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Consuming. Because Pain Can Be Non- Specific and the Abdomen

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Consuming. Because Pain Can Be Non- Specific and the Abdomen cute bdomen: ABy Susan Simmons Holcomb, ARNP,BC, PhD DETERMINING THE CAUSE of ab- hypogastric, and left iliac regions. This the hospital for an appendectomy and dominal pain is often tricky and time- area is dull to percussion; when you recovers completely. consuming. Because pain can be non- palpate it, you note a firm mass. A specific and the abdomen has many complete blood cell (CBC) count Narrowing things down organs and structures, numerous poten- reveals severe anemia. A stat computed So where do you start when a patient tial causes have to be ruled out as clini- tomography (CT) scan of the abdomen has abdominal pain? Anatomically the cians try to pin down the source of pain. and pelvis reveals a benign, totally abdomen is divided into four quad- Reasons for abdominal pain fall into encapsulated left ovarian tumor. The rants and nine regions. You can use three broad categories: inflammation, tumor is removed, her anemia is these divisions to narrow down the organ distension, and ischemia. In resolved, and she’s doing well. area of complaint and document your some cases, the underlying cause is Patrick Leeson, 45, comes in com- findings (see Where does it hurt?). life-threatening, so a fast, accurate plaining of dull, achy periumbilical pain Remember, however, that abdominal assessment is essential. In this article, that migrated to his right lower quad- pain can be referred to many locations, I’ll describe how to assess a patient rant. He says it started about 24 hours including the shoulders, cardiac area with abdominal pain and intervene ago. He has no nausea or vomiting or (substernal and left chest), low and appropriately. Let’s start by looking at a changes in bowel habits. He says he was mid back, and groin. couple of hypothetical situations. treated for testicular cancer 10 years ago Besides pain location, the kind of Laurie Greene, 42, comes to your and it began with abdominal pain simi- pain provides clues to its cause. Type A ED complaining of intermittent lar to what he’s experiencing now. delta nerve fibers innervate cutaneous abdominal pain and bloating that she’s Mr. Leeson has an elevated white tissues and the parietal peritoneum; had for a month. She reports no blood cell count with a left shift, possi- stimulation from an irritant such as change in bowel habits and no other bly indicating a bacterial infection or pus, blood, bile, or urine often leads to significant medical history. inflammation. A CT scan of the localized pain. Type C fibers innervate When you examine Ms. Greene, you abdomen and pelvis shows an inflamed visceral tissue, so visceral pain is more find a protrusion in the umbilical, appendix. Mr. Leeson is admitted to generalized and deeper. 34 | Nursing2008 | September www.nursing2008.com 2.0 ANCC/AACN CONTACT HOURS So many things—some life-threatening—can cause abdominal pain. Here’s how to capture the clues quickly and accurately. What a pain! www.nursing2008.com September | Nursing2008 | 35 Visceral pain can be divided into from infection or other causes also can may have trouble getting comfortable three subtypes: cause this pain. Tension pain that’s and squirm a lot trying to find a com- • Tension pain is caused by organ dis- described as colicky may be caused by fortable position. tension, as from bowel obstruction or increased peristaltic contractile force as • Inflammatory pain may arise from constipation. Blood accumulation from the bowel tries to eliminate irritating inflammation of either the visceral or trauma and pus or fluid accumulation substances. Patients with tension pain parietal peritoneum, as in acute appen- dicitis. This pain may be Where does it hurt? described as deep and bor- ing. Initially, if the visceral You can use the four abdominal regions shown here and the nine abdominal regions peritoneum is involved, the shown below to help you determine what’s causing your patient’s abdominal pain. pain may be poorly local- ized; as the parietal peri- toneum becomes involved, the pain may become local- Right upper ized. Most patients with quadrant or inflammatory abdominal epigastric pain Epigastric pain pain want to lie still. Right upper Left upper from the biliary quadrant quadrant from the stomach, • Ischemic pain is the most tree and liver duodenum, serious type of visceral or pancreas pain—-and, fortunately, the Periumbilical pain least common because the from the small Right lower Left lower affected area will become Suprapubic or quadrant quadrant intestine, appendix, necrotic if blood flow isn’t or proximal colon sacral pain from promptly restored. Sudden the rectum Hypogastric pain in onset, this pain is from the colon, extremely intense, progres- bladder, or uterus. sive in severity, and not Colonic pain may be relieved by analgesics. Like more diffuse than patients with inflammatory illustrated. pain, patients with ischemic pain won’t want to move or change positions. The most common cause of ischemic abdominal pain is strangu- Right hypochondriac Epigastric Left hypochondriac lated bowel.1 Assessment pointers Now let’s look at how to Right lumbar Umbilical Left lumbar begin your assessment of a patient with abdominal pain. Take a health history, gyne- cologic history for women, Left iliac (or inguinal) Right iliac (or inguinal) Hypogastric and family history of abdominal conditions such as gastroesophageal reflux disease (GERD), gallbladder disease, renal calculi, colon 36 | Nursing2008 | September www.nursing2008.com cancer, or inflammatory bowel disease. sounds may indicate an ileus. Hyper- Ask the patient when the pain active bowel sounds may indicate early began, where it’s located, and how he’d intestinal obstruction. Arterial bruits describe its quality and intensity. Ask if with both systolic and diastolic compo- the pain is constant or intermittent, if nents are abnormal sounds made by it wakes him at night, and if anything If you blood traveling through narrowed aggravates or relieves it. If he says that suspect arteries such as the aorta or renal, iliac, food worsens or relieves abdominal or femoral arteries. pain, ask him what kind of food. an aortic • Percussion can help you identify the Assess and document whether he has aneurysm, borders of organs such as the liver, as associated signs and symptoms such as palpation may well as determine the presence of air or fever, nausea or vomiting, change in be contraindicated solid masses such as tumors. Normally bowel habits, weight loss, heartburn, you’ll hear tympany (a drumlike or rectal bleeding. or best left to sound) over the stomach and If he reports nausea and vomiting the physician. intestines, areas that normally are air and a change in bowel habits, ask if filled. You’ll hear dullness over solid he’s recently traveled, eaten food that (such as nonsteroidal anti-inflammatory areas such as the liver, spleen, tumors, was recalled, drunk water that might drugs) or has recently been diagnosed or other masses. have been contaminated, or gone with a condition that might be associ- • Palpation lets you assess local versus swimming in lakes or public pools. ated with abdominal symptoms, such generalized areas of tenderness, as well Ask about frequency of bowel move- as GERD. as check for masses and enlarged ments. If he reports diarrhea, ask if the In children, abdominal migraine can organs. Palpation can go from light to diarrhea is liquid, loose, or a combina- cause abdominal pain. Look for a pat- deep, but keep in mind that a patient tion and whether he’s noticed blood in tern of symptoms, especially if the with abdominal pain may not tolerate the stool. abdominal pain is associated with abdominal palpation at all. He may If he’s had a change in bowel habits vomiting and is cyclical. Ask about fre- guard (tighten his abdominal muscles), without diarrhea, ask about the color quency, duration, and associated symp- preventing you from assessing the and consistency of the stool, whether it toms such as vomiting. Also ask about abdomen adequately via palpation. If floats or sinks, and if it’s associated a personal or family history of this happens, flexing his knees may with mucus or change in odor. migraines.1 relax the abdomen so you can palpate Vomiting that precedes abdominal Your physical assessment should it. If he’s very ticklish, you can cir- pain, or is associated with the onset of include inspection, auscultation, per- cumvent the tickle response by plac- abdominal pain, may suggest infection cussion, and palpation. ing his hand below yours and palpat- as a possible cause of pain. Abdominal • Inspect the abdomen for movement, ing the area first with his hand, then pain that began before vomiting may such as fluid waves or increased peri- switching hands so you can palpate.4 indicate appendicitis or, more rarely, stalsis. Look for scars from past surg- If the presence of a bruit leads you to cholecystitis. Suspect cholecystitis in eries; the patient may have adhesions suspect that the patient has an aortic patients with right upper quadrant that could lead to bowel obstruction. aneurysm, palpation may be con- abdominal pain and a family history of Note the contour of the abdomen; gen- traindicated or best left to the physi- early gallbladder disease.2 Other risk eralized distension may indicate in- cian. factors for cholecystitis include being creased gas, but local bulges may indi- To assess for specific areas of tender- female, age 40 or older, and over- cate a distended bladder or a hernia. ness, use specific palpation techniques. weight. Associated signs and symp- • Auscultate for bowel sounds or addi- Murphy’s sign evaluates gallbladder ten- toms may include vomiting and fever.3 tional sounds such as bruits. Normal derness and inflammation.
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