ABDOMINAL PAIN
Overview
Abdominal pain is a common problem in children. Although most children with acute abdominal pain have self-limited conditions, the pain may be indicative of a surgical or medical emergency (Leung & Sigalet, 2003). Abdominal pain in children is a complicated complaint in the emergency care setting. The chief complaint of abdominal pain comprises approximately 5% to 10% of emergency department visits annually (Kendall & Moreira, 2016). Although many cases of abdominal pain are not life threatening, there are a multitude of causes that may require emergent intervention from emergency room nurses.
Background
Abdominal pain comprises a significant portion of emergency department visits annually (Kendall & Moreira, 2016). Although abdominal pain affects all patient populations, there are key demographics that may have a more significant course, and include the elderly aged 65 years and older, and immunocompromised patients, such as individuals living with HIV. Individuals from these at-risk populations have disproportionately higher rates of mortality and morbidity compared to younger adults with a functioning immune system. In the emergency department, nurses usually are the first point of contact for the patient, and it is important that they are able to recognize life-threatening emergencies and care for the patient appropriately (Cole, Lynch, & Cugnoni, 2006).
The abdomen can be broadly divided into four quadrants: right upper, left upper, right lower, and left lower. Additionally, the epigastric area, just under the xiphoid process, is a key area for assessment. Understanding the location of pain may help in determining the cause of the origin of the pain. Right-upper quadrant pain may be because of cholecystitis, hepatitis, or ulcers. Left-upper quadrant pain may involve the spleen or stomach. Right-lower quadrant pain may be appendicitis or diverticulitis, and left-lower quadrant pain may be from colitis, or diverticulitis. Depending on the gender of the patient, lower abdominal pain can stem from genitourinary processes such as ectopic pregnancy and pelvic inflammatory disease in the female, or testicular disease in the male patient. Diffuse abdominal pain can be from a multitude of causes (Penner, Fishman, & Majumdar, 2016).
Pediatric patients with abdominal pain pose a challenge with diagnosis and may vary widely with age. In the infant through toddler years, patients may not be able to adequately describe their pain. Many of the differential diagnoses remain salient; however, in the very young infant, consider pyloric stenosis, intussusception, Hirschsprung’s disease, and Meckel’s diverticulitis. Pediatric patients may become dehydrated faster than adults, so fluid balance is key. Also, 6pediatric patients can cardiovascular compensate longer than adults; however, when the decompensation occurs, it happens rapidly. To assess a pediatric patient frequently and thoroughly, keep a high index of suspicion for serious disease.
In the pediatric population, gastroenteritis is the most common cause of abdominal pain. Viruses such as rotavirus, Norwalk virus, adenovirus, and enterovirus are the most frequent causes of abdominal pain. The most common bacterial agents include Escherichia coli, Yersinia, Campylobacter, Salmonella, and Shigella (Leung & Sigalet, 2003).
Appendicitis is the most common surgical condition in children who present with abdominal pain. Approximately one in 15 pediatric patients develop appendicitis. Lymphoid tissue or a fecalith obstructs the appendiceal lumen, the appendix becomes distended, and then ischemia and necrosis may develop. Patients with appendicitis classically present with vague, visceral, and poorly localized, periumbilical pain. Within 6 to 48 hours from onset, the pain becomes parietal as the overlying peritoneum becomes inflamed; the pain then becomes well localized and constant in the right iliac fossa (Leung & Sigalet, 2003).
Clinical Aspects
ASSESSMENT
A thorough history is required when evaluating children with abdominal pain to identify the most likely cause. An initial history and evaluation followed by a physical examination and a reassessment of certain points of the history should be conducted to narrow the list of suspicious etiologies (Leung & Sigalet, 2003). Children who are unable to verbalize typically present with late symptoms of disease and children up to the teenage years have a poor sense of onset or location of pain. A classic sequence of shifting pain usually occurs with appendicitis and any child with pain that localizes to the right-lower quadrant should be suspected of having appendicitis (Leung & Sigalet, 2003). Moreover, inquiry into the location, timing of onset, character, severity, duration, and radiation of pain is very important but must be viewed in the context of the child’s age. Any abnormalities during the initial evaluation should be addressed immediately, and only after this should further assessment be performed.
Once it has been established that the patient is otherwise stable, a thorough history and physical examination may commence. All patients should receive a thorough SAMPLE history. This includes signs and symptoms, allergies, medications, past illnesses, last oral intake, and events leading up to the present illness. The patient’s pain should be characterized utilizing the OPQRST mnemonic, which evaluates onset, provocative and palliative factors, quality, radiation, site or location, associated signs and symptoms, and time. With abdominal pain, the location of pain may help to narrow the differential diagnosis although it should not be relied on as many etiologies of abdominal pain can vary from patient to patient. The character and nature of it can also help to narrow the diagnosis. There are three main types of pain described as visceral, somatic, and referred. Visceral pain is typically described as dull and unable to localize, and usually 7originates from solid organs and the walls of hollow organs. Somatic pain is usually described as sharp and can be localized, and is usually caused by inflammation ischemia or peritoneal irritation. Referred pain is pain that is felt at a location distant from its originating source. This is a key concept to remember as several potentially life-threatening disease processes may be felt as abdominal pain but do not originate in the abdominal area; a key example of this would be myocardial ischemia presenting as epigastric pain.
NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS
Initial nursing interventions should include ensuring that airway, breathing, and circulatory status are adequate and secure. All undifferentiated abdominal pain in patients should have nothing by mouth in the case that surgery may be necessary. Pediatric patients are at high risk for dehydration and should have intravenous access secured early, preferably with a large-bore intravenous (IV) catheter in the antecubital space. This is important should fluid resuscitation be necessary; additionally many diagnostic imaging modalities require this for IV contrast administration. The nurse should prepare to obtain diagnostic samples of blood and urine. Local protocol should dictate when and how to obtain the samples. Laboratory evaluation should be tailored to the individual patient to avoid unnecessary testing; however, in some clinical settings, there are established nursing protocols and these should dictate the nurse’s plan of care.
OUTCOMES
When discussing any clinical disease process, it is important to discuss outcomes. Regarding abdominal pain, the main outcome in the emergency department setting is rapid exclusion of life-threatening causes of pain that require emergency intervention. This includes timely diagnosis, early consultation with specialists including surgery, and collaboration with ancillary departments. Pain control is also a significant outcome measure (Kendall & Moreira, 2016). Once an appropriate physical examination has been conducted, pain control should be a priority. Pain should be assessed and reassessed frequently by utilizing a developmentally appropriate pediatric pain scale (Ball, Bindler, Cowen, & Shaw, 2017). The ultimate outcome is to reduce mortality and morbidity.
Summary
Abdominal pain is a common complaint in the emergency department, with a wide variety of potential causes. Although a large portion of pediatric patients with abdominal pain do not have a specific cause of their pain, there are a few disease processes that are immediately life threatening. It is crucial that emergency department nurses can recognize the spectrum of possible causes of pain, be able to recognize unstable or ill patients, and institute appropriate interventions. The key to most abdominal pain complaints is a thorough history and physical examination, with assistance from appropriate laboratories and imaging as necessary.
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