Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 39: Nursing Assessment: Gastrointestinal System Answer Guidelines 1. Possible causes of acute abdominal pain include the following: Appendicitis Bowel obstruction Cholecystitis Diverticulitis Gastroenteritis Pelvic inflammatory disease Perforated gastric or duodenal ulcer Pancreatitis Peritonitis Ruptured abdominal aneurysm Ruptured ectopic pregnancy 2. The most urgent of these problems are those that include bleeding and compromised circulation. A ruptured aneurysm or ectopic pregnancy is on that list. Appendicitis, diverticulitis, or a perforated ulcer can cause rapidly developing infection or shock, and they need to be considered emergent conditions. 3. The proper approach to this problem is a judicious combination of the emergency and focused assessments. The vital signs are particularly important in this case because of what they reveal about the circulatory status of the patient. Increasing pulse rate and decreasing blood pressure are signs that the patient may be experiencing shock. 4. A quick but thorough assessment of the pain is essential. You should investigate her pain using the eight questions on these topics outlined in Table 3-2: Location Quality Quantity Chronology Setting Aggravating and alleviating factors Associated manifestations Meaning of the symptom to the patient You should determine whether the pain has spread or moved to new locations (quadrants) and what makes the pain worse or better. You also should determine whether the pain is associated with other symptoms, such as nausea, vomiting, changes in bowel and bladder habits, or vaginal discharge or bleeding in women. 5. You should inspect the abdominal contour for symmetry and distention, auscultate for bowel sounds (remember to auscultate before palpation), and palpate the abdominal quadrants using a light touch and, if appropriate, a deep technique. You are assessing the presence or absence of bowel sounds and possible hyperactive bowel sounds. You want to know if there is rebound tenderness on palpation, because this finding may indicate peritoneal inflammation (possibly caused by peritonitis). 6. The following are possible diagnostic studies that would be done in the emergency department: CBC and electrolytes
Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Assessment Case Study

39-2

Amylase level Pregnancy tests Clotting studies Blood type and crossmatch The following are possible initial interventions: Ensure patent airway. Administer oxygen by nasal cannula or non-rebreather mask. Establish intravenous access with a large-bore catheter, and infuse warm normal saline or lactated Ringers solution. Insert an indwelling urinary catheter. Obtain a specimen for urinalysis. Insert a nasogastric tube as needed. Anticipate surgical intervention. Keep the patient on no oral intake (NPO).

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.