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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

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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. Trueb. 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, radiationWhat 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: UnderstandingWhat 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.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

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.



a. gallstones.b. bowel obstruction.c. gastroesophageal reflux disease.d. None of the above


a. Trueb. False


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. Trueb. 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. Trueb. 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. Trueb. 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.


a. Trueb. 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. Trueb. False

20. Pain originating in the __________ will typically cause pain to radiate to the lower back.

a. kidneysb. liverc. stomachd. 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 regionb. neckc. the chestd. 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 abscessb. caused by severe pancreatitisc. that is cardiac in natured. 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. Trueb. 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-orientedb. family historyc. medical historyd. 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. Trueb. 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’sb. visual analog


c. Wong-Bakerd. 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 hourb. within 15 minutesc. the following dayd. 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. Trueb. 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 lowerb. left lowerc. subphrenicd. 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. chestb. lower backc. subphrenicd. 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 signb. Murphy’s signc. the Wong-Baker maneuverd. auscultation


42. Visible peristalsis most often indicates ______________ at some point in the intestine.

a. an obstructionb. bleedingc. excess fluidd. 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 abscessb. irritable bowel syndromec. Cushing’s syndromed. 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 abscessb. irritable bowel syndromec. appendicitisd. 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 signb. Murphy’s signc. Costovertebral angle testd. Cullen’s sign

CORRECT ANSWERS:

1. The most common locations of referred abdominal pain include

b. back, shoulders, chest, groin.



c. gastroesophageal reflux disease.


b. False


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

2. ATI Nursing Education. (n.d.). Abdominal examination. Retrieved from http://atitesting.com/ati_next_gen/skillsmodules/content/physical-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/2009/09000/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. Retrieved from http://meded.ucsd.edu/clinicalmed/abdomen.htm

9. Stanford School of Medicine. (2014). Examination of the spleen. Retrieved from http://stanfordmedicine25.stanford.edu/the25/spleen.html

10. Patel, S. (2010). Mesenteric ischemia. Retrieved from http://www.cdemcurriculum.org/ssm/gi/mesenteric_ischemia/mesenteric_ischemia.php

11. University of Arkansas for Medical Sciences. (2007). Superior mesenteric artery and small intestine, inferior mesenteric artery and large intestine. Retrieved from http://anatomy.uams.edu/intestines.html

12. Merck Manuals. (2012, Oct.). Intestinal obstruction. Retrieved from http://www.merckmanuals.com/home/digestive_disorders/gastrointestinal_emergencies/intestinal_obstruction.html


http://www.merckmanuals.com/home/digestive_disorders/gastrointestinal_emergencies/intestinal_obstruction.html

http://www.merckmanuals.com/home/digestive_disorders/gastrointestinal_emergencies/intestinal_obstruction.html

http://anatomy.uams.edu/intestines.html

http://www.cdemcurriculum.org/ssm/gi/mesenteric_ischemia/mesenteric_ischemia.php

http://www.cdemcurriculum.org/ssm/gi/mesenteric_ischemia/mesenteric_ischemia.php

http://stanfordmedicine25.stanford.edu/the25/spleen.html

http://meded.ucsd.edu/clinicalmed/abdomen.htm

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/09000/Making_sense_of_abdominal_assessment.5.aspx

http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2009/09000/Making_sense_of_abdominal_assessment.5.aspx

http://atitesting.com/ati_next_gen/skillsmodules/content/physical-assessment-adult/equipment/ad_exam.html

http://atitesting.com/ati_next_gen/skillsmodules/content/physical-assessment-adult/equipment/ad_exam.html

13. Pothiawala, S., Gogna, A. (2012). Early diagnosis of bowel obstruction and strangulation by computed tomography in emergency department. World J Emerg Med 3(3): 227-231

14. Medline Plus. (2014, Feb.). Small intestinal ischemia and infarction. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001151.htm

15. Goldman, L., Schafer, A. I. (2012). Goldman’s Cecil medicine (24th ed.). Philadelphia, PA: Elsevier

16. Drugs.com. (2014, Nov.). Papaverine. Retrieved from http://www.drugs.com/cdi/papaverine.html

17. Alobaidi, M. (2013, Jul.). Mesenteric ischemia imaging. Retrieved from http://emedicine.medscape.com/article/370688-overview#a01

18. Lee, P., Stevens, T. (2014). Acute pancreatitis. Retrieved from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/acute-pancreatitis/

19. University of Maryland Medical Center. (2012, Dec.). Peritonitis. Retrieved from http://umm.edu/health/medical/altmed/condition/peritonitis

20. Karul, M., Berliner, C., Keller, S., Tsui, T. Y., Yamamura, J. (2014). Imaging of appendicitis in adults. Fortschr Röntgenstr 186(6): 551-558. Retrieved from https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0034-1366074

21. University of Maryland Medical Center. (2014, May). Abdominal pain. Retrieved from http://umm.edu/health/medical/ency/articles/abdominal-pain

22. Hunter, J. (2010). Inflammatory bowel disease: The essential guide to controlling Crohn’s disease, colitis and other IBDS. Chatham, UK: Ebury Publishing

23. Baumgart, D. C., Sandborn, W. J. (2012, Nov.). Crohn’s disease. The Lancet 380(9853): 1590-1605. Retreived from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(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

26. Eckman, M. (Ed.). (2008). Assessment made incredibly easy! (4th ed.). Amber, PA: Lippincott Williams & Wilkins

27. Wilson, S. F., Giddens, J. F. (2013). Health assessment for nursing practice (5th ed.). St. Louis, MO: Elsevier Mosby

28. Subramanian, P., Allcock, N., James, V., Lathlean, J. (2012). Challenges faced by nurses in managing pain in a critical care setting. Journal of Clinical Nursing 21:1254-1262. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2011.03789.x/


http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2011.03789.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60026-9/fulltext

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60026-9/fulltext

http://umm.edu/health/medical/ency/articles/abdominal-pain

http://umm.edu/health/medical/ency/articles/abdominal-pain

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0034-1366074

https://www.thieme-connect.com/products/ejournals/html/10.1055/s-0034-1366074

http://umm.edu/health/medical/altmed/condition/peritonitis

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/acute-pancreatitis/

http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/acute-pancreatitis/

http://emedicine.medscape.com/article/370688-overview#a01

http://www.drugs.com/cdi/papaverine.html

http://www.nlm.nih.gov/medlineplus/ency/article/001151.htm

abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

29. Melzack, R. (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain 1(3): 277-299

30. Melzack, R. (1971). The McGill Pain Questionnaire. Montreal, Canada: McGill University

31. Bickley, L. S. (2013). Bates’ guide to physical examination and history taking (11th ed.). [Chapter 1]. Philadelphia, PA: Lippincott Williams & 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/MedicalImaging/MedicalX-Rays/ucm115317.htm

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 http://encyclopedia.nm.org/Library/TestsProcedures/Gastroenterology/92,P07685

36. Plevris, J., Howden, C. (Eds.). (2012). Problem-based approach to gastroenterology and hepatology. West Sussex, UK: Blackwell Publishing, Ltd.

37. Gyawali, C. P. (Ed.). (2012). The Washington Manual™: Gastroenterology (3rd ed.). St. Louis, MO: Washington University School of Medicine

38. Cervero, F. (n.d.). Visceral pain. Retrieved from http://www.wellcome.ac.uk/en/pain/microsite/science3.html

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 http://rfi.fmrp.usp.br/pg/fisio/cursao2012/viscelpainp1.pdf

41. Paula, R. (2014, Sep.). Abdominal compartment syndrome. Retrieved from http://emedicine.medscape.com/article/829008-overview

42. Bloom, A. A. (2014, Apr.). Cholecystitis. Retrieved from http://emedicine.medscape.com/article/171886-overview

43. Craig, S. (2014, Jul.). Appendicitis. Retrieved from http://emedicine.medscape.com/article/773895-overview

44. Daley, B. J. (2013, Apr.). Peritonitis and abdominal sepsis. Retrieved from http://emedicine.medscape.com/article/180234-overview

45. Sephton, M. (2009). Nursing management of patients with severe ulcerative colitis. Nursing Standard 24(15): 48-57

46. Lokwani, D. P. (2013). The ABC of CBC: Interpretation of complete blood count and histograms. New Delhi, India: Jaypee Brothers Publishing

47. Panebianco, N. L., Jahnes, K., Mills, A. M. (2011). Imaging and laboratory testing in acute abdominal pain. Emerg Med Clin N Am 29: 175-193


http://emedicine.medscape.com/article/180234-overview




http://rfi.fmrp.usp.br/pg/fisio/cursao2012/viscelpainp1.pdf

http://www.wellcome.ac.uk/en/pain/microsite/science3.html

http://encyclopedia.nm.org/Library/TestsProcedures/Gastroenterology/92,P07685

http://encyclopedia.nm.org/Library/TestsProcedures/Gastroenterology/92,P07685

http://nursing.unboundmedicine.com/nursingcentral/view/Davis-Lab-and-Diagnostic-Tests/425425/all/Ultrasound__Abdomen

http://nursing.unboundmedicine.com/nursingcentral/view/Davis-Lab-and-Diagnostic-Tests/425425/all/Ultrasound__Abdomen

http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115317.htm

http://www.fda.gov/Radiation-EmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-Rays/ucm115317.htm



48. Lab Tests Online. (2014, Nov.). Lactate. Retrieved from http://labtestsonline.org/understanding/analytes/lactate/tab/test/

49. Weber, J. R., Kelley, J. H. (2014). Health assessment in nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins

50. Lippincott Williams & Wilkins. (2009). Nursing know-how: Evaluating signs and symptoms. Philadelphia, PA: Lippincott Williams & Wilkins

51. Daniels, R. (2010). Delmar’s guide to laboratory and diagnostic tests (2nd

ed.). Clifton Park, NY: Delmar Cengage Learning52. 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

53. Centers for Disease Control and Prevention. (2014, Jul.). Pelvic inflammatory disease (PID)—CDC fact sheet. Retrieved from http://www.cdc.gov/std/PID/STDFact-PID.htm

54. Orthopaedic Specialists of North Carolina. (2014). Orthopedic physical therapy frequently asked questions. Retrieved from http://www.orthonc.com/patient-information/faqs/physical-therapy-faqs#heat4

55. Fishman, S., Ballantyne, J., Rathmell, J. P. (2010). Bonica’s management of pain. Philadelphia, PA: Lippincott Williams & Wilkins

56. Baylor Surgicare at Garland. (2009). Frequently asked questions. Retrieved from http://www.pas-garland.com/index.php?q=faq

57. Braun, M. B., Simonson, S. J. (2014). Introduction to massage therapy (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins

58. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems (9th ed.). St. Louis, MO: Elsevier Mosby

59. Söyüncü, S., Bektas, F., Cete, Y. (2012, Jan.). Traditional Kehr’s sign: Left shoulder pain related to splenic abscess. Ulus Travma Acil Cerrahi Derg 18(1): 87-88.

60. Fiebach, N. H., Kern, D. E., Thomas, P. A., Ziegelstein, R. C. (Eds.). (2007). Principles of ambulatory medicine. Philadelphia, PA: Lippincott Williams & Wilkins

61. Ombregt, L. (2013). A system of orthopaedic medicine (3rd ed.). London, UK: Churchill Livingstone Elsevier

62. Centers for Disease Control and Prevention. (2013, Aug.). Helicobacter pylori. Retrieved from http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/helicobacter-pylori

63. Crowe, S. E. (2013, Aug). Patient information: Helicobacter pylori infection and treatment. Retrieved from http://www.uptodate.com/contents/helicobacter-pylori-infection-and-treatment-beyond-the-basics

64. The National Pancreas Foundation. (2014). About chronic pancreatitis. Retrieved from


http://www.uptodate.com/contents/helicobacter-pylori-infection-and-treatment-beyond-the-basics

http://www.uptodate.com/contents/helicobacter-pylori-infection-and-treatment-beyond-the-basics

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.pas-garland.com/index.php?q=faq

http://www.orthonc.com/patient-information/faqs/physical-therapy-faqs#heat4

http://www.orthonc.com/patient-information/faqs/physical-therapy-faqs#heat4

http://www.cdc.gov/std/PID/STDFact-PID.htm

http://labtestsonline.org/understanding/analytes/lactate/tab/test/

http://www.pancreasfoundation.org/patient-information/chronic-pancreatitis/

65. Turnbull, J. M. (1995, Oct.). Is listening for abdominal bruits useful in the evaluation of hypertension? The Journal of the American Medical Association (JAMA) 274(16): 1299-1301.

66. Dooley-Hash, S. (2010). Abdominal pain: Biliary tract disease. Retrieved from http://www.cdemcurriculum.org/ssm/gi/biliary/biliary.php

67. Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F. A. Davis Company

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