27
Comments
Excellent
Satisfactory
Needs practice
Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
skill 2-7
Assessing the abdomen
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
Goal:
The assessment is completed accurately without causing
the patient to experience anxiety or discomfort, the findings
are documented and the appropriate referral is made to other
healthcare professionals, as needed, for further evaluation.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
Equipment:
stethoscope, alcohol wipes.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), if indicated.
8. Ensure patient privacy is maintained and that
interruptions are minimal. Ensure adequate lighting.
9. Undertake a health history, as per Skill 2-1.
10. If possible, have the patient empty their bladder. Help the
patient to undress, if needed, and provide a patient gown.
Assist the patient to a supine position with the head
slightly elevated and a pillow under the knees. Expose the
abdomen. Use a blanket or drape to cover any exposed
area other than the one being assessed.
11. Inspect the abdomen for skin colour, contour, peristalsis,
pulsations and masses, and inspect the umbilicus and other
surface characteristics (rashes, lesions, masses, scars).
12. Auscultate all four quadrants of the abdomen
systematically for bowel sounds using the diaphragm of
the stethoscope.
13. Auscultate the abdomen for vascular sounds using the
bell of the stethoscope.
14. Percuss the abdomen for tones.
15. Palpate the abdomen lightly in all four quadrants and
then use deep palpation.
If the patient complains of
pain or discomfort in a particular area of the abdomen,
palpate that area last.
16. Palpate the kidneys on each side of the abdomen, the liver
at the right costal border and the spleen at the left costal
border.
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