Cover these areas at triage for abdominal pain
Here is what your triage assessment should include when a child comes to your ED with abdominal pain, says Carolyn Kesler, RN, BSN, ED nurse at Primary Children's Medical Center in Salt Lake City:
- Obtain a brief history of the current chief complaint.
- Obtain the patient's date of birth.
- Determine whether immunizations are up to date.
- Ask if the child has been exposed to any infectious diseases.
- Ask if the child has any allergies to medications.
- Ask what medications the child is taking. "Remember to use common names such as Tylenol and ibuprofen," says Kesler. "Parents/caregivers often do not think of these when asked for a list of current medications."
- Obtain a past medical history including surgeries, hospitalizations, whether the child was born prematurely, and whether the child has ever been intubated.
- Obtain the name of the child's current medical provider.
- Obtain weight in kilograms.
- Obtain vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oximeter saturation. "Blood pressure is vital for a child who is a cardiovascular patient, endocrine, or with a history of emesis or diarrhea," says Kesler.
Hypotension in the pediatric patient is a late finding of shock and an ominous sign, says Kesler. "Be sure
to look at the patient's pulse pressure; is it narrow or widened? A widened pulse pressure can be an indication of sepsis," she says. In a young pediatric patient with signs of shock, perform a manual blood pressure reading as this type is more reliable, she advises.
- Perform a brief assessment including respiratory, cardiovascular, neurological, skin, musculoskeletal, and capillary refill time. "Visualize every patient immediately," urges Kesler. "The pediatric population is often in a car seat, stroller, or carried and may be covered with a blanket."
By briefly visualizing the patient, it is easy to determine the cyanotic or "shocky" looking patient, says Kesler. "These patients go immediately back to an exam room. Many respiratory patients can be given oxygen in triage via nasal cannula or a non-rebreather mask until an exam room is ready."
Life-threatening signs include fever with abdominal distention, petechial rash, and blood pressure changes, says Kesler. Patients with intussusceptions may have bloody stool, "currant jelly" stool, pulling legs up with crying, emesis of bile/stool, or grunting, she adds. "Patients with appendicitis may exhibit rebound pain, walking slowly or slightly bent over, and unable to hop when requested," says Kesler.
Infants/children with the following signs could have life-threatening abdominal pain and should be triaged with a high priority, says Zelda Piskosz, RN, BSN, pediatric ED nurse at Memorial Hospital West in Pembroke Pines, FL:
— newborns with projectile vomiting;
— a history of crying with quiet intervals, especially with "currant jelly" stool;
— any history of blunt trauma to the abdomen;
— signs of guarding and rebound tenderness.
Ask parents of infants and preschool children these questions, says Piskosz:
- What is the past history, and when did the pain start? "This will help to determine if the pain is acute or chronic," says Piskosz.
- What is the color and consistency of stools or emesis?
- Is the vomiting projectile?
- Is the crying constant or are there quiet intervals between episodes?
- Is there the possibility of an ingestion?
Ask parents of school-age children if there is any history of a recent trauma, suggests Piskosz. "If the child has fallen off a bicycle, ask if they fell to the side or over the handlebars," she says.
Ask the mechanism of injury, because trauma can be difficult to assess, says Piskosz. "It is likely that a child who falls over the handle bars will sustain a blunt trauma to the abdomen. This should be a high priority until proven otherwise," she says. "However, like many abdominal traumas, the signs and symptoms may not present for hours or days."
Consider the possibility of nonaccidental trauma, and look for warning signs such as abdominal tenderness, distention, and bruising, says Kesler. "Ask yourself, does the bruising have a pattern such as circular or grid marks, coupled with a suspicious story," she says. "A common storyline is that the infant rolled off the couch or 'I put the child down for a nap, and they didn't wake up.'"
When assessing pain in children from different cultures, put aside preconceived ideas and evaluate each child individually, says Piskosz. "Some cultures teach children to accept pain and be stoic while other cultures do not accept pain and want it eliminated," she says. "Asking the child without parental intervention, to point to their pain, can help you make a better assessment."
Sources
For more information about triage assessment of pediatric abdominal pain, contact:
- Carolyn Kesler, RN, BSN, Emergency Department, Primary Children's Medical Center, 100 N. Medical Drive, Salt Lake City, UT 84113. E-mail: [email protected].
- Zelda Piskosz, RN, BSN, Staff Nurse, Pediatric Emergency Department, Memorial Hospital West, 703 Flamingo Road, Pembroke Pines, FL 33028. Phone: (954) 430-6881. E-mail: [email protected].
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