Abdominal Pain Case Study

An emergency department nurse is caring for a 44-year-old woman with LLQ abdominal pain and is brought to the emergency department by her husband. Explain what type of assessment is most critical for this patient, providing a rationale for your response. Discuss the questions the nurse would ask, prioritizing these questions from most concerning to least concerning. Use your Jensen (2014) text to support your rationale.

Since this patient is having acute abdominal pain, a focused acute abdominal assessment needs to be conducted to identify the cause of her pain. For this patient, a quick focused history related to abdominal issues is to be conducted, then a focused abdominal physical exam (Jensen, 2011). Since abdominal pain can be tricky to

diagnose and treat, it is important to remember which structures are located in each quadrant. Understanding the different types of pain can help identify clues to the source of the patient's pain (Holcomb, 2009). For the majority of patients with abdominal complaints, the most successful way to identify the source of their compliant is through their medical history. The abdomen is such a complicated area and a complaint of pain could be caused by many different factors. There is also the issue of referred pain, which is common in the abdomen. A strong nursing assessment is important to narrow down causes, in order to make an accurate medical diagnosis (Jensen, 2011).
First, the nurse should perform a general observation of the overall patient, to observe the patient’s positioning. Take note of any abdominal guarding, excessive movement or fidgeting. Conduct a visual inspection of the abdomen looking for masses, checking the skin for discolorations or textures such as rashes, lesions, or dilated veins. Determine if the abdomen is flat, convex or concave. Assess for symmetry, distention or bloating.
Next, perform auscultation in the four quadrants for at least 15 seconds each, note the number of clicks and gurgles. There should be 5-35 high-pitched clicks. Auscultation is performed before percussion or palpation, since both can disrupt normal bowel sounds (Jensen, 2011).
Next, palpation in each quadrant. Including spleen, liver and kidneys. Take note of any pain or tenderness. The types of pain include rebound, deferred, and guarding.
Next, perform percussion to identify borders of the spleen and liver. Checking for tymphany sounds over air filled spaces such as stomach and intestines, and a dullness over solid areas such as the liver and spleen. An unexpected type of sound can indicate an issue such as a tumor, or bleeding (Jensen, 2011).
Health history and a good subjective assessment are really important. When conducting a pain assessment, remember OLDCARTS, which stands for: Onset, Location, Duration, Characteristics, Associated or Aggravating factors, Relieving factors, Timing, and Severity. In addition, to evaluate pain, acquire information concerning Intensity, Quality, and Description (Jensen, 2011).
When assessing pain the first question to ask should be: Where is the pain?

This can give the nurse a place to start the focused exam. Where is the pain located, is it localized or does it radiate, is the pain intermittent or continuous. Ask the patient when the pain began. How long have you had this pain? Ask characteristics: Is the pain sharp, stabbing, burning, dull, is there tenderness, or cramping. Determining the type of pain can be used to identify the type of issue. There is visceral pain, tension pain, and inflammatory pain, each of which corresponds to different types of condition. Describe the quality, and intensity; ask about severity on a scale of 1 to 10. What makes the pain better, or worse? Find out if she has had any recent trauma or surgeries. Does food make the pain better or worse and if so, how long after eating? The answers to this question can help to identify if there is an issue in the digestive system and can narrow down a location. Determine if there are associated signs and symptoms such as fever, nausea, vomiting, weight loss, heartburn, rectal bleeding. Determine if she has vomiting and fever. Vomiting associated with the pain, may suggest an infection. Ask the patient if the abdominal pain began before vomiting. Assess for cholecystitis in this patient. Even though the patient reports pain in the LLQ instead of the RUQ, the patient is female and over forty, which are two criteria of cholecystitis (Holcomb, 2009). If she reports nausea and vomiting and bowel changes, ask about recent travel, what she may have eaten while away. The patient could have been exposed to Hepatitis A. Ask about her normal eating habits, have they changed recently, is she dieting. Has there been any recent unexplained weight loss or gain. Ask if the patient is taking new medications that might cause abdominal pain such as NSAIDs, Acetaminophen, aspirin, antibiotics, laxatives, or weight loss drugs. What is her alcohol intake, and is she taking any other

substances. Take a personal and family history of food allergies, gastrointestinal conditions such as GERD, ulcers, ulcerative colitis, Crohns, irritable bowel syndrome, inflammatory bowel disease, hiatal hernia, ulcers, liver issues including Hepatitis, gallbladder issues, appendicitis. Also, ask about a family history of colorectal cancer, as this increases the risk of cancer for the patient. Ask when was the last bowel movement, and how often she moves her bowels. Ask about stool consistency, frequency, amount, and if there is any blood present in the stool. Ask if the stool floats or sinks and if there is mucus or change in odor, ask about the presence of blood, and the color of stool. Stool that is grey white, or chalky indicates an issue (Jensen, 2011). Ask questions about urinary history. Ask if there is incontinence, frequency and urgency, dysuria. Abdominal distention and low urinary volume may indicate urinary retention. A Doppler ultrasound can be used to scan the bladder (Holcomb, 2009).
For females, take a reproductive history. Patient is female and is within childbearing age, so questions about pregnancy should be asked. These include: When was the last period, is the patient sexually active, does she use birth control, does she have a history of sexually transmitted diseases. The patient could be pregnant and unaware; the pain could indicate an ectopic pregnancy (Jensen, 2011).
To collect further information during the assessment, perform some diagnostic lab tests, including:
• A complete blood count for anemia and bleeding.
• A basic metabolic panel to check electrolyte levels.
• A BUN to check for renal and hepatic function.
• A stool specimen and fecal occult blood test for pathogens and blood in the stool.
• A CT scan of the abdomen and pelvis.
• A colonoscopy to check for colorectal cancer and polyps (Holcomb, 2009).

As a final note, some issues to consider in the patient with LLQ pain include problems with the sigmoid and descending colon, small intestine, including cancer, constipation, and diverticulitis. Also, consider an ectopic pregnancy in the female patient with LLQ pain (Jensen, 2011).