When a 7-year-old boy presented with right-sided abdominal pain, no rebound tenderness was noted, the abdominal flat plate was negative, white blood count was normal, and there was no left shift and no vomiting or bowel changes. "However, he looked ill and had pain every time he coughed," says Patricia Carroll, RN, BC, CEN, RRT, MS, former ED nurse at Manchester (CT) Memorial Hospital and founder of Educational Medical Consultants, a Meriden, CT-based consulting company specializing in educational programs for health care professionals.
When Carroll had a moment alone with the boy, he confided that he had been dared to swallow a toad. When he did so, he had aspirated fungus, Carroll explains. "The initial abdominal pain actually was referred pleuritic pain, and when the chest X-ray was taken to follow up on this new information, it showed infiltrates on the whole right side of his chest," she recalls. The boy had no gastrointestinal problems from digesting the toad, but he was transferred to another facility for bronchoscopy and treatment of fungal pneumonia, says Carroll.
The above example shows the importance of thorough assessment of abdominal pain, says Carroll.
Here are some items to consider:
• Remember that abdominal pain can be referred. Particularly in children and the elderly, abdominal pain may indicate there is a problem elsewhere, she says. Pleuritic pain may be referred to the abdomen in children, as in the above case, she says, and an elderly patient having a myocardial infarction may present with abdominal discomfort. "All bets are off in kids and the elderly," says Carroll. "Children have trouble localizing pain; elderly patients have a diminished perception of pain."
• Look for more subtle signs in older patients. Geriatric patients are much more likely to have serious causes of abdominal pain than younger patients, warns Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, clinical nurse specialist for the ED at Northwestern Memorial Hospital in Chicago. These include a ruptured abdominal aortic aneurysm, mesenteric ischemia, and acute myocardial infarction (AMI).
However, abdominal symptoms may be more subtle in the older patient, because they don’t localize pain as well and are less likely to run a fever with infection, she notes. For this reason, Steinmann recommends having a low threshold for obtaining abdominal computed tomography (CT) scans in this population. "Nurses should advocate for ordering the CT early in the evaluation, if the cause of the patient’s discomfort is not readily discerned," she says.
An 83-year-old patient with constipation and no bowel movement for three days may have a fairly readily identifiable cause of the discomfort, so a CT may not be indicated, but an 83-year-old with vague generalized abdominal discomfort may well benefit from this diagnostic test, she says. "This usually requires awaiting the results of serum blood urea nitrogen and creatinine, as the scan will require contrast to ensure those are sent as part of the initial labs," she says.
AMIs have a very unpredictable pattern in the elderly, and Carroll therefore recommends that electrocardiograms be given to all elderly patients with abdominal pain without an obvious source.
• You can treat pain before a diagnosis. There is an unfortunate misconception about abdominal pain: that the patient’s pain can’t be treated until a definitive diagnosis is made, Steinmann says. She points to a clinical policy from the American College of Emergency Physicians that states that "administration of narcotics to patients with abdominal pain is safe, humane, and in some cases, improves diagnostic accuracy,"1 Steinmann says. "Yet, these patients often are not medicated."
The patient should not have to wait for multiple diagnostic tests to be completed before pain management is initiated, emphasizes Steinmann. "Although we don’t order pain medications, nurses certainly can advocate for the patient," she says. If a physician is concerned that pain medications will obscure repeated exams, encourage the use of short-acting opioids, she recommends.
• Ask the patient to point to the pain with one finger. If the patient is able to do this, there is likely to be a distinct cause for their pain such as appendicitis or ectopic pregnancy, as opposed to the generalized discomfort common with gastroenteritis, says Carroll. People with significant pain will be reluctant to move, notes Carroll. "They may be sitting or standing in a rigid posture, or curled in a fetal position on the stretcher," she says.
• Do a heel strike test. Carroll recommends doing this test if you think the patient has peritoneal irritation, instead of palpating the abdomen. Ask the patient to stand on tiptoes, and then rapidly lower their full weight onto their heels on the floor, she says. This will move the abdominal organs and will be positive in cases of peritoneal irritation, but will cause less pain than palpation and result in less guarding for subsequent exams, she says.
• Don’t miss life-threatening conditions. You always should think of life-threatening problems first, Carroll emphasizes. She gives the following examples: myocardial infarction, a ruptured abdominal aortic aneurysm, ruptured spleen, ectopic pregnancy, ruptured appendix, mesenteric ischemia, or thrombosis. "Sudden onset of localized pain, especially if it awakens the patient from sleep, is a clue of a more serious condition," she says.
Reference
1. American College of Emergency Physicians. Clinical policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic abdominal pain. Ann Emerg Med 2000; 36:406-415.
Sources
For more information on assessment of patients with abdominal pain, contact:
• Patricia Carroll, RN, BC, CEN, RRT, MS. Telephone: (203) 238-1723. Fax: (203) 238-1719. E-mail: [email protected].
• Rebecca A. Steinmann, RN, MS, CEN, CCRN, CCNS, Emergency Department, Northwestern Memorial Hospital, Chicago, IL 60611. Phone: (312) 926-7069. E-mail: [email protected].
When a 7-year-old boy presented with right-sided abdominal pain, no rebound tenderness was noted, the abdominal flat plate was negative, white blood count was normal, and there was no left shift and no vomiting or bowel changes.
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