Acute abdomen: Shaking down the

2.3
ANCC CONTACT HOURS

Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy to discover its cause. We show you how to quickly and accurately uncover the clues so your patient can get the help he needs.
By Amy Wisniewski, BSN, RN, CCM Lehigh Valley Home Care Allentown, Pa.
The author has disclosed that she has no signicant relationships with or nancial interest in any commercial companies that pertain to this educational activity.

NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 43

suspects
Determining the cause of acute abdominal pain is often complex due to the many organs in the abdomen and the fact that pain may be nonspecic. Acute abdomen is a general diagnosis, typically referring to severe abdominal pain that occurs suddenly over a short period (usually no longer than 7 days) and often requires surgical intervention. Symptoms may be severe and progress rapidly, indicating a life-threatening process, so fast and accurate assessment is essential. In this article, Ill describe how to assess a patient with acute abdominal pain and intervene appropriately.

What a pain!
Acute abdominal pain is one of the top three symptoms of patients presenting in

www.NursingMadeIncrediblyEasy.com

January/February 2010 Nursing made Incredibly Easy! 43

NIE0110_124_CEAbdomen.qxd:Deepak 26/11/09 9:38 AM Page 44

Your patients age may give you clues. For example, acute pancreatitis is usually seen in adults.

the ED. Reasons for acute abdominal pain fall into six broad categories: inammatorymay be a bacterial cause, such as acute appendicitis, diverticulitis, or pelvic inammatory disease, or a chemical cause, such as perforation of a peptic ulcer in which gastric contents cause a peritoneal infection or abscess mechanicalsuch as an ileus or obstruction neoplasticsuch as a tumor causing obstruction or impinging on nerves or vessels vascularsuch as a superior mesenteric clot or atherosclerosis congenitalsuch as esophageal atresia (the esophagus doesnt connect normally with the stomach), hernia, or malrotation of the bowel traumaticsuch as blunt trauma, liver laceration, or major organ damage sustained in a motor vehicle accident. The four most common causes of acute abdominal pain requiring surgery are acute appendicitis, acute cholecystitis, small bowel obstruction, and gynecologic disorders (see Some causes of acute abdominal pain). However, over 30% of patients with acute abdomen have nonspecic abdominal pain, or pain for which no cause or source can be identied. Its also possible that the patient is pain free or has minimal pain, which occurs more often in older patients, children, and women in the third trimester of pregnancy. Presentation may be confusing and difcult for the patient to describe. For instance, a hepatic abscess may radiate to the diaphragm and shoulder area, whereas appendicitis may present with pain in the psoas muscle, and cholecystitis with pain in the low and mid back (see Common sites of referred abdominal pain). The pain may be localized or more generalized and deeper (visceral), sharp and constant or dull and intermittent, or any combination of these.

Visceral pain can be divided into three subtypes: tension pain. This type of pain is caused by organ distension, such as in bowel obstruction or constipation. Blood accumulation from trauma and pus or uid accumulation from infection may also cause tension pain. Tension pain thats described as colicky may be caused by increased peristaltic contractile force, such as when the bowel tries to eliminate irritating substances. Patients with tension pain may have trouble getting comfortable. inammatory pain. This type of pain may arise from inammation of either the visceral or parietal peritoneum, such as in acute appendicitis. It may be described as deep and like a boring sensation. Initially, if the visceral peritoneum is involved, the pain may be poorly localized; as the parietal peritoneum becomes involved, the pain may become localized. Most patients with inammatory abdominal pain want to lie still. ischemic pain. This type of pain is the most serious. Sudden in onset, ischemic pain is extremely intense, progressive in severity, and not relieved by analgesics. Like patients with inammatory pain, patients with ischemic pain wont want to move or change positions. The most common cause of ischemic abdominal pain is a strangulated bowel.

Narrowing things down

So where do you start when a patient has abdominal pain? Besides identifying the kind of pain the patient is experiencing, the pains location can provide clues to its cause. So its imperative that you know the anatomy and physiology of the abdominal area. The abdomen is divided into four areas, or quadrants: the upper left quadrant, the upper right quadrant, the lower left quadrant, and the lower right quadrant (see Where does it hurt?). It can further be divided into nine regions (see Understanding the abdominal regions).
www.NursingMadeIncrediblyEasy.com

44 Nursing made Incredibly Easy! January/February 2010

Some causes of acute abdominal pain

Cause Abdominal aortic aneurysm Appendicitis Signs and symptoms Usually asymptomatic, but may cause back and abdominal pain Pulsatile mass may be palpable Abdominal pain over umbilicus, moving to the right lower quadrant Often associated with fever The clinical exam may show rebound tenderness and positive obturator, psoas, and Rovsing signs Complete blood cell count will show an increase in white blood cell count with a shift to the left and increased neutrophils Pain in the right upper quadrant (toward the epigastric area) that may radiate to the shoulder or back Nausea and vomiting may occur Biliary colic (pain that increases over 2 to 3 min and is sustained for 20 min or more) Positive Murphy sign Possible colicky to sharp pain that can mimic appendicitis The patient may have diffuse tenderness on palpation, as well as palpable stool Left lower quadrant pain, often worse after eating and improved after defecation Possible fever Possible diarrhea or constipation Abdomen may be distended and tympanic and tender to palpation over the left lower quadrant Diffuse pain that comes in cramping waves lasting 5 to 15 min Nausea, followed by vomiting when the bowel obstructs Stool may be passed distal to the obstruction and may also involve diarrhea Abdomen may be distended with high-pitched bowel sounds Diffuse tenderness and guarding Pain in the right upper quadrant to epigastric area, possibly radiating to the back; can be associated with nausea and vomiting, as well as fever Possible ileus In severe cases, shock, jaundice, and pleural effusion are present Rare signs include Grey Turner and Cullen signs Usually epigastric pain 1 to 3 h after meals and often associated with nighttime awakenings Sudden and severe pain with radiation to the right shoulder, along with peritoneal signs; may indicate perforation Hematemesis or melena suggests hemorrhage Acute diffuse abdominal pain that may be associated with fever, nausea, and vomiting Pain increases with any motion Abdominal distension and rigidity Rebound tenderness is present but, unlike in appendicitis, its diffuse rather than localized Guarding may be present Possible signs and symptoms of shock

Cholecystitis

Constipation

There are many causes of acute abdomen; use this chart to help narrow them down.

Diverticulitis

Ileus or bowel obstruction

Pancreatitis

Peptic ulcer disease

Peritonitis

www.NursingMadeIncrediblyEasy.com

January/February 2010 Nursing made Incredibly Easy! 45

The patients age may also help narrow the diagnosis. For example, appendicitis is more common in the younger adolescent, whereas an obstruction of the large intestine is more common in patients over age 40. Acute pancreatitis or a perforated ulcer is more often seen in the adult patient. Cholecystitis may be seen in a younger patient, but is more commonly seen in adults. Acute abdominal pain caused by vascular reasons is more common in patients over age 70. Take a health history, gynecologic history for a female patient, and family history of abdominal conditions, such as gastroesophageal reux disease (GERD), gallbladder disease, renal calculi, colon cancer, or inammatory bowel disease. Patients can

often provide clues to guide you to the correct diagnosis; for example, a patient with a history of diabetes may have bowel ischemia or renal dysfunction. A patient with alcoholism may have pancreatitis, liver disease, or poor renal functioning. Ask the patient when the pain began, where its located, and how hed describe its quality and intensity. Ask if the pain is constant or intermittent, if it wakes him at night, and if anything aggravates it or relieves it. Remember to ask open-ended questions, such as What makes the pain better?, rather than Does laying down make the pain better? Determine where the pain was when it began because it may be different from where it is now. Also, ask the patient what he was doing when the pain began. For example, if

Common sites of referred abdominal pain

Pancreatitis Liver Heart

Perforated duodenal ulcer Penetrating duodenal ulcer

Biliary colic Cholecystitis, pancreatitis, duodenal ulcer Appendicitis Colon pain

Renal colic

Cholecystitis Small intestine pain Ureteral colic Pancreatitis, renal colic Rectal lesions

46 Nursing made Incredibly Easy! January/February 2010

www.NursingMadeIncrediblyEasy.com

he indicates that the pain began after eating, ask him what kind of food he ate. Continue your assessment by determining the presence of nausea or vomiting, diarrhea or constipation, anorexia, recent travel, or changes in medications (such as taking nonsteroidal anti-inammatory drugs [NSAIDs], which may cause abdominal pain). Vomiting that precedes abdominal pain, or is associated with the onset of abdominal pain, may suggest infection as a possible cause of pain. Abdominal pain that began before vomiting may indicate appendicitis or, more rarely, cholecystitis. If he reports diarrhea, ask if the diarrhea is liquid, loose, or a combination and whether he has noticed blood in the stool. If he has had a change in bowel habits without diarrhea, ask about the color and consistency of the stool, whether it oats or sinks, and if its associated with mucus or change in odor. If he reports recent travel, he may have drank contaminated water or gone swimming in lakes or public pools.

Assess for jaundice, melena (black, tarry stool), hematochezia (maroon-colored stool), hematemesis (vomiting blood), and hematuria (blood in the urine). Look at the patients hemodynamic status. Does he have a fever, rigors, hypotension, tachycardia, or pallor? Has he had a change in mental status? Often the patients position can give clues as to the etiology of the pain: Writhing in pain is more representative of colicky pain, whereas knees pulled up and exed is more diagnostic of peritonitis. For signs and symptoms specic to common abdominal problems, see Some causes of acute abdominal pain.

Lets get physical

Next, conduct a physical assessment in this order: inspection, auscultation, percussion, and palpation (see Assessing the abdomen). Inspect the abdomen for movement, such as uid waves or increased peristalsis. Look for scars from past surgeries; the patient may have adhesions that could lead

Where does it hurt?

Right upper quadrant or epigastric pain from the biliary tree and liver

Right upper quadrant

Left upper quadrant

Epigastric pain from the stomach, duodenum, or pancreas Periumbilical pain from the small intestine, appendix, or proximal colon Hypogastric pain from the colon, bladder, or uterus. Colonic pain may be more diffuse than illustrated.

Right lower quadrant

Left lower quadrant

Suprapubic or sacral pain from the rectum

www.NursingMadeIncrediblyEasy.com

January/February 2010 Nursing made Incredibly Easy! 47

to bowel obstruction. Note the contour of the abdomen: Generalized distension may indicate increased gas, but local bulges may indicate a distended bladder or a hernia. Auscultate the abdomen for bowel sounds or additional sounds such as bruits. Normal bowel sounds consist of peristaltic clicks and gurgles occurring at a rate of 5 to 34 per minute. Hypoactive bowel sounds may indicate an ileus. Hyperactive bowel sounds may indicate early intestinal obstruction. Arterial bruits with both systolic and diastolic components are abnormal sounds

made by blood traveling through narrowed arteries such as the aorta or renal, iliac, or femoral arteries. Percuss to identify the borders of organs and to determine the presence of air or solid masses such as tumors. Normally youll hear tympany (a drumlike sound) over the stomach and intestinesareas that are normally lled with air. Youll hear dullness over solid areas such as the liver, spleen, tumors, or other masses. If you think the patients abdominal pain may be related to pyelonephritis or renal calculi, assess for costovertebral angle tenderness. Place the

Understanding the abdominal regions

Right and left hypochondriac
Contain the diaphragm, portions of the kidneys, the right side of the liver, the spleen, and part of the pancreas

Epigastric
Contains most of the pancreas and portions of the stomach, liver, inferior vena cava, abdominal aorta, and duodenum

Right and left lumbar (lateral)

Right hypochondriac region Epigastric region Left hypochondriac region Include portions of the small and large intestines and portions of the kidneys

Umbilical
Includes sections of the small and large intestines, inferior vena cava, and abdominal aorta Right lumbar (lateral) region Umbilical region Left lumbar (lateral) region

Right and left iliac (inguinal)

Include portions of the small and large intestines

Right iliac (inguinal) region

Hypogastric region

Left iliac (inguinal) region

Hypogastric (pubic)
Contains a portion of the sigmoid colon, urinary bladder and ureters, and portions of the small intestine

48 Nursing made Incredibly Easy! January/February 2010

www.NursingMadeIncrediblyEasy.com

palm of one hand in the right costovertebral angle and strike it with the ulnar surface of your st. Repeat in the left costovertebral angle. Pain with percussion suggests pyelonephritis. Palpate to assess local versus generalized areas of tenderness, as well as to check for masses and enlarged organs. Palpation can go from light to deep, but keep in mind that a patient with abdominal pain may not tolerate abdominal palpation at all. He may tighten his abdominal muscles, preventing you from assessing the abdomen adequately via palpation. If this happens, exing his knees may relax the abdomen so you can palpate it. If the presence of a bruit leads you to suspect that the patient has an aortic aneurysm, palpation may be contraindicated or best left to the healthcare provider. To assess for specic areas of tenderness, use specic palpation techniques. Murphy sign evaluates gallbladder tenderness and inammation. Hook your ngers under the patients right lower ribs or press them under his ribs, then ask him to take a deep breath. A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign, indicating acute cholecystitis. If you suspect that your patient has appendicitis, check for Rovsing sign and for referred rebound tenderness. Press deeply and evenly in the patients left lower quadrant, then quickly withdraw your ngers. Pain in the right lower quadrant during leftsided pressure (a positive Rovsing sign) suggests appendicitis, as does right lower quadrant pain on quick withdrawal (referred rebound tenderness). Other techniques to assess for appendicitis include looking for a psoas or obturator sign. Place your hand just above the patients right knee and ask him to raise his thigh against your resistance. Alternatively, ask him to turn onto his left side and then extend his right leg at the hip. Flexing the leg at the hip makes the psoas muscle contract; extension stretches it. Increased
www.NursingMadeIncrediblyEasy.com

abdominal pain on either maneuver (a positive psoas sign) suggests that the psoas muscle is irritated by an inamed appendix. To elicit the obturator sign, ask the patient to bend his right knee, then ex his right thigh at the hip and rotate the leg internally at the hip to stretch the internal obturator muscle. Right hypogastric pain (a positive obturator sign) suggests irritation of the obturator muscle by an inamed appendix.

A positive Murphy sign means trouble for me!

Diagnostic tools of the trade

After a complete history and physical are obtained, imaging studies may not be necessary for all acute abdomen patients. If diagnostic testing is indicated, a computed tomography (CT) scan, an abdominal/pelvic ultrasound, or an abdominal X-ray may be ordered. A CT scan is the most frequently used tool for diagnosing acute abdominal pain because its more specic, sensitive, and accurate than an Xray. For acute abdomen, the CT scan may include an I.V. or oral contrast medium and possibly a rectal contrast medium. However, some patients will be unable to tolerate oral contrast, such as a patient whos vomiting, unable to swallow, or is suspected of having a bowel obstruction. With any kind of contrast medium, it must be determined if the patient has adequate renal functioning to clear it and that he isnt allergic to it. Ultrasound is often used to evaluate the kidneys, liver, gallbladder, pancreas, spleen, and abdominal aorta or other blood vessels. It can help identify renal stones, gallstones, appendicitis, and gynecologic problems. Because images are in real time, they can show movement of an organ and blood ow. Its fast, safe, and doesnt always require any preliminary preparation or N.P.O. status. Although ultrasound may not be the only test needed, it can help narrow the differential diagnoses and assist in determining the next step.
January/February 2010 Nursing made Incredibly Easy! 49

If I have a problem, your patient will probably need surgery.

The abdominal X-ray is also of use. It may reveal uid levels indicating bowel obstruction, ileus, and stool and gas patterns. It can also be used to identify problems with the urinary system such as kidney stones, ascites, abdominal masses, foreign objects, and injury to the abdominal tissues. In addition to imaging studies, lab studies that may help narrow the cause of acute abdominal pain include: complete blood cell count for signs of infection, cancer, and inammation complete metabolic prole for blood glucose levels, renal or hepatic dysfunction, electrolyte imbalances, or problems related to low albumin level stool sample to look for infection or parasites urinalysis to look for infection or evidence of renal calculi amylase and lipase levels, which will be elevated in a patient with pancreatic problems Helicobacter pylori level to check for peptic ulcer disease pregnancy test and microscopic examination of vaginal secretions in women to rule out ectopic pregnancy and infections such as bacterial vaginosis or vulvovaginal candidiasis sexually transmitted disease testing in sexually active men and women.

ovarian cyst, and aortic aneurysm. Antibiotics will be prescribed if the cause of pain is an infection such as pyelonephritis or a lower urinary tract infection. If the infection is due to an abscess, surgical drainage may also be performed. Abdominal pain due to viral gastroenteritis will be treated with uids, bowel rest, and antiemetics if the patient is over age 12. Treatment is, of course, based on the diagnosis. Surgery isnt always necessary.

Interventions galore
Triaging patients quickly and accurately is crucial because some causes of abdominal pain are life-threatening. Other nursing interventions include ongoing assessments, managing the patients pain, restoring uid and electrolyte balance, specic interventions to treat the pains underlying cause, and providing emotional support. Immediately report to the healthcare provider any symptoms that indicate shock or instability. If the acute abdomen symptoms occur while the patient is hospitalized for another illness, reviewing all previous care may shed light on the etiology of the pain. Assess previous lab results, changes in medications, dye administration during testing, and treatment outcomes. Manage your patients pain with medications as ordered and nonpharmacologic interventions, including positioning, back rubs, and heating pads (if not contraindicated). It was previously thought that providing pain medication to a patient with acute abdomen would mask the pain and make it more difcult to diagnose; however, this is an unfounded belief. Pain management will depend on the severity of the pain. If opioid management is needed, morphine is the drug of choice. If the patient is allergic to morphine, meperidine or ketorolac may be ordered instead. To protect your patient against complications, such as cardiac dysrhythmias and seizures, you must maintain his uid and electrolyte balance. Patients with diarrhea,
www.NursingMadeIncrediblyEasy.com

Did someone say surgery?

One of the primary goals when diagnosing a patient with acute abdomen is to determine if surgery is necessary and the timing of surgery. A patient presenting as toxic and unstable may need time in the CCU before surgery is performed. However, the patient may also need immediate surgery if the risk of waiting could be life-threatening. The balance of risk versus benet must be weighed in treating the critically ill patient with acute abdominal pain. Generally, surgery is indicated for bowel obstruction, acute appendicitis, a ruptured
50 Nursing made Incredibly Easy! January/February 2010

vomiting, or fever are the most prone to such imbalances. Make sure electrolyte levels are evaluated before electrolyte replacement begins and periodically reassessed during replacement. Maintain accurate intake and output records. If your patients abdominal pain was caused by GERD, hiatal hernia, peptic ulcer disease, or diverticulitis, teach him about foods to avoid and how to time meals in relation to activities and bedtime. He should avoid overeating in general and stay away from fats, fried foods, spices, coffee, tea, tomato products, and alcohol. Tell him not to

eat within 2 to 3 hours of bedtime and not to lie down or exercise immediately after eating. Advise him to try to maintain a normal weight and to lose weight if hes overweight or obese because the risk of GERD and gallbladder disease increases with weight. He should reduce stress, quit smoking, decrease or eliminate alcohol consumption, and reduce his use of medications that can damage the esophagus, such as corticosteroids and NSAIDs (including aspirin). Provide emotional support for the patient and his family. Let them know the plan for diagnosing the pain and the results of any

Assessing the abdomen

Inspecting the abdomen

Auscultating the abdomen

Percussing the abdomen

Palpating the abdomen

www.NursingMadeIncrediblyEasy.com

January/February 2010 Nursing made Incredibly Easy! 51

The more CE, the merrier!

diagnostic testing. Provide instruction on pain management and positions of comfort. Instruct the patient on the use of the pain medication, how often he can receive it, and to report ineffectiveness or a reaction such as itching. After a diagnosis is made, provide the patient with information on treatment options and how his hospital stay may proceed. If surgery is indicated, discuss with the patient and his family what will happen and when he can anticipate going to the OR. Allow family members to visit before surgery and keep them updated.

standing the different types of abdominal pain can help you uncover clues to the cause of your patients pain so he can receive the most timely treatment possible.

Learn more about it

Anatomy & Physiology Made Incredibly Visual! Philadelphia, PA: Lippincott Williams & Wilkins; 2009:5. Holcomb SS. Acute abdomen: What a pain! Nursing2009 Crit Care. 2009;4(4):34-40. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA. 2006;296(14):1764-1774. Scott-Conner C, Perry R. Acute abdomen and pregnancy. http://emedicine.medscape.com/article/195976-overview. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarths Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2008: 1126,1128. Zeller JL, Burke AE, Glass RM. Acute abdominal pain. JAMA. 2006;294(14):1800.

Follow the clues

Although acute abdominal pain can be difcult to diagnose, knowing the anatomy and physiology of the abdomen and under-

For more than 28 additional continuing education articles related to gastrointestinal topics, go to Nursingcenter.com/CE.

Earn CE credit online:

Go to http://www.nursingcenter.com/CE/nmie and receive a certicate within minutes.
INSTRUCTIONS

Acute abdomen: Shaking down the suspects

TEST INSTRUCTIONS To take the test online, go to our secure Web site at http://www.nursingcenter.com/ CE/nmie. On the print form, record your answers in the test answer section of the CE enrollment form on page 54. Each question has only one correct answer. You may make copies of these forms. Complete the registration information and course evaluation. Mail the completed form and registration fee of $21.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certicate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certicate within 2 business days of receiving your enrollment form. You will receive your CE certicate of earned contact hours and an answer key to review your results.There is no minimum passing grade. Registration deadline is February 28, 2012. DISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities on nursingcenter. com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of Nursing made Incredibly Easy!, will award 2.3 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.3 contact hours. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the District of Columbia and Florida #FBN2454. LWW home study activities are classied for Texas nursing continuing education requirements as Type I. Your certicate is valid in all states. The ANCCs accreditation status of Lippincott Williams & Wilkins Department of Continuing Education refers only to its continuing nursing educational activities and does not imply Commission on Accreditation approval or endorsement of any commercial product.

52 Nursing made Incredibly Easy! January/February 2010

www.NursingMadeIncrediblyEasy.com