Abdominal Pain Distention

Abdominal Pain: Distention

Clinical Picture

Neuro: Anxiety, restlessness. Resp: Increased respiratory rate and/or distress. CV: Increased heart rate and/or hypotension. Skin: Fever and/or cool, pale, and diaphoretic. GI/GU: Anorexia, hyperactive, hypoactive, or absent bowel sounds, nausea, vomiting, diarrhea, constipation, GI bleeding. MS: Abdominal tenderness, distention, rigidity, guarding, flank pain, palpable pulsatile mass, fatigue, malaise.

Nursing Interventions

■ Place Pt in position of comfort and offer reassurance. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain focused symptom analysis. ■ Obtain focused history including recent events. ■ Nutritional and hydration status including last PO intake and urine output. ■ Recent bowel habits including laxatives or enemas. ■ Complete focused examination of Pt’s abdomen: ■ Inspect abdomen for symmetry and distention. ■ Auscultate bowel sounds (hyper/hypoactive or absent). ■ Palpate abdomen for masses, pulsations, tenderness, and rigidity. Note: When palpating the abdomen, do so from the area of least tenderness to the area of most tenderness. ■ Assess NG tube placement and output if applicable and initiate nasogastric suctioning if ordered. If Pt does not have NG tube in place, prepare to insert one if ordered. ■ Assess indwelling urinary catheter if applicable to ensure drainage, and record amount, color, and clarity of urine. If Pt does not have urinary catheter in place, prepare to insert one if ordered. ■ Obtain STAT bedside blood glucose level if Pt is diabetic. ■ Test emesis/NG drainage and/or stool for occult blood. ■ Obtain IV access if ordered and titrate to SBP >90 mm Hg. ■ Administer antiemetic and pain medication if ordered. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including insertion of NG tube or urinary catheter, labs (Hct and Hgb, CBC, WBC, guaiac stools, LFTs), possible return to OR (postop Pts), and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.