Download Abdominal Pain Part II Jassin M. Jouria, MD Dr. Jassin M. Jouria is a

Abdominal Pain
Part II
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of
academic medicine, and medical author. He
graduated from Ross University School of Medicine
and has completed his clinical clerkship training in
various teaching hospitals throughout New York,
including King’s County Hospital Center and
Brookdale Medical Center, among others. Dr. Jouria
has passed all USMLE medical board exams, and has served as a test prep tutor and
instructor for Kaplan. He has developed several medical courses and curricula for a variety
of educational institutions. Dr. Jouria has also served on multiple levels in the academic field
including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject
Matter Expert for several continuing education organizations covering multiple basic medical
sciences. He has also developed several continuing medical education courses covering
various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the
University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an emodule training series for trauma patient management. Dr. Jouria is currently authoring an
academic textbook on Human Anatomy & Physiology.
ABSTRACT
Abdominal pain is one of the most common complaints that patients make to
medical professionals, and it has a wide array of causes, ranging from very
simple to complex. Although many cases of abdominal pain turn out to be
minor constipation or gastroenteritis, there are more serious causes that
need to be ruled out. An accurate patient medical history, family medical
history, laboratory work and imaging are important to make an accurate
diagnosis. Initial assessment and diagnostic testing will provide an early
indication of cause and the possible treatment options, which are discussed.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 4 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Health professionals in acute and non-acute health settings need to be able
to recognize overt and subtle signs of conditions associated with abdominal
pain in order to properly treat and/or refer to a specialist.
Course Purpose
To provide nurses with knowledge of the causes and treatments of acute and
chronic abdominal pain.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on
page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned
will be provided at the end of the course.
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1. The most common locations of referred abdominal pain include
a.
b.
c.
d.
face, wrist, elbows, hands.
back, shoulders, chest, groin.
internal organs only.
skin or peripheral areas only.
2. Pain referred to the chest is commonly caused by
a.
b.
c.
d.
gallstones.
bowel obstruction.
gastroesophageal reflux disease.
None of the above
3. True or False: The clinician should base a diagnosis of abdominal
pain solely on the region of associated pain.
a. True
b. False
4. In a study published in the Journal of Clinical Nursing, nursing
perceptions of barriers to adequately control a patient’s pain
included:
a.
b.
c.
d.
Lack of clinical guidelines.
Lack of standard assessment tool for pain management.
Limited autonomy when making decisions about pain control.
All of the above
5. Recurrent abdominal pain is
a.
b.
c.
d.
mild, nagging pain with no resolution.
chronic, intermittent pain with separate episodes within 3-months.
more often seen among children.
Answers b., and c., above
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Introduction
A complicating dynamic in the diagnostic workup of a patient with abdominal
pain is the varied typical or atypical pain symptoms and the wide range of
conditions that could occur in a clinical scenario. As mentioned in Abdominal
Pain Part I, the assessment of pain in the abdomen can be a challenge to
diagnose. A thorough patient history is necessary to help isolate potential
cause and to identify correct treatment. Additionally, the physical
assessment of the abdomen and corresponding diagnostic tests must involve
a systematic, standard approach to foster a correct diagnosis of the cause of
abdominal pain.
Abdominal Pain And Anatomical Location
While abdominal pain is often broken down into anatomical location, it is
important to recognize that often pain in the abdomen may result from an
obscure cause, which can complicate diagnosis. Pain may also be referred
from the site of origin. The following section covers some of the types of
pain and correlating acute or chronic disease conditions.
Referred Pain
Referred pain is felt in a site other than the original location of injury or
pathology. By understanding common sites of referred pain, the clinician
may be able to quickly isolate the underlying cause of the pain the patient is
having, both within the abdomen and at a distant site. The patient may have
abdominal pain that is also referred to other parts of the body; and, the
original abdominal pain may or may not still be present. Often, sites where
pain is referred are innervated along the same pathways as the abdominal
pain.1
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Referred pain may make the abdominal assessment more complex.
Abdominal pain is still usually present, and the initial pain may have
worsened in intensity to the point that the pain radiates to other locations.
When pain is present in both the abdomen and a referred location, it can be
difficult to pinpoint the exact cause, what makes the pain worse or relieves
it, and how long the type of pain has been present. Some of the most
common locations of referred abdominal pain include to the back, shoulders,
chest, or groin.
Back Pain
A number of painful conditions in the abdomen can cause referred pain in
the back. Pain that originates in the pancreas, liver, gall bladder, abdominal
aorta, stomach, and kidneys may all cause discomfort that is felt not only in
or near these structures, but also in areas of the back. Affected organs such
as the liver, gall bladder, and stomach will typically cause referred pain in
the center of the back; whereas, the kidneys tend to radiate pain to the
lower back.
Fortunately, referred pain tends to radiate to the same locations in most
people. For example, individual patients who present with gall bladder pain
will tend to have similar type referred pain to the center of the back. The
healthcare provider should learn and understand the common areas of
referred pain so that he or she can quickly recognize referred pain locations
associated with abdominal organ dysfunction.
Pain with abdominal organs that refer to the back can often be intense and
severe, particularly when associated with damage from ischemic pain or a
significant inflammatory condition, such as severe pancreatitis. The pain
may begin in the abdomen. As the pain intensifies, nerve sensors carry the
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pain to the back. In some cases, the pain in the back may be just as much
or more severe than the pain in the abdomen.
Shoulder Pain
Pain that develops in the shoulders and that is not explained by other
events, such as an injury or disease process, may be considered referred
shoulder pain when it coincides with symptoms of abdominal pain. Pain in
the shoulders and scapula areas can be referred from one or more locations
in the abdomen. An abscess in the abdomen may radiate pain to the
shoulder, and pain from any condition that causes irritation to the
diaphragm may also radiate to this area.
Pain associated with the gall bladder, such as gallstones or pain in the bile
duct leading to the small intestine often radiates to the shoulder or scapula,
in addition to referring to the back.37 Visceral pain associated with the gall
bladder may be referred to the shoulder because the pain messages travel
along a shared dermatome, which is an area of skin that receives sensation
from the same spinal nerve.36
Kehr’s sign refers to a condition in which a patient is suffering from pain in
the shoulder area when the injury is in the abdomen. A German surgeon,
Hans Kehr, first described Kehr’s sign after seeing a patient with severe
clavicle pain due to a splenic abscess. The condition is defined as pain in the
area above the clavicle as a result of irritation of the diaphragm. The phrenic
nerve that stretches between the diaphragm and the neck carries the pain
signal from the area of abdominal injury up to the clavicle and shoulder.82
Patients who have undergone surgical procedures, such as a laparoscopy,
may develop shoulder pain. The pain is referred from the abdominal area
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from the use of air through a surgical instrument to inflate the abdomen
during the procedure. In the days following the procedure, the patient may
experience shoulder pain as the air resolves. Other medical causes of
referred shoulder pain may also develop from conditions such as
pancreatitis, or pelvic conditions such as an ovarian cyst. Some people who
develop shingles from the herpes zoster virus and have an outbreak on the
abdomen may also develop referred pain in the shoulder.38
Chest Pain
Abdominal pain referred to the chest can be frightening for the patient who
may fear that the pain has developed from a cardiac condition. Although
pain from angina is felt as pain in the chest, there are multiple potential
causes of chest pain that are not cardiac in origin, including some types of
abdominal pain.
Pain in the chest is often assumed to be cardiac in origin by affected
individuals likely because of heightened public education and awareness of
the intense symptoms associated with the threat of a heart attack. However,
unless the patient has a pertinent history or other signs that indicate the
need for cardiac testing, other forms of injury or disease should be
investigated to determine whether the patient is actually experiencing
referred pain to the chest.
Conditions such as infection of one of the abdominal organs or peritonitis are
some of the most common causes of abdominal pain referred to the chest.
Chest pain that is cardiac in nature is usually not made worse when the
clinician performs palpation during the abdominal examination. Alternatively,
if the pain in the chest is associated with another condition, the clinician can
elicit a pain response through palpation of various areas. When referred pain
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appears, a thorough abdominal exam is needed. The pain of an
inflammatory abdominal condition, such as peritonitis, can at times be
almost identical to cardiac chest pain when it is referred.83 Diagnostic testing
through laboratory and imaging studies is typically necessary to isolate the
actual cause of the pain.
Pain from gastrointestinal disorders, such as reflux or peptic ulcer disease,
may cause chest pain. The pain can be distinguished from cardiac pain by
discussing time, onset, and duration of symptoms.83 For example, a patient
with gastroesophageal reflux disease (GERD) may complain of pain in the
chest; and, in order for the clinician to determine whether the pain is not
cardiac in origin but, rather, associated with reflux, several questions should
be asked to identify the characteristics of the pain. The clinician should
determine the timing of the chest pain. Chest pain that develops within 30
minutes from the time of eating a meal and that is resolved when taking
antacids is usually indicative of GERD.
Groin Pain
Groin pain may be a confusing term, as the “groin” can refer to a number of
regions where the patient may experience pain, including the upper thigh,
hip, lower pelvis, or genitalia. It is therefore important to take a thorough
history about the patient’s pain and its preceding factors when assessing this
area as a location of referred pain.
Areas of the groin have overlapping dermatomes with some areas of the
abdomen. Consequently, when certain injuries occur in the abdomen, the
pain is referred to the groin. Some examples of abdominal conditions that
lead to pain in the groin include ectopic pregnancy, an ovarian cyst, hernia,
or aortic abdominal aneurysm. An abdominal aortic aneurysm may lead to
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pain in the hip, while pain from an ectopic pregnancy may cause pain in the
upper thigh.84
The assessment of the patient with referred pain to the groin should include
an abdominal and groin assessment, depending on whether the patient’s
history suggests an abdominal injury. The physical assessment should
include examination for bulges, enlarged lymph nodes, palpation for pain,
and rebound tenderness. Additionally, the clinician should determine
whether there are signs that a disease process is occurring within the groin
that is causing the pain, such as an infection or malignancy.84 To narrow
down the range of potential causes, the clinician should ask the patient if he
or she is experiencing signs of infection such as fever, chills, night sweats, or
weight loss; and, whether the patient is experiencing any urinary pain or
changes in bowel habits.
Abdominal Pain Assessment
The abdominal pain assessment begins with a patient history to collect
pertinent background information about past medical disorders, family or
genetic conditions, and data specific to the pain itself. Because abdominal
pain may be caused by conditions that can vary between minor and life
threatening, it is essential to gather as much information as possible as
relates to the condition to better determine a diagnosis and to provide
proper treatment.
According to the Joint Commission, patients who present with pain of any
kind should receive a comprehensive assessment that meets certain
standards. The recommended standards state that the patient should receive
an initial pain assessment and also periodic re-assessments of pain while
under medical care. The pain assessment should also include recognition of
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cultural and ethnic beliefs. The standards recommend educating involved
medical personnel about pain assessment and the management of pain, as
well as educating patients and their families about their roles in pain
management.27
Medical History
The medical history of the patient provides needed clues to pinpoint the
cause of the abdominal pain. Obtaining a patient’s history of his or her
current condition as well as past influencing factors provides a significant
source of information to understand the patient’s current state of health,
factors contributing to the condition for which care is sought, and the
potential for problems or complications associated with abdominal pain. The
history-taking portion of the exam also helps to establish a therapeutic
relationship between the provider and the patient. The provider-patient
relationship is key to successful treatment outcomes. Cooperation will be
needed to determine the source of the patient’s abdominal pain and to find
methods of treatment for relief of the condition. A helpful approach is to
consider the patient’s history at the beginning of the evaluation process to
find needed clues to solve the underlying cause of abdominal pain.
Often, medical history alone may point the clinician to the definite cause of
the disease without other diagnostic or collateral information. For example, a
patient with a history of Crohn’s disease who presents for care of abdominal
pain may already be familiar with the pain associated with a flare of the
disease. By understanding the importance of the medical history, the
clinician prepares for the physical assessment with a very specific foundation
from which to start the diagnostic process.
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The clinician should start the history-taking portion of the assessment by
first allowing time to be introduced to the patient. The initial introduction,
between the clinician and the patient, is the beginning phase of the physical
assessment. The clinician can determine a lot of information about the
patient just during this initial interaction, such as the patient’s affect, mood,
and personality; and, whether the patient appears anxious or in pain, and
the temperature of the patient’s skin through the initial handshake or touch.
The clinician should keep in mind that touching the patient should only be
done when it appears appropriate for the client’s cultural background. If the
client seems uncomfortable or appears to be of a cultural background that
does not encourage touch, the clinician should avoid this step of the initial
introduction.
In some situations, the patient may prefer to discuss his or her medical
history and undergo the exam in private, rather than talking about the
current condition with the clinician in front of family members who may be
present. For example, if a woman arrives for care with abdominal pain
secondary to suspected gynecological disease or injury, such as an ectopic
pregnancy or ovarian cyst, she may want to discuss her personal medical
history in private rather than talking about her menstrual history and current
physical complaints in front of family. Some patients are comfortable
discussing their personal information with family or friends present, while
others would rather be alone with the clinician.
The initial data about the patient may be relayed during the history-taking,
including verifying the patient’s name and age and discussing other details,
such as the patient’s occupation and marital status. The patient may be the
person giving the information or may have someone else who is the source
of the history. The clinician can use this time to determine whether the
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patient would be a good historian; for example, initial introductions and
discussions with the patient may reveal that the patient is cognitively
impaired or has a poor memory and is not necessarily the best source of
information.
When interviewing the patient for past medical or family history, there is no
specific order to obtain pain-focused data. The clinician should take cues
from the patient and work according to the patient’s response to
questioning. While it is best to avoid tangents and to not become completely
off-track from needed information during the history-intake, it is often
preferable for the clinician to listen and allow the patient’s account to direct
the flow of conversation when obtaining the history.31 Some areas of the
patient’s history require further, in-depth discussion, while other areas may
not apply to the current situation at all and can be quickly bypassed.
The clinician should try to make the patient as comfortable as possible in
order to gain the most information when obtaining the history. A patient who
is in pain is usually distracted. Furthermore, a patient with severe abdominal
pain may not be able to give much information about his or her history, and
may instead be focused on the pain felt and efforts to find a comfortable
position and to obtain relief. Although it is most likely not possible to
eliminate the pain before starting the history portion of the exam, the
patient can be assisted to find a comfortable position before being asked to
respond to questions.
After the clinician introduces himself or herself, the clinician should explain
to the patient that some questions asked will relate to their health history
and condition. The questions should start out as generalized questions and
then move into more specific ones. For instance, the clinician may begin by
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asking general questions about the client’s most recent activity to determine
the events leading up to the healthcare encounter. After gaining more
information, the clinician can then focus on specific aspects contributing to
the abdominal pain. Starting out with general questions helps the clinician to
determine which direction of questioning to follow and to narrow down
associated factors related to the patient’s condition.
If other factors are present that would impact the physical assessment, they
should be addressed at this time. The clinician may not be able to determine
the patient’s level of health literacy right away but, through discussion about
the patient’s history, can get a better idea of what the patient understands
about his or her health. It is best for the clinician to avoid using medical
jargon that would only cause more confusion for the patient, and to simplify
medical terms when providing explanations or asking questions. If the
patient needs a language interpreter, it should be arranged to prevent
confusion and misinformation during the history-taking process.
If the patient is unable to give adequate information because of pain or
other factors, the clinician may need to rely on others who have arrived with
the patient, such as family or friends. These people may or may not be good
sources of information, depending on how well they know the patient’s
history and are able to communicate what they know. In these situations, it
is best for the clinician to gather as much information as possible with the
collateral information that is available. The clinician may find out more
helpful information through the physical exam if the patient is unable to
provide much of a report about his or her personal history.
Details of the medical history that are important to discover are typically
related to those factors that can be causing the abdominal pain. Some
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information, while it may not seem to be related to the current situation,
may prove to uncover the cause of abdominal pain especially when the
cause of pain is obscure. For example, it may seem that arthritis would not
be an exact cause of abdominal pain, but when considering extra-abdominal
symptoms that may occur with some conditions, it is important to consider
arthritis as part of the patient’s medical history. Another example would be a
patient with Crohn’s disease who may develop extra-intestinal symptoms
that seem completely unrelated to the inflammation in the bowel; the
patient may also have ocular, dermatologic, or musculoskeletal problems as
well, including arthritis.24
The clinician may find out some initial information by asking general
questions to start and then switching to more specific details. General
questions at the beginning of the patient evaluation include:

Current weight and any changes in weight or appetite

Fatigue, fever, night sweats

History of alcohol or drug use and smoking history

Current medications, including prescription, non-prescription, herbal
remedies, and vitamins

Sleep habits, exercise programs, home safety issues, immunization
status, and relevant health practices

General attitude and well being
The clinician may add or adjust generalized questions based on the patient’s
response. Once the clinician learns initial information, he or she can then
focus questions to gain more specific information about the patient’s history
to include factors that may more likely contribute to the current situation.
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Other significant history to obtain about the patient’s medical background
may include:

Bowel conditions, including constipation, frequent diarrhea, or a
diagnosis of irritable bowel syndrome or inflammatory bowel
disease such as ulcerative colitis.

Pertinent childhood illnesses that would have an impact on the
current condition; for example, a history of chickenpox could
potentiate shingles development in adulthood.

Surgical history of the abdomen, including a history of an
appendectomy, colostomy, bowel resection, cesarean section,
hernia surgery, abdominoplasty, cholescytectomy, or any other
type of laparotomy.

History of liver or pancreatic disease, jaundice or changes in urine
or stools, such as dark-colored urine or clay-colored stools.

Use of non-steroidal anti-inflammatory drugs (NSAIDs), which have
been known to cause irritation to the intestinal lining.

Malignancy, whether of any abdominal organ or another site that
could lead to metastasis to an abdominal organ.

Recent gastrointestinal infections, including infectious
gastroenteritis; bacterial infections with species such as E. coli,
Shigella, or Giardia; or parasitic infections.

Difficulties with eating, chewing, or swallowing; and any history of
indigestion or gastroesophageal reflux.

Any problems with elimination, laxative use, food allergies, and
recent food and fluid intake.

Pain with urination or with sexual intercourse; for women,
information about menstrual cycles and bleeding, discharge, or
uterine cramping.
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
Difficulties with mobility, a history of back injury, problems with
walking or performing activities of daily living.

Depression, anxiety, or any other diagnosed form of mental illness.

Allergic responses to medications, rashes, eczema, joint pain,
kidney problems, or any other diagnosis of autoimmune or
rheumatic disease.
Family History
The family history may contain important components that can give clues
about the cause of the patient’s abdominal pain. The family history can also
expose potential conditions or illnesses that increase the patient’s risk of
developing pain as well. Many conditions that can cause abdominal pain may
also run in families. It is important to know whether the patient is at higher
risk of certain conditions that could be a cause of the abdominal pain.
The clinician may start with general questions about the patient’s parents
and family and their current state of health. Some general questions to start
with while taking this information include:

Are both of your parents living? If not, what was the cause of
death? How old were they when they died?

Do you have children? How many? Do any of your children have
health issues?

Do or did one or both of your parents have significant health issues
or illnesses?

Do you have brothers or sisters and do they have significant health
issues?
Following the general questions to start the family history, the clinician
should then move to ask the patient more specific questions related to the
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preliminary answers received. For example, if a patient states that his or her
father died of pancreatic cancer, the clinician can go on to ask more detailed
questions about any other history of cancer or pancreatic disease in the
family.
The clinician should outline the family history to include pertinent
information about the patient’s immediate relatives and their ages and
causes of death if they have passed away. This should include parents,
siblings, grandparents, children, and grandchildren. The family history
determines and documents the presence of chronic diseases within the
family that could have developed in the patient; and, that are either
contributing to the current abdominal pain or could possibly complicate its
treatment, such as diabetes or hypertension.
If a family member has accompanied the patient, the history-taking portion
of the assessment may be a good time to determine the type and strength
of the relationship. Relationships with family and friends can have an impact
on a patient’s symptoms. When relationships are under stress, the patient
may feel more symptoms or have an exacerbation of symptoms. Therefore,
it is important to determine if family connections are supportive or are
causing more complications to the situation.
Often, the nurse caring for the patient can assess some of the family
dynamics by observing how family members interact with each other and
with the patient. During the assessment and while talking to the patient, the
nurse may also talk with family members who are present and he or she
may have an idea of whether family seems supportive and helpful, or are
causing an added strain to the patient. For example, a patient who arrives
accompanied by his or her mother may seem tenser when the mother is in
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the room as compared to the times she is not present. The interactions
between the patient and his or her mother may seem strained or their
personalities may seem to clash. If it appears that a specific family member
seems to be causing strain for the patient, it may help to ask the patient
about how they are feeling when the other person is not present. If the
patient wants to discuss the impact of his or her family, it may help to better
understand the patient’s state of health, particularly if there are issues or
problems in the home.
Pain-Specific Questions
Once the initial information has been gathered about the patient’s personal
and family medical histories, it is time to focus on pain-specific information.
The focused history concentrates on the patient’s reasons for seeking care,
such as the issue of abdominal pain and potentially contributing factors. In
some situations, the clinician may not have much time to complete
comprehensive medical and family histories, and may need to focus more on
the specifics of the abdominal pain. While medical and family history is
important, the focused assessment specific to the pain is sometimes much
more telling. Also called the problem-oriented assessment, the focused
assessment is where the clinician asks pain-specific questions to determine
not only the type and amount of pain the patient is experiencing, but also
the patient’s concerns about medical care and pain relief.
The clinician should use the information learned during questioning about
specific details in the patient history to focus on contributing factors to the
pain, and, to narrow down the possibilities for a diagnosis. When asking
questions about pain, the clinician should try to use open-ended questions
that give the patient a chance to explain more, rather than closed-ended
questions, which result in very short or “yes” or “no” answers. For example,
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the clinician will most likely gain more information from saying, “describe
how your abdominal pain feels in your own words,” rather than, “does it hurt
when you move?”
It is also important to recognize that some clinicians may not as effectively
treat pain if the patient is expressing pain in a manner differently than the
clinician believes he or she should. Unfortunately, many clinicians have
beliefs about how patients should respond to pain. For example, if a patient
reports pain from a condition that appears to be “minor” but is crying and
screaming in pain, the clinician may believe that the patient is being
dramatic, too expressive, or seeking attention. The Joint Commission has
shown that inadequate pain management in hospitals often occurs when
clinicians do not assess pain appropriately or when the patient’s reaction to
pain does not conform to the clinician’s expectations.27
Some clinicians may also perform pain assessments incorrectly, relying on
information such as changes in the patient’s vital signs or making
assumptions about the patient’s reasons for seeking help. Vital signs are not
a reliable indicator of pain, particularly among patients who are suffering
from chronic pain. Increases in vital signs may occur at times, but elevated
heart rate, respiratory rate, or blood pressure has not been shown to be a
consistent indicator of the depth of the pain the patient is experiencing.27
Some patients, especially those who return for pain medication or continued
help with pain management, may be labeled as “drug seeking” while trying
to secure medications. While this may or may not be true, questions of the
validity of a patient’s actual pain is not a reason to undertreat pain.
There are often many variables in place that prevent some caregivers from
adequately assessing and managing pain for some patients. A study found in
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the Journal of Clinical Nursing showed that nurses caring for patients
experiencing pain identify four main issues with adequately being able to
control a patient’s pain, particularly in a critical situation. These issues are
the lack of clinical guidelines for pain management, lack of a standardized
pain assessment tool, limited autonomy when making decisions about pain
control, and the patient’s actual condition.28
Although nurses may be limited in some settings with regard to their
autonomy to control a patient’s pain, nurses can use assessment tools to
best analyze a patient’s pain and to be advocates to achieve pain control for
their patients. Additionally, if standard protocols are not in place, nurses can
work to change standards and update protocols that involve a patient’s pain
management. The act of change begins by working with patients who are
experiencing pain and analyzing their needs for pain control. The following
sections outline some of the aspects of patient evaluation and pain
assessment that nurses can incorporate into a treatment plan.
Acute versus Chronic Pain
The length of time the patient has been experiencing pain better pinpoints
whether the pain is acute or chronic. By asking the patient when the pain
began, the nurse is determining the onset of pain, which may have started
due to certain factors or may be aggravated by some factors. For example, a
patient may have felt fine until an hour after eating, when he or she slowly
developed abdominal pain in the right upper quadrant. By determining onset
and the circumstances leading up to when the pain began, the nurse can
better determine if there are causative factors. In the patient description of
pain, the abdominal pain could be related to food or digestive issues if it
started after eating a meal. Using this information, the nurse can further
narrow down possible causes, which is more likely to assist in the diagnosis.
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The onset of pain also demonstrates how the pain started and whether it
began gradually or if it started suddenly. How the pain begins also gives an
indication of the type of pain the patient is experiencing, which can better
help to determine cause. For example, acute pain from an injury may be
more likely to develop suddenly; alternatively, pain caused by ischemia may
have a slower onset but then worsens over time.27 Excruciating pain that
occurs suddenly may indicate a medical emergency that requires rapid
management to prevent life-threatening complications. Sudden, severe pain
may indicate a ruptured abdominal aneurysm or perforated viscus, requiring
emergent surgical correction.
During this phase of questioning, it also helps to ask the patient what he or
she believes is the cause of the pain. The nurse may gain much more insight
from the patient by finding out more from them about the abdominal pain,
how it started and the duration. The patient has much more information
about the situation and the circumstances leading up to the abdominal pain.
Whether or not the patient is correct in his or her belief about why they are
having pain, the patient’s opinion and thoughts about the situation can be
helpful to the nurse and to the medical provider when trying to isolate a
diagnosis.
Location of Pain
The initial complaint may be simply described as “abdominal pain,” but when
focusing the assessment on the quality and intensity of the pain, it helps to
know specifically where it hurts for the patient. Asking where the patient
feels the most pain reveals a subjective description of the most specific
location. The patient may be able to point to a certain location where it hurts
the most; alternatively, the patient may describe the pain as “all over” the
abdomen, meaning it is most likely generalized pain. Some pain, such as
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visceral pain around the organs, may feel very deep and it may be hard for
the patient to pinpoint the location of the pain. The location of the pain may
better help the nurse identify the cause of the pain if it is not obvious;
however, in some cases, pain from another site may be referred.
In addition to determining where the patient experiences the most pain, the
nurse may also ask how the pain affects the patient, or what it means to the
patient. Some of this information can be gathered through the nurse’s
observations; for instance, if the pain appears to cause the patient to be
highly anxious, the nurse may observe the patient’s anxious activity. It helps
to hear this information directly from the patient, as the patient’s subjective
explanation of how the pain is affecting him or her can better identify
response. It also makes the nurse aware of other patient factors that may
need to be medically managed in addition to treatment of the abdominal
pain, such as depression, anxiety, anger, or fear.
The nurse should ask the patient how the pain has affected his or her quality
of life and ability to perform activities of daily living. The measurement of
pain is complex, and includes soliciting information from the patient related
to how pain impacts the patient’s emotional state. Turk and Melzack, in the
Handbook of Pain Assessment state that pain disturbance is “the degree of
emotional arousal or the changes in action readiness caused by the sensory
experience of pain.”32 The emotional toll that pain takes on a patient can
impact his or her ability to perform activities of daily living. For example, a
patient in chronic pain may develop depression that can affect whether he or
she can get out of bed each morning. A patient who is anxious because of
pain may limit daily activities outside of the home.
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Pain affects physical activities as well. Some patients, particularly those who
suffer from chronic abdominal pain or conditions in which the pain returns at
regular intervals, may have adjusted their daily living habits, as the pain
takes its toll on quality of life. A patient who has chronic abdominal pain may
be more likely to feel hopelessness, depression, or feelings of helplessness,
as well as have difficulties in other areas of daily life, such as problems with
sleeping, changes in appetite, and strained relationships because of
preoccupation with the pain.27
Intensity of Pain
The intensity level of pain best describes not only that the patient is having
pain, but also how much it hurts. For some, pain may be considered mild,
indicating a low level of intensity. Alternatively, a patient with severe pain is
said to have pain of a high intensity. It can be difficult to determine how
much pain a person has by using descriptive words; calling pain “severe” or
“significant” may mean different things to the patient or the nurse. By
asking the patient to describe the pain and to use a pain scale that
illustrates the level of the pain, the nurse may better determine the level of
intensity the patient is experiencing.
The nurse may also gain better information by asking the patient to describe
the pain in his or her own words. Sometimes, when the patient is able to
describe the pain, the nurse can better imagine the extent of the situation.
Keep in mind, however, that the patient’s description may not always be the
best portrayal of the situation and some patients are very vague in their
accounts, particularly if they are in too much pain to accurately discuss the
situation. The intensity level of a patient’s pain is subjective information and
can be quite difficult to measure from the nurse’s point of view. However,
the patient’s description of the pain may be helpful to better pinpoint the
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cause of the pain, such as if the pain is described as burning, stabbing,
aching, dull, or throbbing. If the patient has difficulty describing the pain, it
may help to give a few words of suggestion, without leading in one direction
or the other, such as by saying, “would you describe this as sharp or dull
pain?”
Pain in the abdomen can be diffuse and general, meaning that it is felt
throughout the abdomen with no specific location of targeted pain. On the
other hand, some patients present with abdominal pain located in a specific
and pinpointed area that can be defined and identified. Pain that is localized
to one specific area is typical of a disease process that affects a certain area,
such as inflammation of the appendix or a bowel obstruction, while
generalized pain may be more likely associated with transient conditions,
such as intestinal gas or gastroenteritis.21 It should be noted though, that
this is not always entirely true. For example, ischemic bowel disease often
causes generalized and diffuse pain. The clinician should not base a
diagnosis simply on the region of associated pain but should instead consider
all clinical and supporting factors for why the pain is localized to a particular
area or why it is distributed throughout the abdomen and diffuse.
There are several methods of determining the intensity of abdominal pain,
such as by using a 0-10 numeric rating scale, or the Wong-Baker FACES
pain rating scale among children. The numeric rating scale allows the patient
to consider a scale between 0 and 10, where 0 is no pain and 10 is the worst
pain imaginable. The patient then rates his or her pain somewhere on the
scale as to the intensity of the abdominal pain that they are experiencing.
This numeric rating scale only works for those patients who can understand
the concept of assigning a number to the intensity for pain. One patient may
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rate very severe pain at a “5” on the scale,
while another may consider similar pain to
be a “10.”
When using the pain rating scale, the
nurse should not only assess at what level
of intensity the patient is currently
experiencing pain, but he or she should
also find out what level is tolerable for the
patient and at what level the patient may
take pain medication. For instance, a
patient may state that his or her current
pain level is an “8,” that would normally
require pain medication when the pain reaches a level of “6”; and, would
consider a level of “2” to be acceptable and tolerable. This helps the nurse to
understand the patient’s pain tolerance and other influencing factors, such
as expectations for pain control, cultural variables, and previous painful
experiences.
The Wong-Baker scale is typically used for children and among adults who
have cognitive delays or who would not understand the numeric scale. The
Wong-Baker scale uses faces that range from happy and smiling on one end
signifying no pain to sad and crying on the opposite end signifying the most
pain. This scale is easier to understand for some patients when expressing
the intensity of their abdominal pain. It may be helpful to use both the
Wong-Baker scale and the numeric intensity scale with some patients,
particularly if there is some question about whether the patient fully
understands the rating scale.
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The level of pain severity does not necessarily indicate the cause of the
abdominal pain. People have different thresholds for pain tolerance and
although it is different between people, similar pain intensities may cause
varied reactions among patients. Additionally, some patients with cultural
backgrounds that are different from the nurse may express pain differently;
some patients may also have difficulty understanding the rating scale as it
measures intensity from left to right. They may choose a random number or
a number that has special meaning, rather than choosing one that best
describes their pain. Wilson and Giddens, authors of Health Assessment for
Nursing Practice use an example of a nurse assessing pain intensity using
the pain rating scale; when asking a Native American patient about his or
her pain intensity with this scale, the patient may choose a number that is
sacred rather than using a number that coincides with the pain intensity.27 If
it appears that the patient is having difficulty understanding the pain rating
scale, the nurse may need to modify his or her approach at determining pain
intensity.
Some patients require a visual scale to better describe the intensity of their
pain. The visual analog scale can be viewed as a 10 cm line that shows the
range of pain the patient may be experiencing. Each end of the line
describes the extremes of pain from “no pain” on one end to “the worst pain
imaginable” at the opposite end. Various points on the line between the two
extremes are locations of varying intensity that move along a scale from
least intense to most intense. The patient may look at the scale and point to
a location somewhere on the line to explain how much pain he or she is
experiencing.32
The visual analog scale can be more thorough in describing pain intensity
when compared to the 0-10 numeric rating scale. The visual analog scale,
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although it may be 10 cm in length, can have more numbers than 1 to 10,
providing a greater amount of sensitivity for pain control. Instead of
choosing a number between 1 and 10 to describe the pain, a visual analog
scale may allow a patient to choose between 1 and 100. The greater number
of potential response categories makes the visual analog scale a more
sensitive instrument of determining pain intensity combined with a graphic
appeal that may be helpful for some patients.
It is important to note that the amount of pain a patient is experiencing is
also related to his or her pain threshold and pain tolerance. The pain
threshold describes the point at which a patient begins to feel pain. When a
stimulus occurs that causes pain, the pain threshold is the point when the
patient feels pain in response. Alternatively, the pain tolerance is the amount
of pain a person is able to endure before expressing it.27 The level of pain
tolerance varies between people and is based on several factors, including
previous experiences with pain, emotional health, and cultural expectations
for expressions of pain.
If medications are ordered for pain management, the nurse must reassess
the patient’s pain at periodic intervals to determine if the patient is
experiencing any pain relief. Depending on the method of medication
administration, the nurse may ask the patient again about his or her pain,
anywhere from 15 minutes to an hour after medication administration. If
intravenous medications are given, the nurse should reassess within 15
minutes, and when oral pain medications are given the nurse should
reassess within one hour. This reassessment determines if the intensity of
the patient’s pain is lessening. The nurse should ask what numeric rating the
patient would give the pain after receiving pain medication and compare that
rating with the patient’s initial pain rating, as well as his or her level of
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expected response. Frequent re-assessment of pain control is just as
important as the initial pain assessment when working with a patient who is
experiencing abdominal pain.
Duration of Pain
Intermittent pain, also sometimes called colicky pain, may start and stop at
various times. The patient may experience intense and severe pain for
minutes to hours, followed by periods of no pain. The pain may then return a
short time later. If the patient describes the pain as intermittent, the nurse
should find out how long the painful episodes occur each time and the
approximate amount of time in between when there is no pain.
Recurrent abdominal pain is a type of chronic, intermittent pain that causes
separate episodes of discomfort over a period of time. The painful episodes
may develop and cause significant pain for a while and then resolve, only to
return later. The condition is more often seen among children. Recurrent
abdominal pain is defined as at least 3 episodes of abdominal pain within a
3-month period. The pain is typically severe, limits quality of life, and
demonstrates a physical cause in less than 10% of cases.90
Recurrent abdominal pain can be frustrating and debilitating for affected
patients. When checking the pain-specific history, assessing whether the
pain is constant or intermittent may uncover not only that the patient has
intermittent pain during the most current episode, but that he or she also
has chronic and recurring pain.
One intervention method that can help with a description of pain is the
McGill Pain Questionnaire. This method was developed at McGill University in
Montreal, Canada and can be used to evaluate certain aspects of the pain by
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helping the patient with descriptions. At times, it may be difficult for the
patient to put into words how strong the pain is or to formulate a description
of what he or she is feeling. The McGill Pain Questionnaire uses three
sections: what the pain feels like, how it changes over time, and the
intensity of the pain to isolate a more specific description of the pain.29
The McGill Pain Questionnaire is a form that a patient can fill out. It is
divided into the three sections and is relatively brief, taking into
consideration that the patient may not be capable of spending a lot of time
filling out a survey when he or she is experiencing pain.
The first section contains 20 groups with various descriptive words listed
with each group. While each group is named with a heading (temporal,
spatial, punctate pressure), the patient is not expected to understand the
meanings of each. He or she must only choose from a list of words for each
section and circle one word that best describes the present pain. For
example, the section headed “temporal pain” gives choices of descriptive
words such as pulsing, throbbing, or pounding; the section titled “sensory
miscellaneous” offers descriptive words such as tender or splitting pain.30
The second section of the questionnaire discusses how the pain changes
over time. The patient is asked to choose what best describes the pattern of
his or her pain, including whether it is constant or intermittent. The
descriptions are written, and the patient only needs to circle the best
response. This section also includes factors that can increase or decrease the
patient’s pain, asking the patient to read the factors and circle those that
apply. Descriptive factors include such stimulants as alcohol, bright lights,
fatigue, eating, or cold temperatures.30
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The final section of the questionnaire discusses the intensity of the patient’s
pain. It asks such questions as “what word describes your pain right now?”
or “which word describes it at its worst?” The patient is given a list of
descriptive words that range from mild to excruciating and is asked to circle
one as an answer for each question. At the end of the questionnaire, a score
is obtained based on points assigned for the patient’s responses. A minimum
score is 0, in which the patient would most likely not be experiencing pain.
The highest score is 78 points.30
While a scoring system based on points may be helpful to determine the
severity of the patient’s pain, a numerical value to describe the pain should
not be the only evidence the nurse should use when treating pain. Although
the questionnaire assigns a numerical value for pain intensity, the form can
also be a useful tool to get an idea of how the patient describes the pain. As
stated, it may be difficult for some patients to form the right words to
describe their pain. A patient may be distracted by his or her pain to the
point of having a difficult time putting the pain experience into the right
words.
The questionnaire gives many choices to allow the patient to describe the
pain, which can better guide the nurse and medical provider toward
understanding the cause. A thorough description is much more helpful to
understand what is going on when compared to a vague account or few
words at all. Because the tool is multidimensional, clinicians can use the
information gained to narrow down factors associated with the pain and its
possible causes. For example, visceral abdominal pain, or pain affecting the
organs in the abdomen, may more likely be described as aching, somatic
pain; and, abdominal pain may also be described differently such as pain
associated with the skin and surrounding tissues.27
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Factors that relieve pain
The nurse may enquire as to whether the patient has taken any measures to
treat the pain, or to make it feel better. It is actually two dimensional,
however, because in asking if anything relieves the pain, the nurse should
also find out if there are factors that make the pain worse. For example,
some patients have discovered that some elements, such as lying in a
specific position, eating, walking, coughing, or drinking fluids have made the
pain feel worse or feel better and they may be able to describe these
activities during the physical evaluation.
Some patients have taken measures to try and relieve their pain. These
measures may range from mild to extreme, depending on circumstances.
This may include use of over-the-counter or prescription medication, which
tends to come up if the patient has taken drugs to relieve pain. The patient
may also describe other activities that have helped or that they have tried to
use to relieve the pain. Such activities as bathing, stretching, deep
breathing, distraction, direct pressure, or rest may be described. The patient
may also take this time to point out if he or she has used alternative or
complementary therapy to help with pain relief, such as massage,
aromatherapy, energy healing, or use of herbal remedies or dietary
supplements.27
If possible, the nurse evaluating the patient with abdominal pain should also
try to determine how methods of pain relief worked for the patient, and if
they found methods of pain relief successful. For example, if a patient states
that he or she has tried to put direct pressure on the painful area by
pressing on it with the hands, the nurse can follow this description with a
clarifying question by saying, “did that help the pain?” or “did that make it
worse or better?”
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A pain experience often requires coping mechanisms in order to better live
and function around the pain. Patients with abdominal pain may or may not
be aware of accommodations that they are making to better cope with pain.
For example, a person may not be aware that he or she is sitting in a
slumped position in an attempt to relieve pressure on the abdomen. The
patient may instead be too focused on finding relief from the pain.
Alternatively, many people are very aware of the strategies they have used
that have helped to control pain and those that did not help.
It is important to observe the patient’s reactions to the pain assessment and
to observe for any apparent signs of pain coping mechanisms being used.
Furthermore, some patients may not give much information about remedies
or medications they used that did not work; and, may only offer information
about what did work to relieve the pain. The clinician attending to the
patient with abdominal pain may need to explore what remedies were
successful or unsuccessful and, in particular, the use of medications that
were effective to relieve pain, or not. When treating the pain, the clinician
should learn what did not work to relieve pain in order to avoid prescribing
medications already shown to not be effective.
The nurse should ask the patient about his or her own expectations for pain
relief. Some people seek help for abdominal pain without expecting much
pain relief, particularly if they have been suffering from chronic pain or the
methods they have tried have not been successful in the past. The nurse
caring for the patient with abdominal pain should not assume that the
patient has the same beliefs about pain control as he or she does. When
asking about the intensity level of the patient’s current pain, the nurse
should also ask what level the patient would like it to be or what he or she
would expect the pain to be after treatment.
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Other Pain Signs and Symptoms
Other signs and symptoms may be present that are related to abdominal
pain. Additional signs and symptoms may develop in the abdominal region or
they may be in separate parts of the body. The nurse may ask some
questions that can better help the patient to determine what other
symptoms he or she is experiencing. For example, the nurse may ask if the
patient has had anything to eat or drink that day, how the patient’s appetite
has been, and if he or she has had a bowel movement recently. Often, these
questions can pinpoint if the patient is also having symptoms of abdominal
bloating or fullness, difficulties with swallowing, nausea, vomiting, flatus,
diarrhea, anorexia, or indigestion.
Pain may stimulate the sympathetic nervous system to cause additional
symptoms, such as sweating, heart palpitations, pallor, and rapid or
irregular breathing.27 The clinician may note these symptoms as part of the
assessment or the patient may report these feelings. A helpful mnemonic to
use when assessing any specific area of the body or discussing the patient’s
chief complaint is P-Q-R-S-T-U. In this case, if the patient’s chief complaint
is abdominal pain, the clinician can walk through this mnemonic in a
sequence to gather comprehensive information about the patient’s pain, with
less chance of forgetting to ask important questions or leaving something
out. The P-Q-R-S-T-U mnemonic stands for:26

P: Precipitating or palliative
Are there any specific symptoms precipitating the onset of the pain?
Is there anything that makes the pain worse or better?

Q: Quality
How would you describe your pain?
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
R: Region, radiation
What area of your abdomen do you feel the most pain? Does the
pain radiate to other areas of your body?

S: Severity
On a scale of 0-10, how would you rate the intensity of your pain?

T: Time
When did your symptoms start? Is the pain constant or
intermittent? Did the pain develop gradually or did it start
suddenly?

U: Understanding
What do you think is causing your pain? How does this situation
make you feel? What do you expect out of treatment for your pain?
By using this as a guide, the nurse may be more likely to remember
important questions and areas of focus without becoming sidetracked during
the assessment. Asking these types of questions also allows the patient to
elaborate on any areas that he or she wants to discuss in the patient’s own
words to explain the pain experienced.
Physical Assessment
The physical exam portion of the assessment further assists the clinician to
identify the cause of the patient’s pain, and supporting the patient’s
thoughts about the cause of his or her pain or why treatment is required.
Furthermore, the physical exam helps the clinician to decide if further steps
are necessary to formulate a diagnosis. Following the physical assessment,
the clinician may determine that lab testing, imaging studies, or other forms
of testing are needed before deciding on a diagnosis, but the physical exam
narrows down potential options and should pinpoint ideas of the cause of
abdominal pain or the need to rule out other problems.
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The initial discussion with the patient while taking the medical history will
clue the clinician into the patient’s behavior and response to the pain.
Grimacing, restlessness, or a slumped posture are physical cues that the
patient is experiencing acute pain. The patient may also be guarded and
protective of the abdomen or may lie very still and avoid much movement.
Additionally, the patient may also be making sounds in response to pain or
responding verbally through moaning, crying, screaming, or whimpering.
It is important to note that during the initial assessments when discussing
the patient’s medical or family histories or starting the physical exam, the
clinician should take note of any signs of medical emergency associated with
the abdominal pain. Signs such as hemodynamic instability, a drop in blood
pressure, and gastrointestinal bleeding evidenced by hematochezia or
vomiting blood, or rapid progression of symptoms combined with clinical
deterioration, are types of warning signs that require a quick response.
While it is important to discuss the patient’s pain and to perform a detailed
assessment, in an emergent situation the nurse should be notifying the
healthcare provider and implementing orders as prescribed. Warning signs of
the patient’s decline when he or she has abdominal pain cannot wait, as they
can quickly become life threatening and need to be addressed.36
If the patient presents with abdominal pain, the physical exam should be
focused mostly on the abdomen; however, it is important to know if other
body systems are affected and to include a review of other symptoms as
part of the physical assessment. It may not be necessary to spend an
abundance of time in other areas, but the clinician should know if other body
systems are affected. The clinician should examine, either before or after the
abdominal assessment, such areas as the:
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
skin and mucous membranes and their overall appearance,
including any areas of redness, rash, lesions, or scarring.

lymph nodes, to look for areas of enlargement or swelling.

hands and fingers, to assess for signs of cyanosis, clubbing, or
arthritis.

patient’s mood, affect, patterns of behavior, and habits.

patient’s general appearance, noting signs of poor hygiene and self
care.

other areas where the patient complains of pain, discomfort, or
abnormality.
Additionally, the clinician should have obtained a set of vital signs, including
the heart rate, respiratory rate, blood pressure, temperature, and oxygen
saturation levels. The clinician should also listen to the patient’s heart and
lungs as part of a general assessment, whether the patient complains of
specific issues with these body systems or not. The cardiac and respiratory
systems, because they send oxygenated blood throughout the body, are
fundamental points of assessment and should not be excluded as part of the
exam.
Although increased vital signs are not necessarily a sign of increased pain,
vital signs can point to potential systemic difficulties and may be a precursor
to increased health problems. For example, tachycardia may or may not be
associated with increased pain, but tachycardia, when combined with a drop
in blood pressure, can signal hypovolemia. Hypovolemia can put the patient
at risk of severe complications and should be considered if the patient’s
presentation suggests the potential for bleeding or fluid loss. Likewise, an
increase in respiratory rate may suggest an infectious process in the body
and should be noted.
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The patient with abdominal pain may be very nervous about the abdominal
exam. If the pain is severe, the patient may try several tactics to prevent
the clinician from examining or pressing on the abdomen. Most people try to
avoid pain when possible, and some patients may make attempts to avoid
the abdominal exam even knowing that the clinician needs to examine the
abdomen to formulate a diagnosis. The clinician should move slowly, if
possible, and speak in a gentle tone of voice, rather than working in a fast,
hasty manner, which may make the patient more apprehensive.
Before performing a physical
assessment focused on the
abdomen, it is necessary to
understand the location of prominent
organs within the abdominal cavity
to best determine whether they are
in the normal position and if they
are of normal size. The abdomen is
generally divided into four main
quadrants, of which each of the
abdominal organs can be classified
and described: the right and left
upper quadrants and the right and
left lower quadrants. The clinician can visualize each of the quadrants by
picturing an imaginary line running vertically down the center of the
abdomen and another horizontal line running across the center of the
abdomen in a perpendicular fashion.
The right upper quadrant consists of the liver, and gall bladder; the edge of
the liver can be palpated just under the lower margin of the ribcage. The gall
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bladder lies just under the liver, however, it is typically deep enough that it
cannot be felt on palpation. The right kidney lies deep in the abdomen,
toward the back. Other organs that may be found in the right upper
quadrant and that may be felt through palpation include the edges of the
stomach and pancreas, part of the duodenum of the small intestine, and the
abdominal aorta.1
The left upper quadrant consists of the spleen, stomach, pancreas, and left
kidney. The spleen lies behind several ribs where it is protected, but the
lower edge of the spleen may be located with palpation, especially if it is
enlarged. Next to and slightly in front of the spleen lies the stomach, which
lies mostly within the left upper quadrant but also extends somewhat into
the right upper quadrant. The pancreas also lies mostly within the left upper
quadrant but extends toward the right; and, behind these organs, toward
the back, is the left kidney.
Portions of the small and large intestine are found in the right lower
quadrant. The appendix, found near the cecum of the large intestine, is also
located in the right lower quadrant. The left lower quadrant contains the
large intestine, including the sigmoid colon. Midline between the left and
right lower quadrants is the bladder, as well as the uterus and ovaries in
female patients.1
The Abdominal Assessment
Before starting the assessment the patient must be positioned properly to
better view and examine the abdomen. If possible, the patient should lie
down on his or her back with arms at the sides and not extended above the
head. When a person stretches the arms over the head while lying supine,
the abdominal muscles stretch, which makes for an inaccurate assessment.
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It is most comfortable for the clinician to have warm hands before touching
the patient. Some people are ticklish or do not like to be touched. In this
case, the clinician may use the patient’s hands along with his or her own to
first touch the abdomen before completing the assessment using only the
clinician’s hands.1 If possible, the patient’s legs should be flexed at the
knees, rather than extended straight out; knee flexion may help the patient
to relax the abdominal muscles more and may make the examination go
more smoothly. If there is a specific location on the abdomen where the
patient is experiencing the most pain, the clinician should palpate that area
last to help the patient remain the most comfortable and to avoid muscle
tension and guarding that typically occurs in response to palpating a tender
area.
Inspection
Inspection involves viewing the abdomen as it is uncovered and exposed.
The patient should be lying supine and still in order for the clinician to best
inspect the abdomen. While abdominal organs obviously cannot be inspected
without radiographic images, the condition of the exterior of the abdomen
can often give clues as to injury or damage to internal organs, which better
guides the clinician toward further diagnostic procedures.
Lifting the patient’s shirt to see the skin should expose the abdomen. If the
patient is wearing a gown, it should be pulled up to the level of the chest
and the area below the waist draped for cover. The clinician should note the
general surface of the skin as well as the contour of the abdomen,
recognizing prominent landmarks that may be visible, such as the lower
intercostal margin of the ribcage, the umbilicus, and the iliac crests of the
pelvis. A patient who is obese may have large folds of adipose tissue that
may make certain landmarks less prominent or completely obscured.
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The clinician should note the condition of the skin, such as the presence of
rashes, visible veins, redness, or bruising. The skin should be mostly even in
color throughout. Visible veins are not an abnormal finding unless the veins
appear very dilated or distended, which is called caput medusae. This
condition can indicate portal hypertension, cirrhosis, or severe heart disease,
in which increased pressure in the veins of the abdomen is occurring;
abdominal veins can become so distended that they are visible through the
skin. Men often have hair at various locations on the abdomen, including
around the umbilicus and extending down toward the groin. The clinician
should note areas of uneven hair distribution, including thick hair or areas
that are patchy or bald.
If the patient has a rash or it appears that he or she has been scratching the
skin on the abdomen, the clinician should note the areas of irritation and
attempt to determine the cause of the pruritus. Intense itching on the skin
of the abdomen can develop with liver cirrhosis, biliary obstruction, or
infectious hepatitis. Less commonly, intense itching may also occur with
iron-deficiency anemia or a tumor.4
The umbilicus is typically in the lower midline of the abdomen, although for
some people, it may be off center. The location of the umbilicus and
anything unusual about its appearance should be noted, such as whether it
is red, if there is swelling or bruising nearby, or if a bulge is noted. Bruising
near the umbilicus is known as Cullen’s sign, which can indicate bleeding in
the abdomen and is sometimes associated with pancreatitis.
Another condition that may cause abdominal bruising is Grey Turner’s sign,
which appears as bruising around the sides of the abdomen near the flank.
Grey Turner’s sign has also been associated with pancreatitis; it may also
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indicate a severe injury to the retroperitoneum that results in bleeding,
which leads to the bruising noted on the flank.4
Movement
Peristalsis, smooth muscle contractions that moves food through the
digestive tract, is typically not seen when inspecting the abdomen. However,
visible peristalsis may appear as waves of the digestive tract seen on the
surface of the skin; and, the patient may also have other symptoms along
with the condition, including increased abdominal girth, nausea, or vomiting.
Visible peristalsis most often indicates an obstruction at some point in the
intestine.5
A patient with an abdominal aortic aneurysm may have a marked pulsation
in the abdomen that coincides with the pulse. The pulsation of the abdomen
may cause the skin above the area to move rhythmically with the heartbeat.
The movement is more prominently seen when the patient is lying supine.
Some people move the abdominal muscles while breathing. In these cases,
the abdominal wall may move up and down with respirations. Also called
diaphragmatic breathing, this method of breathing is often employed as a
form of complementary or alternative medicine because it involves deep
breathing, which can be calming. Infants also naturally use the abdominal
muscles to breathe, and movement of the abdomen may be noted with
respirations when assessing a very young child or infant.
Scars
The presence of scars on the abdomen suggests some type of injury or
medical procedure that has occurred in the area. Many times, information
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about the scars is made available through the patient’s medical history, such
as including information about past surgical procedures.
Many women who have been pregnant have striae, known as stretch marks,
which may be red or have silvery undertones. When striae follow pregnancy,
they are considered normal. Striae may also develop after weight loss in the
abdominal region, which is a normal response of the skin to stretching and
changing. Cushing’s syndrome also may cause abdominal striae, which often
appear purple; the condition causes changes in hormones that affect
fibroblasts in the skin. Normally, these fibroblasts keep the skin elastic and
flexible, but when Cushing’s syndrome develops, small tears may occur in
the epidermis and the dermis, leading to decreased elasticity and striae.4
When striae are present on the abdomen without an obvious source, such as
previous pregnancy or weight changes, the clinician should assess the
patient’s medical or family history for Cushing’s syndrome.
The clinician should also ask the patient about any large scar that has not
previously been explained through the patient’s history. Scars should be
noted and mentioned in the documentation. When documenting a scar on
the abdomen, the clinician should note its size and include approximate
measurement, its location on the abdomen, and any other prominent
characteristics, such as whether the skin is raised or hyperpigmentation is
present. Other lesions may also be present on the skin of the patient’s
abdomen and should be noted in documentation, particularly if they are near
the area of pain or are otherwise associated with the patient’s history as
related to the abdominal pain. For example, a patient may have an area of
petechiae, which indicates hemorrhage in the skin and that could be related
to abdominal trauma. Other types of lesions that the clinician may note
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when inspecting the abdomen include areas of purpura, ulcerated skin,
nodules under the skin, pustules, or blisters.
Bulges
Each person’s abdomen has a normal contour, which should be noted with
inspection. The abdomen may be flat, rounded, protruding, or concave in
appearance. A person who is not overweight or who is physically active will
most likely have a flat abdomen. Whereas, a person who is overweight or
obese may have a protuberant abdomen, and a person who is very thin or
underweight may have a scaphoid, or concave abdomen. The abdomen
should be symmetric in appearance, but the presence of bulges or
protuberances suggests an injury or hernia.
Organ enlargement may also appear as a bulge in the area where the organ
is located. For example, an enlarged spleen may be demonstrated as a bulge
in the right upper quadrant of the abdomen near the lower intercostal
margin of the ribcage. Additionally, hepatomegaly, or liver enlargement,
may be associated with backup of fluid into the liver circulation due to heart
failure or severe liver disease; it has also been seen with patients who have
abdominal infections, inflammation, or tumors, all of which can lead to
abdominal pain.
To assess for a hernia, the clinician may ask the patient to raise the head off
of the bed while the rest of the body remains flat. Alternatively, the patient
may also be asked to bear down with the Valsalva maneuver, which can
produce the same results. If a hernia is present, these actions produce a
bulge in the affected area, most commonly around the umbilicus or the
groin. The bulge appears because the action of raising the head or bearing
down increases abdominal pressure. The hernia appears as a bulge through
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the abdominal muscles in which the contents of the abdomen move and fill
the space.3
The presence of ascites, or excess fluid that has accumulated in the
abdomen, is caused by a medical condition that may or may not be
associated with the patient’s abdominal pain. Although ascites is most
commonly associated with liver disease, it can also develop in response to a
number of clinical conditions that can be painful, such as the presence of a
tumor, intestinal obstruction, or the rupture of lymphatic vessels.4 Ascites
most commonly appears as a bulging, fluid-filled abdomen that
demonstrates a fluid wave.
Because it may be difficult to distinguish ascites from adipose tissue in some
patients who are overweight, the fluid wave test can be performed to
determine whether there is fluid under the skin of the abdomen versus
excess fat tissue. To perform the fluid wave test to check for ascites, an
assistant or the patient places one hand on the abdomen at the midline near
the umbilicus. The fingers are extended and the wrist is turned so that the
flat side of the hand is pressing down 2 to 3 cm into the abdomen. The
clinician then places one hand on each side of the abdomen and taps the
side of the abdomen with one hand while keeping the opposite hand fixed in
place. If the patient has ascites, a wave of fluid can be seen passing from
one side of the abdomen to the other, under the hand placed at midline.7
Just as when assessing for abdominal movements, the clinician may note
that some patients who are very thin and who have scaphoid abdomens may
demonstrate intestinal peristalsis, which can be seen upon inspection.
Similarly, a pulsation in the abdomen of a thin person is typically the
abdominal aorta, and is a normal finding.1 The clinician should inspect the
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abdomen from several views; looking down from above while the patient lies
supine, as well as from the side at eye level to determine a transverse angle
of the contour of the abdomen. The clinician may also stand at the patient’s
feet or head to view the abdomen from these angles.
Auscultation
Auscultation is mainly performed to determine bowel motility and to listen
for normal bowel sounds while identifying any abnormal sounds in the
abdomen. Many forms of body assessment involve inspection, palpation,
percussion, and auscultation, in that order. However, when performing an
abdominal assessment, the order of assessment strategies changes slightly.
After inspection, the clinician should auscultate the abdomen before
percussing or palpating. The rationale for this is that by auscultating first,
the clinician can listen to the bowel before it has been otherwise manipulated
through the assessment process. By palpating first before auscultation, the
clinician may stimulate the bowel, which can lead to more frequent bowel
sounds and ultimately change the examination findings. Therefore, the
clinician should always auscultate first before percussion or palpation.2
Bowel Sounds
Using both the diaphragm and the bell of the stethoscope, the clinician
should assess for bowel sounds in the abdomen, listening to each of the four
quadrants. The diaphragm of the stethoscope can be used to detect highpitched sounds when it is held firmly against the abdomen; alternatively, the
bell, when held lightly against the skin, can detect low-pitched sounds.26
Under normal circumstances, bowel sounds can be heard in all four
quadrants of the abdomen, and they can be heard as gurgling or clicking
noises that happen several times per minute. The clinician should move
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around the abdomen, listening to each quadrant, although it does not
necessarily matter which quadrant is first.
Normal bowel sounds are classified as hearing these noises between 5 and
34 times per minute.1 Alternatively, absence of bowel sounds for more than
one minute upon auscultation is an abnormality that should be investigated.
If the patient recently had surgery, he or she may have decreased bowel
sounds from anesthetic. However, decreased bowel sounds indicate that the
bowel has decreased activity and is slow. The cause of reduced activity
should be identified, as it may be associated with injury or an infection.
Hypoactive bowel sounds are classified as only one or two sounds within two
minutes of auscultation.6 If no bowel sounds are heard within five minutes,
the provider should suspect significant injury or a disease process, such as
an intestinal obstruction or ischemic bowel.3
Stomach or intestinal rumbling, known as borborygmi, is the sound of gas
moving through the intestines, and is a normal part of digestion. If the
clinician auscultates frequent bowel sounds—more than six sounds within 30
seconds—the patient is said to have hyperactive bowel sounds. Hyperactive
bowel sounds may more likely be heard in patients who are experiencing
intestinal processes that cause an increase in peristalsis, such as
inflammation of the digestive tract from an infection that causes diarrhea.8
Bruits
After listening for bowel sounds, the clinician should turn over the bell of the
stethoscope to listen for bruits, which is a sound of blood in the vessels. A
bruit sounds similar to turbulent blood flow and makes a whooshing sound
upon auscultation. The turbulence is caused by abnormalities within the
blood vessel, such as atherosclerosis or hypertension.91 The bruit is usually
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heard only during systole, but in some cases, it can be heard during both
systole and diastole.
As with the other portion of the abdominal assessment, the patient should
be lying supine with the abdomen exposed to best hear an abdominal bruit.
When heard, a bruit is typically located approximately midway between the
xiphoid process and the umbilicus, in the midline of the abdomen. Other
areas to listen for include the renal and iliac arteries, which branch off from
the main abdominal aorta. The renal arteries can be heard just lateral to the
aorta at about midway between the xiphoid process and the umbilicus, while
the iliac arteries may be heard midway between the umbilicus and the
symphysis pubis.2
The presence of a bruit does not always indicate a disease process. In fact,
some bruits are considered innocent and are not the result of any form of
injury or disease. Instead, they are heard on auscultation and should be
noted while examining for other signs of possible pathology. Alternatively, a
bruit may also be a sign of a disease process that affects blood flow in major
arteries of the abdomen. This is clinically significant and should be further
investigated. A bruit is often caused by alterations in the renal circulation,
however, it may also develop from other conditions, and has been seen in
such circumstances as intra-abdominal fistulas between certain organs,
hepatoma, abdominal aortic aneurysm, ischemic bowel disease, and the
presence of tortuous arteries within the abdominal cavity.91
If the clinician hears a bruit when assessing the abdomen, there should be
further investigation of several factors, including the cause of the patient’s
abdominal pain if known; the patient’s history for cardiac or renal
abnormalities, and other signs that indicate disease of the abdominal organs.
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When documenting the bruit, the clinician should include its approximate
location and sound, whether heard on systole or diastole. If the patient has
few other symptoms, and no evidence of hypertension or cardiac disease,
the bruit may be innocent and may not cause any other problems.
Percussion
Percussion is best performed to identify masses of tissue under the surface
of the skin; percussion can determine structures that are approximately 2 to
3 inches under the skin surface,2 and can help to locate such organs as the
liver or spleen, as well as to identify any abnormal masses that are present.
The clinician should percuss in all four quadrants of the abdomen to reveal
sounds of tympany or dullness. Tympany is the resonating sound of gas or
space in the abdomen; the clinician should hear tympany with percussion
when moving over areas in which there is not a solid organ underneath.
Tympany sounds higher in pitch when compared to other sounds that may
be heard with percussion.
Alternatively, dullness with percussion suggests the presence of a solid mass
under the skin and can indicate an underlying organ, stool in the intestine,
or an abdominal mass. Dullness on percussion sounds flat and muted. It is
most often heard when percussing organs or masses, however, fluid may
also produce a dull sound with percussion. Shifting dullness is another result
of percussion that may be apparent in the patient with ascites; shifting
dullness is heard when areas of dullness are found on percussion, but they
are shifted to a different area when the patient then turns to a side.
There are two types of percussion that may be used: direct and indirect
percussion. Direct percussion notes areas of tenderness and may be used for
superficial abdominal pain, although it is more commonly used in other areas
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of the body, such as in the face. To use direct percussion, the clinician taps
the area of tenderness with two fingers while noting the patient’s response.26
Indirect percussion is more commonly used when assessing the abdomen.
To perform indirect percussion appropriately, the clinician should stretch out
the fingers of the non-dominant hand and place them flat on the patient’s
abdomen, with the middle finger hyperextended. Using the middle finger of
the other hand, the clinician taps the center of the middle finger placed on
the abdomen. The action is quick and uses a flick of the wrist when
performed properly. When percussing, the clinician then decides if the
resulting sound is tympanic or dull. Following the action, the clinician moves
to another area of the abdomen to repeat, eventually percussing all
quadrants of the abdomen.
To specifically locate the liver through percussion, the clinician should begin
in the right upper quadrant of the abdomen at the midclavicular line.
Because most of the liver lies behind the ribcage, percussion begins over the
ribs. Starting at approximately the nipple line, the clinician should percuss,
moving in a line down toward the abdomen. Percussing over lung fields will
produce resonance because of the lung tissue. This sound will change to dull
when the clinician reaches the liver through percussion. Once the clinician
reaches an area of dullness, the upper margin of the liver has been reached.
After determining the upper edge of the liver, the clinician then moves down
to the abdomen to identify the lower margin. Starting below the umbilicus,
the clinician should percuss and move upward until the sound changes from
that of tympany to one of dullness. Upon reaching this sound, the lower
margin of the liver has been found. To determine the size of the liver, the
clinician then measures the distance between the lower and upper margins
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as determined through percussion. If the liver is enlarged, the size of the
area of dullness noted with percussion will be increased.
The spleen may also be identified through percussion, although much of it
also lies above the ribcage in the left upper quadrant. However, the spleen
can be found through percussion by assessing in that quadrant of the
abdomen and listening for the difference between the resonance of the lungs
and the dullness of percussing the spleen. Percussion can particularly detect
an enlarged spleen, which may be present because of such conditions as
infection, trauma, or inflammation.
To identify the spleen through percussion, the clinician should percuss below
the level of lung resonance at the costal margin. The clinician should then
percuss laterally toward the mid-axillary line. The patient may take a deep
breath or breathe in and out during percussion in order to hear the
difference in tones, as the spleen lies quite deep and lateral in the abdominal
cavity. Identifying the spleen through percussion may more likely indicate
splenomegaly, but percussion alone does not completely confirm the
condition.9 If percussion elicits pain in any part of the abdomen, the clinician
should further consider if there is an underlying disease process that is
causing inflammation or swelling that would elicit the pain. Based on the
patient’s medical history and the physical exam, the clinician can further
investigate what condition is causing the pain from percussion.
Palpation
Palpation is the final step of the abdominal assessment. It involves using the
fingers to depress the skin and tissue and to feel for any abnormalities under
the skin. The clinician keeps the fingers together and the hand on a
horizontal level; after placing the hand flat on the patient’s abdomen, the
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clinician lightly compresses the skin
using the fingers. Light palpation
compresses the skin approximately ½
inch, while deep palpation compresses
more firmly. To use deep palpation for
assessment, the clinician uses two
hands, with one on top of the other.
The lower hand is placed flat on the
abdomen with the opposite hand
directly on top of it. Using the top
hand, the clinician applies deep, gentle pressure to the hand below. Deep
palpation is performed very carefully; the use of two hands diffuses some of
the pressure with palpation so that the clinician is not directly pushing on
one specific area with the fingers.7
To identify and palpate the liver, the clinician places the left hand behind the
edge of the patient’s back for support. Using the opposite hand and starting
below the level of the liver as found during percussion, the clinician gently
and firmly presses with the fingertips and slowly moves upward toward the
lower margin of the liver. It often helps to have the patient take a deep
breath during palpation in order to better feel the edge of the liver when the
hand contacts it. The edge of the liver is normally smooth and soft; liver
abnormalities may cause it to feel sharp or hard on its edge.1 The lower
edge of the liver is approximately 3 cm below the level of the ribcage; the
normal span of the liver is between 6 and 12 cm.3 Any abnormalities found
on liver palpation should be noted and documented.
The spleen can be identified through palpation, particularly if it is enlarged.
As noted, the spleen lies in the lateral space of the left upper quadrant; it
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cannot always be identified through palpation, however, with enlargement,
palpation of the spleen can better pinpoint an infectious process or injury
that would cause the spleen to become enlarged. To palpate the spleen, the
clinician works from below the lower margin of where the spleen normally
lies behind the ribcage in the left upper quadrant. One hand is placed behind
the back for support. Starting below the ribcage, the provider places a hand
on the abdomen and asks the patient to take a deep breath and then
breathe out. As the patient breathes in and out, the provider moves the
hands to palpate and feel for the area of the spleen. With the deep breaths
of the patient, the provider should be able to feel the edge of the spleen if it
is enlarged. It is essential to avoid manipulating the tissue too much in an
attempt to identify the spleen; if it is enlarged, too vigorous of manipulation
could result in injury to the spleen or cause it to rupture.
A patient who has abdominal pain may guard his or her abdomen,
preventing adequate palpation. Before starting this process of the
assessment, the clinician should help the patient to stay calm and to relax, if
possible. Muscle tension and rigidity often develop in response to pain, and
the clinician who palpates a tense abdomen will feel little more than
abdominal muscles. Before palpating the abdomen of a patient experiencing
pain, the clinician must first determine the location where the patient is
experiencing the most pain and then begin palpation at a distant point from
that spot.
The area of greatest pain should be palpated last. The clinician should begin
with light palpation and then follow with deep palpation. If the patient
presents with generalized abdominal pain that extends over most of the
abdomen, it may be difficult to complete the palpation component of the
assessment. Despite pain, guarding, and the patient’s attempts to stop the
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clinician from performing the assessment, the clinician should attempt to
palpate the abdomen as much as allowed in order to better gauge the
internal structures and to assess for the cause of the pain.
If the clinician suspects a certain condition based on the patient’s history and
the abdominal assessment, there are several tests that may be performed to
better define the actual cause of pain and to identify a diagnosis. The patient
who presents with acute abdominal pain most likely will have tension of the
abdominal muscles that results in a rigid and stiff abdomen. It may be
difficult for the patient to stretch out supine to participate in the abdominal
exam. If the clinician has been unable to perform much of an assessment up
to this point because of the patient’s pain, some of the tests described below
can be performed instead of portions of the abdominal examination, or they
may be done to support findings on the abdominal examination.
Murphy’s Sign
Murphy’s sign is commonly used if the patient presents with pain or
tenderness in the right upper quadrant that could suggest cholecystitis. To
perform Murphy’s sign, the clinician places the right hand flat on the
patient’s abdomen in the right upper quadrant just below the costal margin
of the ribcage. The clinician then presses down onto the abdomen several
inches while the patient lets out a breath at the same time. The patient is
then asked to take a deep breath while the clinician keeps his or her hand in
the same place. By taking a deep breath, the gallbladder is pushed up
toward the provider’s hand.
A patient with cholecystitis will typically complain of pain when taking a deep
breath with this movement and may not be able to complete the test
because of tenderness in the area. The classic result that indicates a positive
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Murphy’s sign occurs when the pain is elicited and the patient suddenly stops
trying to take a deep breath. The sharp pain induced through palpation
indicates a disease process in the area examined. Murphy’s sign has up to
90% sensitivity for cholecystitis in cases when it is performed.92
Rebound Tenderness
When appendicitis is a possibility based on the client’s presentation, a test of
rebound tenderness may elicit a response that can clarify whether further
testing is needed. Rebound tenderness is a simple test often used to identify
appendicitis or to rule out other potential causes of abdominal pain. To
assess for rebound tenderness, the clinician palpates an area away from the
tender point by pressing down at a 90-degree angle and then rapidly
releasing the pressure. As pressure is released, the clinician should watch
the patient to see if the action elicited a response and then determine if the
patient felt more pain with the pressure or with the release of pressure.
A negative sign of rebound tenderness occurs when the patient does not
complain of further pain with the maneuver.50 A patient has a positive
rebound tenderness sign when he or she feels a sharp or stabbing pain in
the abdomen when the clinician releases pressure during the test. This is
known as Blumberg’s sign. A positive test indicates some level of
inflammation within the peritoneum and is often indicative of appendicitis.50
Referred rebound tenderness may appear when the patient feels pain at an
area that is different from the rebound tenderness assessment. This may
also be similar to Rovsing’s sign, in which a positive test is indicated when
the patient feels pain in an area opposite the side initially palpated. A
positive sign for rebound tenderness or referred rebound tenderness when a
different area of the abdomen is palpated may guide the clinician toward
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further diagnostic tests to isolate and clarify whether appendicitis or
peritonitis is present.
Rovsing’s Sign
Often used to determine whether appendicitis is present, Rovsing’s sign
assesses for abdominal tenderness by palpating one side of the abdomen.
The key component of this sign is palpation of the left lower quadrant of the
abdomen; if appendicitis is present, the patient will feel pain in the right
lower quadrant, where the appendix is located. It is thought that palpation
of the left side of the abdomen stretches the muscle and tissue across the
abdomen, including over the appendix. If the appendix is inflamed, the
patient may feel pain in the area in response to the tissue contacting the
inflammation. Rovsing’s sign is also used to palpate inflammation or
tenderness of other abdominal organs as well.
A patient with appendicitis typically has pain that starts near the umbilicus
and extends toward the location of the appendix in the right lower quadrant.
The patient may be asked to cough, as coughing can increase the pain of
appendicitis. The patient may have rigid abdominal pain, tenderness with
movement and palpation, and may guard the area carefully to protect from
further pain.
Further assessment for appendicitis includes eliciting pain from pressure on
McBurney’s point, which is found halfway between the umbilicus and the iliac
crest in the right lower quadrant. Placing pressure on this point can also
elicit a pain response; this would be considered a positive McBurney’s sign
and can be used as an additional test for appendicitis.93
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Obturator Sign
The obturator sign is a specific test that can be used to determine if
appendicitis is present and causing abdominal pain. To assess for the
obturator sign, the patient lies on his or her back while the provider grasps
the right ankle and pulls back to bend at the knee. This flexes the right leg
at the hip to a 90-degree angle from the rest of the body. Turning the knee
inward internally rotates the leg. This movement shifts the obturator muscle,
which extends across the lower end of the pelvis. If the patient has
appendicitis, he or she will feel pain in the right lower quadrant as the
inflamed appendix is stretched with the internal rotation of the leg and the
movement of the muscle tissue as it passes over it.4,7
A second test that can be administered along with the obturator sign is the
psoas sign. To perform this test, the patient is turned onto the left side and
is told to lift the right leg when it is extended at the hip. The clinician places
pressure against the leg as the patient tries to lift it. The test is considered
positive when the patient experiences pain as he or she tries to lift the leg.
This action indicates that the psoas muscle, which extends diagonally from
the middle of the abdomen toward the outer portions of the lower quadrant,
is moving across the appendix. If the appendix is inflamed, the rub of the
muscle over the organ will cause pain and it typically indicates
appendicitis.93
Costovertebral Angle Tenderness
A patient with distention of the renal capsule may have costovertebral angle
tenderness upon assessment. This condition may most likely result in
abdominal pain in the flank and is often caused by peritoneal abscess,
kidney stones, pyelonephritis, or occlusion of one of the renal arteries. A
positive sign of costovertebral angle tenderness occurs when the patient
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feels pain during the exam that results from stretching of the renal capsule
and stimulating associated nerves. The pain is often intense and may travel
anteriorly toward the umbilicus.51 The test is negative when the patient
simply feels the effects of the exam without any pain.
To elicit costovertebral angle tenderness, the clinician assists the patient to
sit upright with his back facing the clinician. The clinician places the palm of
one hand on the costovertebral angle of the same side; for instance, to
assess the left costovertebral angle, the clinician uses the left hand. With the
opposite hand, the clinician makes a fist and strikes the back of the hand
that is on the patient, using the ulnar surface of the fist. The test is then
repeated on the opposite side. As noted, a positive sign results in intense
pain due to the underlying disease process when this method of percussion
is performed.51
In addition to flank pain associated with the costovertebral angle tenderness,
the patient may also have pain radiating from the flank and extending down
toward the groin or the leg. The pain may be intermittent or it may wax or
wane in intensity levels. Cases of pyelonephritis also may cause nausea,
vomiting, pain with urination, weakness, fever, chills, and tenesmus.51
Similar to other types of physical tests, costovertebral angle tenderness is a
useful tool for narrowing down the scope of potential conditions that could
be causing abdominal pain.
Summary
The patient history and physical examination of a patient with abdominal
pain requires a consistent, systematic approach to determine the level of
pain and the cause of pain. The appearance of the abdomen during
inspection, and findings obtained during auscultation, percussion and
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palpation provide clues as to the location and cause of abdominal pain. While
the clinician is performing the abdominal examination, the patient is also
being asked questions about their activities prior to the onset of pain, as well
as the duration and intensity of pain. Possible correlating symptoms relating
to the upper and lower gastrointestinal systems are explored during the
physical examination.
When evaluating the patient with abdominal pain the nurse should attempt
to determine methods of pain relief that worked for the patient. A pain
experience often requires coping mechanisms to better function, which the
patient may or may not be aware about or be able to adequately describe.
Being attentive to patient posture and behaviors provide clues about how
they may be attempting to relieve abdominal pain. Often, the patient with
abdominal may be too focused on finding relief from the pain than describing
the pain felt.
Some patients may not give much information about remedies or
medications used prior to their encounter with a health provider; what
worked or did not work to relieve their pain. The clinician attending to the
patient with abdominal pain may need to explore the patient’s remedies
used to alleviate pain. When treating the pain, the clinician should learn
what did not work to relieve pain in order to avoid prescribing medications
already shown to be ineffective. Additionally, it is important to explore the
patient’s cultural beliefs and expectations for pain relief.
A thorough patient history and physical assessment is a critical component
of the complete work up of abdominal pain that includes further diagnostic
testing. The type of diagnostic testing to perform depends on many of the
aspects of the patient’s examination, as discussed in this course. The next
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course, Abdominal Pain Part III, informs the clinician on how to determine
the need for further testing, such as obscure findings during the physical
assessment or the potential for more than one cause of abdominal pain. The
clinician should consider all factors in the physical history and assessment
carefully before determining the necessity of further testing to pinpoint the
cause of abdominal pain and the course of treatment.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1. The most common locations of referred abdominal pain include
a.
b.
c.
d.
face, wrist, elbows, hands.
back, shoulders, chest, groin.
internal organs only.
skin or peripheral areas only.
2. Pain referred to the chest is commonly caused by
a.
b.
c.
d.
gallstones.
bowel obstruction.
gastroesophageal reflux disease.
None of the above
3. True or False: The clinician should base a diagnosis of abdominal
pain solely on the region of associated pain.
a. True
b. False
4. In a study published in the Journal of Clinical Nursing, nursing
perceptions of barriers to adequately control a patient’s pain
included:
a.
b.
c.
d.
Lack of clinical guidelines.
Lack of standard assessment tool for pain management.
Limited autonomy when making decisions about pain control.
All of the above
5. Recurrent abdominal pain is
e.
f.
g.
h.
mild, nagging pain with no resolution.
chronic, intermittent pain with separate episodes within 3-months.
more often seen among children.
Answers b., and c., above
6. True or False: While performing the physical assessment it is
helpful for the clinician to use clarifying questions, such as: “did
that help the pain?” or “did that make it worse or better?”
a. True
b. False
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7. Murphy’s sign is commonly used to test for gallbladder disease
and for
a.
b.
c.
d.
pain or tenderness in the left upper quadrant.
pain or tenderness in the right upper quadrant.
pain or tenderness in the substernal region.
None of the above
8. Auscultation is mainly performed to
a. listen to bowel sounds.
b. determine bowel motility.
c. determine whether there is organ enlargement.
d. Answers a., and b., above
9. Rovsing’s sign aids in the assessment of abdominal pain
a.
b.
c.
d.
by palpation of the left lower quadrant of the abdomen.
when pain is isolated to the right lower quadrant.
as an indication of inflammation or tenderness of the appendix.
All of the above
10. True or False: The Joint Commission has shown that inadequate
pain management in hospitals often occurs when clinicians do
not assess pain appropriately or when the patient’s reaction to
pain does not conform to the clinician’s expectations.
a. True
b. False
11. During abdominal palpation, organ enlargement may indicate
a.
b.
c.
d.
fluid back up into the liver circulation.
severe liver disease.
a tumor.
All of the above
12. True or False: Pain localized to one specific area is typical of a
disease process associated with transient conditions, such as
intestinal gas or gastroenteritis.
a. True
b. False
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13. The right upper quadrant consists of all EXCEPT the
a.
b.
c.
d.
liver.
gallbladder.
pancreas.
descending colon.
14. To assess for rebound tenderness, the clinician palpates an area
away from the tender point by pressing down
a.
b.
c.
d.
at a 90-degree angle.
slowly releasing the pressure.
at a 45-degree angle.
to see if the patient felt less pain with release of pressure.
15. True or False: Pain localized to one specific area is typical of a
disease process associated with transient conditions, such as
intestinal gas or gastroenteritis.
a. True
b. False
16. Kehr’s sign refers to a condition in which a patient is suffering
from pain
a.
b.
c.
d.
in the neck.
in the shoulder.
in the abdomen.
In the back.
17. An abdominal aortic aneurysm may lead to referred pain in the
a.
b.
c.
d.
hip.
upper thigh.
back.
shoulder blades.
18. Direct percussion notes areas of tenderness and may be used
a.
b.
c.
d.
for deep abdominal pain.
with the palm of the hand to note the patient’s response.
for superficial abdominal pain.
Both a., and b., above
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19. True or False: The McGill Pain Questionnaire is a form that a
patient’s family fills out and not the patient.
a. True
b. False
20. Pain originating in the __________ will typically cause pain to
radiate to the lower back.
a.
b.
c.
d.
kidneys
liver
stomach
gallbladder
21. Pain associated with the gallbladder, such as gallstones or pain
in the bile duct leading to the small intestine often radiates to
_____________________, in addition to referring to the back.
a.
b.
c.
d.
pelvic region
neck
the chest
the shoulder or scapula
22. When certain injuries occur in the abdomen, the pain is referred
to the groin because areas of the abdomen and groin
a.
b.
c.
d.
are in the same quadrant.
are in the subphrenic region.
have overlapping dermatomes.
are proximate to the pelvic bone.
23. Chest pain ___________________ is usually not made worse
when the clinician performs palpation during the abdominal
examination.
a.
b.
c.
d.
from a splenic abscess
caused by severe pancreatitis
that is cardiac in nature
caused by organ enlargement
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24. Conditions such as infection of one of the abdominal organs or
peritonitis are some of the most common causes of abdominal
pain referred to the
a.
b.
c.
d.
center of the back.
shoulder.
lower back.
chest.
25. True or False: Referred pain tends to radiate to the same
locations in most people.
a. True
b. False
26. Pain from an ectopic pregnancy may cause pain in the
a.
b.
c.
d.
center of the back.
upper thigh.
hip.
subphrenic region.
27. A clinician observing a patient’s affect is observing the patient’s
a.
b.
c.
d.
reaction to medication.
expression of emotion or feelings.
body temperature.
cognition and communication skills.
28. The _______________________ assessment is where the
clinician asks pain-specific questions to determine the type and
amount of pain the patient is experiencing and the patient’s
concerns about medical care and pain relief.
a.
b.
c.
d.
problem-oriented
family history
medical history
cognition-oriented
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29. Some clinicians perform pain assessments incorrectly by relying
on information such as
a.
b.
c.
d.
the problem-oriented assessment.
the patient’s cultural and ethnic beliefs.
the patient’s reasons for seeking help.
changes in the patient’s vital signs.
30. True or False: Elevated heart rate, respiratory rate, or blood
pressure has not been shown to be a consistent indicator of the
depth of the pain the patient is experiencing.
a. True
b. False
31. The ______________ scale uses faces that range from happy
and smiling on one end signifying no pain to sad and crying on
the opposite end signifying the most pain.
a.
b.
c.
d.
Rovsing’s
visual analog
Wong-Baker
McGill Pain
32. If intravenous medications are given, the nurse should reassess
the patient’s pain ___________ to determine if the patient is
experiencing any pain relief.
a.
b.
c.
d.
within an hour
within 15 minutes
the following day
at least once during the shift
33. Colicky pain is defined as pain that
a.
b.
c.
d.
is
is
is
is
intermittent.
constant.
imaginary.
typically mild.
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34. Intense itching on the skin of the abdomen can more commonly
develop with
a.
b.
c.
d.
ectopic pregnancy.
left lower quadrant abdominal pain.
liver cirrhosis.
a tumor.
35. Bruising near the umbilicus is known as
a.
b.
c.
d.
Rovsing’s sign.
Cullen’s sign.
Grey Turner’s sign.
Murphy’s sign.
36. True or False: Cushing’s syndrome causes changes in hormones
that affect fibroblasts in the skin.
a. True
b. False
37. Abdominal bruising, which appears as bruising around the sides
of the abdomen near the flank, is known as
a.
b.
c.
d.
Cullen’s sign.
Grey Turner’s sign.
Murphy’s sign.
Kehr’s sign.
38. Which of the following is sometimes associated with
pancreatitis?
a.
b.
c.
d.
Kehr’s sign.
Murphy’s sign.
Cullen’s sign.
All of the above
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39. Murphy’s sign is commonly used if the patient presents with
pain or tenderness in the _______________ quadrant that could
suggest cholecystitis.
a.
b.
c.
d.
right lower
left lower
subphrenic
right upper
40. A German surgeon, Hans Kehr, first described Kehr’s sign after
seeing a patient with severe _________ pain due to a splenic
abscess.
a.
b.
c.
d.
chest
lower back
subphrenic
clavicle
41. To perform _______________, the clinician places the right
hand flat on the patient’s abdomen in the right upper quadrant
just below the costal margin of the ribcage.
a.
b.
c.
d.
Rovsing’s sign
Murphy’s sign
the Wong-Baker maneuver
auscultation
42. Visible peristalsis most often indicates ______________ at
some point in the intestine.
a.
b.
c.
d.
an obstruction
bleeding
excess fluid
a peritoneal abscess
43. When ________________ develops, small tears may occur in
the epidermis and the dermis, leading to decreased elasticity
and striae.
a.
b.
c.
d.
a peritoneal abscess
irritable bowel syndrome
Cushing’s syndrome
Cullen’s sign
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44. Rebound tenderness is a simple test often used to identify
_____________ or to rule out other potential causes of
abdominal pain.
a.
b.
c.
d.
a peritoneal abscess
irritable bowel syndrome
appendicitis
splenic abscess
45. Often used to determine whether appendicitis is present,
_____________ assesses for abdominal tenderness by
palpating one side of the abdomen.
a.
b.
c.
d.
Rovsing’s sign
Murphy’s sign
Costovertebral angle test
Cullen’s sign
CORRECT ANSWERS:
1. The most common locations of referred abdominal pain include
b. back, shoulders, chest, groin.
2. Pain referred to the chest is commonly caused by
c. gastroesophageal reflux disease.
3. True or False: The clinician should base a diagnosis of abdominal
pain solely on the region of associated pain.
b. False
4. In a study published in the Journal of Clinical Nursing, nursing
perceptions of barriers to adequately control a patient’s pain
included:
d. All of the above
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69
5. Recurrent abdominal pain is
d. Answers b., and c., above
6. True or False: While performing the physical assessment it is
helpful for the clinician to use clarifying questions, such as: “did
that help the pain?” or “did that make it worse or better?”
a. True
7. Murphy’s sign is commonly used to test for gallbladder disease
and for
b. pain or tenderness in the right upper quadrant.
8. Auscultation is mainly performed to
d. Answers a., and b., above
9. Rovsing’s sign aids in the assessment of abdominal pain
d. All of the above
10. True or False: The Joint Commission has shown that inadequate
pain management in hospitals often occurs when clinicians do
not assess pain appropriately or when the patient’s reaction to
pain does not conform to the clinician’s expectations.
a. True
11. During abdominal palpation, organ enlargement may indicate
d. All of the above
12. True or False: Pain localized to one specific area is typical of a
disease process associated with transient conditions, such as
intestinal gas or gastroenteritis.
b. False
13. The right upper quadrant consists of all EXCEPT the
d. descending colon.
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14. To assess for rebound tenderness, the clinician palpates an area
away from the tender point by pressing down
a. at a 90-degree angle.
15. True or False: Pain localized to one specific area is typical of a
disease process associated with transient conditions, such as
intestinal gas or gastroenteritis.
a. True
16. Kehr’s sign refers to a condition in which a patient is suffering
from pain
b. in the shoulder.
17. An abdominal aortic aneurysm may lead to referred pain in the
a. hip.
18. Direct percussion notes areas of tenderness and may be used
c. for superficial abdominal pain.
19. True or False: The McGill Pain Questionnaire is a form that a
patient’s family fills out and not the patient.
b. False
20. Pain originating in the __________ will typically cause pain to
radiate to the lower back.
a. kidneys
21. Pain associated with the gallbladder, such as gallstones or pain
in the bile duct leading to the small intestine often radiates to
_____________________, in addition to referring to the back.
d. the shoulder or scapula
22. When certain injuries occur in the abdomen, the pain is referred
to the groin because areas of the abdomen and groin
c. have overlapping dermatomes.
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23. Chest pain ___________________ is usually not made worse
when the clinician performs palpation during the abdominal
examination.
c. that is cardiac in nature
24. Conditions such as infection of one of the abdominal organs or
peritonitis are some of the most common causes of abdominal
pain referred to the
d. chest.
25. True or False: Referred pain tends to radiate to the same
locations in most people.
a. True
26. Pain from an ectopic pregnancy may cause pain in the
b. upper thigh.
27. A clinician observing a patient’s affect is observing the patient’s
b. expression of emotion or feelings.
28. The _______________________ assessment is where the
clinician asks pain-specific questions to determine the type and
amount of pain the patient is experiencing and the patient’s
concerns about medical care and pain relief.
a. problem-oriented
29. Some clinicians perform pain assessments incorrectly by relying
on information such as
d. changes in the patient’s vital signs.
30. True or False: Elevated heart rate, respiratory rate, or blood
pressure has not been shown to be a consistent indicator of the
depth of the pain the patient is experiencing.
a. True
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31. The ______________ scale uses faces that range from happy
and smiling on one end signifying no pain to sad and crying on
the opposite end signifying the most pain.
c. Wong-Baker
32. If intravenous medications are given, the nurse should reassess
the patient’s pain ___________ to determine if the patient is
experiencing any pain relief.
b. within 15 minutes
33. Colicky pain is defined as pain that
a. is intermittent.
34. Intense itching on the skin of the abdomen can more commonly
develop with
c. liver cirrhosis.
35. Bruising near the umbilicus is known as
b. Cullen’s sign.
36. True or False: Cushing’s syndrome causes changes in hormones
that affect fibroblasts in the skin.
a. True
37. Abdominal bruising, which appears as bruising around the sides
of the abdomen near the flank, is known as
b. Grey Turner’s sign.
38. Which of the following is sometimes associated with
pancreatitis?
c. Cullen’s sign.
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39. Murphy’s sign is commonly used if the patient presents with
pain or tenderness in the _______________ quadrant that could
suggest cholecystitis.
d. right upper
40. A German surgeon, Hans Kehr, first described Kehr’s sign after
seeing a patient with severe _________ pain due to a splenic
abscess.
d. clavicle
41. To perform _______________, the clinician places the right
hand flat on the patient’s abdomen in the right upper quadrant
just below the costal margin of the ribcage.
b. Murphy’s sign
42. Visible peristalsis most often indicates ______________ at
some point in the intestine.
a. an obstruction
43. When ________________ develops, small tears may occur in
the epidermis and the dermis, leading to decreased elasticity
and striae.
c. Cushing’s syndrome
44. Rebound tenderness is a simple test often used to identify
_____________ or to rule out other potential causes of
abdominal pain.
c. appendicitis
45. Often used to determine whether appendicitis is present,
_____________ assesses for abdominal tenderness by
palpating one side of the abdomen.
a. Rovsing’s sign
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
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