The Skinny on Documenting an Abdominal Exam
If you're a newer nurse practitioner, chances are you may find documentation a challenge, especially if you don't have an electronic medical records system prompting the input of your physical exam findings. Documentation is key to continuity of care for your patients, as well as to protecting yourself should questions arise about the patient encounter. Given the importance of this foundational skill, we're going to spend some time covering how to document a physical exam, system-by-system (in no particular order) over the next few weeks here on MidlevelU.
Today, we'll start with the abdominal exam because, well, it's one of my favorites.
What You're Looking For:
The abdominal exam consists of a number of components, the most basic being inspection, auscultation for bowel sounds, percussion, and palpation. The exam must be completed in this order as palpation before auscultation can lead to an inaccurate representation of bowel sounds. The patient should be lying supine for the exam with the abdomen exposed - examining over clothing doesn't count!
Why do these components matter?
- Inspection - Evaluation of the external abdomen. Bruising, for example, may indicate trauma. Distention could be a sign of ascites.
- Auscultation - Assessment of bowel sounds, can give you a clue as to the patient's pathology. Absence of bowel sounds, for example, may indicate a blockage.
- Percussion - Evaluation of the liver. This one takes some practice.
- Palpation - Is the patient tender? If so, in which quadrant? This gives you information that will help lead to a diagnosis. Upper right abdominal tenderness, for example, may mean gallbladder pathology. Lower right abdominal tenderness may signal an appendicitis. Tip: Assess tender areas last. Watch the patient's facial expression as you perform your exam for signs of discomfort.
Buzzwords to Know:
There are a few physical exam tricks you can do to help you reach a diagnosis. Here are a few basic tests nurse practitioners should know:
- Murphy's Sign - indicates gallbladder or liver inflammation
- Rebound Tenderness - indicates peritoneal inflammation
- McBurney's Point - tenderness can indicate appendicitis
Sample Normal Exam Documentation:
Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation. Umbilicus is midline without herniation. Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.
Sample Abnormal Documentation:
Note that the abdomen is divided into four quadrants, the right upper quadrant, the right lower quadrant, the left upper quadrant, and the left lower quadrant. The epigastric area (central abdomen) may also be used as a reference point in documentation. The more specific you can be about where an abnormality lies, the better.
While you won't use all of these elements in documenting an abnormal abdominal exam on the same patient, the following are examples of some abnormal abdominal physical exam findings you may need to note.
Abnormals on an abdominal exam may include:
- Tenderness (location)
- Guarding (location)
- Rebound (location)
- Positive Murphy's Sign
- McBurney's point tenderness
- External findings (lesions, scarring)
- Signs of trauma (ecchymosis)
- Hepatomegaly or splenomegaly
- Masses (visible or palpable, size, shape, location, texture)
- Abnormal bowel sounds (hypoactive, hyperactive, absent)
- Aortic bruit or visible pulsation
**Note: This is not meant to be a comprehensive guide. You are responsible for performing and appropriate physical exam and corresponding documentation on each and every patient you interact with.
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We're working on it! More documentation posts are scheduled for this week and next. Let us know if there's anything else that would be helpful for us to cover as well.
More post like this would be fantastic!!!!!