NOAH CARPENTER, MD
Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.
ABSTRACT
Abdominal pain is a common physical complaint that patients report to medical clinicians, 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 conditions, such as constipation or gastroenteritis, there are more serious causes that need to be ruled out. An accurate patient medical history, family medical history, and medical testing are important to make an accurate diagnosis. Initial assessment and diagnostic testing will help to provide an early indication of the cause of abdominal pain and the possible treatment options.
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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.
Continuing Education Credit Designation This educational activity is credited for 2.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes).
Statement of Learning Need Health clinicians need to be able to recognize overt and subtle signs of abdominal disease in order to properly treat or refer patients to the appropriate medical specialist. Common causes of abdominal pain can lead to complications without appropriate treatment. Complications can vary depending on the cause of abdominal pain and duration of symptoms, as well as patient compliance with treatment and recommended surveillance.
Course Purpose To provide health clinicians with knowledge of the causes, diagnostic methods and treatments of acute and chronic abdominal pain so that patients can receive safe and appropriate options for treatment.
Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members.
Disclosures Noah Carpenter, MD, Kellie Wilson, PharmD, William Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. There is no commercial support.
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1. The most common locations of referred abdominal pain include
a. face, wrist, elbows, hands. b. back, shoulders, chest, groin. c. internal organs only. d. skin or peripheral areas only.
2. Pain referred to the chest is commonly caused by
a. gallstones. b. a condition in the abdominal aorta. c. infection of an abdominal organ or peritonitis. d. the kidneys.
3. Murphy’s sign is commonly used if the patient presents with pain or tenderness in the ____________________ that could suggest cholecystitis.
a. left upper quadrant. b. right upper quadrant c. substernal region d. right lower quadrant
4. When a clinician is accessing a patient’s abdomen, auscultation is mainly performed
a. after the clinician percusses the abdomen. b. after the clinician palpates the abdomen c. to feel if there is swelling of the appendix. d. to listen for normal bowel sounds.
5. Rovsing’s sign aids in the assessment of appendicitis by palpating
a. the left lower quadrant of the abdomen. b. the area of the abdomen where the appendix is located. c. different quadrants of the abdomen in a clockwise rotation. d. the area of the abdomen above the appendix.
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Introduction
Varied typical or atypical pain symptoms and a wide range of conditions often complicate the diagnostic workup in a case of abdominal pain. A thorough patient history is necessary to help isolate potential cause and to identify the correct course of treatment. The physical assessment of the abdomen and corresponding diagnostic tests must involve a systematic, standard approach to promote 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. This section covers some of the types of abdominal pain and any correlating acute or chronic disease conditions.
Referred Pain
Referred pain is felt in a body location other than the original site of injury or pathology. By understanding common body locations 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 location. The patient may have abdominal pain that is 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
Referred pain may make the abdominal assessment more challenging during the assessment process. 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.1 What makes the pain worse or relieves it, and how long the type of pain has been present,
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may take time to fully know. Some of the most common locations of referred abdominal pain include 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, gallbladder, 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, gallbladder, and stomach will typically cause referred pain in the center of the back, whereas the kidneys tend to radiate pain to the lower back.2-5 Fortunately, referred pain tends to radiate to the same locations in most people. For example, individual patients who present with gallbladder pain will tend to have a similar type of referred pain to the center of the back. The health clinician should learn and understand the common areas of referred pain in order to 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 and, as the pain intensifies, nerve sensors carry the 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.2-5
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.2-5
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Pain associated with the gallbladder, 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. Visceral pain associated with the gallbladder 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.
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.5 A German surgeon, Hans Kehr, first described this phenomenon 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.2-5
Patients who have undergone surgical procedures, such as a laparoscopy, may develop shoulder pain. The pain is referred from the abdominal area from insufflation of air through a surgical instrument to inflate the abdomen during a surgical procedure.2-5 Following the procedure, the patient may experience shoulder pain as the residual air remaining in the abdomen resolves. Other medical causes of referred shoulder pain may 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.2-5
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.2-5 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,
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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.2-5
Infection in one of the abdominal organs or peritonitis are 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 pain in the chest is associated with another condition, the clinician can elicit a pain response through palpation of various areas.2-5 When referred pain 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. 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 also cause chest pain. The pain can be distinguished from cardiac pain by evaluating the time, onset, and duration of symptoms. 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.2-5 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.
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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 pain in the hip, while pain from an ectopic pregnancy may cause pain in the upper thigh.
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.2-5 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.6 To narrow down the range of potential causes, the clinician should determine whether the patient is experiencing signs of infection such as fever, chills, night sweats, or weight loss, and 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 vary between minor and life threatening, it is essential to gather as much information as possible relative to the condition in order to better determine a diagnosis and to provide proper treatment.6-9 Patients who present with pain of any kind should receive a comprehensive assessment that meets certain standards. The patient should receive an initial pain assessment and periodic reassessments of pain while under medical care.
The pain assessment should also include recognition of cultural and ethnic beliefs. Patients with limited language proficiency are a vulnerable population in the United States healthcare system. Inequitable outcomes may occur during the initial and subsequent patient encounters, including during the history and physical examination that can impact patient care later on.10
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Educating involved medical personnel about pain assessment and pain management, as well as educating patients and their families about their roles and responsibilities related to pain management will help to improve care outcomes.10
Medical History
The medical history of the patient provides needed clues to pinpoint the cause of abdominal pain. Obtaining a patient’s history of a current condition as well as past influencing health factors provides a significant source of information to understand a patient’s existing 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 physical examination also helps to establish a therapeutic relationship between the clinician and the patient.10,11
The clinician-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.10,11 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.
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 facial expression, mood, whether the patient appears anxious or in pain, personality type, and the temperature of the patient’s skin through the initial handshake or touch.10,11 Touching the patient during the assessment should only be done when it appears appropriate for the patient’s cultural background. If the patient 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.10,11
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In some situations, patients may prefer to discuss their medical history and undergo a physical examination in private, rather than talking about the current condition with the clinician in front of family members or multiple members of the health team.10,11 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 (history of menses, sexual activity, diseases, etc.) in private rather than 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 there may be someone else who is a better collateral source of the patient history.10,11 The clinician can use this time to determine whether the patient would be a good person to convey their own medical history or whether there is cognitive impairment, such as poor memory, and an inability to provide accurate information.
When interviewing the patient for past medical or family history, there is no specific order by which the clinician may obtain pain-focused data. The clinician should try to take cues from the patient and work according to the patient’s response to questioning. While it is best to avoid tangents and to be side-tracked from needed information during the history-intake, it is often preferable for the clinician to listen and to allow the patient’s account to direct the flow of conversation when obtaining the health history.10,11
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. Often the patient medical history alone will lead the clinician to identify the definite cause of abdominal pain without other diagnostic or collateral information. For example, a patient with a history of Crohn’s disease who reports an issue of abdominal pain may already be familiar with the pain associated with a flare of Crohn’s disease.12 By understanding the importance
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of the medical history, the clinician prepares for the physical assessment with a very specific foundation from which to start the diagnostic process.
In the case of pediatric patients, given the spectrum of etiologies that manifest as abdominal pain, the differential is generally broad and the diagnosis of abdominal conditions can be challenging. In most cases, a thorough history-taking can narrow a broad differential. Depending on the child’s age, additional investigations may be required to delineate diseases that present with similar symptoms. Furthermore, even with the assistance of parents or guardians, a comprehensive history is often difficult to obtain, and diagnosis therefore relies heavily on the clinical experience of the medical clinician.13
A patient with severe abdominal pain may not be able to give much health history information, and may instead be focused on the pain felt and efforts to find a comfortable position and to obtain relief. Although it may not be possible to eliminate the patient’s pain before starting the history portion of the physical examination, the patient can be assisted to find a comfortable position before being asked to respond to questions. A patient who is in pain is usually distracted, so assisting the patient to be as comfortable as possible before and while obtaining the history will support the history taking process.
Following the initial introduction, the clinician should proceed to explain to the patient that some questions asked will relate to the patient’s health history and condition. The clinician should start out by asking generalized questions and then focus more specifically on important health questions during the initial encounter. For instance, the clinician may begin by asking general questions about the patient’s most recent activity to understand more fully the events leading up to the health 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 pursue and to narrow down associated factors related to the patient’s condition.
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The presence of other factors may impact the physical assessment, and they should be addressed during the initial encounter. The clinician may not be able to determine the patient’s level of health literacy right away, but during the patient history taking the clinician can develop a better understanding of the patient’s health literacy.10-13 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 a patient is unable to give adequate information because of pain or other factors, the clinician may need to rely on others accompanying 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 examination if the patient is unable to provide much of a personal medical history.10-14
Details of the medical history that are important to discover are typically related to those factors that can be causing the abdominal pain. Some information, while it may not seem to be related to the current situation, may uncover the cause of abdominal pain, especially when the cause of pain is obscure.10-14 Arthritis, for example, would not seem to 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 extraintestinal symptoms that seem completely unrelated to the inflammation in the bowel.
As previously mentioned, the clinician may discover 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 should include:10-14
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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 wellbeing.
The clinician may add or adjust generalized questions based on the patient’s response. Once the clinician learns initial information, questions may be focused to gain more specific information about the patient’s history to include factors that may more likely contribute to the current situation. Other significant history to obtain about the patient’s medical background may include any of the following factors.10-14
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, cholecystectomy, 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 nonsteroidal antiinflammatory 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.
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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.
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.15-17
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 obtaining patient information may include those listed here. 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 preliminary answers received. For example, if a patient states that a parent 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.
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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.15-17 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 family 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 clinician 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 clinician may also talk with family members who are present and may have an idea of whether family seems supportive and helpful, or are causing an added strain during the patient encounter.15-17 For example, a patient who arrives accompanied by a parent may seem tenser when the parent is in the room. The interactions between the patient and the parent may appear strained or conflicted, and, if it appears that the family member is contributing to strain for the patient, the clinician may opt to engage more fully with the patient without the family member present. Discussion of the impact family members have on patients may help clinicians to better understand the home issues or problems influencing health outcomes during the physical assessment process.
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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.15-17 While the patient’s personal 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.18
The clinician should use the information learned during questioning about specific details in the patient history to focus on contributing factors to the pain. This approach narrows down the possible causes of the pain. 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, 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 should happen. Eliciting from the patient what is felt and understanding their goals for pain treatment requires “a thoughtful and systematic process.”18 Patients may not be accustomed to saying much about themselves, their health and general challenges in the setting of pain. They may not think about explaining to a health clinician what had worked for them in the past relative to pain.18 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
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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.19
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. 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. Clinicians caring for patients experiencing pain need to be aware of barriers to adequately identify and to control a patient’s pain.18,19 There need to be standard clinical guidelines for pain management and a standardized pain assessment tool used to manage a patient’s pain condition. Also, clinicians may be limited in certain settings with regard to autonomous decision-making to control patient reports of pain and to advocate for improved pain control. When standard pain protocols are not in place, interdisciplinary health team members can work together to change standards and to update pain protocols.18,19
Change within a health system begins with the interdisciplinary health team working together to manage patient reports of pain and to analyze outcomes of pain management being used.18,19 The following sections outline some of the aspects of patient evaluation and pain assessment that clinicians can incorporate into a treatment plan.
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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 clinician is determining the onset of pain, which may have started or become aggravated by certain factors. For example, a patient may have felt physically well until an hour after eating and the subsequent development of right upper quadrant abdominal pain. By determining onset and the circumstances leading up to when the pain began, the clinician can better determine the causative factors. In the patient’s description of pain, abdominal pain could be related to food or digestive issues if it started after eating a meal. Using this information, the clinician can further narrow down possible causes, which is more likely to assist in the diagnosis.
The onset of pain 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 worsen over time. Excruciating pain that occurs suddenly may indicate a medical emergency that requires rapid management to prevent life-threatening complications.22,23 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 patients what they believe is the cause of abdominal pain. The clinician may gain much more insight from the patient by finding out more about the abdominal pain, how it started, and the duration of the pain. The patient can provide much more information about the situation and the circumstances leading up to the abdominal pain.22,23 Whether or not the patient is correct about why they are having pain, the patient’s opinion and thoughts about the situation can be helpful to clinicians when they are trying to isolate a diagnosis.
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Location of Pain
The initial physical 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 generally leads to 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 visceral pain around the organs, may feel very deep and it may be hard for the patient to pinpoint the location of the pain.22,23 The location of the pain helps the clinician to identify the cause of the pain if it is not obvious; however, in some cases, pain from another body site may be referred.
In addition to determining where the patient experiences the most pain, the clinician 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 clinician’s observations, for example if the pain appears to cause an anxious response in the patient. It helps to hear directly from the patient how pain is affecting quality of life and to identify patient response to pain. Hearing the patient’s subjective explanation of pain and how it affects daily routines makes the clinician aware of related factors that may need to be medically managed in addition to the treatment of abdominal pain, such as symptoms of depression, anxiety, anger, or fear.24,25
The health clinician should ask the patient how the pain has affected the patient’s quality of life and the ability of the patient to perform activities of daily living. The measurement of pain is complex, and includes soliciting information from the patient related to the emotional toll of pain. For example, a patient in chronic pain may develop depression that can affect the patient’s level of energy and motivation to get out of bed and perform daily duties.24,25 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 be the pain takes its toll on quality of life. A patient who has chronic abdominal pain may be more likely to feel depression, feelings of helplessness and hopelessness, as well as to have symptoms of poor sleep, changes in appetite, and strained relationships because of the patient’s preoccupation with the pain.25
Pain Intensity
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 clinician assessing the patient’s pain level.26 By asking the patient to describe the pain and to use a pain scale that illustrates the level of pain, the clinician may better determine the level of pain intensity the patient is experiencing.
The health clinician may also gain better information by asking patients to describe pain in their own words. Sometimes, when the patient is able to describe the pain, the clinician 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 clinician’s point of view. However, the patient’s description of the pain may be helpful to better pinpoint the cause of the pain, such as if the pain is described as burning, stabbing, aching, dull, or throbbing.26 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?”
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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. It should be noted though, that this is not always entirely true. For example, ischemic bowel disease often causes generalized and diffuse pain.27 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.27,28 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 pain somewhere on the scale as to the intensity of the pain that the patient is 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 rate very severe pain at a “5” on the scale, while another may consider similar pain to be a “10.”27,28
When using the pain rating scale, the clinician should not only assess at what level of intensity the patient is currently experiencing pain, but 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 describe current pain as a level 8, that would normally require pain medication when the pain reaches a level 6, and consider level 2 pain to be acceptable and tolerable.29 This helps the clinician to understand the patient’s pain tolerance and other influencing factors, such as expectations for pain control, cultural variables, and previous painful experiences.
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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.30 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.
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 clinician 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 the one that best describes their pain. If it appears that the patient is having difficulty understanding the pain rating scale, the clinician may need to modify the clinical approach or pain assessment tool for determining pain intensity. The goal is to identify pain severity using the pain assessment tool and to track how the patient responds to pain interventions.30 Postoperative pain management of the abdomen, for example, can be guided with the pain assessment tool or by the patient’s own self report. Chronic pain frequency, duration, and severity of pain episodes must be carefully monitored to ensure the best quality of care outcomes, and using a standard pain assessment tool supports this treatment goal.30
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.30 Various points on the line between the two extremes are locations of varying intensity that move along a scale from least
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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 is being experienced.
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, 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.30
It is important to note that the amount of pain a patient is experiencing is also related to the patient’s pain threshold and 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. 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 clinician must reassess the patient’s pain at periodic intervals to determine if the patient is experiencing any pain relief.31-33 Depending on the method of medication administration, the clinician may ask the patient again about pain, anywhere from 15 minutes to an hour after medication administration. If intravenous medications are given, the clinician should reassess within 15 minutes, and when oral pain medications are given the clinician should reassess within one hour. This reassessment determines if the intensity of the patient’s pain is lessening. The clinician 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 level of the expected response.31-33
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Frequent reassessment 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 clinician should find out how long the painful episodes occur each time and the approximate amount of time in between when there is no pain.31-33
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.34 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. 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 the patient also has chronic and recurring pain.34 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 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 is felt. The McGill Pain Questionnaire uses three sections: 1) what the pain feels like, 2) how it changes over time, and 3) the intensity of the pain to isolate a more specific description of the pain.35-37
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The McGill Pain Questionnaire is a form that a patient can fill out. It is divided into three sections. It is relatively brief, taking into consideration that the patient may not be capable of spending a lot of time filling out a survey when pain is present. 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.35-37 The patient 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.
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 pain, including whether it is constant or intermittent.35 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.35
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.35-37
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 clinician should use when treating pain. Although the questionnaire assigns a numerical value for pain intensity, the form can
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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 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 clinician toward understanding the cause.35-37 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.
Factors that Relieve Pain
There are many psychological and behavioral pain management therapies that have been reported.38 The health clinician 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 the patient if anything relieves the pain, the clinician 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.38,39
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 relieve the pain. Such activities as bathing, stretching, deep breathing, distraction, direct
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pressure, or rest may be described. The patient may also take this time to raise whether alternative or complementary therapy was used to help with pain relief, such as massage, aromatherapy, energy healing, or use of herbal remedies or dietary supplements.40,41
If possible, the clinician evaluating the patient with abdominal pain should 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 effort was made to put direct pressure on the painful area by pressing on it with the hands, the clinician can follow this description with a clarifying question by saying, “did that help the pain?” or “did that make it worse or better?”
Pain 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 of sitting in a slumped position in an attempt to relieve pressure on the abdomen. 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.40,41 The clinician who is treating a patient with abdominal pain may need to evaluate which remedies were successful or unsuccessful in relieving the patient’s pain. In particular, the clinician will want to evaluate which medications were effective in relieving pain, and which ones were not effective. This way, the clinician can avoid prescribing medications that are not effective.
Clinicians should ask patients about existing 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
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have tried have not been successful in the past. The clinician caring for the patient with abdominal pain should not assume that the patient has the same beliefs about pain control as the clinician. When asking the patient about the current intensity level of pain, the clinician should also ask the patient what level of pain is expected after treatment.
Other Pain Signs and Symptoms
Additional signs and symptoms of abdominal pain may develop specific to the abdominal region or they may be in separate parts of the body.42,43 The clinician may ask some questions that can better help the patient to relay other symptoms; for example, the clinician may ask the patient to report on quality of appetite and the regularity of bowel movements. Often, these questions can determine whether the patient is 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. 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 is described in the table below.42,43 By using this mnemonic as a guide, the clinician may be more likely to remember important questions and areas of focus without becoming sidetracked during the physical assessment.
Asking the patient the following types of questions allows the patient to elaborate on any areas that the patient wants to express to describe the pain felt.
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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.44-46 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 examination, the clinician should take note of any signs of medical emergency associated with the abdominal pain.44-46 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. In an emergent situation, the clinician needs to respond quickly to patient complaints of abdominal pain as it could indicate a life threatening situation.
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 through a review of other symptoms during the physical assessment. It may not be necessary to spend an abundance of time focused on other body areas, but the clinician should know if other body systems are affected. The clinician should assess, either before or after the abdominal assessment, the following objective and subjective patient symptoms:44-46 Skin and mucous membranes and their overall appearance, including any
areas of redness, rash, lesions, or scarring. Lymph nodes, areas of enlargement or swelling. Hands and fingers, for signs of cyanosis, clubbing, or arthritis. Mood, and patterns of behavior and habits. General appearance, noting signs of poor hygiene and self-care. Other body areas of pain, discomfort, or abnormality.
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Additionally, the clinician should have obtained a set of vital signs, including the patient’s 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 physical examination.44-46
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.44-46 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.
The patient with abdominal pain may be very nervous about the abdominal examination. 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 assessment even knowing that the clinician needs to examine the abdomen to formulate a diagnosis.44-46 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.44-46 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
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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.44-46
The right upper quadrant consists of the liver, and gallbladder; the edge of the liver can be palpated just under the lower margin of the ribcage. The gallbladder 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.44-46
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.44-46
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.44-46
The Abdominal Assessment
Before starting the abdominal assessment, the patient must be positioned properly to better view and examine the full abdomen. If possible, the patient should lie down on the back with arms at the sides and not
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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.
It is most comfortable for the patient if the clinician has warm hands before touching the patient. Some people are ticklish or do not like to be touched. In this case, clinicians may use the patient’s hands along with their own to first touch the abdomen before completing the assessment using only the clinician’s hands. The patient’s legs should be flexed at the knees, if possible, 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.46-48
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.46-48
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 inspect the 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.46-48 The
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clinician may also stand at the patient’s feet or head to view the abdomen from these angles.
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.
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.46-48 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 to have 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.46-48
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
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that may cause abdominal bruising is Grey Turner’s sign, which appears as bruising around the sides of the abdomen near the flank.46-48 Grey Turner’s sign has also been associated with pancreatitis; it may also indicate a severe injury to the retroperitoneum that results in bleeding, which leads to the bruising noted on the flank.
Abdominal Movement
Peristalsis, smooth muscle contractions that move 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.46-48
A patient with an abdominal aortic aneurysm may have a marked pulsation in the abdomen that coincides with the patient’s 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.46-48 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.
Abdominal 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.46-48 Normally, these fibroblasts keep the skin elastic and flexible, but when Cushing’s syndrome develops, small tears may occur in the epidermis and dermis, leading to decreased elasticity and striae. 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.46-48 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 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
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appearance.46-48 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.46-48
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.46-48 The bulge appears because the action of raising the head or bearing down increases abdominal pressure. The hernia appears as a bulge through the abdominal muscles in which the contents of the abdomen move and fill the space.
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. Ascites most commonly appears as a bulging, fluid-filled abdomen that demonstrates a fluid wave.46-48
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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.46-48
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.
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.46-48 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.46-48
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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.46-48 The diaphragm of the stethoscope can be used to detect high- pitched sounds when it is held firmly against the abdomen; alternatively, the bell, when held lightly against the skin, can detect low-pitched sounds. 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 around the abdomen, listening to each quadrant, although it does not necessarily matter which quadrant is first.46-48
Normal bowel sounds are classified as hearing these noises between 5 and 34 times per minute. 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, decreased bowel sounds may result from the 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 an injury or an infection. Hypoactive bowel sounds are classified as only one or two sounds within two minutes of auscultation.46-48 If no bowel sounds are heard within five minutes, the clinician should suspect significant injury or a disease process, such as an intestinal obstruction or ischemic bowel.
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.46-48 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.
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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.46-48 The turbulence is caused by abnormalities within a blood vessel, such as atherosclerosis or hypertension. The bruit is usually 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.46-48 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.46-48
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 the major arteries of the abdomen.46-48 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.46-48
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
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abnormalities, and other signs that indicate disease of the abdominal organs. When documenting the bruit, the clinician should include its approximate location and sound, whether heard on systole or diastole.46-48 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, 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.46-48 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.46-48
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 of the body, such as in the face.46-48 To use direct percussion, the clinician taps the area of tenderness with two fingers while noting the patient’s response.
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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.46-48 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.46-48
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 rib cage, percussion begins over the ribs. Starting at approximately the nipple line, the clinician should percuss, moving in a line down toward the abdomen. Percussion 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.46-48 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 as determined through percussion. If the liver is enlarged, the size of the area of dullness noted with percussion will be increased.46-48
The spleen may also be identified through percussion, although much of it also lies above the rib cage 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.46-48 Percussion can particularly
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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.46-48 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.
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 clinician lightly compresses the skin using the fingers. Light palpation compresses the skin approximately ½ inch, while deep palpation compresses more firmly.46-48 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 pressu