What comes first percussion or palpation?

This content is based upon The Correctional Nurse Educator class entitled Abdominal Assessment: Basic Assessment for the Correctional Nurse.

The physical examination of the patient begins with inspection.  Unique to the sequence of the abdomen, the abdomen is then auscultated, percussed and finally, palpated.  Auscultating before the percussion and palpation of the abdomen ensures that the examiner is listening to undisturbed bowel sounds.  In addition, if the patient is complaining of pain, leaving the palpation until last allows the examiner to gather other data before potentially causing the patient more discomfort.  When completing the physical examination, it is helpful to divide the abdomen into regions in order to consider which organs are involved.  A four-quadrant system – left upper quadrant, left lower quadrant, right upper quadrant and right lower quadrant provides a more general overview, and is acceptable in situations when there is no abdominal complaint.  The nine-region system provides more specific information if the patient is complaining of discomfort or problems in a certain area.  The nine regions include the following:  right hypochondriac (upper) region, right lumbar (middle) region, right iliac (lower) region, left hypochondriac (upper) region, left lumbar (middle) region, left iliac (lower) region, epigastric region, umbilical region, and hypogastric (suprapubic) region.   

PALPATION

Palpation of the abdomen should include both light and deep palpation methods to detect tenderness and changes to underlying structures.  It is important to explain to the patient what you will be doing, as this part of the abdominal assessment typically causes increased anxiety for the patient (especially if the patient’s complaint is abdominal pain).  Also, ask the patient not to talk during this part of the exam, unless you ask a specific question, and not to raise his/her head, as these actions could cause the abdominal musculature to tighten, making palpation of the underlying structures difficult.  Just as you did with auscultation and percussion, divide the patient’s abdomen into regions, and systematically assess each.  If the patient is complaining of abdominal pain, assess that area last.

Begin with light palpation, pressing only .25 – .50 inches into the abdomen.  This is used to determine the characteristics of the skin and subcutaneous tissue, and to note temperature, tenderness, and large masses.  Using a circular motion with your fingers, proceed slowly and methodically.  Palpate the femoral pulse and the inguinal lymph nodes.  If the abdominal muscles contract during your palpation, determine whether it is voluntary or involuntary by correlating the contraction to the patient’s breathing.  If the contraction is noted during both inspiration and expiration, then most likely the spasm is involuntary, indicating that it is the body’s attempt to protect inflamed abdominal viscera from pressure.  This is known as “guarding”.  If the abdominal contraction occurs more strongly during inspiration and less strongly during expiration, then it is more likely that the contraction is voluntary and due to the patient’s anxiety level.  

Once the light palpation is complete, begin the deep palpation part of the examination.  Deep palpation is CONTRAINDICATED for patients with suspected abdominal aortic aneurysm, appendicitis, a tender spleen, a kidney transplant or polycystic kidney disease.  Deep palpation is used to identify normal structures and masses, and assess for tenderness. During deep palpation, you will press 1.5-2.0 inches into the patient’s abdomen. In the patient with obesity, you may not be able to feel the abdominal organs.  In patients who are thin, you may be able to feel the muscular structures of the abdomen, such as the rectus muscle, the bowel and the aortic pulsations.  The liver may be palpated by feeling deeply beneath the costal margin while the patient takes a deep breath.  During inspiration, the liver descends and you may be able to feel the edges against your hand.  A healthy liver is firm and rubbery.  To palpate the kidneys, place your non-dominant hand under the patient’s flank as you press downward against the right outer edge of the abdomen and try to “sandwich” the kidney between your hands.  It typically feels firm and smooth.  Please note that the left kidney is usually not able to be palpated due to its position behind the bowel. Unless they are enlarged, all of the other structures of the abdomen, including the gall bladder and the spleen, are typically not palpable.  

If the patient’s complaint includes symptoms of a potential hernia, then an evaluation of the femoral and inguinal areas, including the palpation of the inguinal ring, should be done.  If a mass is discovered on palpation, its size, shape, location, consistency (soft, solid), surface (smooth, irregular), tenderness, pulsatility, and mobility should be documented.  If the mass is small, this can be ascertained through palpation between your thumb and index finger; if it is larger, then a bi-manual evaluation should occur.  A mobile mass should bounce upward and strike your fingers when you press quickly and deeply into the region.  

Abnormal findings that may be present on Palpation

Hepatomegaly – Liver enlargement – may be caused by cirrhosis, hepatitis, right heart failure, cysts and malignancy.  

Splenomegaly – Spleen enlargement – may be due to infectious or inflammatory diseases

Aortic Aneurysm – arteriosclerosis is the most common cause of aortic aneurysm.  Aging, cigarette smoking and hypertension are contributing factors.  Trauma, syphilis, congenital connective tissue disorders such as Marfans syndrome, and positive history of aneurysm also increases the incidence.  Characteristics include a prominent lateral pulsation.

This completes our series on Abdominal Assessment. If you are interested in more resources, go to The Correctional Nurse Educator, where you can find abdominal classes about Nausea and Vomiting; Constipation and Diarrhea; Upper Abdominal Pain and Lower Abdominal Pain. 

Why do you palpate before percussion?

Do you Percuss the abdomen before palpation?

What is the order of abdominal assessment?

Why is auscultation done before percussion and palpation?