Where would the nurse expect to assess tympany when performing percussion on a patient with ascites?

Department: Topics in Progressive Care

Marjaana Mehta is an adult nurse practitioner in adult medical oncology at Hackensack (N.J.) University Medical Center.

Assessing your patient's abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation. Changing the order of these assessment techniques could alter the frequency of bowel sounds and make your findings less accurate.

Have your patient empty his bladder, then lie supine with a pillow under his head. Expose his abdomen from above the xiphoid process to the symphysis pubis.

Figure. Inspection

1. Picture your patient's abdomen in four quadrants. Standing at his right side, look at the abdomen from the side and from above, from the xiphoid process to the symphysis pubis, to determine whether it's flat, scaphoid, rounded, or protuberant. If it's protuberant, ask whether this is normal for him. If it isn't, you'll assess for distension or ascites during percussion and palpation.
Next, assess for any visible mass, bulging, or asymmetry. Look for unusual coloring, scars, striae, lesions, petechiae, ecchymoses, spider angiomas, and suspicious-looking moles. Inspect the umbilicus and note any hernias. Look for pulsations. You won't see any on most patients, but in a thin patient you may see pulsation of the aorta in his epigastric area and possibly peristaltic waves.


Figure. Auscultation
2. Place the diaphragm of your stethoscope lightly over the right lower quadrant and listen for bowel sounds. If you don't hear any, continue listening for 5 minutes within that quadrant. Then, listen to the right upper quadrant, the left upper quadrant, and the left lower quadrant. Describe bowel sounds as absent, normoactive, hypoactive, or hyperactive. Absent bowel sounds may indicate ileus or peritonitis. Hyperactive bowel sounds may occur with an early intestinal obstruction or gastrointestinal hypermotility.
3. With the bell of your stethoscope, listen over the aorta, as shown, and the renal, iliac, and femoral arteries. If the patient has hypertension, you may hear a bruit—a vascular sound similar to a heart murmur—caused by turbulent blood flow through a narrowed artery. Occasionally, you may hear a bruit limited to systole in the epigastric region of a healthy person.

Figure. Percussion
4. Lightly percuss all four quadrants of your patient's abdomen. You'll hear dull sounds over solid structures (such as the liver) and fluid-filled structures (such as a full bladder). Air-filled areas (such as the stomach) produce tympany. Dullness is a normal finding over the liver, but a large, dull area elsewhere may indicate a tumor or mass.

Figure. Palpation
5. Place the palmar aspect of the fingers on your dominant hand flat and together on your patient's abdomen. Using a light, gentle, dipping motion, palpate for abnormalities, such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting your fingers as you move from one location to another. After light palpation of the entire abdomen, place your nondominant hand on your dominant hand to perform deeper palpation (1½ to 2 inches [3.8 to 5 cm]). However, avoid deep palpation if your patient may have a problem such as splenomegaly, appendicitis, or aneurysm or if palpation is painful for any reason.
6. To palpate the liver, place your left hand under your patient, parallel to and supporting the right 11th and 12th ribs and your right hand lateral to the rectus muscle with your fingertips below the liver border (as identified by dullness during percussion). As shown, press gently in and up as your patient takes a deep breath.

Figure
Another approach is to stand by his right shoulder, hook the fingers of both hands (side by side) below the liver border, press in and up toward the costal margin, and ask him to inhale. You may be able to feel the soft, smooth, sharp edge of the liver descending during inspiration. The liver is considered enlarged if the edge extends more than 1.2 inch (3 cm) below the right costal margin. Document your assessment findings in the medical record.

SELECTED REFERENCES

Bickley L. Bates Guide to Physical Examination and History Taking, 10th ed. Philadelphia, Pa., Lippincott Williams & Wilkins, 2009.

Jarvis C. Physical Examination and Health Assessment, 5th ed. Philadelphia, Pa., W.B. Saunders Co., 2007.