Acute. Learn best practices for treating adult sufferers of acute abdominal pain. By Terri Core, ARNP, ACNP, MSN, and Karen Hayes, FNP,C, MSN, PhD

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1 Acute abdomi Learn best practices for treating adult sufferers of acute abdominal pain. By Terri Core, ARNP, ACNP, MSN, and Karen Hayes, FNP,C, MSN, PhD Abdominal pain remains one of the most common presentations in the emergency department (ED), accounting for approximately 7.3 million visits and totaling 5% to 10% of all ED visits. 1-3 Diagnosis and treatment of acute abdominal pain remains a perplexing problem to both healthcare providers and nursing staff. This challenge is in part due to the many variables and confounding factors associated with patients who present with acute abdominal pain. Determining the cause of abdominal pain is a difficult task because of factors such as age, past medical and surgical history, the use of medications both prescription and over the counter. Further compounding the problem is the long list of differential diagnoses associated with abdominal pain. Diseases causing abdominal pain can range from minor to life threatening and from common to obscure. Differential diagnosis of acute abdominal pain lists some causes of abdominal pain and divides them into common and uncommon etiologies. Delays or misdiagnosis of abdominal pain can result in significant morbidity and mortality. Misdiagnosis of abdominal pain also places the healthcare staff at risk for litigation. A frequent reason for malpractice claims against ED physicians is the misdiagnosis of appendicitis in women of childbearing age. 4,5 It is therefore imperative for physicians and nurses caring for patients who complain of abdominal pain to be able to differentiate acute situations from non-acute situations. Emergent or nonemergent Among the top priorities is determining whether the patient is in need of emergent treatment. Begin with the ABCs of airway, breathing, and circulation, followed by a rapid pain assessment. Severe pain, tachycardia, diaphoresis, and pallor are among the signs and symptoms that signal a need for emergency medical or surgical intervention. 6,7 The relationship of pain to vomiting can be a helpful clue in determining whether a patient is in emergent need of a surgical consult. Vomiting in the patient with a surgical abdomen is a reaction to visceral pain. The clinical presentation of a surgical abdomen is that pain precedes the vomiting. Vomiting is typically severe and occurs without nausea. Another clue would be the color of the vomitus, which if bright green-yellow in color contains bile and indicates an intestinal obstruction. On the other hand, if the vomiting occurred MICHAEL SLOAN 30 l Nursing2008Critical Care l Volume 3, Number 3

2 nal pain A systematic approach to adult assessment May l Nursing2008Critical Care l 31

3 Acute abdominal pain prior or concurrent to the pain, a surgical abdomen is unlikely. 7 The nurse is often the first person the patient with abdominal pain encounters: therefore, it is critical that the nurse be able to obtain a thorough history and perform a comprehensive physical assessment. The history alone can provide up to 70% of the clues needed to make an accurate diagnosis. 7 The nurse must be vigilant in an effort to obtain an accurate history of the events prior to onset of the abdominal pain. The nurse must also be able to get a precise description of the pain the patient is experiencing. Patient history A chronological sequence of events is crucial. The nurse should find out as much as possible about the onset of pain, including a description of what the patient was doing when the pain began. This information can key the nurse into some possible etiologies of the pain. Did the pain begin after ingestion of food? Discomfort beginning 2 hours after ingestion of food might indicate a gastric ulcer; pain 30 to 90 minutes after eating could be related to biliary colic. 8 Have the patient describe the pain. Questions should be asked regarding the characteristics of the pain, including timing, location, intensity, quality, and precipitating or relieving factors. Determine if the pain is localized or diffuse, and if it radiates. Ask whether the patient has experienced similar episodes before. Ask about nausea and vomiting in relation to the pain. Ascertain whether there has been a change in bowel habits, including episodes of diarrhea or constipation. Has the Differential diagnosis of acute abdominal pain Common causes Appendicitis Cholecystitis Pancreatitis Intussusception Abdominal aortic aneurysm (AAA) Alcoholic hepatitis Crohn s disease Colitis Diverticulitis Bowel ischemia Ectopic pregnancy Pelvic inflammatory disease Gastric and duodenal ulcers Renal colic Gastroenteritis Malignancy Small bowel obstruction Hepatic abscess Splenic infarction Mesenteric ischemia Constipation Peptic ulcer disease Aortic dissection Adhesions Incarcerated hernia Embolism, thrombus Sickle cell crisis Strangulated bowel Renal infection Pneumonia Biliary colic patient had episodes of blood or mucus in the stool? Has the patient had any recent unexplained weight loss? Also determine if the patient is experiencing any associated signs or symptoms, such as fever, chills, heartburn, excessive gas, or belching. 9 Understanding the anatomy and positioning of the abdominal organs is essential for the nurse caring for patients with abdominal pain. (See Location of abdominal organs for a list of the organs and their location within the abdomen.) Incorporating this Less common causes Diabetic ketoacidosis Hyperthyroidism Malaria Familial Mediterranean fever Hypercalcemia Herpes zoster Myocardial infarction Osteomyelitis Ovarian cysts Ovarian torsion Tuberculosis Hepatic adenoma Adverse drug effects Vasculitis Urinary tract infection Pulmonary embolism Congestive heart failure Black widow spider bite Hyperkalemia knowledge, the nurse asks the patient to try and localize the area of pain as precisely as possible. Encourage the patient to point to the exact area of discomfort. If the patient can localize the pain into one of the four abdominal quadrants it can give the nurse a clue to potential etiologies of the patient s pain. (See Types of visceral pain.) Combining the history and characteristics of the pain together with the location of the pain can help to narrow the possible differential diagnoses to be con- 32 l Nursing2008Critical Care l Volume 3, Number 3

4 sidered. However, not all presentations are classic and if this combined information leads to certain differentials, one should not rule anything out until absolute diagnosis is confirmed by his or her healthcare provider. Other organs such as the kidneys are situated behind the intraperitoneal organs and will paint a different picture. Pain affecting these structures may manifest in the flanks or lower back. Organs such as the reproductive organs and bladder are positioned in the lower abdomen within the pelvis. The pain associated with the reproductive organs may be described as lower abdominal tenderness. The intensity of the pain is not necessarily an indication of the severity of the Location of abdominal organs Right upper quadrant Right lobe of the liver Gallbladder Head of the pancreas Duodenum Sections of the ascending and transverse colon Right lower quadrant Caecum Appendix Sections of the ascending colon condition. 4 Conditions involving these organs should be included in the diagnostic differential of patients with abdominal pain. If the patient is a female of Left upper quadrant Left lobe of the liver Stomach Spleen Body of the pancreas Sections of the descending and transverse colon Left lower quadrant Sigmoid colon Sections of the descending colon childbearing age, the nurse must establish what form of birth control is being practiced along with whether the pain is associated with menses. Ask if she is sexualwww.nursing2008criticalcare.com May l Nursing2008Critical Care l 33

5 Acute abdominal pain Types of visceral pain Right upper quadrant or epigastric pain from the biliary tree and liver Epigastric pain from the stomach, duodenum, or pancreas Periumbilical pain from the small intestine, appendix, or proximal colon Suprapubic or sacral pain from the rectum Hypogastric pain from the colon, bladder, or uterus. Colonic pain may be more diffuse than illustrated. Source: Bickley L. Bates Guide to Physical Examination and History Taking. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007:364. ly active and if there is any history of sexually transmitted diseases. Determine if there is vaginal discharge or bleeding. Finally take a pregnancy history. Misdiagnosis of women of childbearing age can lead to significant morbidity and mortality. A report by The American College of Emergency Physicians revealed that one third of women of childbearing age with appendicitis are misdiagnosed with pelvic inflammatory disease. 4 Due to the complications of misdiagnosis of abdominal pain, it is essential for the nurses and physicians to be aware of which evaluation strategies are helpful and which are not. Next, gather information regarding medication history. Have the patient name every prescription drug and over-thecounter product being taken, including herbal remedies and dietary supplements. Also ask about illicit drug use, as well as alcohol. Find out if the patient has any drug allergies. Is the patient taking medications that are associated with gastric irritation and bleeding, such as prednisone or warfarin? Include in your history questions regarding employment; does the patient work around toxic substances? Is there a high degree of stress associated with their employment? After the thorough history has been obtained, proceed with a more detailed review of systems. This information should include previous gastrointestinal (GI) problems, jaundice or liver disease, any past abdominal surgeries, and trauma. Has the patient ever had gallstones, kidney stones, or diverticular disease? Does the client have a cardiac history? Obtain information regarding any and all past medical problems the patient has experienced. Gather information regarding pertinent family history, including presence of colorectal cancer, inflammatory bowel disease, polyposis, and hepatitis. Question the patient regarding potentially inheritable diseases such as sickle cell anemia or cystic fibrosis. The older adult Obtaining a history from older adults can pose a problem for the nurse. Physiologic changes that 34 l Nursing2008Critical Care l Volume 3, Number 3

6 occur with aging can make taking a detailed history difficult. They may have difficulty hearing or may have altered mentation related to disease process. They may take multiple medications that compound the problem. Older adults experience altered pain perception from chronic pain medications and comorbid disease processes, such as neuropathy. Therefore, they may have difficulty describing and locating the pain. They may also describe pain as minimal in the presence of an acute emergency. 10,11 Older adults consume more resources than other ED patients who present with abdominal pain. Their length of stay is longer, and they require admission nearly half of the time and surgical intervention one-third of the time. 10 Overall mortality rates vary from 2% to 13%, with those requiring emergency surgery exhibiting a mortality rate from 15% to 30%. 11 As the population continues to age there will likely be an increase in the number of older adults who are evaluated with the complaint of abdominal pain and it is the job of the nurse to obtain an accurate history from these patients. In order to obtain this history, the nurse may also need to incorporate family members into the history taking phase. No matter what age, an accurate history is a critical component of the diagnostic process. Physical examination Obtaining and evaluating vital signs is usually the first step of an assessment. Is the patient febrile or hypothermic? Patients with temperatures between 95 and 96 F may be at the onset of intraperitoneal hemorrhage, perforated gastric ulcer, pancreatitis, or intestinal strangulation. High fever on the other hand may represent problems in the kidney or thorax. 8 High fever may also suggest the presence of a bacterial infection or an inflammatory process such as appendicitis. Tachycardia may indicate pain, infection, hypovolemic shock, or septic shock. Any patient who exhibits fever, tachycardia, and abdominal pain should be considered an emergency and in need May l Nursing2008Critical Care l 35

7 Acute abdominal pain of urgent medical care. Is the patient hypotensive? Any adult patient with abdominal pain and a systolic blood pressure of 100 mm Hg or less should also be considered emergent until proven otherwise. 7 Vital sign measurements can serve as indicators to the urgency of medical or surgical evaluation. Be sure to observe the patient s facial expressions and body language during the examination. Patients with peritonitis will lie still because of the increase in pain upon movement. Patients with biliary or renal colic or small bowel obstruction may toss and turn, unable to find a comfortable position. They will grimace with the pain. The pain will gradually decrease, then for 3 to 6 minutes they will appear comfortable before experiencing another wave of discomfort. 8 Be sure to key into these clues. Physical assessment should not be limited to the abdomen, but should include a thorough examination of the client. Overall appearance can be important in determining volume status. Conjunctival pallor could indicate hemorrhage. A thorough exam of the cardiopulmonary system is also crucial. This exam could reveal signs of pneumonia, heart failure, pericarditis, or pulmonary embolism. A patient experiencing atrial fibrillation is more at risk for mesenteric ischemia. Careful examination of the client from head to toe should be done using a systematic approach. Assessment of the abdomen can yield important information and should be meticulously performed. Remember that with an abdominal assessment, inspection and auscultation should precede percussion and palpation. Position the client supine, with arms at his sides and knees flexed. This position will help to relax the abdomen. Inspect the abdomen noting any masses, distension, scars, asymmetry, ecchymosis, or local bulges that may be present. Observe for pulsations (possible sign of abdominal aortic aneurysm) and peristaltic movement (could indicate intestinal obstruction). 5 Auscultation can also provide clues to diagnosis. Determine whether bowel sounds are present, and then determine their frequency and character. Increased bowel sounds may be a sign of early intestinal obstruction. High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. Borborygmi, or the long, prolonged gurgles of hyperperistalsis, may also be an early sign of bowel obstruction. Listen for bowel sounds for 1 to 3 minutes in each of the four abdominal quadrants before determining that bowel sounds are absent. Hypoactive bowel sounds may be missed if auscultation is done for shorter periods Signs and indications from physical assessment of the abdomen Signs Murphy s sign: Examiner exerts downward pressure in right upper quadrant just under rib cage while asking patient to take a deep breath Obturator sign: Examiner flexes patient s right thigh at the hip, and with the knee bent, internally rotates the hip by moving flexed leg inward, stretching the internal obturator muscle Psoas sign: Examiner exerts pressure on the patient s right thigh and asks the patient to raise that thigh against the pressure Indications A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy s sign of acute cholecystitis Right hypogastric pain constitutes a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix Increased abdominal pain constitutes a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix Rebound tenderness: Examiner presses down slowly Pain induced or increased by quick withdrawal constitutes and firmly with fingers and then withdraws them rebound tenderness caused by rapid movement of an quickly inflamed peritoneum Source: Bickley L. Bates Guide to Physical Examination and History Taking. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007: l Nursing2008Critical Care l Volume 3, Number 3

8 of time. Hypoactive or absent bowel sounds may indicate peritonitis, paralytic ileus, mesenteric thrombosis, bowel ischemia, or hypokalemia. If an abdominal bruit is heard, do not proceed with percussion and palpation as this sound may indicate an abdominal aneurysm. This finding should be reported immediately. If a friction rub is heard over the upper abdominal quadrants, a hepatic tumor, splenic infarct, or inflammation of the peritoneum may be present. 5 Percussion can reveal peritoneal irritation and the presence of free air or fluid. Tympany is normally heard over most of the abdomen because of gas in the GI tract. Any large areas of dullness may indicate an abdominal mass or an enlarged organ. Sharp pain observed during percussion may indicate underlying inflammation. Palpation is the last step in the examination of the abdomen. Initial palpation should be light. Avoid rapid sharp movements. Palpation can elicit diagnostic signs such as Murphy s, McBurney s, psoas, and obturator. (See Signs and indications from physical assessment of the abdomen.) During palpation determine the area of greatest tenderness. Watch for guarding and rebound tenderness while palpating the abdomen. If the patient tolerates light palpation proceed cautiously with deeper palpation. Lastly, if there is any stool present, check it for occult blood. You may also need to send a specimen to the lab for further diagnostic testing. It is important to remember that the absence of physical findings does not indicate the absence of an acute emergency. Diagnostic studies The next step is to review diagnostic studies. There are multiple studies that can be performed on the patient with abdominal pain. Studies will vary depending on the suspected etiology of the pain and also on facility availability. (See Diagnostic studies used to evaluate abdominal pain for some of the more common laboratory tests along with the imaging studies of choice.) As mentioned, diagnostic testing will depend on the facility s available resources. Ultrasound is a noninvasive, rapid, and relatively inexpensive study that most facilities have the capability of performing. It does have its limitations especially in patients who are obese and patients with excess gas formation. 12,13 Ultrasound is also operator dependent. Ultrasound does have its place in diagnosing the acute abdomen and should be considered prior to invasive procedures. Computed tomography (CT) has become more widespread as the cost associated with the test has become less expensive. It is now being utilized in a more timely manner in the diagnostic process. Its diagnostic advantages are well established in a wide range of acute abdominal problems. This widespread use has resulted in a decreased need for exploratory laparotomy. 12 Another useful diagnostic evaluation tool is the 12-lead electrocardiogram. It will be useful in determining whether the abdominal pain is cardiac in nature. An electrocardiogram is recommended for all adult patients over the age of 40 who are complaining of upper epigastric abdominal pain and on those younger than age 40 who are at increased risk of heart disease. 8 Determining the best diagnostic tool for a client can be one of the toughest decisions healthcare staff has to make. There are many diagnostic pitfalls to avoid; therefore, it is important that the healthcare team take a step-bystep approach in choosing the best diagnostic test. Once all information has been gathered, it is the responsibility of the nurse to ensure that the healthcare provider has been made aware of the results of the diagnostic tests. Nursing care Regardless of the presenting signs and symptoms, patients should have their psychological and physical needs addressed. Providing privacy and maintaining patient dignity should be a top priority for the critical care nurse. 8 It is important that the patient receives nothing by mouth until after surgical pathology has been ruled out. It is recommended that all patients with abdominal pain have a large bore intravenous catheter in place, in case of the need for rapid fluid resuscitation. For any patient exhibiting respiratory difficulties, oxygen therapy should be utilized to maintain adequate oxygen saturation. The nurse may be required to place an indwelling urinary catheter in order to adequately monitor output. Any vomitus or diarrhea should be recorded as output. If ordered the nurse will need to insert a nasogastric tube. Patients with abdominal pain may benefit from nonpharmacologic methods of pain control such as warm compresses. Some healthcare providers are still under the May l Nursing2008Critical Care l 37

9 Acute abdominal pain impression that administration of analgesics will potentially lead to the mismanagement of abdominal pain. Recent studies indicate that administration of opioids does not mask peritoneal signs and often makes examination easier by decreasing pain and anxiety. 1,8 In addition, the use of opioids leads to virtually no increase in incorrect management decisions. It is therefore the nurse s duty to assist in relieving the patient s abdominal pain by either administering the appropriate Diagnostic studies used to evaluate abdominal pain Test Usefulness Disadvantages/Considerations Complete blood cell Elevated white blood cell count may indicate May be normal especially count with differential infection or inflammation, detects anemia, in older adults 3 blood dyscrasias Serum chemistries: Detects hepatic dysfunction, biliary tract disease, Cholecystitis may be present comprehensive or basic diabetes, renal dysfunction, anion gap can despite the presence of normal metabolic profile with indicate a serious intra-abdominal process liver function tests liver function tests Serum lipase and Detects pancreatitis, intestinal or biliary Lipase may be the better indicator amylase obstruction, intra-abdominal abscess Urinalysis Aids in determining urinary tract infection In female patients, a catheterized (UTI); hematuria can indicate ruptured specimen has a higher specificity abdominal aortic aneurysm (AAA) for UTI Blood cultures Indicates infection/sepsis Useful in older adults with hypothermia and sepsis Arterial blood gases Indicated for patients with suspected bowel May be a rapid method of obtainischemia, sepsis, or diabetic ketoacidosis ing a hematocrit Pregnancy test Type and crossmatch Indicates pregnancy Replacement of lost blood Plain radiography Limited to evaluation for free intraperitoneal Limited use in younger patient; air, signs of obstruction, foreign body overall low sensitivity Ultrasound Diagnosing AAA, biliary tract disease, or Cannot determine leaking AAA, ectopic pregnancy limited in obese clients, operator dependence Chest radiography Detects pneumonia, shows free intraperitoneal air Computed tomography Highly sensitive in diagnosing perforation, AAA, Avoid barium in patients with (CT) appendicitis, diverticulitis, mesenteric venous suspected gastrointestinal tract thrombosis perforation Angiography Gold standard for diagnosing mesenteric May be difficult to obtain on an ischemia emergency basis; contrast media is potentially nephrotoxic Source: Bickley L. Bates Guide to Physical Examination and History Taking. Philadelphia, Pa: Lippincott Williams & Wilkins; 2007: l Nursing2008Critical Care l Volume 3, Number 3

10 analgesic or providing some form of nonpharmacologic pain management. Reassess the patient frequently for any changes and notify the healthcare provider of changes in a timely manner. Remember that the patient with acute abdominal pain may be apprehensive and fearful about what is happening to them. Sometimes the best nursing practice is to listen and let the patient verbalize their fears and concerns and to reassure and comfort them as needed. Critical care nurses are in the forefront of patient care and physicians rely on their sound nursing judgments to assist them in determining the appropriate choice of treatment options. The critical care nurse must maintain the skills necessary to obtain an accurate history and perform a comprehensive physical exam on patients with abdominal pain in order to assure improved patient outcomes. REFERENCES 1. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14): Khan NU, Razzak JA. Abdominal pain with rigidity secondary to the anti-emetic drug metoclopramide. J Emerg Med. 2006; 30(4): Esses D, Bormbai A, Bijur P, et al. Ability of CT to alter decision making in elderly patients with acute abdominal pain. Am J Emerg Med. 2004;22(4): Dahlberg D, Lee C, Fenion T, Willoughby D. Differential diagnosis of abdominal pain in women of childbearing age: appendicitis or pelvic inflammatory disease? Adv Nurse Pract. 2004;12(1): Dagiely S. An algorithm for triaging commonly missed causes of acute abdominal pain. J Emerg Nurs. 2006;32(1): Movius M. What s causing that gut pain? RN. 2006;69(7): Miller SK, Alpert PT. Assessment and differential diagnosis of abdominal pain. Nurse Pract. 2006;31(7): Cole E, Lynch A, Cugnoni H. Assessment of the patient with acute abdominal pain. Nursing Standard. 2006;20(39): Fishman EK, Friedman L, Johnson GL. Evaluation of the acute abdomen. Patient Care. 2000;34(14): Martinez JP, Mattu A. Abdominal pain in the elderly. Emerg Med Clin North Am. 2006;24(2): Lyon C, Clark DC. Diagnosis of acute abdominal pain in older patients. Am Fam Physician. 2006;74(9): Chambers A, Halligan S, Goh V, et al. Therapeutic impact of abdominopelvic computed tomography in patients with acute abdominal symptoms. Acta Radiol. 2004; 45(3): Laurell H, Hansson LE, Gunnarsson U. Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain. Scand J Gastroenterol. 2006;41(10): At Wichita State University, Wichita, Kansas, Terri Core is a member of the School of Nursing faculty, and Karen Hayes is an assistant professor with the School of Nursing, as well as a nurse practitioner at Ashley Clinic, Yates Center, Kan. May l Nursing2008Critical Care l 39