Introduction
A nurse is the first healthcare professional many patients with abdominal pain may encounter, whether in an A&E department, walk-in centre, outpatient clinic, primary care setting ot surgical ward.
Traditional professional working boundaries are no longer fixed in the current healthcare climate (Coombs and Ersser 2004). Many nurses of all levels arc involved inthe initial assessment and treatment of a patient before a medical consultation. It is therefore desirable that in addition to traditional nutsing assessments, registered nurses are able to ask the correct questions, initiate tests and implement first-line treatments to ensure a timely and effective experience for the patient.
Abdominal pain is one of the most common reasons that people seek medical care (Kelso and Kugelmas 1 997). It may be difficult to establish the cause of the abdominal pain because of the diversity of clinical signs and symptoms. However, the history can provide 70 per cent or more of the clues to the diagnosis and must be taken accurately and carefully (Birkitt and Quick 2002, Talley and O’Connor 2006).
When assessing a patient with abdominal pain, it is essential that the nurse understands abdominal anatomy and knows the position of the abdominal organs, Duringclinical exammation the abdomen is often divided into four quadrants: right upper quadrant, left upper quadrant, right lower quadrant and left lower quadrant (Higure 1). Patients may be able to localise the position of their abdominal pain within the four quadrants and this enables the nurse to decide which organs or structures may be involved.
The structures located within the left lower quadrant are: sigmoid colon and section of the descending colon, A large membrane called the peritoneum surrounds all the organs and viscera within the abdt)minal cavity. Kidneys and ureters are situated posterior to (behind) the intraperitoneal organs and their position is described as retroperitoneal. Pain affecting these structures may not always involve the abdomen, and may manifest in the loin area (at the back of the torso between the ribs and the bips).
The bladder and reproductive organs are situated in the lower abdomen within the pelvis. Before reading on, make a list of the organs and viscera named above and briefly describe their functions. Check in an anatomy and physiology textbook to see if you are correct. About halfofthese are for abdominal symptoms, predominantly pain, and half of this group resolve withtiut operation, Tbe rest undergo emergency surgery or a scheduled procedure during the same admission (Birkittand Quick 2002),
The common causes of abdominal pain are summarised, however, this is not an exhaustive list. Appendicitis Appendicitis is the most common surgical emergency (Longmoreei a/2004). Appendicitis is inflammation ofthe appendix, and as the iniLimmatory process begins, there is colicky pain that usually starts around the umbilicus or epigastrium.
However, as the inflammation increases and the peritoneum becomes involved, the pain shifts to the right iliac fossa (within the right lower quadrant). Associated symptoms may include loss of appetite, vomiting, constipation and occasional diarrhoea. Biliary colic Biliary colic describes tbe symptoms caused by intermittent cystic duct or common bile duct obstruction caused by gallstones. Typically patients are female and overweight. Pain is usually colicky and localised in tbe right upper quadrant and in the epigastrium radiating to tbe back.
Both the small and large Intestines can become obstructed. The patient maycomplain of anorexia, vomiting with relief afterwards, colicky abdominal pain and a distended abdomen. Auscultation may reveal tinkling bowel sounds although this is not a consistent finding. Some patients may also be constipated and may not be passing any flatus, as stool and wind are unable to pass the obstruction
The position ofthe obstruction may be confirmed on abdominal X-ray. Causes of large bowel obstruction include impacted faeces, tumours and volvulus (where the intestine has twisted around itself]. Causes of small bowel obstruction include adhesions, Crohn’s disease, tumours and swallowed foreign bodies. This is defined as acute or chronic inflammation of the gall bladder, usually caused by stones of mixed chemical composition, predominantly cholesterol with some bile.
Symptoms develop from mechanical obstruction, local inflammation or a combination of these factors (Uphold and Graham 1999). Pain can be colicky or constant and is usually localised to the right upper quadrant. Associated symptoms often include anorexia. , nausea, vomiting and fever. Gastrointestinal disease Gastrointestinal haemorrhage is a common reason for acute surgical referral and is manifested by haematemesis (vomiting of blood). , rectal bleed or melaena {black, ‘tarry’ faeces or vomit that contains blood} (Birkitt and Quick 2002).
Patients may present with hypotension, shock and collapse. Peptic ulceration is the most common cause of serious gastrointestinal haemorrhage. Dyspeptic pain and tenderness in the epigastrium are the cardinal features of peptic ulceration. Vomiting may also occur, especially with a gastric ulcer. Bleeding may be seen in gastritis following alcohol or non-steroidal anti-inflammatory drug INSAID) consumption. Gastroenteritis is inflammation ofthe intestine from an infective cause. Symptoms include diarrhoea, vomiting and generalised colicky abdominal pain.
Patients may tolerate these symptoms well although severe cases can cause the patient to become pyrexial, dehydrated and systemicallyunwell. lt is a notifiable disease. Gynaecological emergencies Patients with gynaecological disorders presenting to A&E with abdominal pain may be difficult to distinguish from patients with other pathologies (Wyatt et al 2005 ). As stated earlier, the history can provide 70 per cent of the clues to the underlying diagnosis. These may include early pregnancy abortions (miscarriages), ovarian cysts and endometriosis.
