs in children
Weight loss or failure to gain adequately (if vomiting is severe)
Anemia
Irritability
Heartburn (older children)
|
Gastroesophageal reflux |
| Episodic vomiting |
Headache
Visual symptoms (blurring, flashing lights, stars, scotomata, photophobia)
Dizziness
Abdominal pain
Strong family history of migraine
Local weakness
Sensory disturbances
|
Migraine |
| Recurrent vomiting, possibly hematemesis |
Stabbing, burning pain that radiates to the back
Chronic abdominal pain
Family history
Use of alcohol or tobacco or ulcerogenic drugs
Presence of stress
Presence of bacterium
Helicobacter pylori
|
Peptic ulcer disease |
| Vomiting (morning, with or without feeding, becomes increasingly projectile) |
Headache on waking or with sneezing
Clumsiness
Spasticity
Irritability
Weakness
Seizures
Positive Babinski’s sign
Decreased appetite
|
Brain tumor |
| Forceful vomiting (non bile-stained, progressive) |
Dehydration
Weight loss
Infant hungry following vomiting
Visible peristalsis in the left hypochondrium
Palpable mass between the umbilicus and right costal margin
Usually presents in infants 3 to 6 weeks
|
Pyloric stenosis |
| Location | Characteristics | Possible Age Group | Etiology | Related Factors | Associated Symptoms |
|---|---|---|---|---|---|
| Lower abdomen, flank | Severe, colicky | Adolescent | Urolithiasis |
▪ Hypercalciuria
▪ Urinary tract infection
|
▪ Restlessness
▪ Dysuria
|
| Lower abdomen, especially suprapubic | Constant | Any | Cystitis |
▪ Bubble baths
▪ Tight jeans
▪ Nylon panties
▪ Sexual activity
|
▪ Urinary frequency
▪ Dysuria
|
| Lower abdomen | Any | Obstruction |
▪ Adhesions related to surgery
▪ Ingestion of hairballs or trichobezoars
▪ Developmental or psychologic problems
|
▪ Frequent tinkling sounds (early obstruction) or high-pitched rumbles
▪ Diminished bowel sounds (late obstruction)
▪ Absence of bowel sounds (total obstruction)
|
|
| Lower abdomen | Acute or chronic, crampy | Older school-age or adolescent | Ulcerative colitis |
▪ Infection
▪ Dietary habits
▪ Familial tendency
|
▪ Diarrhea
▪ Blood in stools
▪ Growth failure
|
| Bilateral, lower abdomen | Constant | Adolescent | Pelvic inflammatory disease |
▪ Multiple sex partners
▪ Alcohol/drug use
▪ Begins during or within week of menses
|
▪ Guarding upon palpation
▪ Fever
▪ Pain with movement
▪ Walks slightly bent over and tends to hold abdomen
|
| Constant | Adolescent | Endometriosis | ▪ Menses | ||
| Constant, crampy | Adolescent | Ectopic pregnancy | ▪ Amenorrhea | ▪ Morning vomiting | |
| Constant, crampy | Any | Constipation |
▪ Spinal injury
▪ Meningomyelocele
▪ Use of anticholinergics, laxatives
▪ Eating disorders
|
▪ Lack of stooling
▪ Bloating
▪ Presence of a mass
|
|
| Nonspecific | Chronic | School-age adolescent | Psychogenic |
▪ Abuse
▪ Depression
▪ Eating disorders
▪ Minor adjustment problems
|
▪ Pain might interfere with stressful activities but not with pleasurable ones
▪ Can be associated with specific situations
▪ Eyes remain closed during palpation
|
| Generalized | Any | Streptococcal pharyngitis | ▪ Infection |
▪ Erythematous pharynx
▪ Fever
▪ Pain
|
