Years ago I helped a friend teach the correct method to perform an abdominal exam to A&E nurses as part of a physical assessment course. We also taught auscultation of the heart and lungs .
Most abdominal exams are performed in the supine position with the head and knees well supported with small pillows or sheets for comfort and also to relax the abdominal muscles. The hands should be at their sides and not under their head as this causes tensing of the abdominal wall. In addition good lighting is essential, as subtle shadows of abdominal wall masses can be observed.
Initial observations are made for any signs of distention and if present it is localized or generalized this also includes the flanks. The skin should be observed for any areas of discoloration such as the bluish discoloration of the umbilicus (Cullen's sign) or flanks (Grey Turner's sign) or for striae or "stretch marks," and surgical scars. The skin of the abdomen should also be checked carefully for engorged veins in the abdominal wall and the direction of blood flow in these veins.
Next, the abdomen should be inspected for masses. Any mass of the abdominal wall will become more prominent with tensing of the abdominal wall whereas an intra-abdominal mass will become less prominent or disappear. Useful maneuvers include having the patient hold his/her head unsupported off the examining table, or holding their nose and blow, or to raising their feet off the table.
Abdominal wall masses are most commonly hernias (either umbilical, epigastric, incisional, or spigelian), neoplasms (benign and malignant), infections, and hematomas.
Once a mass is determined to be intra-abdominal, its location should be described in relation to the abdominal quadrants. As the relationship of intra-abdominal organs to these quadrants can help in attempting to determine the cause of the mass. The mass should be examined for movement with respiration or for pulsation with each heartbeat or peristalsis
Lastly, the abdominal wall should be observed for motion with respiration as normally the abdominal wall moves posteriorly in a symmetrical fashion with inspiration.
Then auscultation should be performed on the abdomen. When listening you should listen over several areas of the abdomen for several minutes for the presence of or absence of bowel sounds ( generally a minimum of 3 minutes).
After which palpation and percussion should be performed, but always ask patients with abdominal pain to point to the area of greatest pain. You should first gently examine the abdominal wall with the fingertips followed by deep palpation of the abdomen. Performed by placing the flat of the hand on the abdominal wall and applying firm, steady pressure using a two-handed technique. Percussion is used to determine the presence of fluid or gas.
Abdominal tenderness is the objective expression of pain from palpation. When elicited, it should be described as to its location (quadrant), depth of palpation required to elicit it (superficial or deep), and the patient's response (mild or severe). Observing for spasm or rigidity, Guarding or Rebound tenderness.