Nurses: Here's how to pinpoint source of abdominal pain

ED nurses should be on the lookout for life-threatening causes of abdominal pain and know unique risks of elderly patients and women of childbearing age

As any ED nurse knows, patients with abdominal pain demand top-notch assessment skills. "The most unique challenge for abdominal pain is getting patients seen, treated, and evaluated within a timely manner," says Darlene Bradley, RN, MSN, MAOM, CCRN, CEN, clinical director for emergency/express care at Loma Linda University Medical Center and Children's Hospital (CA). "It is this group of patients that seems to take the greatest amount of time in the ED. This is particularly true for women of childbearing age."

The list of possible diagnoses seems endless, says Bradley. "It's such a difficult category because there are so many systems in that small area to deal with," she notes. "Each of those systems needs to be evaluated to determine the source of the pain. Systems that need consideration include cardiac, gynecology, genitourinary, digestive (ulcers, colitis, appendicitis, pancreatitis)-in addition, splenic or liver injury may be a complication of trauma." A good history and physical with appropriate testing may be time consuming and lead to prolonged stays in the ED, she says.

There are multitudinous causes of abdominal pain, including injury or illness of abdominal organs, cardiovascular disease, genitourinary disease, or psychological disorders. "The challenge comes in trying to pinpoint the cause and then treat it appropriately," says Judy Selfridge-Thomas, RN, MSN, CEN, FNP, nurse practitioner at the department of emergency medicine at St. Mary Medical Center in Long Beach, CA. "In the ED, the initial challenge is trying to determine if the cause will require immediate surgery to correct it or if it can be managed on a medical model outpatient basis."

The following tips for managing patients with abdominal pain could be helpful:

Do serial assessments. "The serial abdominal assessments of inspection, auscultation, percussion, and palpation are invaluable to detect changes in the abdomen itself," says Selfridge-Thomas. "Rating abdominal pain using a pain scale and then re-evaluating this is also important. These assessments should be performed on an ongoing basis."

Get a rectal temperature. Any patient who presents with abdominal pain should get a rectal temperature, says Stephen Colucciello, MD, FACEP, clinical services director and trauma coordinator for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. "Oral temperatures are inadequate, and tympanic membrane temperatures are absolutely unacceptable," Colucciello says. "Patients in pain breathe faster, which decreases the accuracy of oral temperatures." If a patient has a fever and abdominal pain, there is a higher concern for surgical illness, so it's vital that the temperature be accurate, he adds.

At triage, consider MIs. "Recognize that abdominal pain may be a manifestation of MI," says Colucciello. "When triaging patients with upper abdominal pain, ask about risk factors for coronary disease, as there may be a cardiac etiology, particularly if the belly isn't tender."

Check respiratory rates and blood pressure. Respiratory rates are important to check at triage, says Colucciello. "Pneumonia also causes abdominal pain, so you want to see if the patient is in respiratory distress," he explains. "Blood pressure is also important to determine the presence of shock. If a patient presents with low blood pressure and abdominal pain, they may have an intra-abdominal catastrophe, such as rupture of an abdominal aneurysm or the spleen."

Consider orthostatics. "Clearly, the patient who is hypotensive or looks just fine should not get orthostatics, but in patients in suspicion of volume depletion or intra-abdominal bleed, orthostatics may be useful," says Colucciello. "This is controversial because there is a wide overlap between normals and abnormals. But generally, you look for a 20- to 30-point increase in pulse rate or a 30 point drop in systolic pressure."

Expedite urinalysis. "At many facilities, the nurse will order and send the urine prior to a physician exam for women with lower abdominal pain," says Bradley. "The women should stop at the bathroom to get their urine as they walk from triage to the back for bed placement," she advises. "They should also be placed on a gyn table and be prepared for a pelvic exam."

Obtaining early urine specimens is important and can be done in the ED, says Colucciello. "In women, a midstream clean catch, if performed correctly, is essentially equal to a catheterized specimen. If the patient is alert and cooperative, a clean catch can be obtained by having the woman sit facing the back of the toilet instead of the front. Sitting in this reverse position spreads the labia," he says.

Once the urine is obtained, it can be analyzed with the dipstick and used for a urine pregnancy test, says Colucciello. "By the time a woman leaves triage, the health care workers know if she is pregnant or if she has a UTI," he notes.

When a clean specimen can be obtained at triage, it can be dipped to look for leukocytes, ketones, nitrites, and blood," Colucciello explains. "The recognition of early pregnancy may make all the difference in the world, if they have an ectopic pregnancy. Even if pain is not due to the pregnancy, what drugs are given may depend on whether the patient is pregnant."

Be proactive to ensure fast test results. "For patients with right-sided abdominal pain who are guarding and present with fever and nausea or vomiting, we prepare for an appendectomy work up by starting an IV and initiating fluids," says Bradley. "Blood is drawn as soon as possible to expedite the return of a CBC."

Ask children with abdominal pain to hop. "When it causes them too much discomfort to do so, it is a sign of peritoneal irritation and, often, appendicitis," says Bradley. "It clues us in to the degree of illness of the child."

Consider the sequence of exam. "The most important thing to remember in the abdominal pain patient is that the sequence of exam is different in that system than for all others," says Bradley. "After inspection, auscultation is done of the abdomen before hands are placed on it for the rest of the exam. This sequence of the exam will cue us in to some more serious findings. The auscultation may determine bruits."

Use ultrasound and CAT scan. Ultrasounds have emerged as the primary imaging modality for abdominal pain in women, says William Mallon, MD, FACEP, associate professor of emergency medicine at University of Southern California Medical Center in Los Angeles. "Ultrasound is particularly adept at identifying gynecologic pathology, particularly low abdominal pain, because the bladder creates a clear window," he says.

It's difficult to identify the source of women's abdominal pain, says Mallon. "Among the differential diagnoses include ovarian cysts, ovarian torsion, and a whole variety of emergencies not even counting pregnancy-related conditions, which makes women much more difficult to assess. That means you need a better anatomical assessment than a physical exam." Ultrasound can give information about the reproductive organs in addition to the appendix, says Mallon. "The vaginal probe is probably superior to trans abdominal sonography with ectopics," he notes.

One study showed that women prefer vaginal probes to trans abdominal sonography. "A lot of people feel it would be less invasive to get a Foley catheter and, instead, do a trans abdominal, but the study showed that women objected to the Foley catheter more than the vaginal probe," says Mallon. "For many physicians, that was counter intuitive, so nurses might bring that to their attention."

Ultrasound is a good way to evaluate abdominal pain in third trimester pregnancy, says Mallon. "As the uterus enlarges and stretches all the peritoneal nerve endings, the ability to localize pain becomes less," he says. "The physiology of pain is changing because of the distorted anatomy, so that makes the assessment harder."

Perforation rates of women in the third trimester is worse because the appendix is pushed to an abnormal location, says Mallon. "The pain localization is worse, which delays the diagnosis and results in a higher perforation rate," he notes. "Nurses should realize that diffuse, poorly localized pain may be appendicitis and not to rely on RLQ location."

Use CAT scan with oral, intravenous, and rectal contrast to detect appendicitis. CAT scan is playing a more important role in abdominal pain. "One study showed an accuracy in the high 90s for appendicitis, which is better than clinical impression," says Colucciello. However, CT is much less useful in pregnancy due to radiation concerns, he notes.

Rule out abdominal aortic aneurysm. "It can be ruled out in the first several minutes of an ED visit with ultrasound by finding an aorta of normal size," says Colucciello. "Ultrasound can also help detect renal colic."

Watch for urinary tract infections (UTIs). "There is a frequency of UTIs in women due to their short urethral length," says Mallon. "A severe rapidly progressing pyelonephretis actually can mimic intra-abdominal pain and can produce what almost looks like an acute abdomen, so that is a diagnostic dilemma as well."

A good urine sample for microscopic analysis can help avoid confusion, says Mallon. "Pyuria, bacteria organisms, and fever strongly suggest pylonephritis."

Perform serial exams. "It's important that patients be examined on several occasions," says Colucciello. "If you have labs and X-rays done, it's important to feel the belly and talk to the patient again before discharge."

That is especially important when there is a risk of appendicitis. "If a patient has right lower quadrant pain and is discharged, in general they should be instructed to return in 12 hours if they still have pain," says Colucciello. (See discharge instructions below and MI Ruled out protocol supplement, page 1)

Patients with right lower quadrant pain have appendicitis until proven otherwise, says Colucciello. "A normal white count should not dissuade you from that diagnosis," he notes. "Neither should an abnormal urine-up to 30% of patients with appendicitis have leukocytes in their urine, and patients are easily misdiagnosed as having a UTI."

Don't place too much emphasis on white counts. "White counts in abdominal pain are overrated," says Colucciello. "The patient may have horrible abdominal pathology and still have a normal white count. In fact, at least 20% of patients with appendicitis have a normal white count. An over-reliance on CBC leads to errors."

Look for signs that it's serious. A rigid belly, guarding, pain when tapping on the patient's heel with your hand are all signs of a serious abdominal problem, says Colucciello. "Also, if the patient has pain when they cough, they will need urgent medical evaluation."1

Questions to ask abdominal pain patients

Obtaining as much and accurate information as possible during history questions is important," says Selfridge-Thomas.

When assessing patients with abdominal pain, ask these questions:

    · Was pain sudden or gradual? "Sudden causes of abdominal pain include AAA or perforated ulcer," says Colucciello. "If the pain has been going on for weeks, it's less likely to be an acute emergency."

    · Is the pain central or diffuse? "Can it be localized to a quadrant, where did it start, and where did it go?" says Colucciello. "For example, the pain of appendicitis often starts around the navel, then migrates to the right lower quadrant."

    · What is your history? "Is there a history of ulcers, MI, (or) hypertension? That is important for triple A and mesenteric ischemia," says Colucciello.

    · How was the pain on the trip to the ED? "If the patient complains of pain whenever the car hit a bump, they are likely to have peritonitis," says Colucciello.

    · When did the pain start? "Time of onset is important," says Selfridge-Thomas. "Usually, if abdominal pain has occurred acutely, such as less than six hours, and is becoming more intense, significant pathology is often present."

    · What other symptoms do you have? "Associated symptoms, such as vomiting or diarrhea, are also important clues, as is any immediate or recent history of trauma to the abdomen, along with any abnormality in menstrual history or flow in females," says Selfridge-Thomas. Other signs and symptoms include the presence of abdominal distention, decreased bowel sounds, abdominal discoloration, point tenderness, rebound tenderness, guarding and rigidity, and, of course, increasing pain.

    · Where is the pain located? "Pain location is a cue to planning ahead," says Bradley. "For instance, epigastric pain could not exclude the possibility that this is a cardiac condition. In addition, the location that is near the pelvic or genital region could indicate a GYN condition, whereas flank pain may indicate a kidney condition." The location of the pain is crucial in order to anticipate the next steps of that patient's care, she notes. Colucciello points out that patients with pelvic pathology can present with upper abdominal pain. "Women with a severe form of PID known as Fitz-Hugh-Curtis syndrome, will complain of upper abdominal pain. Only by performing a pelvic exam will a physician make the diagnosis."

    · Are you taking NSAIDs (by prescription or OTC)? "A nurse can emphasize that OTC meds can cause gastritis or PUD," says William Mallon, MD, FACEP, associate professor of emergency medicine at University of Southern California Medical Center in Los Angeles.

    · Are you abusing drugs? "Drugs such as alcohol and cocaine are associated with PUD," Mallon notes.

References

    1. Bennett DH, et al. The use of coughing tests to diagnose peritonitis. BMJ 1994;308:1336.

    2. Attard AR et al. Safety of early relief for abdominal pain. BMJ 1992;305:554-556.

    3. LoVecchio F, et al. The use of analgesics in patients with acute abdominal pain. J Emerg Med 1997; 15:775-779.