Pain with fever, prolonged vomiting, fainting, and/or evidence of GI bleeding must be assessed immediately.

Clinical Findings

Neuro: Anxiety, restlessness, fatigue, malaise.

Resp: Increased respiratory rate and/or distress.

CV: Increased heart rate and/or hypotension.

Skin: Fever and/or coolness, pallor, and diaphoresis.

GI/GU: Anorexia; hyperactive, hypoactive, hyperresonant, or absent bowel sounds; nausea, vomiting, diarrhea, constipation, GI bleeding.

MS: Abdominal tenderness, distention, rigidity, guarding, flank pain, palpable pulsatile mass.

Lab: Abnormal CBC, amylase, lipase, and liver function tests.

Possible Causes: Bowel obstruction, ileus, peritonitis, irritable bowel syndrome, ascites, gastroenteritis, malignancy, liver disease, ulcers, appendicitis, cholecystitis, pancreatitis.

Collaborative Management

• Place Pt in position of comfort, and obtain a complete set of VS including a STAT bedside blood glucose level if Pt has diabetes.
• Assess pain using OPQRST format.
• Inquire about recent bowel habits including laxatives or enemas.
• Assess NG tube placement and output if present—if present but disconnected from suction, reconnect and assess output and Pt for improvement of symptoms.
• Assess indwelling urinary catheter if present to ensure drainage, and record amount, color, and clarity of urine (consider bladder scan if no catheter).
• Inspect abdomen for symmetry and distention.
• Auscultate bowel sounds (hyperactivehypoactive or absent)—if connected to NG suction, remember to temporarily turn off suction during auscultation.
• Palpate all abdominal quadrants for masses, pulsations, tenderness, and rigidity (from area of least tenderness to area of most tenderness). Lower right abdominal rebound tenderness may indicate appendicitis.
• Assess hydration status by reviewing recent I&O.
• Hold all prn laxatives/enemas until origin of pain has been established and use of these meds okayed by physician.
• Check recent labs (CBC, amylase, lipase, and liver function tests).
• Test emesis/NG drainage and/or stool for occult blood.
• Initiate SBAR to surgeon, primary provider, or on-call care provider.
• Establish IV access as ordered if not already present.
• Administer antiemetic, pain medication, or antibiotics as ordered.
• Obtain or arrange for ordered lab and diagnostic tests—prepare Pt for possible x-ray, CT, ultrasound, or endoscopy.
• Insert NG tube and initiate nasogastric suctioning as ordered.
• Perform bladder scan and/or insert urinary catheter as ordered.