Acute abdomen: Shaking down the Acute abdominal pain can be difficult to diagnose, requiring astute assessment skills and knowledge of abdominal anatomy 2.3 ANCC to discover its cause. We show you how to quickly and accurately CONTACT HOURS 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 significant relationships with or financial 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 rapidly, indicating a life-threatening process, pain is often complex due to the many or- so fast and accurate assessment is essential. gans in the abdomen and the fact that pain In this article, I’ll describe how to assess a may be nonspecific. Acute abdomen is a patient with acute abdominal pain and inter- general diagnosis, typically referring to se- vene appropriately. vere abdominal pain that occurs suddenly over a short period (usually no longer than What a pain! 7 days) and often requires surgical interven- Acute abdominal pain is one of the top tion. Symptoms may be severe and progress 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 the ED. Reasons for acute abdominal pain Visceral pain can be divided into three Your patient’s fall into six broad categories: subtypes: age may give • inflammatory—may be a bacterial cause, • tension pain. This type of pain is caused you clues. For such as acute appendicitis, diverticulitis, or by organ distension, such as in bowel ob- example, acute pelvic inflammatory disease, or a chemical struction or constipation. Blood accumula- pancreatitis cause, such as perforation of a peptic ulcer tion from trauma and pus or fluid accumu- is usually seen in which gastric contents cause a peritoneal lation from infection may also cause tension in adults. infection or abscess pain. Tension pain that’s described as col- • mechanical—such as an ileus or icky may be caused by increased peristaltic obstruction contractile force, such as when the bowel • neoplastic—such as a tumor causing ob- tries to eliminate irritating substances. Pa- struction or impinging on nerves or vessels tients with tension pain may have trouble • vascular—such as a getting comfortable. superior mesenteric clot • inflammatory pain. This type of pain or atherosclerosis may arise from inflammation of either the • congenital—such visceral or parietal peritoneum, such as in as esophageal atresia acute appendicitis. It may be described as (the esophagus doesn’t deep and like a boring sensation. Initially, connect normally with if the visceral peritoneum is involved, the the stomach), hernia, or malrota- pain may be poorly localized; as the parietal tion of the bowel peritoneum becomes involved, the pain • traumatic—such as blunt trauma, liver may become localized. Most patients with laceration, or major organ damage sus- inflammatory abdominal pain want to lie tained in a motor vehicle accident. still. The four most common causes of acute • ischemic pain. This type of pain is the abdominal pain requiring surgery are acute most serious. Sudden in onset, ischemic appendicitis, acute cholecystitis, small pain is extremely intense, progressive in bowel obstruction, and gynecologic disor- severity, and not relieved by analgesics. ders (see Some causes of acute abdominal Like patients with inflammatory pain, pa- pain). However, over 30% of patients with tients with ischemic pain won’t want to acute abdomen have nonspecific abdomi- move or change positions. The most com- nal pain, or pain for which no cause or mon cause of ischemic abdominal pain is source can be identified. It’s also possible a strangulated bowel. that the patient is pain free or has minimal pain, which occurs more often in older Narrowing things down patients, children, and women in the third So where do you start when a patient has trimester of pregnancy. abdominal pain? Besides identifying the Presentation may be confusing and kind of pain the patient is experiencing, difficult for the patient to describe. For the pain’s location can provide clues to its instance, a hepatic abscess may radiate to cause. So it’s imperative that you know the the diaphragm and shoulder area, whereas anatomy and physiology of the abdominal appendicitis may present with pain in the area. The abdomen is divided into four ar- psoas muscle, and cholecystitis with pain in eas, or quadrants: the upper left quadrant, the low and mid back (see Common sites of the upper right quadrant, the lower left referred abdominal pain). The pain may be quadrant, and the lower right quadrant localized or more generalized and deeper (see Where does it hurt?). It can further be di- (visceral), sharp and constant or dull and vided into nine regions (see Understanding intermittent, or any combination of these. the abdominal regions). 44 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com Some causes of acute abdominal pain Cause Signs and symptoms Abdominal aortic • Usually asymptomatic, but may cause back and abdominal pain aneurysm • Pulsatile mass may be palpable Appendicitis • 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 Cholecystitis • Pain in the right upper quadrant (toward the epigastric area) that may radiate to the shoulder or back There are many • Nausea and vomiting may occur causes of acute • Biliary colic (pain that increases over 2 to 3 min and is sustained for abdomen; use 20 min or more) • Positive Murphy sign this chart to Constipation • Possible colicky to sharp pain that can mimic appendicitis help narrow • The patient may have diffuse tenderness on palpation, as well as them down. palpable stool Diverticulitis • 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 Ileus or bowel • Diffuse pain that comes in cramping waves lasting 5 to 15 min obstruction • 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 Pancreatitis • 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 Peptic ulcer disease • 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 Peritonitis • 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, it’s diffuse rather than localized • Guarding may be present • Possible signs and symptoms of shock www.NursingMadeIncrediblyEasy.com January/February 2010 Nursing made Incredibly Easy! 45 The patient’s age may also help narrow often provide clues to guide you to the cor- the diagnosis. For example, appendicitis is rect diagnosis; for example, a patient with a more common in the younger adolescent, history of diabetes may have bowel ischemia whereas an obstruction of the large intestine or renal dysfunction. A patient with alco- is more common in patients over age 40. holism may have pancreatitis, liver disease, Acute pancreatitis or a perforated ulcer is or poor renal functioning. more often seen in the adult patient. Ask the patient when the pain began, Cholecystitis may be seen in a younger where it’s located, and how he’d describe its patient, but is more commonly seen in quality and intensity. Ask if the pain is con- adults. Acute abdominal pain caused by stant or intermittent, if it wakes him at night, vascular reasons is more common in patients and if anything aggravates it or relieves it. over age 70. Remember to ask open-ended questions, Take a health history, gynecologic history such as “What makes the pain better?,” rather for a female patient, and family history of than “Does laying down make the pain bet- abdominal conditions, such as gastroe- ter?” Determine where the pain was when it sophageal reflux disease (GERD), gallblad- began because it may be different from where der disease, renal calculi, colon cancer, or it is now. Also, ask the patient what he was inflammatory bowel disease. Patients can doing when the pain began. For example, if Common sites of referred abdominal pain Perforated Pancreatitis duodenal ulcer Liver Heart Penetrating duodenal ulcer Renal Biliary colic colic Cholecystitis, pancreatitis, duodenal ulcer Appendicitis Cholecystitis Small Pancreatitis, Colon pain intestine pain renal colic Ureteral colic Rectal lesions 46 Nursing made Incredibly Easy! January/February 2010 www.NursingMadeIncrediblyEasy.com he indicates that the pain began after eating, Assess for jaundice, melena (black, tarry ask him what kind of food he ate. stool), hematochezia (maroon-colored Continue your assessment by determin- stool), hematemesis (vomiting blood), and ing the presence of nausea or vomiting, hematuria (blood in the urine). Look at the diarrhea or constipation, anorexia, recent patient’s hemodynamic status. Does he travel, or changes in medications (such as have a fever, rigors, hypotension, tachycar- taking nonsteroidal anti-inflammatory dia, or pallor? Has he had a change in men- drugs [NSAIDs], which may cause abdomi- tal status? Often the patient’s position can nal pain).