CHAPTER 10 Abdominal Emergencies

Lucinda W. Rossoll, RN, MS, CCRN, CEN

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Abdominal Emergencies

Gastritis

Ulcers

Bowel Obstruction

Gastroenteritis/Infectious Diarrhea

Gastroesophageal Reflux Disease

Intussusception

Pyloric Stenosis

Appendicitis

Pancreatitis

Cholecystitis

Diverticulitis

Irritable Bowel Syndrome

Esophagitis

Esophageal Varices

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain: PQRST (see Chapter 9)

b) Vomiting

(1) Timing of pain in relation to onset of vomiting

(2) Blood (color, e.g., dark brown, bright red)

(3) Bile

(4) Fecal matter

(5) Onset

(6) Frequency

(7) Duration

c) Gastrointestinal (GI) bleeding

d) Recent changes in weight

e) Changes in bowel habits

f) Changes in appetite

g) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current and preexisting diseases/illness

b) Previous surgical procedures

c) Recent foreign travel

d) Substance and/or alcohol use/abuse

e) Smoking history

f) Last normal menstrual period: female patients of childbearing age

g) Current medications

(1) Prescription

(2) Over-the-counter/herbal

h) Allergies

i) Immunization status

3) Psychological/social/environmental factors

a) Lifestyle

b) Coping patterns

c) Precipitating events

d) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Contour (flat, distended, rounded, herniation)

b) Obvious pulsating mass

c) Symmetry

d) Umbilicus (contour, location, herniation)

e) Striae

f) Diastasis rectus

g) Lesions

h) Scars

i) Discolorations

3) Auscultation

a) Bowel sounds: present or absent; character

b) Bruit

4) Palpation/percussion

a) Abdominal tenderness

b) Rigidity/guarding

c) Masses

d) Rebound tenderness with deep palpation: indicating peritoneal irritation

e) Percussion sounds: tympanic, dullness

5) Rectal examination: check stool for occult blood

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Liver function tests (aspartate aminotransaminase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH], alkaline phosphatase)

4) Serum amylase, lipase

5) Serum phosphate

6) Serum lactate

7) Sickle cell screen

8) Fecal antigen assay, urea blood test or blood (less specific) for Helicobacter pylori

9) Type and crossmatch

10) Serial hematocrits

11) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR)

12) Urinalysis; urine culture, pregnancy test in female patients of childbearing age

13) Stool for occult blood, parasites, white blood cell (WBC) count, mucus, protein, culture

14) Enzyme-linked immunosorbent assay (ELISA) of stool

b. Imaging studies

1) Flat plate abdominal radiograph

2) Upright abdominal radiograph

3) Left lateral decubitus radiograph

4) Cross-table lateral abdominal radiograph

5) Posteroanterior (PA) chest upright radiograph (to detect thoracic involvement)

6) Abdominal computed tomography (CT) scan

7) Sonography

8) Magnetic resonance imaging (MRI)

9) Barium enema

10) Upper GI series

11) Angiography

12) Nuclear scanning

13) Intravenous (IV) cholangiography

14) IV urography or cystography

15) Hepatobiliary iminodiacetic acid (HIDA) scan

c. Other

1) 12- to15-lead electrocardiogram (ECG)

2) Gastroscopy or endoscopy

3) Sigmoidoscopy/proctoscopy/colonoscopy

4) Abdominal paracentesis

5) Esophageal manometry

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Acute/chronic pain

2. Ineffective tissue perfusion

3. Impaired gas exchange

4. Deficient fluid volume

5. Anxiety/fear

6. Imbalanced nutrition

7. Constipation

8. Diarrhea

9. Risk for infection

10. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/blood products/medications as needed

d. Obtain and set up necessary equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient responses/outcomes and modify nursing care plan as appropriate

3. If positive outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatrics

a. Growth or development related

1) Immature kidney function in infants limits their ability to concentrate and dilute urine and most often results in dehydration

2) Higher percentage of water compared with body weight, higher metabolic rate, and increased insensible fluid loss make fluid, fluid/electrolyte, and acid-base balance more precarious

3) Decreased glycogen stores along with the higher metabolic rate increase the risk of hypoglycemia

4) Hypotension is a late sign of shock and does not appear until circulating blood volume is decreased by 25%

5) Diarrhea is a major cause of metabolic acidosis; potassium, glucose, and calcium must be carefully monitored

b. “Pearls”

1) Avoid restraining the child as much as possible

2) Use distraction such as television, movies, rhythmic breathing, and imagery for relaxation and pain control

3) Pain medication may be administered in various ways: intravenously, suppositories, flavored syrup elixirs, pills, or capsules in ice cream

4) When obtaining history, use face-to-face interviewing, ask specific questions to caregivers, and age-appropriate questions to child

5) Oral replacement therapy (ORT) is the rehydration route of choice for children with mild to moderate dehydration who can tolerate oral fluids. Fluids of choice for ORT include glucose water, dilute apple juice, pediatric Gatorade, oral electrolyte solution, broth, Jell-O, Kool-Aid, tea, or popsicles

6) IV fluid replacement to correct dehydration should be done with isotonic fluids and fluids containing chloride, glucose, water, sodium, and potassium

2. Geriatrics

a. Aging related

1) Obtaining a history from an elderly patient may be difficult secondary to impaired cognitive function, diminished vision, diminished hearing, and slower psychomotor responses

2) Elderly patients usually do not present with classic signs and symptoms, because of aging changes or medications. They are inclined to underreport or be vague about symptoms

3) An emergency department visit may be a crisis to an elderly person because they fear the loss of independence or that the visit may trigger a financial crisis

4) Older patients have a reduced ability to adjust to extremes in environmental temperature. Care should be taken to minimize body exposure in the elderly

5) Alterations in GI function associated with aging include decreased gastric secretions and decreased gastric motility

6) Slower metabolism of medications increases the risk of developing medication toxicities

7) Decreases in stomach acid secretion and GI tract motility can lead to nutritional problems

II. SPECIFIC ABDOMINAL EMERGENCIES

A. Gastritis

Gastritis is inflammation of the stomach that most often originates from ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, salicylates, steroids, caustic ingestion (acids, alkalis, or food with excessive seasoning), or ingestion of infected foods. Other causes include physical or emotional stress, tobacco, radiation, bacterial or viral infection, and diseases that affect the gastric mucosal cells. Chronic gastritis may be caused by H. pylori, which is present in 30% to 50% of the population. The gastric mucous membrane undergoes superficial erosion, causing excessive secretion of gastric juices containing acid and mucus. Acute episodes may cause epigastric pain, nausea, vomiting, diarrhea, anorexia, and eructations of gas. Chronic episodes of gastritis may lead to duodenal and gastric (peptic) ulcers, hemorrhage, pernicious anemia, pyloric obstruction, and perforation.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) Relieved by intake of food

(2) Squeezing, burning, dull, gnawing, colicky

(3) Epigastric area

(4) Sudden or gradual onset, may be chronic, intermittent, or constant

b) Nausea and/or vomiting

(1) Frequent nausea

(2) Vomiting (blood, mucus, undigested food)

2) Past medical history

a) Current or preexisting diseases/illness

(1) Ulcer disease, chronic indigestion, malignancy

(2) Cardiovascular disease

(3) Diabetes

b) Consumption of alcohol or tobacco use

c) Unusual or chronic tension or anxiety

d) Ingestion of an irritant (spicy foods or alcohol)

e) Medication use: NSAIDs, steroids, antacids, or over-the-counter histamine 2 (H₂) blockers

f) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Possible positive orthostasis

(2) Mild to moderate distress/discomfort

b) Inspection

(1) Hematemesis

c) Auscultation

(1) Bowel sounds: normal to hyperactive

d) Palpation

(1) Epigastric tenderness on palpation

(2) Muscular guarding

2) Diagnostic procedures

a) Serum chemistries

b) CBC with differential

c) Coagulation profile (PT, PTT, INR)

d) Urinalysis; pregnancy test in female patients of childbearing age

e) Fecal antigen assay, urea breath test, or blood test (less specific) for H. pylori

f) Radiograph flat and upright of abdomen (presence of free air)

g) Stool examination for occult blood

h) Upper GI series

i) Upper endoscopy with biopsy

j) Gastric analysis

2. Analysis: differential nursing diagnoses/collaborative problems

a. Pain

b. Risk for deficient fluid volume

c. Deficient knowledge

3. Planning and implementation/interventions

a. Establish IV access for administration of crystalloid fluid/medications as needed

b. Prepare for/assist with medical interventions

1) Initiate and maintain nothing by mouth (NPO) status

2) Insert gastric tube and attach to suction as indicated

c. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Antiemetics

4) Antacids, histamine receptor antagonist, or proton pump inhibitors

5) Anticholinergics

d. Educate patient and significant others

1) Regular diet on cessation of vomiting, medications

2) Avoid causative factors

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Pain relief

c. Intake and output

d. Gastric emesis for blood

e. Bowel sounds

f. Stools for tarry appearance and/or occult blood

B. Ulcers

An ulcer results from the sloughing of the mucous membrane of the esophagus, stomach, or duodenum. The origin is poorly understood, but ulcers commonly occur in the areas of the GI tract that are exposed to hydrochloric acid and pepsin. Duodenal ulcers occur most frequently in persons between the ages of 30 and 55 years, whereas gastric ulcers are more common in those aged 55 to 70 years. Seventy-five to 95% of persons with ulcers also have gastritis associated with H. pylori. Ulcers are more common in men, smokers, and persons who take NSAIDs regularly.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) Associated with eating or fasting

(2) Squeezing, indigestion, gnawing, colicky, aching, feeling full

(3) Epigastric, may radiate to midback

(4) Duodenal ulcer pain typically is felt before meals and relieved by food or antacids; gastric ulcer pain usually occurs after eating

2) Past medical history

a) Current or preexisting diseases/illness

(1) Ulcer disease, recurring or chronic gastritis

(2) Bleeding tendencies

b) Consumption of alcohol, caffeine, and tobacco use

c) Chronic ingestion of irritants or drugs (NSAIDs, aspirin)

d) Change in appetite

e) Medications

f) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Moderate distress/discomfort

b) Inspection

(1) Vomiting

(2) Hematemesis

c) Auscultation

(1) Bowel sounds: hypoactive or absent

d) Palpation

(1) Midepigastric tenderness

(2) Muscular guarding

2) Diagnostic procedures

a) CBC with differential

b) Serum chemistries

c) Urinalysis; pregnancy test in female patients of childbearing age

d) Fecal antigen assay, urea breath test or blood (less specific) for H. pylori

e) Type and crossmatch

f) Liver enzymes, amylase

g) Upper GI barium contrast study

h) Upper endoscopy with biopsy

i) Stool for occult blood

j) Gastric analysis

2. Analysis: differential nursing diagnoses/collaborative problems

a. Pain

b. Risk for deficient fluid volume

c. Anxiety/fear

d. Deficient knowledge

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/blood products/medications as indicated

1) Administer normal saline solution bolus(es)

2) Administer blood products

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Initiate and maintain NPO status initially

3) Insert gastric tube and attach to suction

4) Assist with hospital admission and surgical intervention as indicated

e. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Antiemetics

4) Antacids

5) Histamine receptor antagonists or proton pump inhibitors

6) Antibiotics for H. pylori

f. Educate patient and significant others

1) Bland, low-fiber diet and medications

2) Avoiding causative factors

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Pain relief

c. Intake and output

d. Gastric emesis for blood

e. Stools for tarry appearance and/or occult blood

f. Bowel sounds

C. Bowel Obstruction

An intestinal obstruction results in the inability of intestinal contents to flow normally along the intestinal tract. Obstruction may be partial, in which the bowel lumen is narrowed, or complete, in which the bowel lumen is closed. Causes include cancer, foreign bodies, strictures, hernias, postoperative peritoneal adhesions, volvulus, paralytic ileus, intussusception, Crohn’s disease, congenital defects, stenosis, and neurogenic conditions. A bowel obstruction results in the accumulation of intestinal contents, fluids, and gas proximal to the obstruction. The absorption of fluids is decreased and gastric secretions are increased. Fluids and electrolytes are lost, and increasing pressure within the intestinal lumen causes a decrease in venous and arteriolar capillary pressure. This leads to edema, congestion, necrosis, and eventual rupture or perforation of the intestinal wall.

1. Assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain (see Chapter 9)

(1) May have temporary relief after emesis

(2) Colicky, crampy, intermittent, wavelike

(3) Poorly localized

(4) Intermittent: rapid onset in small bowel, gradual onset in large bowel

2) Past medical history

a) Current or preexisting diseases/illness

b) History of abdominal surgery

c) Change in bowel habits

d) Medications

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Elevated temperature

(2) Tachycardia and hypertension in early sepsis: may become hypotensive later

(3) Moderate to severe distress/discomfort, critically ill

b) Inspection

(1) Abdominal distention: minimal (small intestine) to maximal (large intestine)

(2) Vomiting: bilious, fecal material may be present if bacterial proliferation

c) Auscultation

(1) Bowel sounds

(a) High-pitched peristaltic rush sounds proximal to the area of obstruction

(b) Audible borborygmi (hyperactive bowel sounds)

(c) Absent bowel sounds: late finding

d) Palpation

(1) Diffuse abdominal tenderness and rigidity

2) Diagnostic procedures

a) CBC with differential: possible leukocytosis with left shift

b) Serum chemistries including BUN and creatinine

c) Serum amylase and lipase: may be elevated with ischemia

d) Urinalysis; pregnancy test in female patients of childbearing age

e) Type and crossmatch

f) Stool for occult blood

g) Flat and upright abdominal radiograph

h) Abdominal CT scan

i) Barium studies

2. Analysis: differential nursing diagnoses/collaborative problems

a. Pain

b. Deficient fluid volume

c. Imbalanced nutrition: less than body requirements

d. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/medications as needed

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Initiate and maintain NPO status

3) Insert gastric tube (no benefit in use of a long intestinal tube) and attach to suction

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