Abdominal Pain Part II - Nurse CEUs Online - No Test ... · PDF fileAbdominal Pain Part II ......

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Abdominal Pain

Part II

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of

academic medicine, and medical author. He

graduated from Ross University School of Medicine

and has completed his clinical clerkship training in

various teaching hospitals throughout New York,

including King’s County Hospital Center and

Brookdale Medical Center, among others. Dr. Jouria

has passed all USMLE medical board exams, and has served as a test prep tutor and

instructor for Kaplan. He has developed several medical courses and curricula for a variety

of educational institutions. Dr. Jouria has also served on multiple levels in the academic field

including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject

Matter Expert for several continuing education organizations covering multiple basic medical

sciences. He has also developed several continuing medical education courses covering

various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the

University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-

module training series for trauma patient management. Dr. Jouria is currently authoring an

academic textbook on Human Anatomy & Physiology.

ABSTRACT

Abdominal pain is one of the most common complaints that patients make to

medical professionals, and it has a wide array of causes, ranging from very

simple to complex. Although many cases of abdominal pain turn out to be

minor constipation or gastroenteritis, there are more serious causes that

need to be ruled out. An accurate patient medical history, family medical

history, laboratory work and imaging are important to make an accurate

diagnosis. Initial assessment and diagnostic testing will provide an early

indication of cause and the possible treatment options, which are discussed.


Policy Statement

This activity has been planned and implemented in accordance with the

policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's Commission on

Accreditation for registered nurses. It is the policy of NurseCe4Less.com to

ensure objectivity, transparency, and best practice in clinical education for

all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 4 hours. Nurses may only claim credit

commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

Health professionals in acute and non-acute health settings need to be able

to recognize overt and subtle signs of conditions associated with abdominal

pain in order to properly treat and/or refer to a specialist.

Course Purpose

To provide nurses with knowledge of the causes and treatments of acute and

chronic abdominal pain.


Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and

Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.


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. bowel obstruction.

c. gastroesophageal reflux disease. d. None of the above

3. True or False: The clinician should base a diagnosis of abdominal

pain solely on the region of associated pain.

a. True

b. False

4. In a study published in the Journal of Clinical Nursing, nursing perceptions of barriers to adequately control a patient’s pain

included:

a. Lack of clinical guidelines. b. Lack of standard assessment tool for pain management.

c. Limited autonomy when making decisions about pain control. d. All of the above

5. Recurrent abdominal pain is

a. mild, nagging pain with no resolution. b. chronic, intermittent pain with separate episodes within 3-months.

c. more often seen among children. d. Answers b., and c., above


Introduction

A complicating dynamic in the diagnostic workup of a patient with abdominal

pain is the varied typical or atypical pain symptoms and the wide range of

conditions that could occur in a clinical scenario. As mentioned in Abdominal

Pain Part I, the assessment of pain in the abdomen can be a challenge to

diagnose. A thorough patient history is necessary to help isolate potential

cause and to identify correct treatment. Additionally, the physical

assessment of the abdomen and corresponding diagnostic tests must involve

a systematic, standard approach to foster a correct diagnosis of the cause of

abdominal pain.

Abdominal Pain And Anatomical Location

While abdominal pain is often broken down into anatomical location, it is

important to recognize that often pain in the abdomen may result from an

obscure cause, which can complicate diagnosis. Pain may also be referred

from the site of origin. The following section covers some of the types of

pain and correlating acute or chronic disease conditions.

Referred Pain

Referred pain is felt in a site other than the original location of injury or

pathology. By understanding common sites of referred pain, the clinician

may be able to quickly isolate the underlying cause of the pain the patient is

having, both within the abdomen and at a distant site. The patient may have

abdominal pain that is also referred to other parts of the body; and, the

original abdominal pain may or may not still be present. Often, sites where

pain is referred are innervated along the same pathways as the abdominal

pain.1


Referred pain may make the abdominal assessment more complex.

Abdominal pain is still usually present, and the initial pain may have

worsened in intensity to the point that the pain radiates to other locations.

When pain is present in both the abdomen and a referred location, it can be

difficult to pinpoint the exact cause, what makes the pain worse or relieves

it, and how long the type of pain has been present. Some of the most

common locations of referred abdominal pain include to the back, shoulders,

chest, or groin.

Back Pain

A number of painful conditions in the abdomen can cause referred pain in

the back. Pain that originates in the pancreas, liver, gall bladder, abdominal

aorta, stomach, and kidneys may all cause discomfort that is felt not only in

or near these structures, but also in areas of the back. Affected organs such

as the liver, gall bladder, and stomach will typically cause referred pain in

the center of the back; whereas, the kidneys tend to radiate pain to the

lower back.

Fortunately, referred pain tends to radiate to the same locations in most

people. For example, individual patients who present with gall bladder pain

will tend to have similar type referred pain to the center of the back. The

healthcare provider should learn and understand the common areas of

referred pain so that he or she can quickly recognize referred pain locations

associated with abdominal organ dysfunction.

Pain with abdominal organs that refer to the back can often be intense and

severe, particularly when associated with damage from ischemic pain or a

significant inflammatory condition, such as severe pancreatitis. The pain

may begin in the abdomen. As the pain intensifies, nerve sensors carry the


pain to the back. In some cases, the pain in the back may be just as much

or more severe than the pain in the abdomen.

Shoulder Pain

Pain that develops in the shoulders and that is not explained by other

events, such as an injury or disease process, may be considered referred

shoulder pain when it coincides with symptoms of abdominal pain. Pain in

the shoulders and scapula areas can be referred from one or more locations

in the abdomen. An abscess in the abdomen may radiate pain to the

shoulder, and pain from any condition that causes irritation to the

diaphragm may also radiate to this area.

Pain associated with the gall bladder, such as gallstones or pain in the bile

duct leading to the small intestine often radiates to the shoulder or scapula,

in addition to referring to the back.37 Visceral pain associated with the gall

bladder may be referred to the shoulder because the pain messages travel

along a shared dermatome, which is an area of skin that receives sensation

from the same spinal nerve.36

Kehr’s sign refers to a condition in which a patient is suffering from pain in

the shoulder area when the injury is in the abdomen. A German surgeon,

Hans Kehr, first described Kehr’s sign after seeing a patient with severe

clavicle pain due to a splenic abscess. The condition is defined as pain in the

area above the clavicle as a result of irritation of the diaphragm. The phrenic

nerve that stretches between the diaphragm and the neck carries the pain

signal from the area of abdominal injury up to the clavicle and shoulder.82

Patients who have undergone surgical procedures, such as a laparoscopy,

may develop shoulder pain. The pain is referred from the abdominal area


from the use of air through a surgical instrument to inflate the abdomen

during the procedure. In the days following the procedure, the patient may

experience shoulder pain as the air resolves. Other medical causes of

referred shoulder pain may also develop from conditions such as

pancreatitis, or pelvic conditions such as an ovarian cyst. Some people who

develop shingles from the herpes zoster virus and have an outbreak on the

abdomen may also develop referred pain in the shoulder.38

Chest Pain

Abdominal pain referred to the chest can be frightening for the patient who

may fear that the pain has developed from a cardiac condition. Although

pain from angina is felt as pain in the chest, there are multiple potential

causes of chest pain that are not cardiac in origin, including some types of

abdominal pain.

Pain in the chest is often assumed to be cardiac in origin by affected

individuals likely because of heightened public education and awareness of

the intense symptoms associated with the threat of a heart attack. However,

unless the patient has a pertinent history or other signs that indicate the

need for cardiac testing, other forms of injury or disease should be

investigated to determine whether the patient is actually experiencing

referred pain to the chest.

Conditions such as infection of one of the abdominal organs or peritonitis are

some of the most common causes of abdominal pain referred to the chest.

Chest pain that is cardiac in nature is usually not made worse when the

clinician performs palpation during the abdominal examination. Alternatively,

if the pain in the chest is associated with another condition, the clinician can

elicit a pain response through palpation of various areas. When referred pain


appears, a thorough abdominal exam is needed. The pain of an

inflammatory abdominal condition, such as peritonitis, can at times be

almost identical to cardiac chest pain when it is referred.83 Diagnostic testing

through laboratory and imaging studies is typically necessary to isolate the

actual cause of the pain.

Pain from gastrointestinal disorders, such as reflux or peptic ulcer disease,

may cause chest pain. The pain can be distinguished from cardiac pain by

discussing time, onset, and duration of symptoms.83 For example, a patient

with gastroesophageal reflux disease (GERD) may complain of pain in the

chest; and, in order for the clinician to determine whether the pain is not

cardiac in origin but, rather, associated with reflux, several questions should

be asked to identify the characteristics of the pain. The clinician should

determine the timing of the chest pain. Chest pain that develops within 30

minutes from the time of eating a meal and that is resolved when taking

antacids is usually indicative of GERD.

Groin Pain

Groin pain may be a confusing term, as the “groin” can refer to a number of

regions where the patient may experience pain, including the upper thigh,

hip, lower pelvis, or genitalia. It is therefore important to take a thorough

history about the patient’s pain and its preceding factors when assessing this

area as a location of referred pain.

Areas of the groin have overlapping dermatomes with some areas of the

abdomen. Consequently, when certain injuries occur in the abdomen, the

pain is referred to the groin. Some examples of abdominal conditions that

lead to pain in the groin include ectopic pregnancy, an ovarian cyst, hernia,

or aortic abdominal aneurysm. An abdominal aortic aneurysm may lead to


pain in the hip, while pain from an ectopic pregnancy may cause pain in the

upper thigh.84

The assessment of the patient with referred pain to the groin should include

an abdominal and groin assessment, depending on whether the patient’s

history suggests an abdominal injury. The physical assessment should

include examination for bulges, enlarged lymph nodes, palpation for pain,

and rebound tenderness. Additionally, the clinician should determine

whether there are signs that a disease process is occurring within the groin

that is causing the pain, such as an infection or malignancy.84 To narrow

down the range of potential causes, the clinician should ask the patient if he

or she is experiencing signs of infection such as fever, chills, night sweats, or

weight loss; and, whether the patient is experiencing any urinary pain or

changes in bowel habits.

Abdominal Pain Assessment

The abdominal pain assessment begins with a patient history to collect

pertinent background information about past medical disorders, family or

genetic conditions, and data specific to the pain itself. Because abdominal

pain may be caused by conditions that can vary between minor and life

threatening, it is essential to gather as much information as possible as

relates to the condition to better determine a diagnosis and to provide

proper treatment.

According to the Joint Commission, patients who present with pain of any

kind should receive a comprehensive assessment that meets certain

standards. The recommended standards state that the patient should receive

an initial pain assessment and also periodic re-assessments of pain while

under medical care. The pain assessment should also include recognition of


cultural and ethnic beliefs. The standards recommend educating involved

medical personnel about pain assessment and the management of pain, as

well as educating patients and their families about their roles in pain

management.27

Medical History

The medical history of the patient provides needed clues to pinpoint the

cause of the abdominal pain. Obtaining a patient’s history of his or her

current condition as well as past influencing factors provides a significant

source of information to understand the patient’s current state of health,

factors contributing to the condition for which care is sought, and the

potential for problems or complications associated with abdominal pain. The

history-taking portion of the exam also helps to establish a therapeutic

relationship between the provider and the patient. The provider-patient

relationship is key to successful treatment outcomes. Cooperation will be

needed to determine the source of the patient’s abdominal pain and to find

methods of treatment for relief of the condition. A helpful approach is to

consider the patient’s history at the beginning of the evaluation process to

find needed clues to solve the underlying cause of abdominal pain.

Often, medical history alone may point the clinician to the definite cause of

the disease without other diagnostic or collateral information. For example, a

patient with a history of Crohn’s disease who presents for care of abdominal

pain may already be familiar with the pain associated with a flare of the

disease. By understanding the importance of the medical history, the

clinician prepares for the physical assessment with a very specific foundation

from which to start the diagnostic process.


The clinician should start the history-taking portion of the assessment by

first allowing time to be introduced to the patient. The initial introduction,

between the clinician and the patient, is the beginning phase of the physical

assessment. The clinician can determine a lot of information about the

patient just during this initial interaction, such as the patient’s affect, mood,

and personality; and, whether the patient appears anxious or in pain, and

the temperature of the patient’s skin through the initial handshake or touch.

The clinician should keep in mind that touching the patient should only be

done when it appears appropriate for the client’s cultural background. If the

client seems uncomfortable or appears to be of a cultural background that

does not encourage touch, the clinician should avoid this step of the initial

introduction.

In some situations, the patient may prefer to discuss his or her medical

history and undergo the exam in private, rather than talking about the

current condition with the clinician in front of family members who may be

present. For example, if a woman arrives for care with abdominal pain

secondary to suspected gynecological disease or injury, such as an ectopic

pregnancy or ovarian cyst, she may want to discuss her personal medical

history in private rather than talking about her menstrual history and current

physical complaints in front of family. Some patients are comfortable

discussing their personal information with family or friends present, while

others would rather be alone with the clinician.

The initial data about the patient may be relayed during the history-taking,

including verifying the patient’s name and age and discussing other details,

such as the patient’s occupation and marital status. The patient may be the

person giving the information or may have someone else who is the source

of the history. The clinician can use this time to determine whether the


patient would be a good historian; for example, initial introductions and

discussions with the patient may reveal that the patient is cognitively

impaired or has a poor memory and is not necessarily the best source of

information.

When interviewing the patient for past medical or family history, there is no

specific order to obtain pain-focused data. The clinician should take cues

from the patient and work according to the patient’s response to

questioning. While it is best to avoid tangents and to not become completely

off-track from needed information during the history-intake, it is often

preferable for the clinician to listen and allow the patient’s account to direct

the flow of conversation when obtaining the history.31 Some areas of the

patient’s history require further, in-depth discussion, while other areas may

not apply to the current situation at all and can be quickly bypassed.

The clinician should try to make the patient as comfortable as possible in

order to gain the most information when obtaining the history. A patient who

is in pain is usually distracted. Furthermore, a patient with severe abdominal

pain may not be able to give much information about his or her history, and

may instead be focused on the pain felt and efforts to find a comfortable

position and to obtain relief. Although it is most likely not possible to

eliminate the pain before starting the history portion of the exam, the

patient can be assisted to find a comfortable position before being asked to

respond to questions.

After the clinician introduces himself or herself, the clinician should explain

to the patient that some questions asked will relate to their health history

and condition. The questions should start out as generalized questions and

then move into more specific ones. For instance, the clinician may begin by


asking general questions about the client’s most recent activity to determine

the events leading up to the healthcare encounter. After gaining more

information, the clinician can then focus on specific aspects contributing to

the abdominal pain. Starting out with general questions helps the clinician to

determine which direction of questioning to follow and to narrow down

associated factors related to the patient’s condition.

If other factors are present that would impact the physical assessment, they

should be addressed at this time. The clinician may not be able to determine

the patient’s level of health literacy right away but, through discussion about

the patient’s history, can get a better idea of what the patient understands

about his or her health. It is best for the clinician to avoid using medical

jargon that would only cause more confusion for the patient, and to simplify

medical terms when providing explanations or asking questions. If the

patient needs a language interpreter, it should be arranged to prevent

confusion and misinformation during the history-taking process.

If the patient is unable to give adequate information because of pain or

other factors, the clinician may need to rely on others who have arrived with

the patient, such as family or friends. These people may or may not be good

sources of information, depending on how well they know the patient’s

history and are able to communicate what they know. In these situations, it

is best for the clinician to gather as much information as possible with the

collateral information that is available. The clinician may find out more

helpful information through the physical exam if the patient is unable to

provide much of a report about his or her personal history.

Details of the medical history that are important to discover are typically

related to those factors that can be causing the abdominal pain. Some


information, while it may not seem to be related to the current situation,

may prove to uncover the cause of abdominal pain especially when the

cause of pain is obscure. For example, it may seem that arthritis would not

be an exact cause of abdominal pain, but when considering extra-abdominal

symptoms that may occur with some conditions, it is important to consider

arthritis as part of the patient’s medical history. Another example would be a

patient with Crohn’s disease who may develop extra-intestinal symptoms

that seem completely unrelated to the inflammation in the bowel; the

patient may also have ocular, dermatologic, or musculoskeletal problems as

well, including arthritis.24

The clinician may find out some initial information by asking general

questions to start and then switching to more specific details. General

questions at the beginning of the patient evaluation include:

Current weight and any changes in weight or appetite

Fatigue, fever, night sweats

History of alcohol or drug use and smoking history

Current medications, including prescription, non-prescription, herbal

remedies, and vitamins

Sleep habits, exercise programs, home safety issues, immunization

status, and relevant health practices

General attitude and well being

The clinician may add or adjust generalized questions based on the patient’s

response. Once the clinician learns initial information, he or she can then

focus questions to gain more specific information about the patient’s history

to include factors that may more likely contribute to the current situation.


Other significant history to obtain about the patient’s medical background

may include:

Bowel conditions, including constipation, frequent diarrhea, or a

diagnosis of irritable bowel syndrome or inflammatory bowel

disease such as ulcerative colitis.

Pertinent childhood illnesses that would have an impact on the

current condition; for example, a history of chickenpox could

potentiate shingles development in adulthood.

Surgical history of the abdomen, including a history of an

appendectomy, colostomy, bowel resection, cesarean section,

hernia surgery, abdominoplasty, cholescytectomy, or any other

type of laparotomy.

History of liver or pancreatic disease, jaundice or changes in urine

or stools, such as dark-colored urine or clay-colored stools.

Use of non-steroidal anti-inflammatory drugs (NSAIDs), which have

been known to cause irritation to the intestinal lining.

Malignancy, whether of any abdominal organ or another site that

could lead to metastasis to an abdominal organ.

Recent gastrointestinal infections, including infectious

gastroenteritis; bacterial infections with species such as E. coli,

Shigella, or Giardia; or parasitic infections.

Difficulties with eating, chewing, or swallowing; and any history of

indigestion or gastroesophageal reflux.

Any problems with elimination, laxative use, food allergies, and

recent food and fluid intake.

Pain with urination or with sexual intercourse; for women,

information about menstrual cycles and bleeding, discharge, or

uterine cramping.


Difficulties with mobility, a history of back injury, problems with

walking or performing activities of daily living.

Depression, anxiety, or any other diagnosed form of mental illness.

Allergic responses to medications, rashes, eczema, joint pain,

kidney problems, or any other diagnosis of autoimmune or

rheumatic disease.

Family History

The family history may contain important components that can give clues

about the cause of the patient’s abdominal pain. The family history can also

expose potential conditions or illnesses that increase the patient’s risk of

developing pain as well. Many conditions that can cause abdominal pain may

also run in families. It is important to know whether the patient is at higher

risk of certain conditions that could be a cause of the abdominal pain.

The clinician may start with general questions about the patient’s parents

and family and their current state of health. Some general questions to start

with while taking this information include:

Are both of your parents living? If not, what was the cause of

death? How old were they when they died?

Do you have children? How many? Do any of your children have

health issues?

Do or did one or both of your parents have significant health issues

or illnesses?

Do you have brothers or sisters and do they have significant health

issues?

Following the general questions to start the family history, the clinician

should then move to ask the patient more specific questions related to the


preliminary answers received. For example, if a patient states that his or her

father died of pancreatic cancer, the clinician can go on to ask more detailed

questions about any other history of cancer or pancreatic disease in the

family.

The clinician should outline the family history to include pertinent

information about the patient’s immediate relatives and their ages and

causes of death if they have passed away. This should include parents,

siblings, grandparents, children, and grandchildren. The family history

determines and documents the presence of chronic diseases within the

family that could have developed in the patient; and, that are either

contributing to the current abdominal pain or could possibly complicate its

treatment, such as diabetes or hypertension.

If a family member has accompanied the patient, the history-taking portion

of the assessment may be a good time to determine the type and strength

of the relationship. Relationships with family and friends can have an impact

on a patient’s symptoms. When relationships are under stress, the patient

may feel more symptoms or have an exacerbation of symptoms. Therefore,

it is important to determine if family connections are supportive or are

causing more complications to the situation.

Often, the nurse caring for the patient can assess some of the family

dynamics by observing how family members interact with each other and

with the patient. During the assessment and while talking to the patient, the

nurse may also talk with family members who are present and he or she

may have an idea of whether family seems supportive and helpful, or are

causing an added strain to the patient. For example, a patient who arrives

accompanied by his or her mother may seem tenser when the mother is in


the room as compared to the times she is not present. The interactions

between the patient and his or her mother may seem strained or their

personalities may seem to clash. If it appears that a specific family member

seems to be causing strain for the patient, it may help to ask the patient

about how they are feeling when the other person is not present. If the

patient wants to discuss the impact of his or her family, it may help to better

understand the patient’s state of health, particularly if there are issues or

problems in the home.

Pain-Specific Questions

Once the initial information has been gathered about the patient’s personal

and family medical histories, it is time to focus on pain-specific information.

The focused history concentrates on the patient’s reasons for seeking care,

such as the issue of abdominal pain and potentially contributing factors. In

some situations, the clinician may not have much time to complete

comprehensive medical and family histories, and may need to focus more on

the specifics of the abdominal pain. While medical and family history is

important, the focused assessment specific to the pain is sometimes much

more telling. Also called the problem-oriented assessment, the focused

assessment is where the clinician asks pain-specific questions to determine

not only the type and amount of pain the patient is experiencing, but also

the patient’s concerns about medical care and pain relief.

The clinician should use the information learned during questioning about

specific details in the patient history to focus on contributing factors to the

pain, and, to narrow down the possibilities for a diagnosis. When asking

questions about pain, the clinician should try to use open-ended questions

that give the patient a chance to explain more, rather than closed-ended

questions, which result in very short or “yes” or “no” answers. For example,


the clinician will most likely gain more information from saying, “describe

how your abdominal pain feels in your own words,” rather than, “does it hurt

when you move?”

It is also important to recognize that some clinicians may not as effectively

treat pain if the patient is expressing pain in a manner differently than the

clinician believes he or she should. Unfortunately, many clinicians have

beliefs about how patients should respond to pain. For example, if a patient

reports pain from a condition that appears to be “minor” but is crying and

screaming in pain, the clinician may believe that the patient is being

dramatic, too expressive, or seeking attention. The Joint Commission has

shown that inadequate pain management in hospitals often occurs when

clinicians do not assess pain appropriately or when the patient’s reaction to

pain does not conform to the clinician’s expectations.27

Some clinicians may also perform pain assessments incorrectly, relying on

information such as changes in the patient’s vital signs or making

assumptions about the patient’s reasons for seeking help. Vital signs are not

a reliable indicator of pain, particularly among patients who are suffering

from chronic pain. Increases in vital signs may occur at times, but elevated

heart rate, respiratory rate, or blood pressure has not been shown to be a

consistent indicator of the depth of the pain the patient is experiencing.27

Some patients, especially those who return for pain medication or continued

help with pain management, may be labeled as “drug seeking” while trying

to secure medications. While this may or may not be true, questions of the

validity of a patient’s actual pain is not a reason to undertreat pain.

There are often many variables in place that prevent some caregivers from

adequately assessing and managing pain for some patients. A study found in


the Journal of Clinical Nursing showed that nurses caring for patients

experiencing pain identify four main issues with adequately being able to

control a patient’s pain, particularly in a critical situation. These issues are

the lack of clinical guidelines for pain management, lack of a standardized

pain assessment tool, limited autonomy when making decisions about pain

control, and the patient’s actual condition.28

Although nurses may be limited in some settings with regard to their

autonomy to control a patient’s pain, nurses can use assessment tools to

best analyze a patient’s pain and to be advocates to achieve pain control for

their patients. Additionally, if standard protocols are not in place, nurses can

work to change standards and update protocols that involve a patient’s pain

management. The act of change begins by working with patients who are

experiencing pain and analyzing their needs for pain control. The following

sections outline some of the aspects of patient evaluation and pain

assessment that nurses can incorporate into a treatment plan.

Acute versus Chronic Pain

The length of time the patient has been experiencing pain better pinpoints

whether the pain is acute or chronic. By asking the patient when the pain

began, the nurse is determining the onset of pain, which may have started

due to certain factors or may be aggravated by some factors. For example, a

patient may have felt fine until an hour after eating, when he or she slowly

developed abdominal pain in the right upper quadrant. By determining onset

and the circumstances leading up to when the pain began, the nurse can

better determine if there are causative factors. In the patient description of

pain, the abdominal pain could be related to food or digestive issues if it

started after eating a meal. Using this information, the nurse can further

narrow down possible causes, which is more likely to assist in the diagnosis.


The onset of pain also demonstrates how the pain started and whether it

began gradually or if it started suddenly. How the pain begins also gives an

indication of the type of pain the patient is experiencing, which can better

help to determine cause. For example, acute pain from an injury may be

more likely to develop suddenly; alternatively, pain caused by ischemia may

have a slower onset but then worsens over time.27 Excruciating pain that

occurs suddenly may indicate a medical emergency that requires rapid

management to prevent life-threatening complications. Sudden, severe pain

may indicate a ruptured abdominal aneurysm or perforated viscus, requiring

emergent surgical correction.

During this phase of questioning, it also helps to ask the patient what he or

she believes is the cause of the pain. The nurse may gain much more insight

from the patient by finding out more from them about the abdominal pain,

how it started and the duration. The patient has much more information

about the situation and the circumstances leading up to the abdominal pain.

Whether or not the patient is correct in his or her belief about why they are

having pain, the patient’s opinion and thoughts about the situation can be

helpful to the nurse and to the medical provider when trying to isolate a

diagnosis.

Location of Pain

The initial complaint may be simply described as “abdominal pain,” but when

focusing the assessment on the quality and intensity of the pain, it helps to

know specifically where it hurts for the patient. Asking where the patient

feels the most pain reveals a subjective description of the most specific

location. The patient may be able to point to a certain location where it hurts

the most; alternatively, the patient may describe the pain as “all over” the

abdomen, meaning it is most likely generalized pain. Some pain, such as


visceral pain around the organs, may feel very deep and it may be hard for

the patient to pinpoint the location of the pain. The location of the pain may

better help the nurse identify the cause of the pain if it is not obvious;

however, in some cases, pain from another site may be referred.

In addition to determining where the patient experiences the most pain, the

nurse may also ask how the pain affects the patient, or what it means to the

patient. Some of this information can be gathered through the nurse’s

observations; for instance, if the pain appears to cause the patient to be

highly anxious, the nurse may observe the patient’s anxious activity. It helps

to hear this information directly from the patient, as the patient’s subjective

explanation of how the pain is affecting him or her can better identify

response. It also makes the nurse aware of other patient factors that may

need to be medically managed in addition to treatment of the abdominal

pain, such as depression, anxiety, anger, or fear.

The nurse should ask the patient how the pain has affected his or her quality

of life and ability to perform activities of daily living. The measurement of

pain is complex, and includes soliciting information from the patient related

to how pain impacts the patient’s emotional state. Turk and Melzack, in the

Handbook of Pain Assessment state that pain disturbance is “the degree of

emotional arousal or the changes in action readiness caused by the sensory

experience of pain.”32 The emotional toll that pain takes on a patient can

impact his or her ability to perform activities of daily living. For example, a

patient in chronic pain may develop depression that can affect whether he or

she can get out of bed each morning. A patient who is anxious because of

pain may limit daily activities outside of the home.


Pain affects physical activities as well. Some patients, particularly those who

suffer from chronic abdominal pain or conditions in which the pain returns at

regular intervals, may have adjusted their daily living habits, as the pain

takes its toll on quality of life. A patient who has chronic abdominal pain may

be more likely to feel hopelessness, depression, or feelings of helplessness,

as well as have difficulties in other areas of daily life, such as problems with

sleeping, changes in appetite, and strained relationships because of

preoccupation with the pain.27

Intensity of Pain

The intensity level of pain best describes not only that the patient is having

pain, but also how much it hurts. For some, pain may be considered mild,

indicating a low level of intensity. Alternatively, a patient with severe pain is

said to have pain of a high intensity. It can be difficult to determine how

much pain a person has by using descriptive words; calling pain “severe” or

“significant” may mean different things to the patient or the nurse. By

asking the patient to describe the pain and to use a pain scale that

illustrates the level of the pain, the nurse may better determine the level of

intensity the patient is experiencing.

The nurse may also gain better information by asking the patient to describe

the pain in his or her own words. Sometimes, when the patient is able to

describe the pain, the nurse can better imagine the extent of the situation.

Keep in mind, however, that the patient’s description may not always be the

best portrayal of the situation and some patients are very vague in their

accounts, particularly if they are in too much pain to accurately discuss the

situation. The intensity level of a patient’s pain is subjective information and

can be quite difficult to measure from the nurse’s point of view. However,

the patient’s description of the pain may be helpful to better pinpoint the


cause of the pain, such as if the pain is described as burning, stabbing,

aching, dull, or throbbing. If the patient has difficulty describing the pain, it

may help to give a few words of suggestion, without leading in one direction

or the other, such as by saying, “would you describe this as sharp or dull

pain?”

Pain in the abdomen can be diffuse and general, meaning that it is felt

throughout the abdomen with no specific location of targeted pain. On the

other hand, some patients present with abdominal pain located in a specific

and pinpointed area that can be defined and identified. Pain that is localized

to one specific area is typical of a disease process that affects a certain area,

such as inflammation of the appendix or a bowel obstruction, while

generalized pain may be more likely associated with transient conditions,

such as intestinal gas or gastroenteritis.21 It should be noted though, that

this is not always entirely true. For example, ischemic bowel disease often

causes generalized and diffuse pain. The clinician should not base a

diagnosis simply on the region of associated pain but should instead consider

all clinical and supporting factors for why the pain is localized to a particular

area or why it is distributed throughout the abdomen and diffuse.

There are several methods of determining the intensity of abdominal pain,

such as by using a 0-10 numeric rating scale, or the Wong-Baker FACES

pain rating scale among children. The numeric rating scale allows the patient

to consider a scale between 0 and 10, where 0 is no pain and 10 is the worst

pain imaginable. The patient then rates his or her pain somewhere on the

scale as to the intensity of the abdominal pain that they are experiencing.

This numeric rating scale only works for those patients who can understand

the concept of assigning a number to the intensity for pain. One patient may


rate very severe pain at a “5” on the scale,

while another may consider similar pain to

be a “10.”

When using the pain rating scale, the

nurse should not only assess at what level

of intensity the patient is currently

experiencing pain, but he or she should

also find out what level is tolerable for the

patient and at what level the patient may

take pain medication. For instance, a

patient may state that his or her current

pain level is an “8,” that would normally

require pain medication when the pain reaches a level of “6”; and, would

consider a level of “2” to be acceptable and tolerable. This helps the nurse to

understand the patient’s pain tolerance and other influencing factors, such

as expectations for pain control, cultural variables, and previous painful

experiences.

The Wong-Baker scale is typically used for children and among adults who

have cognitive delays or who would not understand the numeric scale. The

Wong-Baker scale uses faces that range from happy and smiling on one end

signifying no pain to sad and crying on the opposite end signifying the most

pain. This scale is easier to understand for some patients when expressing

the intensity of their abdominal pain. It may be helpful to use both the

Wong-Baker scale and the numeric intensity scale with some patients,

particularly if there is some question about whether the patient fully

understands the rating scale.


The level of pain severity does not necessarily indicate the cause of the

abdominal pain. People have different thresholds for pain tolerance and

although it is different between people, similar pain intensities may cause

varied reactions among patients. Additionally, some patients with cultural

backgrounds that are different from the nurse may express pain differently;

some patients may also have difficulty understanding the rating scale as it

measures intensity from left to right. They may choose a random number or

a number that has special meaning, rather than choosing one that best

describes their pain. Wilson and Giddens, authors of Health Assessment for

Nursing Practice use an example of a nurse assessing pain intensity using

the pain rating scale; when asking a Native American patient about his or

her pain intensity with this scale, the patient may choose a number that is

sacred rather than using a number that coincides with the pain intensity.27 If

it appears that the patient is having difficulty understanding the pain rating

scale, the nurse may need to modify his or her approach at determining pain

intensity.

Some patients require a visual scale to better describe the intensity of their

pain. The visual analog scale can be viewed as a 10 cm line that shows the

range of pain the patient may be experiencing. Each end of the line

describes the extremes of pain from “no pain” on one end to “the worst pain

imaginable” at the opposite end. Various points on the line between the two

extremes are locations of varying intensity that move along a scale from

least intense to most intense. The patient may look at the scale and point to

a location somewhere on the line to explain how much pain he or she is

experiencing.32

The visual analog scale can be more thorough in describing pain intensity

when compared to the 0-10 numeric rating scale. The visual analog scale,


although it may be 10 cm in length, can have more numbers than 1 to 10,

providing a greater amount of sensitivity for pain control. Instead of

choosing a number between 1 and 10 to describe the pain, a visual analog

scale may allow a patient to choose between 1 and 100. The greater number

of potential response categories makes the visual analog scale a more

sensitive instrument of determining pain intensity combined with a graphic

appeal that may be helpful for some patients.

It is important to note that the amount of pain a patient is experiencing is

also related to his or her pain threshold and pain tolerance. The pain

threshold describes the point at which a patient begins to feel pain. When a

stimulus occurs that causes pain, the pain threshold is the point when the

patient feels pain in response. Alternatively, the pain tolerance is the amount

of pain a person is able to endure before expressing it.27 The level of pain

tolerance varies between people and is based on several factors, including

previous experiences with pain, emotional health, and cultural expectations

for expressions of pain.

If medications are ordered for pain management, the nurse must reassess

the patient’s pain at periodic intervals to determine if the patient is

experiencing any pain relief. Depending on the method of medication

administration, the nurse may ask the patient again about his or her pain,

anywhere from 15 minutes to an hour after medication administration. If

intravenous medications are given, the nurse should reassess within 15

minutes, and when oral pain medications are given the nurse should

reassess within one hour. This reassessment determines if the intensity of

the patient’s pain is lessening. The nurse should ask what numeric rating the

patient would give the pain after receiving pain medication and compare that

rating with the patient’s initial pain rating, as well as his or her level of


expected response. Frequent re-assessment of pain control is just as

important as the initial pain assessment when working with a patient who is

experiencing abdominal pain.

Duration of Pain

Intermittent pain, also sometimes called colicky pain, may start and stop at

various times. The patient may experience intense and severe pain for

minutes to hours, followed by periods of no pain. The pain may then return a

short time later. If the patient describes the pain as intermittent, the nurse

should find out how long the painful episodes occur each time and the

approximate amount of time in between when there is no pain.

Recurrent abdominal pain is a type of chronic, intermittent pain that causes

separate episodes of discomfort over a period of time. The painful episodes

may develop and cause significant pain for a while and then resolve, only to

return later. The condition is more often seen among children. Recurrent

abdominal pain is defined as at least 3 episodes of abdominal pain within a

3-month period. The pain is typically severe, limits quality of life, and

demonstrates a physical cause in less than 10% of cases.90

Recurrent abdominal pain can be frustrating and debilitating for affected

patients. When checking the pain-specific history, assessing whether the

pain is constant or intermittent may uncover not only that the patient has

intermittent pain during the most current episode, but that he or she also

has chronic and recurring pain.

One intervention method that can help with a description of pain is the

McGill Pain Questionnaire. This method was developed at McGill University in

Montreal, Canada and can be used to evaluate certain aspects of the pain by


helping the patient with descriptions. At times, it may be difficult for the

patient to put into words how strong the pain is or to formulate a description

of what he or she is feeling. The McGill Pain Questionnaire uses three

sections: what the pain feels like, how it changes over time, and the

intensity of the pain to isolate a more specific description of the pain.29

The McGill Pain Questionnaire is a form that a patient can fill out. It is

divided into the three sections and is relatively brief, taking into

consideration that the patient may not be capable of spending a lot of time

filling out a survey when he or she is experiencing pain.

The first section contains 20 groups with various descriptive words listed

with each group. While each group is named with a heading (temporal,

spatial, punctate pressure), the patient is not expected to understand the

meanings of each. He or she must only choose from a list of words for each

section and circle one word that best describes the present pain. For

example, the section headed “temporal pain” gives choices of descriptive

words such as pulsing, throbbing, or pounding; the section titled “sensory

miscellaneous” offers descriptive words such as tender or splitting pain.30

The second section of the questionnaire discusses how the pain changes

over time. The patient is asked to choose what best describes the pattern of

his or her pain, including whether it is constant or intermittent. The

descriptions are written, and the patient only needs to circle the best

response. This section also includes factors that can increase or decrease the

patient’s pain, asking the patient to read the factors and circle those that

apply. Descriptive factors include such stimulants as alcohol, bright lights,

fatigue, eating, or cold temperatures.30


The final section of the questionnaire discusses the intensity of the patient’s

pain. It asks such questions as “what word describes your pain right now?”

or “which word describes it at its worst?” The patient is given a list of

descriptive words that range from mild to excruciating and is asked to circle

one as an answer for each question. At the end of the questionnaire, a score

is obtained based on points assigned for the patient’s responses. A minimum

score is 0, in which the patient would most likely not be experiencing pain.

The highest score is 78 points.30

While a scoring system based on points may be helpful to determine the

severity of the patient’s pain, a numerical value to describe the pain should

not be the only evidence the nurse should use when treating pain. Although

the questionnaire assigns a numerical value for pain intensity, the form can

also be a useful tool to get an idea of how the patient describes the pain. As

stated, it may be difficult for some patients to form the right words to

describe their pain. A patient may be distracted by his or her pain to the

point of having a difficult time putting the pain experience into the right

words.

The questionnaire gives many choices to allow the patient to describe the

pain, which can better guide the nurse and medical provider toward

understanding the cause. A thorough description is much more helpful to

understand what is going on when compared to a vague account or few

words at all. Because the tool is multidimensional, clinicians can use the

information gained to narrow down factors associated with the pain and its

possible causes. For example, visceral abdominal pain, or pain affecting the

organs in the abdomen, may more likely be described as aching, somatic

pain; and, abdominal pain may also be described differently such as pain

associated with the skin and surrounding tissues.27


Factors that relieve pain

The nurse may enquire as to whether the patient has taken any measures to

treat the pain, or to make it feel better. It is actually two dimensional,

however, because in asking if anything relieves the pain, the nurse should

also find out if there are factors that make the pain worse. For example,

some patients have discovered that some elements, such as lying in a

specific position, eating, walking, coughing, or drinking fluids have made the

pain feel worse or feel better and they may be able to describe these

activities during the physical evaluation.

Some patients have taken measures to try and relieve their pain. These

measures may range from mild to extreme, depending on circumstances.

This may include use of over-the-counter or prescription medication, which

tends to come up if the patient has taken drugs to relieve pain. The patient

may also describe other activities that have helped or that they have tried to

use to relieve the pain. Such activities as bathing, stretching, deep

breathing, distraction, direct pressure, or rest may be described. The patient

may also take this time to point out if he or she has used alternative or

complementary therapy to help with pain relief, such as massage,

aromatherapy, energy healing, or use of herbal remedies or dietary

supplements.27

If possible, the nurse evaluating the patient with abdominal pain should also

try to determine how methods of pain relief worked for the patient, and if

they found methods of pain relief successful. For example, if a patient states

that he or she has tried to put direct pressure on the painful area by

pressing on it with the hands, the nurse can follow this description with a

clarifying question by saying, “did that help the pain?” or “did that make it

worse or better?”


A pain experience often requires coping mechanisms in order to better live

and function around the pain. Patients with abdominal pain may or may not

be aware of accommodations that they are making to better cope with pain.

For example, a person may not be aware that he or she is sitting in a

slumped position in an attempt to relieve pressure on the abdomen. The

patient may instead be too focused on finding relief from the pain.

Alternatively, many people are very aware of the strategies they have used

that have helped to control pain and those that did not help.

It is important to observe the patient’s reactions to the pain assessment and

to observe for any apparent signs of pain coping mechanisms being used.

Furthermore, some patients may not give much information about remedies

or medications they used that did not work; and, may only offer information

about what did work to relieve the pain. The clinician attending to the

patient with abdominal pain may need to explore what remedies were

successful or unsuccessful and, in particular, the use of medications that

were effective to relieve pain, or not. When treating the pain, the clinician

should learn what did not work to relieve pain in order to avoid prescribing

medications already shown to not be effective.

The nurse should ask the patient about his or her own expectations for pain

relief. Some people seek help for abdominal pain without expecting much

pain relief, particularly if they have been suffering from chronic pain or the

methods they have tried have not been successful in the past. The nurse

caring for the patient with abdominal pain should not assume that the

patient has the same beliefs about pain control as he or she does. When

asking about the intensity level of the patient’s current pain, the nurse

should also ask what level the patient would like it to be or what he or she

would expect the pain to be after treatment.


Other Pain Signs and Symptoms

Other signs and symptoms may be present that are related to abdominal

pain. Additional signs and symptoms may develop in the abdominal region or

they may be in separate parts of the body. The nurse may ask some

questions that can better help the patient to determine what other

symptoms he or she is experiencing. For example, the nurse may ask if the

patient has had anything to eat or drink that day, how the patient’s appetite

has been, and if he or she has had a bowel movement recently. Often, these

questions can pinpoint if the patient is also having symptoms of abdominal

bloating or fullness, difficulties with swallowing, nausea, vomiting, flatus,

diarrhea, anorexia, or indigestion.

Pain may stimulate the sympathetic nervous system to cause additional

symptoms, such as sweating, heart palpitations, pallor, and rapid or

irregular breathing.27 The clinician may note these symptoms as part of the

assessment or the patient may report these feelings. A helpful mnemonic to

use when assessing any specific area of the body or discussing the patient’s

chief complaint is P-Q-R-S-T-U. In this case, if the patient’s chief complaint

is abdominal pain, the clinician can walk through this mnemonic in a

sequence to gather comprehensive information about the patient’s pain, with

less chance of forgetting to ask important questions or leaving something

out. The P-Q-R-S-T-U mnemonic stands for:26

P: Precipitating or palliative

Are there any specific symptoms precipitating the onset of the pain?

Is there anything that makes the pain worse or better?

Q: Quality

How would you describe your pain?


R: Region, radiation

What area of your abdomen do you feel the most pain? Does the

pain radiate to other areas of your body?

S: Severity

On a scale of 0-10, how would you rate the intensity of your pain?

T: Time

When did your symptoms start? Is the pain constant or

intermittent? Did the pain develop gradually or did it start

suddenly?

U: Understanding

What do you think is causing your pain? How does this situation

make you feel? What do you expect out of treatment for your pain?

By using this as a guide, the nurse may be more likely to remember

important questions and areas of focus without becoming sidetracked during

the assessment. Asking these types of questions also allows the patient to

elaborate on any areas that he or she wants to discuss in the patient’s own

words to explain the pain experienced.

Physical Assessment

The physical exam portion of the assessment further assists the clinician to

identify the cause of the patient’s pain, and supporting the patient’s

thoughts about the cause of his or her pain or why treatment is required.

Furthermore, the physical exam helps the clinician to decide if further steps

are necessary to formulate a diagnosis. Following the physical assessment,

the clinician may determine that lab testing, imaging studies, or other forms

of testing are needed before deciding on a diagnosis, but the physical exam

narrows down potential options and should pinpoint ideas of the cause of

abdominal pain or the need to rule out other problems.


The initial discussion with the patient while taking the medical history will

clue the clinician into the patient’s behavior and response to the pain.

Grimacing, restlessness, or a slumped posture are physical cues that the

patient is experiencing acute pain. The patient may also be guarded and

protective of the abdomen or may lie very still and avoid much movement.

Additionally, the patient may also be making sounds in response to pain or

responding verbally through moaning, crying, screaming, or whimpering.

It is important to note that during the initial assessments when discussing

the patient’s medical or family histories or starting the physical exam, the

clinician should take note of any signs of medical emergency associated with

the abdominal pain. Signs such as hemodynamic instability, a drop in blood

pressure, and gastrointestinal bleeding evidenced by hematochezia or

vomiting blood, or rapid progression of symptoms combined with clinical

deterioration, are types of warning signs that require a quick response.

While it is important to discuss the patient’s pain and to perform a detailed

assessment, in an emergent situation the nurse should be notifying the

healthcare provider and implementing orders as prescribed. Warning signs of

the patient’s decline when he or she has abdominal pain cannot wait, as they

can quickly become life threatening and need to be addressed.36

If the patient presents with abdominal pain, the physical exam should be

focused mostly on the abdomen; however, it is important to know if other

body systems are affected and to include a review of other symptoms as

part of the physical assessment. It may not be necessary to spend an

abundance of time in other areas, but the clinician should know if other body

systems are affected. The clinician should examine, either before or after the

abdominal assessment, such areas as the:


skin and mucous membranes and their overall appearance,

including any areas of redness, rash, lesions, or scarring.

lymph nodes, to look for areas of enlargement or swelling.

hands and fingers, to assess for signs of cyanosis, clubbing, or

arthritis.

patient’s mood, affect, patterns of behavior, and habits.

patient’s general appearance, noting signs of poor hygiene and self

care.

other areas where the patient complains of pain, discomfort, or

abnormality.

Additionally, the clinician should have obtained a set of vital signs, including

the heart rate, respiratory rate, blood pressure, temperature, and oxygen

saturation levels. The clinician should also listen to the patient’s heart and

lungs as part of a general assessment, whether the patient complains of

specific issues with these body systems or not. The cardiac and respiratory

systems, because they send oxygenated blood throughout the body, are

fundamental points of assessment and should not be excluded as part of the

exam.

Although increased vital signs are not necessarily a sign of increased pain,

vital signs can point to potential systemic difficulties and may be a precursor

to increased health problems. For example, tachycardia may or may not be

associated with increased pain, but tachycardia, when combined with a drop

in blood pressure, can signal hypovolemia. Hypovolemia can put the patient

at risk of severe complications and should be considered if the patient’s

presentation suggests the potential for bleeding or fluid loss. Likewise, an

increase in respiratory rate may suggest an infectious process in the body

and should be noted.


The patient with abdominal pain may be very nervous about the abdominal

exam. If the pain is severe, the patient may try several tactics to prevent

the clinician from examining or pressing on the abdomen. Most people try to

avoid pain when possible, and some patients may make attempts to avoid

the abdominal exam even knowing that the clinician needs to examine the

abdomen to formulate a diagnosis. The clinician should move slowly, if

possible, and speak in a gentle tone of voice, rather than working in a fast,

hasty manner, which may make the patient more apprehensive.

Before performing a physical

assessment focused on the

abdomen, it is necessary to

understand the location of prominent

organs within the abdominal cavity

to best determine whether they are

in the normal position and if they

are of normal size. The abdomen is

generally divided into four main

quadrants, of which each of the

abdominal organs can be classified

and described: the right and left

upper quadrants and the right and

left lower quadrants. The clinician can visualize each of the quadrants by

picturing an imaginary line running vertically down the center of the

abdomen and another horizontal line running across the center of the

abdomen in a perpendicular fashion.

The right upper quadrant consists of the liver, and gall bladder; the edge of

the liver can be palpated just under the lower margin of the ribcage. The gall


bladder lies just under the liver, however, it is typically deep enough that it

cannot be felt on palpation. The right kidney lies deep in the abdomen,

toward the back. Other organs that may be found in the right upper

quadrant and that may be felt through palpation include the edges of the

stomach and pancreas, part of the duodenum of the small intestine, and the

abdominal aorta.1

The left upper quadrant consists of the spleen, stomach, pancreas, and left

kidney. The spleen lies behind several ribs where it is protected, but the

lower edge of the spleen may be located with palpation, especially if it is

enlarged. Next to and slightly in front of the spleen lies the stomach, which

lies mostly within the left upper quadrant but also extends somewhat into

the right upper quadrant. The pancreas also lies mostly within the left upper

quadrant but extends toward the right; and, behind these organs, toward

the back, is the left kidney.

Portions of the small and large intestine are found in the right lower

quadrant. The appendix, found near the cecum of the large intestine, is also

located in the right lower quadrant. The left lower quadrant contains the

large intestine, including the sigmoid colon. Midline between the left and

right lower quadrants is the bladder, as well as the uterus and ovaries in

female patients.1

The Abdominal Assessment

Before starting the assessment the patient must be positioned properly to

better view and examine the abdomen. If possible, the patient should lie

down on his or her back with arms at the sides and not extended above the

head. When a person stretches the arms over the head while lying supine,

the abdominal muscles stretch, which makes for an inaccurate assessment.


It is most comfortable for the clinician to have warm hands before touching

the patient. Some people are ticklish or do not like to be touched. In this

case, the clinician may use the patient’s hands along with his or her own to

first touch the abdomen before completing the assessment using only the

clinician’s hands.1 If possible, the patient’s legs should be flexed at the

knees, rather than extended straight out; knee flexion may help the patient

to relax the abdominal muscles more and may make the examination go

more smoothly. If there is a specific location on the abdomen where the

patient is experiencing the most pain, the clinician should palpate that area

last to help the patient remain the most comfortable and to avoid muscle

tension and guarding that typically occurs in response to palpating a tender

area.

Inspection

Inspection involves viewing the abdomen as it is uncovered and exposed.

The patient should be lying supine and still in order for the clinician to best

inspect the abdomen. While abdominal organs obviously cannot be inspected

without radiographic images, the condition of the exterior of the abdomen

can often give clues as to injury or damage to internal organs, which better

guides the clinician toward further diagnostic procedures.

Lifting the patient’s shirt to see the skin should expose the abdomen. If the

patient is wearing a gown, it should be pulled up to the level of the chest

and the area below the waist draped for cover. The clinician should note the

general surface of the skin as well as the contour of the abdomen,

recognizing prominent landmarks that may be visible, such as the lower

intercostal margin of the ribcage, the umbilicus, and the iliac crests of the

pelvis. A patient who is obese may have large folds of adipose tissue that

may make certain landmarks less prominent or completely obscured.


The clinician should note the condition of the skin, such as the presence of

rashes, visible veins, redness, or bruising. The skin should be mostly even in

color throughout. Visible veins are not an abnormal finding unless the veins

appear very dilated or distended, which is called caput medusae. This

condition can indicate portal hypertension, cirrhosis, or severe heart disease,

in which increased pressure in the veins of the abdomen is occurring;

abdominal veins can become so distended that they are visible through the

skin. Men often have hair at various locations on the abdomen, including

around the umbilicus and extending down toward the groin. The clinician

should note areas of uneven hair distribution, including thick hair or areas

that are patchy or bald.

If the patient has a rash or it appears that he or she has been scratching the

skin on the abdomen, the clinician should note the areas of irritation and

attempt to determine the cause of the pruritus. Intense itching on the skin

of the abdomen can develop with liver cirrhosis, biliary obstruction, or

infectious hepatitis. Less commonly, intense itching may also occur with

iron-deficiency anemia or a tumor.4

The umbilicus is typically in the lower midline of the abdomen, although for

some people, it may be off center. The location of the umbilicus and

anything unusual about its appearance should be noted, such as whether it

is red, if there is swelling or bruising nearby, or if a bulge is noted. Bruising

near the umbilicus is known as Cullen’s sign, which can indicate bleeding in

the abdomen and is sometimes associated with pancreatitis.

Another condition that may cause abdominal bruising is Grey Turner’s sign,

which appears as bruising around the sides of the abdomen near the flank.

Grey Turner’s sign has also been associated with pancreatitis; it may also


indicate a severe injury to the retroperitoneum that results in bleeding,

which leads to the bruising noted on the flank.4

Movement

Peristalsis, smooth muscle contractions that moves food through the

digestive tract, is typically not seen when inspecting the abdomen. However,

visible peristalsis may appear as waves of the digestive tract seen on the

surface of the skin; and, the patient may also have other symptoms along

with the condition, including increased abdominal girth, nausea, or vomiting.

Visible peristalsis most often indicates an obstruction at some point in the

intestine.5

A patient with an abdominal aortic aneurysm may have a marked pulsation

in the abdomen that coincides with the pulse. The pulsation of the abdomen

may cause the skin above the area to move rhythmically with the heartbeat.

The movement is more prominently seen when the patient is lying supine.

Some people move the abdominal muscles while breathing. In these cases,

the abdominal wall may move up and down with respirations. Also called

diaphragmatic breathing, this method of breathing is often employed as a

form of complementary or alternative medicine because it involves deep

breathing, which can be calming. Infants also naturally use the abdominal

muscles to breathe, and movement of the abdomen may be noted with

respirations when assessing a very young child or infant.

Scars

The presence of scars on the abdomen suggests some type of injury or

medical procedure that has occurred in the area. Many times, information


about the scars is made available through the patient’s medical history, such

as including information about past surgical procedures.

Many women who have been pregnant have striae, known as stretch marks,

which may be red or have silvery undertones. When striae follow pregnancy,

they are considered normal. Striae may also develop after weight loss in the

abdominal region, which is a normal response of the skin to stretching and

changing. Cushing’s syndrome also may cause abdominal striae, which often

appear purple; the condition causes changes in hormones that affect

fibroblasts in the skin. Normally, these fibroblasts keep the skin elastic and

flexible, but when Cushing’s syndrome develops, small tears may occur in

the epidermis and the dermis, leading to decreased elasticity and striae.4

When striae are present on the abdomen without an obvious source, such as

previous pregnancy or weight changes, the clinician should assess the

patient’s medical or family history for Cushing’s syndrome.

The clinician should also ask the patient about any large scar that has not

previously been explained through the patient’s history. Scars should be

noted and mentioned in the documentation. When documenting a scar on

the abdomen, the clinician should note its size and include approximate

measurement, its location on the abdomen, and any other prominent

characteristics, such as whether the skin is raised or hyperpigmentation is

present. Other lesions may also be present on the skin of the patient’s

abdomen and should be noted in documentation, particularly if they are near

the area of pain or are otherwise associated with the patient’s history as

related to the abdominal pain. For example, a patient may have an area of

petechiae, which indicates hemorrhage in the skin and that could be related

to abdominal trauma. Other types of lesions that the clinician may note


when inspecting the abdomen include areas of purpura, ulcerated skin,

nodules under the skin, pustules, or blisters.

Bulges

Each person’s abdomen has a normal contour, which should be noted with

inspection. The abdomen may be flat, rounded, protruding, or concave in

appearance. A person who is not overweight or who is physically active will

most likely have a flat abdomen. Whereas, a person who is overweight or

obese may have a protuberant abdomen, and a person who is very thin or

underweight may have a scaphoid, or concave abdomen. The abdomen

should be symmetric in appearance, but the presence of bulges or

protuberances suggests an injury or hernia.

Organ enlargement may also appear as a bulge in the area where the organ

is located. For example, an enlarged spleen may be demonstrated as a bulge

in the right upper quadrant of the abdomen near the lower intercostal

margin of the ribcage. Additionally, hepatomegaly, or liver enlargement,

may be associated with backup of fluid into the liver circulation due to heart

failure or severe liver disease; it has also been seen with patients who have

abdominal infections, inflammation, or tumors, all of which can lead to

abdominal pain.

To assess for a hernia, the clinician may ask the patient to raise the head off

of the bed while the rest of the body remains flat. Alternatively, the patient

may also be asked to bear down with the Valsalva maneuver, which can

produce the same results. If a hernia is present, these actions produce a

bulge in the affected area, most commonly around the umbilicus or the

groin. The bulge appears because the action of raising the head or bearing

down increases abdominal pressure. The hernia appears as a bulge through


the abdominal muscles in which the contents of the abdomen move and fill

the space.3

The presence of ascites, or excess fluid that has accumulated in the

abdomen, is caused by a medical condition that may or may not be

associated with the patient’s abdominal pain. Although ascites is most

commonly associated with liver disease, it can also develop in response to a

number of clinical conditions that can be painful, such as the presence of a

tumor, intestinal obstruction, or the rupture of lymphatic vessels.4 Ascites

most commonly appears as a bulging, fluid-filled abdomen that

demonstrates a fluid wave.

Because it may be difficult to distinguish ascites from adipose tissue in some

patients who are overweight, the fluid wave test can be performed to

determine whether there is fluid under the skin of the abdomen versus

excess fat tissue. To perform the fluid wave test to check for ascites, an

assistant or the patient places one hand on the abdomen at the midline near

the umbilicus. The fingers are extended and the wrist is turned so that the

flat side of the hand is pressing down 2 to 3 cm into the abdomen. The

clinician then places one hand on each side of the abdomen and taps the

side of the abdomen with one hand while keeping the opposite hand fixed in

place. If the patient has ascites, a wave of fluid can be seen passing from

one side of the abdomen to the other, under the hand placed at midline.7

Just as when assessing for abdominal movements, the clinician may note

that some patients who are very thin and who have scaphoid abdomens may

demonstrate intestinal peristalsis, which can be seen upon inspection.

Similarly, a pulsation in the abdomen of a thin person is typically the

abdominal aorta, and is a normal finding.1 The clinician should inspect the


abdomen from several views; looking down from above while the patient lies

supine, as well as from the side at eye level to determine a transverse angle

of the contour of the abdomen. The clinician may also stand at the patient’s

feet or head to view the abdomen from these angles.

Auscultation

Auscultation is mainly performed to determine bowel motility and to listen

for normal bowel sounds while identifying any abnormal sounds in the

abdomen. Many forms of body assessment involve inspection, palpation,

percussion, and auscultation, in that order. However, when performing an

abdominal assessment, the order of assessment strategies changes slightly.

After inspection, the clinician should auscultate the abdomen before

percussing or palpating. The rationale for this is that by auscultating first,

the clinician can listen to the bowel before it has been otherwise manipulated

through the assessment process. By palpating first before auscultation, the

clinician may stimulate the bowel, which can lead to more frequent bowel

sounds and ultimately change the examination findings. Therefore, the

clinician should always auscultate first before percussion or palpation.2

Bowel Sounds

Using both the diaphragm and the bell of the stethoscope, the clinician

should assess for bowel sounds in the abdomen, listening to each of the four

quadrants. The diaphragm of the stethoscope can be used to detect 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.26

Under normal circumstances, bowel sounds can be heard in all four

quadrants of the abdomen, and they can be heard as gurgling or clicking

noises that happen several times per minute. The clinician should move


around the abdomen, listening to each quadrant, although it does not

necessarily matter which quadrant is first.

Normal bowel sounds are classified as hearing these noises between 5 and

34 times per minute.1 Alternatively, absence of bowel sounds for more than

one minute upon auscultation is an abnormality that should be investigated.

If the patient recently had surgery, he or she may have decreased bowel

sounds from anesthetic. However, decreased bowel sounds indicate that the

bowel has decreased activity and is slow. The cause of reduced activity

should be identified, as it may be associated with injury or an infection.

Hypoactive bowel sounds are classified as only one or two sounds within two

minutes of auscultation.6 If no bowel sounds are heard within five minutes,

the provider should suspect significant injury or a disease process, such as

an intestinal obstruction or ischemic bowel.3

Stomach or intestinal rumbling, known as borborygmi, is the sound of gas

moving through the intestines, and is a normal part of digestion. If the

clinician auscultates frequent bowel sounds—more than six sounds within 30

seconds—the patient is said to have hyperactive bowel sounds. Hyperactive

bowel sounds may more likely be heard in patients who are experiencing

intestinal processes that cause an increase in peristalsis, such as

inflammation of the digestive tract from an infection that causes diarrhea.8

Bruits

After listening for bowel sounds, the clinician should turn over the bell of the

stethoscope to listen for bruits, which is a sound of blood in the vessels. A

bruit sounds similar to turbulent blood flow and makes a whooshing sound

upon auscultation. The turbulence is caused by abnormalities within the

blood vessel, such as atherosclerosis or hypertension.91 The bruit is usually


heard only during systole, but in some cases, it can be heard during both

systole and diastole.

As with the other portion of the abdominal assessment, the patient should

be lying supine with the abdomen exposed to best hear an abdominal bruit.

When heard, a bruit is typically located approximately midway between the

xiphoid process and the umbilicus, in the midline of the abdomen. Other

areas to listen for include the renal and iliac arteries, which branch off from

the main abdominal aorta. The renal arteries can be heard just lateral to the

aorta at about midway between the xiphoid process and the umbilicus, while

the iliac arteries may be heard midway between the umbilicus and the

symphysis pubis.2

The presence of a bruit does not always indicate a disease process. In fact,

some bruits are considered innocent and are not the result of any form of

injury or disease. Instead, they are heard on auscultation and should be

noted while examining for other signs of possible pathology. Alternatively, a

bruit may also be a sign of a disease process that affects blood flow in major

arteries of the abdomen. This is clinically significant and should be further

investigated. A bruit is often caused by alterations in the renal circulation,

however, it may also develop from other conditions, and has been seen in

such circumstances as intra-abdominal fistulas between certain organs,

hepatoma, abdominal aortic aneurysm, ischemic bowel disease, and the

presence of tortuous arteries within the abdominal cavity.91

If the clinician hears a bruit when assessing the abdomen, there should be

further investigation of several factors, including the cause of the patient’s

abdominal pain if known; the patient’s history for cardiac or renal

abnormalities, and other signs that indicate disease of the abdominal organs.


When documenting the bruit, the clinician should include its approximate

location and sound, whether heard on systole or diastole. If the patient has

few other symptoms, and no evidence of hypertension or cardiac disease,

the bruit may be innocent and may not cause any other problems.

Percussion

Percussion is best performed to identify masses of tissue under the surface

of the skin; percussion can determine structures that are approximately 2 to

3 inches under the skin surface,2 and can help to locate such organs as the

liver or spleen, as well as to identify any abnormal masses that are present.

The clinician should percuss in all four quadrants of the abdomen to reveal

sounds of tympany or dullness. Tympany is the resonating sound of gas or

space in the abdomen; the clinician should hear tympany with percussion

when moving over areas in which there is not a solid organ underneath.

Tympany sounds higher in pitch when compared to other sounds that may

be heard with percussion.

Alternatively, dullness with percussion suggests the presence of a solid mass

under the skin and can indicate an underlying organ, stool in the intestine,

or an abdominal mass. Dullness on percussion sounds flat and muted. It is

most often heard when percussing organs or masses, however, fluid may

also produce a dull sound with percussion. Shifting dullness is another result

of percussion that may be apparent in the patient with ascites; shifting

dullness is heard when areas of dullness are found on percussion, but they

are shifted to a different area when the patient then turns to a side.

There are two types of percussion that may be used: direct and indirect

percussion. Direct percussion notes areas of tenderness and may be used for

superficial abdominal pain, although it is more commonly used in other areas


of the body, such as in the face. To use direct percussion, the clinician taps

the area of tenderness with two fingers while noting the patient’s response.26

Indirect percussion is more commonly used when assessing the abdomen.

To perform indirect percussion appropriately, the clinician should stretch out

the fingers of the non-dominant hand and place them flat on the patient’s

abdomen, with the middle finger hyperextended. Using the middle finger of

the other hand, the clinician taps the center of the middle finger placed on

the abdomen. The action is quick and uses a flick of the wrist when

performed properly. When percussing, the clinician then decides if the

resulting sound is tympanic or dull. Following the action, the clinician moves

to another area of the abdomen to repeat, eventually percussing all

quadrants of the abdomen.

To specifically locate the liver through percussion, the clinician should begin

in the right upper quadrant of the abdomen at the midclavicular line.

Because most of the liver lies behind the ribcage, percussion begins over the

ribs. Starting at approximately the nipple line, the clinician should percuss,

moving in a line down toward the abdomen. Percussing over lung fields will

produce resonance because of the lung tissue. This sound will change to dull

when the clinician reaches the liver through percussion. Once the clinician

reaches an area of dullness, the upper margin of the liver has been reached.

After determining the upper edge of the liver, the clinician then moves down

to the abdomen to identify the lower margin. Starting below the umbilicus,

the clinician should percuss and move upward until the sound changes from

that of tympany to one of dullness. Upon reaching this sound, the lower

margin of the liver has been found. To determine the size of the liver, the

clinician then measures the distance between the lower and upper margins


as determined through percussion. If the liver is enlarged, the size of the

area of dullness noted with percussion will be increased.

The spleen may also be identified through percussion, although much of it

also lies above the ribcage in the left upper quadrant. However, the spleen

can be found through percussion by assessing in that quadrant of the

abdomen and listening for the difference between the resonance of the lungs

and the dullness of percussing the spleen. Percussion can particularly detect

an enlarged spleen, which may be present because of such conditions as

infection, trauma, or inflammation.

To identify the spleen through percussion, the clinician should percuss below

the level of lung resonance at the costal margin. The clinician should then

percuss laterally toward the mid-axillary line. The patient may take a deep

breath or breathe in and out during percussion in order to hear the

difference in tones, as the spleen lies quite deep and lateral in the abdominal

cavity. Identifying the spleen through percussion may more likely indicate

splenomegaly, but percussion alone does not completely confirm the

condition.9 If percussion elicits pain in any part of the abdomen, the clinician

should further consider if there is an underlying disease process that is

causing inflammation or swelling that would elicit the pain. Based on the

patient’s medical history and the physical exam, the clinician can further

investigate what condition is causing the pain from percussion.

Palpation

Palpation is the final step of the abdominal assessment. It involves using the

fingers to depress the skin and tissue and to feel for any abnormalities under

the skin. The clinician keeps the fingers together and the hand on a

horizontal level; after placing the hand flat on the patient’s abdomen, the


clinician lightly compresses the skin

using the fingers. Light palpation

compresses the skin approximately ½

inch, while deep palpation compresses

more firmly. To use deep palpation for

assessment, the clinician uses two

hands, with one on top of the other.

The lower hand is placed flat on the

abdomen with the opposite hand

directly on top of it. Using the top

hand, the clinician applies deep, gentle pressure to the hand below. Deep

palpation is performed very carefully; the use of two hands diffuses some of

the pressure with palpation so that the clinician is not directly pushing on

one specific area with the fingers.7

To identify and palpate the liver, the clinician places the left hand behind the

edge of the patient’s back for support. Using the opposite hand and starting

below the level of the liver as found during percussion, the clinician gently

and firmly presses with the fingertips and slowly moves upward toward the

lower margin of the liver. It often helps to have the patient take a deep

breath during palpation in order to better feel the edge of the liver when the

hand contacts it. The edge of the liver is normally smooth and soft; liver

abnormalities may cause it to feel sharp or hard on its edge.1 The lower

edge of the liver is approximately 3 cm below the level of the ribcage; the

normal span of the liver is between 6 and 12 cm.3 Any abnormalities found

on liver palpation should be noted and documented.

The spleen can be identified through palpation, particularly if it is enlarged.

As noted, the spleen lies in the lateral space of the left upper quadrant; it


cannot always be identified through palpation, however, with enlargement,

palpation of the spleen can better pinpoint an infectious process or injury

that would cause the spleen to become enlarged. To palpate the spleen, the

clinician works from below the lower margin of where the spleen normally

lies behind the ribcage in the left upper quadrant. One hand is placed behind

the back for support. Starting below the ribcage, the provider places a hand

on the abdomen and asks the patient to take a deep breath and then

breathe out. As the patient breathes in and out, the provider moves the

hands to palpate and feel for the area of the spleen. With the deep breaths

of the patient, the provider should be able to feel the edge of the spleen if it

is enlarged. It is essential to avoid manipulating the tissue too much in an

attempt to identify the spleen; if it is enlarged, too vigorous of manipulation

could result in injury to the spleen or cause it to rupture.

A patient who has abdominal pain may guard his or her abdomen,

preventing adequate palpation. Before starting this process of the

assessment, the clinician should help the patient to stay calm and to relax, if

possible. Muscle tension and rigidity often develop in response to pain, and

the clinician who palpates a tense abdomen will feel little more than

abdominal muscles. Before palpating the abdomen of a patient experiencing

pain, the clinician must first determine the location where the patient is

experiencing the most pain and then begin palpation at a distant point from

that spot.

The area of greatest pain should be palpated last. The clinician should begin

with light palpation and then follow with deep palpation. If the patient

presents with generalized abdominal pain that extends over most of the

abdomen, it may be difficult to complete the palpation component of the

assessment. Despite pain, guarding, and the patient’s attempts to stop the


clinician from performing the assessment, the clinician should attempt to

palpate the abdomen as much as allowed in order to better gauge the

internal structures and to assess for the cause of the pain.

If the clinician suspects a certain condition based on the patient’s history and

the abdominal assessment, there are several tests that may be performed to

better define the actual cause of pain and to identify a diagnosis. The patient

who presents with acute abdominal pain most likely will have tension of the

abdominal muscles that results in a rigid and stiff abdomen. It may be

difficult for the patient to stretch out supine to participate in the abdominal

exam. If the clinician has been unable to perform much of an assessment up

to this point because of the patient’s pain, some of the tests described below

can be performed instead of portions of the abdominal examination, or they

may be done to support findings on the abdominal examination.

Murphy’s Sign

Murphy’s sign is commonly used if the patient presents with pain or

tenderness in the right upper quadrant that could suggest cholecystitis. To

perform Murphy’s sign, the clinician places the right hand flat on the

patient’s abdomen in the right upper quadrant just below the costal margin

of the ribcage. The clinician then presses down onto the abdomen several

inches while the patient lets out a breath at the same time. The patient is

then asked to take a deep breath while the clinician keeps his or her hand in

the same place. By taking a deep breath, the gallbladder is pushed up

toward the provider’s hand.

A patient with cholecystitis will typically complain of pain when taking a deep

breath with this movement and may not be able to complete the test

because of tenderness in the area. The classic result that indicates a positive


Murphy’s sign occurs when the pain is elicited and the patient suddenly stops

trying to take a deep breath. The sharp pain induced through palpation

indicates a disease process in the area examined. Murphy’s sign has up to

90% sensitivity for cholecystitis in cases when it is performed.92

Rebound Tenderness

When appendicitis is a possibility based on the client’s presentation, a test of

rebound tenderness may elicit a response that can clarify whether further

testing is needed. Rebound tenderness is a simple test often used to identify

appendicitis or to rule out other potential causes of abdominal pain. To

assess for rebound tenderness, the clinician palpates an area away from the

tender point by pressing down at a 90-degree angle and then rapidly

releasing the pressure. As pressure is released, the clinician should watch

the patient to see if the action elicited a response and then determine if the

patient felt more pain with the pressure or with the release of pressure.

A negative sign of rebound tenderness occurs when the patient does not

complain of further pain with the maneuver.50 A patient has a positive

rebound tenderness sign when he or she feels a sharp or stabbing pain in

the abdomen when the clinician releases pressure during the test. This is

known as Blumberg’s sign. A positive test indicates some level of

inflammation within the peritoneum and is often indicative of appendicitis.50

Referred rebound tenderness may appear when the patient feels pain at an

area that is different from the rebound tenderness assessment. This may

also be similar to Rovsing’s sign, in which a positive test is indicated when

the patient feels pain in an area opposite the side initially palpated. A

positive sign for rebound tenderness or referred rebound tenderness when a

different area of the abdomen is palpated may guide the clinician toward


further diagnostic tests to isolate and clarify whether appendicitis or

peritonitis is present.

Rovsing’s Sign

Often used to determine whether appendicitis is present, Rovsing’s sign

assesses for abdominal tenderness by palpating one side of the abdomen.

The key component of this sign is palpation of the left lower quadrant of the

abdomen; if appendicitis is present, the patient will feel pain in the right

lower quadrant, where the appendix is located. It is thought that palpation

of the left side of the abdomen stretches the muscle and tissue across the

abdomen, including over the appendix. If the appendix is inflamed, the

patient may feel pain in the area in response to the tissue contacting the

inflammation. Rovsing’s sign is also used to palpate inflammation or

tenderness of other abdominal organs as well.

A patient with appendicitis typically has pain that starts near the umbilicus

and extends toward the location of the appendix in the right lower quadrant.

The patient may be asked to cough, as coughing can increase the pain of

appendicitis. The patient may have rigid abdominal pain, tenderness with

movement and palpation, and may guard the area carefully to protect from

further pain.

Further assessment for appendicitis includes eliciting pain from pressure on

McBurney’s point, which is found halfway between the umbilicus and the iliac

crest in the right lower quadrant. Placing pressure on this point can also

elicit a pain response; this would be considered a positive McBurney’s sign

and can be used as an additional test for appendicitis.93


Obturator Sign

The obturator sign is a specific test that can be used to determine if

appendicitis is present and causing abdominal pain. To assess for the

obturator sign, the patient lies on his or her back while the provider grasps

the right ankle and pulls back to bend at the knee. This flexes the right leg

at the hip to a 90-degree angle from the rest of the body. Turning the knee

inward internally rotates the leg. This movement shifts the obturator muscle,

which extends across the lower end of the pelvis. If the patient has

appendicitis, he or she will feel pain in the right lower quadrant as the

inflamed appendix is stretched with the internal rotation of the leg and the

movement of the muscle tissue as it passes over it.4,7

A second test that can be administered along with the obturator sign is the

psoas sign. To perform this test, the patient is turned onto the left side and

is told to lift the right leg when it is extended at the hip. The clinician places

pressure against the leg as the patient tries to lift it. The test is considered

positive when the patient experiences pain as he or she tries to lift the leg.

This action indicates that the psoas muscle, which extends diagonally from

the middle of the abdomen toward the outer portions of the lower quadrant,

is moving across the appendix. If the appendix is inflamed, the rub of the

muscle over the organ will cause pain and it typically indicates

appendicitis.93

Costovertebral Angle Tenderness

A patient with distention of the renal capsule may have costovertebral angle

tenderness upon assessment. This condition may most likely result in

abdominal pain in the flank and is often caused by peritoneal abscess,

kidney stones, pyelonephritis, or occlusion of one of the renal arteries. A

positive sign of costovertebral angle tenderness occurs when the patient


feels pain during the exam that results from stretching of the renal capsule

and stimulating associated nerves. The pain is often intense and may travel

anteriorly toward the umbilicus.51 The test is negative when the patient

simply feels the effects of the exam without any pain.

To elicit costovertebral angle tenderness, the clinician assists the patient to

sit upright with his back facing the clinician. The clinician places the palm of

one hand on the costovertebral angle of the same side; for instance, to

assess the left costovertebral angle, the clinician uses the left hand. With the

opposite hand, the clinician makes a fist and strikes the back of the hand

that is on the patient, using the ulnar surface of the fist. The test is then

repeated on the opposite side. As noted, a positive sign results in intense

pain due to the underlying disease process when this method of percussion

is performed.51

In addition to flank pain associated with the costovertebral angle tenderness,

the patient may also have pain radiating from the flank and extending down

toward the groin or the leg. The pain may be intermittent or it may wax or

wane in intensity levels. Cases of pyelonephritis also may cause nausea,

vomiting, pain with urination, weakness, fever, chills, and tenesmus.51

Similar to other types of physical tests, costovertebral angle tenderness is a

useful tool for narrowing down the scope of potential conditions that could

be causing abdominal pain.

Summary

The patient history and physical examination of a patient with abdominal

pain requires a consistent, systematic approach to determine the level of

pain and the cause of pain. The appearance of the abdomen during

inspection, and findings obtained during auscultation, percussion and


palpation provide clues as to the location and cause of abdominal pain. While

the clinician is performing the abdominal examination, the patient is also

being asked questions about their activities prior to the onset of pain, as well

as the duration and intensity of pain. Possible correlating symptoms relating

to the upper and lower gastrointestinal systems are explored during the

physical examination.

When evaluating the patient with abdominal pain the nurse should attempt

to determine methods of pain relief that worked for the patient. A pain

experience often requires coping mechanisms to better function, which the

patient may or may not be aware about or be able to adequately describe.

Being attentive to patient posture and behaviors provide clues about how

they may be attempting to relieve abdominal pain. Often, the patient with

abdominal may be too focused on finding relief from the pain than describing

the pain felt.

Some patients may not give much information about remedies or

medications used prior to their encounter with a health provider; what

worked or did not work to relieve their pain. The clinician attending to the

patient with abdominal pain may need to explore the patient’s remedies

used to alleviate pain. When treating the pain, the clinician should learn

what did not work to relieve pain in order to avoid prescribing medications

already shown to be ineffective. Additionally, it is important to explore the

patient’s cultural beliefs and expectations for pain relief.

A thorough patient history and physical assessment is a critical component

of the complete work up of abdominal pain that includes further diagnostic

testing. The type of diagnostic testing to perform depends on many of the

aspects of the patient’s examination, as discussed in this course. The next


course, Abdominal Pain Part III, informs the clinician on how to determine

the need for further testing, such as obscure findings during the physical

assessment or the potential for more than one cause of abdominal pain. The

clinician should consider all factors in the physical history and assessment

carefully before determining the necessity of further testing to pinpoint the

cause of abdominal pain and the course of treatment.

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a. face, wrist, elbows, hands.

b. back, shoulders, chest, groin. c. internal organs only.

d. skin or peripheral areas only.


a. gallstones. b. bowel obstruction.

c. gastroesophageal reflux disease. d. None of the above

3. True or False: The clinician should base a diagnosis of abdominal

pain solely on the region of associated pain.

a. True

b. False

4. In a study published in the Journal of Clinical Nursing, nursing perceptions of barriers to adequately control a patient’s pain

included:

a. Lack of clinical guidelines. b. Lack of standard assessment tool for pain management.

c. Limited autonomy when making decisions about pain control. d. All of the above


e. mild, nagging pain with no resolution. f. chronic, intermittent pain with separate episodes within 3-months.

g. more often seen among children. h. Answers b., and c., above

6. True or False: While performing the physical assessment it is

helpful for the clinician to use clarifying questions, such as: “did that help the pain?” or “did that make it worse or better?”

a. True

b. False


7. Murphy’s sign is commonly used to test for gallbladder disease

and for

a. pain or tenderness in the left upper quadrant. b. pain or tenderness in the right upper quadrant.

c. pain or tenderness in the substernal region. d. None of the above

8. Auscultation is mainly performed to

a. listen to bowel sounds.

b. determine bowel motility. c. determine whether there is organ enlargement.

d. Answers a., and b., above

9. Rovsing’s sign aids in the assessment of abdominal pain

a. by palpation of the left lower quadrant of the abdomen.

b. when pain is isolated to the right lower quadrant. c. as an indication of inflammation or tenderness of the appendix.

d. All of the above

10. True or False: The Joint Commission has shown that inadequate pain management in hospitals often occurs when clinicians do

not assess pain appropriately or when the patient’s reaction to pain does not conform to the clinician’s expectations.

a. True

b. False

11. During abdominal palpation, organ enlargement may indicate

a. fluid back up into the liver circulation.

b. severe liver disease. c. a tumor.

d. All of the above

12. True or False: Pain localized to one specific area is typical of a disease process associated with transient conditions, such as

intestinal gas or gastroenteritis.

a. True b. False


13. The right upper quadrant consists of all EXCEPT the

a. liver.

b. gallbladder. c. pancreas.

d. descending colon.

14. To assess for rebound tenderness, the clinician palpates an area away from the tender point by pressing down

a. at a 90-degree angle.

b. slowly releasing the pressure. c. at a 45-degree angle.

d. to see if the patient felt less pain with release of pressure.

15. True or False: Pain localized to one specific area is typical of a

disease process associated with transient conditions, such as intestinal gas or gastroenteritis.

a. True

b. False

16. Kehr’s sign refers to a condition in which a patient is suffering from pain

a. in the neck.

b. in the shoulder. c. in the abdomen.

d. In the back.

17. An abdominal aortic aneurysm may lead to referred pain in the

a. hip.

b. upper thigh. c. back.

d. shoulder blades.

18. Direct percussion notes areas of tenderness and may be used

a. for deep abdominal pain. b. with the palm of the hand to note the patient’s response.

c. for superficial abdominal pain. d. Both a., and b., above


19. True or False: The McGill Pain Questionnaire is a form that a

patient’s family fills out and not the patient.

a. True b. False

20. Pain originating in the __________ will typically cause pain to

radiate to the lower back.

a. kidneys b. liver

c. stomach d. gallbladder

21. Pain associated with the gallbladder, such as gallstones or pain

in the bile duct leading to the small intestine often radiates to

_____________________, in addition to referring to the back.

a. pelvic region b. neck

c. the chest d. the shoulder or scapula

22. When certain injuries occur in the abdomen, the pain is referred

to the groin because areas of the abdomen and groin

a. are in the same quadrant. b. are in the subphrenic region.

c. have overlapping dermatomes. d. are proximate to the pelvic bone.

23. Chest pain ___________________ is usually not made worse when the clinician performs palpation during the abdominal

examination.

a. from a splenic abscess b. caused by severe pancreatitis

c. that is cardiac in nature d. caused by organ enlargement


24. Conditions such as infection of one of the abdominal organs or

peritonitis are some of the most common causes of abdominal pain referred to the

a. center of the back.

b. shoulder. c. lower back.

d. chest.

25. True or False: Referred pain tends to radiate to the same locations in most people.

a. True

b. False

26. Pain from an ectopic pregnancy may cause pain in the

a. center of the back.

b. upper thigh. c. hip.

d. subphrenic region.

27. A clinician observing a patient’s affect is observing the patient’s

a. reaction to medication. b. expression of emotion or feelings.

c. body temperature. d. cognition and communication skills.

28. The _______________________ assessment is where the

clinician asks pain-specific questions to determine the type and

amount of pain the patient is experiencing and the patient’s concerns about medical care and pain relief.

a. problem-oriented

b. family history c. medical history

d. cognition-oriented


29. Some clinicians perform pain assessments incorrectly by relying

on information such as

a. the problem-oriented assessment. b. the patient’s cultural and ethnic beliefs.

c. the patient’s reasons for seeking help. d. changes in the patient’s vital signs.

30. True or False: Elevated heart rate, respiratory rate, or blood

pressure has not been shown to be a consistent indicator of the depth of the pain the patient is experiencing.

a. True

b. False

31. The ______________ scale uses faces that range from happy

and smiling on one end signifying no pain to sad and crying on the opposite end signifying the most pain.

a. Rovsing’s

b. visual analog c. Wong-Baker

d. McGill Pain

32. If intravenous medications are given, the nurse should reassess the patient’s pain ___________ to determine if the patient is

experiencing any pain relief.

a. within an hour b. within 15 minutes

c. the following day

d. at least once during the shift

33. Colicky pain is defined as pain that

a. is intermittent. b. is constant.

c. is imaginary. d. is typically mild.


34. Intense itching on the skin of the abdomen can more commonly

develop with

a. ectopic pregnancy. b. left lower quadrant abdominal pain.

c. liver cirrhosis. d. a tumor.

35. Bruising near the umbilicus is known as

a. Rovsing’s sign.

b. Cullen’s sign. c. Grey Turner’s sign.

d. Murphy’s sign.

36. True or False: Cushing’s syndrome causes changes in hormones

that affect fibroblasts in the skin.

a. True b. False

37. Abdominal bruising, which appears as bruising around the sides

of the abdomen near the flank, is known as

a. Cullen’s sign. b. Grey Turner’s sign.

c. Murphy’s sign. d. Kehr’s sign.

38. Which of the following is sometimes associated with

pancreatitis?

a. Kehr’s sign.

b. Murphy’s sign. c. Cullen’s sign.

d. All of the above


39. Murphy’s sign is commonly used if the patient presents with

pain or tenderness in the _______________ quadrant that could suggest cholecystitis.

a. right lower

b. left lower c. subphrenic

d. right upper

40. A German surgeon, Hans Kehr, first described Kehr’s sign after seeing a patient with severe _________ pain due to a splenic

abscess.

a. chest b. lower back

c. subphrenic

d. clavicle

41. To perform _______________, the clinician places the right hand flat on the patient’s abdomen in the right upper quadrant

just below the costal margin of the ribcage.

a. Rovsing’s sign b. Murphy’s sign

c. the Wong-Baker maneuver d. auscultation

42. Visible peristalsis most often indicates ______________ at

some point in the intestine.

a. an obstruction

b. bleeding c. excess fluid

d. a peritoneal abscess

43. When ________________ develops, small tears may occur in the epidermis and the dermis, leading to decreased elasticity

and striae.

a. a peritoneal abscess b. irritable bowel syndrome

c. Cushing’s syndrome d. Cullen’s sign


44. Rebound tenderness is a simple test often used to identify

_____________ or to rule out other potential causes of abdominal pain.

a. a peritoneal abscess

b. irritable bowel syndrome c. appendicitis

d. splenic abscess

45. Often used to determine whether appendicitis is present, _____________ assesses for abdominal tenderness by

palpating one side of the abdomen.

a. Rovsing’s sign b. Murphy’s sign

c. Costovertebral angle test

d. Cullen’s sign

CORRECT ANSWERS:


b. back, shoulders, chest, groin.


c. gastroesophageal reflux disease.

3. True or False: The clinician should base a diagnosis of abdominal pain solely on the region of associated pain.

b. False

4. In a study published in the Journal of Clinical Nursing, nursing

perceptions of barriers to adequately control a patient’s pain included:

d. All of the above



d. Answers b., and c., above

6. True or False: While performing the physical assessment it is

helpful for the clinician to use clarifying questions, such as: “did that help the pain?” or “did that make it worse or better?”

a. True

7. Murphy’s sign is commonly used to test for gallbladder disease

and for

b. pain or tenderness in the right upper quadrant.

8. Auscultation is mainly performed to

d. Answers a., and b., above

9. Rovsing’s sign aids in the assessment of abdominal pain

d. All of the above

10. True or False: The Joint Commission has shown that inadequate

pain management in hospitals often occurs when clinicians do not assess pain appropriately or when the patient’s reaction to

pain does not conform to the clinician’s expectations.

a. True

11. During abdominal palpation, organ enlargement may indicate

d. All of the above



b. False

13. The right upper quadrant consists of all EXCEPT the

d. descending colon.


14. To assess for rebound tenderness, the clinician palpates an area

away from the tender point by pressing down

a. at a 90-degree angle.



a. True

16. Kehr’s sign refers to a condition in which a patient is suffering from pain

b. in the shoulder.

17. An abdominal aortic aneurysm may lead to referred pain in the

a. hip.

18. Direct percussion notes areas of tenderness and may be used

c. for superficial abdominal pain.

19. True or False: The McGill Pain Questionnaire is a form that a patient’s family fills out and not the patient.

b. False

20. Pain originating in the __________ will typically cause pain to

radiate to the lower back.

a. kidneys

21. Pain associated with the gallbladder, such as gallstones or pain

in the bile duct leading to the small intestine often radiates to _____________________, in addition to referring to the back.

d. the shoulder or scapula

22. When certain injuries occur in the abdomen, the pain is referred

to the groin because areas of the abdomen and groin

c. have overlapping dermatomes.


23. Chest pain ___________________ is usually not made worse

when the clinician performs palpation during the abdominal examination.

c. that is cardiac in nature

24. Conditions such as infection of one of the abdominal organs or

peritonitis are some of the most common causes of abdominal pain referred to the

d. chest.

25. True or False: Referred pain tends to radiate to the same

locations in most people.

a. True

26. Pain from an ectopic pregnancy may cause pain in the

b. upper thigh.

27. A clinician observing a patient’s affect is observing the patient’s

b. expression of emotion or feelings.

28. The _______________________ assessment is where the

clinician asks pain-specific questions to determine the type and amount of pain the patient is experiencing and the patient’s

concerns about medical care and pain relief.

a. problem-oriented

29. Some clinicians perform pain assessments incorrectly by relying

on information such as

d. changes in the patient’s vital signs.

30. True or False: Elevated heart rate, respiratory rate, or blood pressure has not been shown to be a consistent indicator of the

depth of the pain the patient is experiencing.

a. True


31. The ______________ scale uses faces that range from happy

and smiling on one end signifying no pain to sad and crying on the opposite end signifying the most pain.

c. Wong-Baker

32. If intravenous medications are given, the nurse should reassess

the patient’s pain ___________ to determine if the patient is experiencing any pain relief.

b. within 15 minutes

33. Colicky pain is defined as pain that

a. is intermittent.

34. Intense itching on the skin of the abdomen can more commonly develop with

c. liver cirrhosis.

35. Bruising near the umbilicus is known as

b. Cullen’s sign.

36. True or False: Cushing’s syndrome causes changes in hormones

that affect fibroblasts in the skin.

a. True

37. Abdominal bruising, which appears as bruising around the sides

of the abdomen near the flank, is known as

b. Grey Turner’s sign.

38. Which of the following is sometimes associated with pancreatitis?

c. Cullen’s sign.


39. Murphy’s sign is commonly used if the patient presents with

pain or tenderness in the _______________ quadrant that could suggest cholecystitis.

d. right upper

40. A German surgeon, Hans Kehr, first described Kehr’s sign after

seeing a patient with severe _________ pain due to a splenic abscess.

d. clavicle

41. To perform _______________, the clinician places the right

hand flat on the patient’s abdomen in the right upper quadrant just below the costal margin of the ribcage.

b. Murphy’s sign

42. Visible peristalsis most often indicates ______________ at some point in the intestine.

a. an obstruction

43. When ________________ develops, small tears may occur in

the epidermis and the dermis, leading to decreased elasticity and striae.

c. Cushing’s syndrome

44. Rebound tenderness is a simple test often used to identify

_____________ or to rule out other potential causes of

abdominal pain.

c. appendicitis

45. Often used to determine whether appendicitis is present, _____________ assesses for abdominal tenderness by

palpating one side of the abdomen.

a. Rovsing’s sign


References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. Bickley, L. S. (2013). Bates’ guide to physical examination and history

taking (11th ed.). [Chapter 11]. Philadelphia, PA: Lippincott Williams & Wilkins

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assessment-adult/equipment/ad_exam.html 3. O’Laughlen, M. C. (2009). Making sense of abdominal assessment.

Nursing Made Incredibly Easy! 7(5): 15-19. Retrieved from http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/0900

0/Making_sense_of_abdominal_assessment.5.aspx

4. Dennis, M., Talbot Bowen, W., Cho, L. (2012). Mechanisms of clinical signs. Chatswood, NSW: Elsevier Australia

5. Shimizu, T., Tokuda, Y. (2013). Visible intestinal peristalsis. BMJ Case Rep. doi: 10.1136/bcr-2013- 201748

6. Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (Eds.). (2010). Brunner and Suddarth’s textbook of medical-surgical nursing,

Volume 1 (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins 7. Kauffman, M. (2014). History and physical examination: A common

sense approach. Burlington, MA: Jones & Bartlett Learning 8. University of California, San Diego. (2009, Jul.). Exam of the abdomen.

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10. Patel, S. (2010). Mesenteric ischemia. Retrieved from

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nal_emergencies/intestinal_obstruction.html

http://atitesting.com/ati_next_gen/skillsmodules/content/physical-assessment-adult/equipment/ad_exam.html

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http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/09000/Making_sense_of_abdominal_assessment.5.aspx

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http://meded.ucsd.edu/clinicalmed/abdomen.htm

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controlling Crohn’s disease, colitis and other IBDS. Chatham, UK: Ebury Publishing

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6736(12)60026-9/fulltext 24. Levine, J. S., Burakoff, R. (2011, Apr.). Extraintestinal manifestations of

inflammatory bowel disease. Gastroenterol Hepatol (NY) 7(4): 235-241. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/

25. Cox, C. (Ed.). (2010). Physical assessment for nurses (2nd ed.). West Sussex, UK: Blackwell Publishing

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27. Wilson, S. F., Giddens, J. F. (2013). Health assessment for nursing practice (5th ed.). St. Louis, MO: Elsevier Mosby

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Clinical Nursing 21:1254-1262. Retrieved from

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http://umm.edu/health/medical/altmed/condition/peritonitis

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0034-1366074

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http://umm.edu/health/medical/ency/articles/abdominal-pain

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/


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Wilkins 32. Turk, D. C., Melzack, R. (2011). Handbook of pain assessment. New

York, NY: The Guilford Press 33. U.S. Food and Drug Administration. (2014, Aug.). Computed

tomography (CT). Retrieved from http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImag

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34. Nursing Central. (2014). Ultrasound, abdomen. Retrieved from http://nursing.unboundmedicine.com/nursingcentral/view/Davis-Lab-

and-Diagnostic-Tests/425425/all/Ultrasound__Abdomen 35. Northwestern Medicine. (2014, Jan.). Abdominal x-rays. Retrieved from

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36. Plevris, J., Howden, C. (Eds.). (2012). Problem-based approach to gastroenterology and hepatology. West Sussex, UK: Blackwell

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39. Saladin, K. S. (2012). Anatomy and physiology (6th ed.). New York: NY:

McGraw-Hill 40. Gebhart, G. F., Bielefeldt, K. (2008). Visceral pain. Retrieved from

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from http://emedicine.medscape.com/article/829008-overview 42. Bloom, A. A. (2014, Apr.). Cholecystitis. Retrieved from

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The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in

addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address

any specific situation. This publication in no way absolves facilities of their responsibility for

the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation

processes should review the contents of this publication to ensure accuracy and compliance

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The contents of this publication may not be reproduced without written permission from

NurseCe4Less.com.

http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/helicobacter-pylori

http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/helicobacter-pylori

http://www.uptodate.com/contents/helicobacter-pylori-infection-and-treatment-beyond-the-basics

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http://www.pancreasfoundation.org/patient-information/chronic-pancreatitis/

http://www.cdemcurriculum.org/ssm/gi/biliary/biliary.php

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