Abdominal mass
Abdominal mass: Excerpt from Nursing: Interpreting Signs and Symptoms
Commonly detected on routine physical examination, an abdominal mass is a localized swelling in one abdominal quadrant. Typically, this sign develops insidiously and may represent an enlarged organ, a neoplasm, an abscess, a vascular defect, or a fecal mass.
Distinguishing an abdominal mass from a normal structure requires skillful palpation. At times, palpation must be repeated with the patient in a different position or performed by a second examiner to verify initial findings. A palpable abdominal mass is an important clinical sign and usually represents a serious—and perhaps life-threatening—disorder.
Action stat!
If the patient has a pulsating midabdominal mass and severe abdominal or back pain, suspect an aortic aneurysm. Quickly take his vital signs. Because the patient may require emergency surgery, withhold food or fluids until he's examined. Prepare to administer oxygen and to start an I.V. infusion for fluid and blood replacement. Obtain routine preoperative tests, and prepare the patient for computed tomography scan. Frequently monitor vital signs and urine output.
History and physical examination
If the patient's abdominal mass doesn't suggest an aortic aneurysm, continue with a detailed history. Ask the patient if the mass is painful. If so, ask if the pain is constant or if it occurs only on palpation. Is it localized or generalized? Determine if the patient was already aware of the mass. If he was, find out if he noticed any change in the size or location of the mass.
Next, review the patient's medical history, paying special attention to GI disorders. Ask the patient about GI symptoms, such as constipation, diarrhea, rectal bleeding, abnormally colored stools, and vomiting. Has the patient noticed a change in his appetite? If the patient is female, ask whether her menstrual cycles are regular and the first day of her last menses.
A complete physical examination should be performed. Inspect the abdomen for asymmetry, scarring, discoloration, or other skin abnormalities. Also observe for pulsations. Next, auscultate for bowel sounds in each quadrant. Listen for bruits or friction rubs, and check for enlarged veins. Lightly palpate and then deeply palpate the abdomen, assessing any painful or suspicious areas last. Note the patient's position when you locate the mass. Some masses can be detected only with the patient in a supine position; others require a side-lying position.
Estimate the size of the mass in centimeters. Determine its shape. Is it round or sausage shaped? Describe its contour as smooth, rough, sharply defined, nodular, or irregular. Determine the consistency of the mass. Is it doughy, soft, solid, or hard? Percuss the mass. A dull sound indicates a fluid-filled mass; a tympanic sound, an air-filled mass.
Next, determine if the mass moves with your hand or in response to respiration. Is the mass free-floating or attached to intra-abdominal structures? To determine whether the mass is located in the abdominal wall or the abdominal cavity, ask the patient to lift his head and shoulders off the examination table, thereby contracting his abdominal muscles. While these muscles are contracted, try to palpate the mass. If you can, the mass is in the abdominal wall; if you can't, the mass is within the abdominal cavity. (See Abdominal masses: Locations and common causes, page 8.)
After the abdominal examination is complete, perform pelvic, genital, and rectal examinations.
Medical causes
Abdominal aortic aneurysm.An abdominal aortic aneurysm may exist for years, producing only a pulsating periumbilical mass with a systolic bruit over the aorta. It may become life-threatening if the aneurysm expands and its walls weaken. In such cases, the patient initially reports constant upper abdominal pain or, less commonly, low back or dull abdominal pain. If the aneurysm ruptures, he'll report severe abdominal and back pain. After rupture, the aneurysm no longer pulsates.
Associated signs and symptoms of rupture include mottled skin below the waist, absent femoral and pedal pulses, lower blood pressure in the legs than in the arms, mild to moderate tenderness with guarding, and abdominal rigidity. Signs of shock—such as altered mental status, tachycardia, and cool, clammy skin—appear with significant blood loss.
Cholecystitis.Deep palpation below the liver border may reveal a smooth, firm, sausage-shaped mass. With acute inflammation, the gallbladder is usually too tender to be palpated. Cholecystitis can cause severe right upper quadrant pain that may radiate to the right shoulder, chest, or back; abdominal rigidity and tenderness; fever; pallor; diaphoresis; anorexia; nausea; and vomiting. Recurrent attacks usually occur 1 to 6 hours after meals. Murphy's sign (inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath) is common.
Colon cancer.A right lower quadrant mass may occur with cancer of the right colon, which may also cause occult bleeding with anemia and abdominal aching, pressure, or dull cramps. Associated findings include weakness, fatigue, exertional dyspnea, vertigo, and signs and symptoms of intestinal obstruction, such as obstipation and vomiting.
Occasionally, cancer of the left colon also causes a palpable mass. It usually produces rectal bleeding, intermittent abdominal fullness or cramping, and rectal pressure. The patient may also report fremitus and pelvic discomfort. Later, he develops obstipation, diarrhea, or pencil-shaped, grossly bloody, or mucus-streaked stools. Typically, defecation relieves pain.
Crohn's disease.With Crohn's disease, tender, sausage-shaped masses are usually palpable in the right lower quadrant and, at times, in the left lower quadrant. Attacks of colicky right lower quadrant pain and diarrhea are common. Associated signs and symptoms include fever, anorexia, weight loss, hyperactive bowel sounds, nausea, abdominal tenderness with guarding, and perirectal, skin, or vaginal fistulas.
Diverticulitis.Most common in the sigmoid colon, diverticulitis may produce a left lower quadrant mass that's usually tender, firm, and fixed. It also produces intermittent abdominal pain that's relieved by defecation or passage of flatus. Other findings may include alternating constipation and diarrhea, nausea, a low-grade fever, and a distended and tympanic abdomen.
Gastric cancer.Advanced gastric cancer may produce an epigastric mass. Early findings include chronic dyspepsia and epigastric discomfort, whereas late findings include weight loss, a feeling of fullness after eating, fatigue and, occasionally, coffee-ground vomitus or melena.
Hepatomegaly.Hepatomegaly produces a firm, blunt, irregular mass in the epigastric region or below the right costal margin. Associated signs and symptoms vary with the causative disorder but commonly include ascites, right upper quadrant pain and tenderness, anorexia, nausea, vomiting, leg edema, jaundice, palmar erythema, spider angiomas, gynecomastia, testicular atrophy and, possibly, splenomegaly.
Hernia.The soft and typically tender bulge is usually an effect of prolonged, increased intra-abdominal pressure on weakened areas of the abdominal wall. An umbilical hernia is typically located around the umbilicus and an inguinal hernia in either the right or left groin. An incisional hernia can occur anywhere along a previous incision. Hernia may be the only sign until strangulation occurs.
Hydronephrosis.Enlarging one or both kidneys, hydronephrosis produces a smooth, boggy mass in one or both flanks. Other findings vary with the degree of hydronephrosis. The patient may have severe colicky renal pain or dull flank pain that radiates to the groin, vulva, or testes. Hematuria, pyuria, dysuria, alternating oliguria and polyuria, nocturia, accelerated hypertension, nausea, and vomiting may also occur.
Ovarian cyst.A large ovarian cyst may produce a smooth, rounded, fluctuant mass, resembling a distended bladder, in the suprapubic region. Large or multiple cysts may also cause mild pelvic discomfort, low back pain, menstrual irregularities, and hirsutism. A twisted or ruptured cyst may cause abdominal tenderness, distention, and rigidity.
Splenomegaly.With splenomegaly,the smooth edge of the enlarged spleen is palpable in the left upper quadrant. Associated signs and symptoms vary with the causative disorder but usually include a feeling of abdominal fullness, left upper quadrant abdominal pain and tenderness, splenic friction rub, splenic bruits, and a low-grade fever.
Uterine leiomyomas (fibroids).If large enough, these common, benign uterine tumors produce a round, multinodular mass in the suprapubic region. The patient's chief complaint is usually menorrhagia; she may also experience a feeling of heaviness in the abdomen, and pressure on surrounding organs may cause back pain, constipation, and urinary frequency or urgency. Edema and varicosities of the lower extremities may develop. Rapid fibroid growth in perimenopausal or postmenopausal women needs further evaluation.
Nursing considerations
▪ Offer emotional support to the patient and his family as they await the results of diagnostic testing.
▪ Position the patient comfortably, and administer drugs for pain or anxiety as needed.
▪ If an abdominal mass causes bowel obstruction, watch for indications of peritonitis—abdominal pain and rebound tenderness—and for signs of shock, such as tachycardia and hypotension.
▪ Prepare the patient for surgery, if indicated.
Patient teaching
▪ Explain any diagnostic tests that are needed.
▪ Teach the patient about the cause of the abdominal mass, once a diagnosis is made. Also explain treatment and potential outcomes.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
More About Cholecystitis
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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