Types of Patients IV: Abdominal Pain

Part of the art of medicine is the differential diagnosis.

As mentioned before, with chest pain patients, the differential diagnosis--the things that could be wrong with the patient, given the symptoms--includes gastrointestinal problems like heartburn, respiratory problems like pneumonia, and connective tissue problems like costachondritis.

A complaint that we encounter frequently in the ER is abdominal pain, a disorder that is particularly subject to the vagaries of the differential diagnosis.

The abdominal cavity includes a variety of organs--stomach, liver, gallbladder, intestines large and small, pancreas, spleen, even a couple of kidneys and a bladder--any one of which can be anatomically or physiologically compromised. In fact, there are so many potential problems with the gut that it is divided into four quadrants for the purposes of assessment.

Patients with abdominal pain may have associated symptoms. Nausea and vomiting are common, as well as diarrhea. Loss of appetite and/or weight loss are not uncommon.

The primary nursing response to abdominal pain is differentiated by location of pain as well as the sex of the patient. If the patient is male, it is presumed that abdominal pain is gastrointestinal in origin. Why? Because there is less in the male abdominal cavity than there is in the female's, and almost all of it is the gastrointestinal tract.

In both men and women, right lower quadrant pain (RLQ) is suggestive of appendicitis. RUQ (right upper quadrant) pain is suggestive of cholethiasis, or gall bladder problems, perhaps liver disease in someone with a history of hepatitis or alcoholism. LUQ and LLQ pain are suggestive of ulcers, bowel obstructions, pancreatitis and/or constipation.

For women, the organs of sexual reproduction complicate the diagnosis. In addition to the above mentioned afflictions, women of child-bearing years can experience abdominal pain as the result of pregnancy, ectopic pregnancy, endometriosis, ovarian cysts, ovarian torsion (a twisting of the ovarian and/or fallopian tube), etc.

What does an ER nurse do?

After vital signs and a focused assessment of the abdomen (auscultation of bowel sounds, palpation of the abdomen, history of current pain as well as medical history), the nurse will assess for possible dehydration (the result of excessive vomiting and/or diarrhea, lack of intake) and initiate an IV infusion of normal saline. A blood draw for labratory tests may be conducted at this time.

The nurse will expect MD orders for some sort of anti-emetic (for nausea and vomiting), narcotic (for pain), and some sort of radiographic procedure depending upon the complaint and location of the pain.

Again, the differential diagnosis is informative. If constipation or bowel obstruction is suspected, an abdominal xray series may be ordered. If gallstones or gallbladder disease is suspected, or if gynecological problems are suspected, an ultrasound may be ordered. Other complaints may warrant a CAT scan.

The three objectives are to hydrate; decrease or eliminate nausea,vomiting, and/or diarrhea; and make the patient more comfortable.

Rarely do patients die of abdominal pain, however, there are some abdominal problems that are life-threatening. An aneurysm of the abdominal aorta, ischemic bowel, ruptured appendix, etc., can all be life-threatening and may require immediate surgery.

Again, the differential diagnosis must be ever-present in mind when a nurse triages and cares for a patient with abdominal pain. Unless otherwise specified, an emergency nurse must expect the worst and plan for it.

And when it turns out to be that the patient is just FOS (full of shit, i.e., constipated), then the bases have been already covered.