Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST
NAME: _____________________________________ DATE PERFORMED:
_________________
YEAR & SECTION: ______________

PURPOSE:
1. Assess Gastro-intestinal Peristalsis.
2. Determine the condition of underlying intestinal organs.

ASSESSING THE ABDOMEN

PREPARATION 1 2 3 4 5
1. Assemble equipment:
 Examining light
 Tape measure (metal or unstretchable cloth)
 Water-soluble skin-marking pencil
 Stethoscope
PROCEDURE
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it
is necessary, and how the client can cooperate.
2. Perform hand hygiene and observe other appropriate
infection control procedures.
3. Provide for client privacy.
4. Determine the client’s history of the following:
 Incidence of abdominal pain: its location, onset,
sequence, and chronology; its quality
(description); its frequency; associated symptoms
 Bowel habits
 Incidence of constipation or diarrhea
 Change in appetite
 Food intolerances
 Foods ingested in last 24 hours
 Specific signs and symptoms
 Previous problems and treatment
5. Assist the client to a supine position, with the arms
placed comfortably at the sides.
Place small pillows beneath the knees and the head
to reduce tension in the abdominal muscles. Expose
only the client’s abdomen from chest line to the pubic
area to avoid chilling and shivering, which can tense
the abdominal muscles.
Assessment

Inspection of the Abdomen

6. Inspect the abdomen for skin integrity.
7. Inspect the abdomen for contour and symmetry.
Observe the abdominal contour while standing at the
client’s side when the client is supine.
Ask the client to take a deep breath and to hold it.
Assess the symmetry of contour while standing at
the foot of the bed.
 If distention is present, measure the abdominal girth
by placing a tape around the abdomen at the level of
the umbilicus.
8. Observe abdominal movements associated with
respiration, peristalsis, or aortic pulsations.
9. Observe the vascular pattern.

Auscultation of the Abdomen

10. Auscultate the abdomen for bowel sounds, vascular
sounds, and peritoneal friction rubs.
Percussion of the Abdomen
11. Percuss several areas in each of the four quadrants
to determine presence of tympany and dullness.
Use a systematic pattern: Begin in the lower left
quadrant, then proceed to the lower right quadrant,
the upper right quadrant, and the upper left quadrant.
Percussion of the Liver
12. Percuss the liver to determine its size.

Palpation of the Abdomen

13. Perform light palpation first to detect areas of
tenderness and/or muscle guarding.
Systematically explore all four quadrants.
14. Perform deep palpation over all four quadrants.

Palpation of the Liver

15. Palpate the liver to detect enlargement and
tenderness.
Palpation of the Bladder
16. Palpate the area above the pubic symphysis if the
client’s history indicates possible urinary retention.
17. Document findings in the client record.

TOTAL

________________________
Clinical Instructor
(sign over printed name)