FNP Student Assessment of Acute Abdominal Pain

Tags: abdominal abdominal pain Acute eating habits pain

This article serves to assist the novice family nurse practitioner student in the examination of abdomen in a patient presenting with acute abdominal pain.

Introduction

Abdominal pain is pain felt in any location between the groin and chest. It is a very common and nonspecific complaint that can be difficult to diagnose, especially for the family nurse practitioner student. On questioning people about abdominal pain during routine physical assessments, pain is present in about 50% of adults and 75% of adolescents at some point (Cash & Glass, 2011). Irritable bowel syndrome and gastroenteritis are the most common causes of acute abdominal pain (Cash & Glass, 2011). Constipation and chronic stool retention are the most common causes of chronic abdominal pain (Cash & Glass, 2011).

Abdominal pain can be categorized as acute, chronic, and/ or emergent. Emergent abdominal pain lasts 3 hours or longer and is most often accompanied by vomiting or fever (Cash & Glass, 2011). Acute abdominal pain is pain lasting less than a couple days that has worsened to the point that the patient seeks medical evaluation (Cash & Glass, 2011). Chronic abdominal pain is pain that lasts longer than 12 weeks. Chronic pain can remain unchanged for months or even years (Cash & Glass, 2011).

Abdominal pain can be further broken down by anatomical location. Pain can be present in the right upper quadrant, the right lower quadrant, the left upper quadrant, the left lower quadrant, the epigastric area, the umbilical area, and/or the hypogastric/ suprapubic/ pelvic area (Bickley, 2009). There are several methods used to describe the quadrants and regions of the abdomen.

Pain can also be referred to the abdomen from other anatomical locations. Referred pain is pain that is felt at a site where the organ was located during fetal development (Jarvis, 2012). Cholecystitis is biliary colic, which can cause sudden pain in the right upper quadrant of the abdomen. The pain can be referred to the right or left scapula. The pain is often worse after ingesting alcohol, caffeine, or fatty foods (Jarvis, 2012). Pancreatitis pain is typically seen in the right upper quadrant, but can be referred to the back, left scapula or flank (Jarvis, 2012). A perforated duodenal ulcer can cause referred pain to the right shoulder (Jarvis, 2012). Liver pain can be referred to the right shoulder as well (Jarvis, 2012).

Anatomy review

It is important to remember the anatomy of the abdomen when assessing abdominal pain. The organs in the right upper quadrant of the abdomen include the liver, the gallbladder, the right kidney/ adrenal, the hepatic fixture of the colon, the head of the pancreas, and part of the ascending and transverse colon (Jarvis, 2012). The organs in the left upper quadrant of the abdomen include the spleen, the left kidney/ adrenal, the stomach, the left lobe of the liver, the body of the pancreas, the splenic fixture of the colon, and part of the transverse and descending colon (Jarvis, 2012). The right lower quadrant organs include the appendix, the cecum, the right ureter, and the right iliac artery. In females, the right ovary and the right fallopian tube are present in the right lower quadrant of the abdomen. In males, the right spermatic cord is located in the right lower quadrant of the abdomen (Jarvis, 2012). The left lower quadrant organs include the sigmoid colon, part of the descending colon, the left iliac artery, and the left ureter. In females, the left ovary and the left fallopian tube are present in the left lower quadrant of the abdomen. In males, the left spermatic cord is present in the left lower quadrant of the abdomen. (Jarvis, 2012).

Health history:

It is important for the provider to obtain a thorough and appropriate health history for a patient presenting with abdominal pain. A suggested framework to consider using is the SOAPIER format (Haider, 2009). S stands for subjective data, which is the information provider by the patient to the examiner. O is objective data, or what is observed by the provider. Objective data can also include vital signs and the results of laboratory tests and diagnostic tests. Assessment (A) represents the conclusions of the problem as determined by the provider. Plan (P) is the interventions planned to resolve the problem. I represents the implementation of the plan. E is for the evaluation of how effective the plan was. Finally, R stands for the reflection of the whole process (Haider, 2009). This format helps the provider to follow a specific order when assessing a patient presenting with abdominal pain. It is also important for the provider to evaluate their interactions with patients and reflect on the process. Providers can learn from what was done well or what could be improved upon from previous interactions.

Subjective data, or what the patient tells you, is critical in terms of directing the provider’s subsequent assessment. It is very important that the chief complaint, as presented by the patient, is documented in the patient’s own words. Quotation marks should be used. The first question to be asked is: “Where is the pain?” (Jarvis, 2012). The patient should be encouraged to point to the area of pain using one finger. This can direct the provider to the specific organs that might be involved.

Some other important questions to ask the patient include:

Have you ever had this pain before? When did it start? What is the quality of the pain (sharp, dull, tender, cramping, burning)? Is it intermittent or continuous? Does the pain travel anywhere (radiate) or is it localized? On the 0 to 10 pain scale, 0 being no pain and 10 being the worst pain ever felt, what is your pain level right now?
Are there associated symptoms, such as nausea and vomiting and/ or diarrhea?
Have you noticed any black stools or blood in your stool? Have your stools been white or chalky?
Have you noticed blood in your urine?
Do you feel as though you have had a fever?
Does anything make the pain better or worse?
Have you taken any medication for the pain? If so, what did you take and how did it work?
Is the pain associated with eating? Has the pain affected your food intake and appetite? Have you had any recent weight loss? If so, was it planned weight loss or not planned?
Have you have any recent injuries?
Have you had any abdominal surgeries? If so, what was the procedure and what was the outcome of the procedure?
Have you had any penile or vaginal discharge?
Have you had any menstrual irregularities?
Do you have a history of ulcers, liver issues, gallbladder issues, colitis, hernias, or appendicitis? (Jarvis, 2012).

When interviewing a patient presenting with abdominal pain, there are several other important topics to cover. It is important to obtain a complete medication history, including the use of prescription medication, over-the-counter (OTC) medication, and the use of herbs and other supplements (Jarvis, 2012). Pay special attention to medications including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, aspirin, antibiotics, and laxatives. People taking anti-inflammatory drugs and aspirin are at a five-fold increased risk of developing peptic ulcers (National Digestive Diseases Information Clearinghouse, 2012). NSAIDs and aspirin also increase the risk of gastrointestinal bleeding. Acetaminophen can cause liver damage in excessive and prolonged dosages. Symptoms of acetaminophen toxicity include nausea, vomiting, and abdominal pain (Life Extension, 2012). Antibiotics can cause diarrhea as well as clostridium difficile, which can cause abdominal pain. Laxative abuse or overdose can cause nausea, vomiting, abdominal pain, diarrhea, and/ or electrolyte disturbances (Medline Plus, 2012).

It is important to determine if the patient has had changes in their bowel habits or eating habits, as this can be a clue to the cause of the abdominal pain. Urinary function must also be considered, because infections of the urinary system can be a source of abdominal pain. Information regarding urinary frequency, urgency, dysuria, flank pain or back pain should be ascertained. If the patient is male, the provider should ask about hesitancy, nocturia, difficulty starting the stream, low urinary volume, or abdominal distention, as these symptoms could indicate urinary retention (Jarvis, 2012).

For females presenting with abdominal pain, obtain information about last menstrual period. Ask if they are having any unusually vaginal discharge or bleeding. Females presenting with abdominal pain could possibly have pelvic inflammatory disease or a sexually transmitted disease (Jarvis, 2012). In females of childbearing age, it is important to rule out pregnancy. An ectopic pregnancy occurs when a fertilized egg attaches itself outside the uterus (American Pregnancy Association, 2010). Symptoms of ectopic pregnancy include pelvic/ abdominal pain, weakness, dizziness and vaginal bleeding (American Pregnancy Association, 2010). Ectopic pregnancies must be treated immediately, as they can be life-threatening.

The provider also needs to review the patient’s use of alcohol and other substances. Chronic alcohol use can lead to cirrhosis, hepatitis, and increases the risk of alcohol related pancreatitis, which can all cause abdominal pain (Cash & Glass, 2011). The provider should also obtain information about recreational drug use and safe-sex practices. Intravenous drug abuse with needle sharing and unsafe sex can potentially lead to HIV/AIDS, hepatitis, and/or other sexually transmitted diseases.

Physical examination:

After obtaining a complete health history related to the chief complaint, a thorough physical examination follows. This is absolutely necessary for any patient presenting with acute abdominal pain. The general survey could potentially provide important clues about the cause of abdominal pain. Patients presenting sitting or laying still can potentially have peritonitis, because pain cause by peritonitisi is aggravated by movement (Jarvis, 2012). Typically, patients writhing around with colicky pain tend to have kidney stones (Jarvis, 2012).

As the provider begins the physical examination, inspection should be performed first. The provider should assess the skin to determine if there are any rashes, lesions, or dilated veins. Dilated veins can be caused by hepatic cirrhosis or inferior vena cava obstruction. If there is a bulge in the umbilical area, this could indicate a hernia. If the abdomen is asymmetric, it could indicate a mass or enlarged organ. A protuberant abdomen can be caused by fat, tumors, gas, ascities, or pregnancy (Bickley, 2009).

Auscultation of the abdomen should be performed next. Normal bowel sounds consist of approximately 5 to 34 gurgles and/or clicks a minute (Bickley, 2009). Bowel sounds are usually hyperactive with early mechanical bowel obstruction, diarrhea, laxative use, gastroenteritis, and resolving paralytic ileus (Jarvis, 2012). Bowel sounds are usually hypoactive or absent with late intestinal obstruction, with peritonitis due to inflammation, and with paralytic ileus (Jarvis, 2012). Listen for bruits in the aortic region, at the renal arteries, iliac arteries, and femoral arteries. The presence of a bruit over the renal arteries could suggest renal artery stenosis. The presence of a bruit at the abdominal aorta could suggest an aortic aneurysm. The presence of a bruit at any vascular location could also indicate arterial insufficiency or partial occlusion (Jarvis, 2012). The provider should auscultate over the liver and spleen for friction rubs, which can be caused by gonococcal infection around the liver, a liver tumor, a liver abscess, splenic infarction, splenic abscess, splenic infection, or splenic tumor (Bickley, 2009).

Percussion is the next step to the physical examination of the abdomen. All four quadrants of the abdomen need to be percussed, with a mindful recall as to the underlying structures. Percussion is the technique of tapping on a surface to determine the location of underlying structures (Jarvis, 2012). Tympany is usually the dominating sound when percussing the abdomen because of the large amount of air/ gas in the gastrointestinal tract (Bickley, 2009). Dullness will be present over the liver and spleen. A larger area of dullness than anticipated could indicate an enlarged organ or mass (Bickley, 2009). The normal liver span is 4-8cm in the mid-sternal line and 6-12cm in the right mid-clavicular line (Bickley, 2009). It is also important to percuss the costo-vertebral angles bilaterally for tenderness, as this could indicate pyelonephritis (Jarvis, 2012).

Palpation is the last technique used in the assessment of the abdomen. The patient should be approached cautiously to avoid voluntary guarding. The patient should be supine with a pillow under their head with their knees bent and arms at their side. To avoid abdominal tensing, the provider should take steps to ensure that their stethescope and hands are warm. The provider should also examine painful areas last to help prevent voluntary guarding (Jarvis, 2012). The provider should use distraction, a technique used to help avoid involuntary guarding. While performing the physical examination of the abdomen, the provider can distract the patient by engaging the patient in conversation, by inquiring about the health history while palpating the abdomen, by talking in a low and soothing voice, and by using emotive imagery or by having the patient use breathing techniques (Jarvis, 2012).

Light palpation should be performed first to determine if there is abdominal tenderness. Palpation must include all four quadrants. Involuntary rigidity could suggest peritoneal inflammation (Bickley, 2009). Deep palpation must then be performed to assess the size of the organs and to assess for the presence of any masses. If there is a palpable mass, note its size, shape, location, consistency, tenderness, and if there are pulsations related to the identified mass (Bickley, 2009). It is important to palpate the liver, spleen, and bladder.

Deep palpation will also determine if rebound tenderness is present. The provider should press down with their fingers slowly but firmly into the patient’s abdomen, then the provider should quickly withdraw their hands. If the reported pain is greater with the withdrawal of the hands as compared to the deep palpation itself, the patient is positive for rebound tenderness. Rebound tenderness could indicate peritoneal inflammation (Bickley, 2009).

If acute abdomen is suspected, other physical examination techniques can be used. These include the Rovsing’s sign, the psoas sign, and the obturator sign (Bickley, 2009). A positive Rovsing’s sign occurs when the provider elicits referred right lower quadrant pain when assessing for rebound tenderness in the left lower quadrant (Bickley, 2009). A positive psoas sign occurs when the patient has pain when the practitioner places their hand above the patient’s right knee and asks the patient to raise their thigh against the practitioner’s resistance. A positive psoas sign is also elicited when the patient has pain when the practitioner asks the patient to turn on their left side and extend their right leg at the hip (Bickley, 2009). The obturator sign is positive when the patient has pain when the practitioner flexes the patient’s right thigh at the hip with their knee bent, and internally rotates their leg at the hip (Bickley, 2009).

If cholecystitis is suspected, the practitioner can also perform the Murphy test. A positive Murphy sign is elicited when the patient has pain with inspiration when the practitioner palpates the right upper quadrant (Jarvis, 2012). Although this is a good physical examination technique to perform, it is not 100% accurate. A positive sonographic Murphy sign is elicited during ultrasound when the patient has pain when the ultrasound probe is placed directly over the gallbladder. According to a study done by Blackstock, Wu, Lewiss, Saul, & Bagley (2010), the accuracy of sonographic Murphy sign is 87.2%.

A rectal exam should always be performed on a patient presenting with abdominal pain. A digital rectal exam with guaiac for occult blood can rule out gastrointestinal bleeding as the cause of abdominal pain. In all females presenting with abdominal pain, a pelvic exam should always be performed. This can rule out pelvic inflammatory disease or sexually transmitted diseases (Jarvis, 2012).

Laboratory and Diagnostic tests:

It is important to know which laboratory tests and/or diagnostic tests are indicated for certain abdominal disorders to help accurately diagnose the abdominal pain. Laboratory tests for abdominal pain include: complete blood count with differential, basic metabolic panel, hepatic function panel, amylase, lipase, urinalysis and culture if indicated, stool for guaiac, H. pylori, stool culture, stool for ova and parasites, erythrocyte sedimentation rate, C-Reactive protein, and serum HCG (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

A complete blood count evaluates for numerous conditions involving the red blood cells, white blood cells, and platelets. In a patient with abdominal pain, a complete blood count can evaluate for infection, inflammation or bleeding. A basic metabolic panel includes glucose, electrolytes, blood urea nitrogen (BUN) and creatinine. BUN and creatinine evaluate kidney function. These values can be altered in kidney failure or dehydration. A hepatic function panel, or liver function tests, includes aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALK), and bilirubin. All components of the hepatic function panel evaluate the function of the liver and elevated values can indicate liver damage or disease. Amylase and lipase are enzymes specific to the pancreas, and are elevated with pancreatitis. Urinalysis includes urine pH, protein, glucose, ketones, hemoglobin, bilirubin, urobilinogen, nitrite, leukocytes, and specific gravity. Urinalysis can help evaluate for infections, assess hydration status, and assess for renal disease or liver disease. A culture should be performed, if indicated. If the patient has a urinary tract infection, the culture will give important information about which antibiotic will be effective to treat the infection (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

Guaiac of the stool provides information about occult blood, or blood that cannot be seen. A positive guaiac test means that there is blood in the stool. This means that the patient is bleeding somewhere in their gastrointestinal tract. This must be further investigated by a gastroeneterologist. Heliobactor pylori, or H. pylori, is a bacteria that can be found in the stomach. H. pylori can cause peptic ulcers, which can cause abdominal pain. If a patient is positive for H. pylori, the patient should be treated with antibiotics. A stool culture evaluates the stool for the organisms Clostridium difficile, also known as C. diff, Salmonella, Shigella, Escherichia coli, also known as E. coli, Campylobacter, and Yersinia enterocolitica. A stool sample tested for ova and parasites evaluates the stool for the presence of parasites, eggs, or larvae in the stool. This assists in diagnosing a parasitic infection (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

C-Reactive Protein, or CRP, is a nonspecific marker of inflammatory response. CRP levels are elevated with Crohn’s disease, acute bacterial infections, and inflammatory bowel disease. Erythrocyte Sedimentation Rate, or ESR, is a marker of inflammation or tissue necrosis. ESR levels are elevated with anemia, carcinoma, Crohn’s disease, infections, and inflammatory diseases. It is also important to remember that all females of childbearing age are considered pregnant until ruled out by HCG analysis (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

First line diagnostic studies useful is determining the origin of abdominal pain include computed tomography (CT) scan of the abdomen/ pelvis, ultrasound of the abdomen, and flat plate, lateral and upright x-rays of the abdomen. Further testing, done by a gastroeneterologist, may include colonoscopy, barium enema, gastric emptying study, or upper endoscopy (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

CT scan of the abdomen and pelvis is a noninvasive procedure (unless contrast medium is used) used to view abdominal structures. A CT scan will detect inflammation, tumors, cysts, obstructions, aortic aneurysms, calculi, and trauma in the abdomen and pelvis. Ultrasound of the abdomen is a noninvasive procedure that can help to visualize the structures in the abdomen. An abdominal ultrasound will help visualize the liver, gallbladder, spleen, pancreas, kidneys, and blood vessels. A trans-vaginal ultrasound can also be performed to visualize the uterus, ovaries, cervix and the vagina. Abdominal flat plate, lateral and upright are x-ray views of the abdomen that can help diagnose intestinal obstruction, masses, renal calculi, or visceral injury (Van Leeuwen, Poelheuis-Leth, & Bladh, 2011).

Differential diagnoses:

Right Upper Quadrant

Biliary colic
Acute cholecystitis
Hepatitis
Hepatic abscess
Hepatomegaly
Perforated duodenal ulcer
Acute pancreatitis
Myocardial ischemia
Pain of a pulmonary origin

Left Upper Quadrant

Gastritis
Splenic infarction or infection
Myocardial ischemia
Left lower lobe pneumonia

Right Lower Quadrant

Appendicitis
Leaking aneurysm,
Regional enteritis
Meckel’s diverticultitis
Abdominal wall hematoma
Incarcerated or strangulated inguinal hernia
Ureteral calculi
Endometriosis
Ruptured ectopic pregnancy
Twisted ovarian cyst
Pelvic inflammatory disease

Left Lower Quadrant

Regional enteritis
Leaking aneurysm
Sigmoid diverticulitis
Incarcerated or strangulated inguinal hernia
Ureteral calculi
Ruptured ectopic pregnancy
Twisted ovarian cyst
Pelvic inflammatory disease

Generalized Abdominal Pain

Trauma
Intestinal obstruction
Peritoneal irritation

Conclusion

While abdominal pain is a very common complaint, it can be difficult to diagnose. It is important for the novice family nurse practitioner student to take all the appropriate steps to accurately diagnose abdominal pain. It is also very important to remember that a sudden onset of severe abdominal pain, especially if accompanied by fever and/or nausea and vomiting, should be evaluated immediately, as it could be a medical emergency (Jarvis, 2012). It is important to note that less than 50% of patients reporting to their primary care provider with abdominal pain are definitively diagnosed on the initial examination. Many times, referrals will need to be made to specialists including surgeons, gastroenterologists, gynecologists, etc. Many patients presenting with chronic abdominal pain may require repeated examination by the primary care provider in order to accurately assess, diagnose and manage abdominal complaints.

References

American Pregnancy Assiciation. (2010). Ectopic pregnancy. Retrieved from: http://www.americanpregnancy.org/pregnancycomplications/ectopicpregnancy.html
Bickley, L.S. (2009). Bates’ guide to physical xamination and history taking. (10^th ed). Philadelphia: Lippincott, Williams & Wilkins.
Blackstock, U., Wu, S., Lewiss, R., Saul, T., & Bagley, W. (2010). Focus on: beside biliary ultrasound. ACEP News.
Cash, J.C. & Glass, C.A. (2011). Family practice guidelines. (2^nd ed). New York, NY: Springer Publishing Company.
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Haider, E. (2009). Differential diagnosis of abdominal pain. Primary Health Care 19(1), 20-22.
Jarvis, C. (2012). Physical examination and Health Assessment. (6^th ed). St. Louis, MO:
Elsevier Saunders. Life Extension. (2012). Acetaminophen and NSAID toxicity. Retrieved from: http://www.lef.org/protocols/appendix/otc_toxicity_01.htm
Medline Plus. (2012). Laxative overdose. Retrieved from: http://www.nlm.nih.gov/medlineplus/ency/article/002586.htm
National Digestive Diseases Information Clearinghouse. (2012). NSAIDs and peptic ulcers. Retrieved from: http://digestive.niddk.nih.gov/ddiseases/pubs/nsaids/
Van Leeuwen, A., Poelheuis-Leth, D., & Bladh, M. (2011). Laboratory and diagnostic tests with nursing implications. (4^th ed). Philadelphia, PA: FA Davis Company.