Clinical Findings

Neuro:Anxiety, restlessness.

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, or absent bowel sounds; nausea, vomiting, diarrhea, constipation, GI bleeding.

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

Collaborative Management

• Inquire about recent bowel habits including laxatives or enemas.
• Inspect abdomen for symmetry and distention.
• Auscultate bowel sounds (hyperactive/hypoactive or absent).
• Palpate all abdominal quadrants for masses, pulsations, tenderness, and rigidity (from area of least tenderness to area of most tenderness).
• Assess NG tube placement and output if present.
• Assess indwelling urinary catheter if present to ensure drainage, and record amount, color, and clarity of urine (consider bladder scan if no catheter).
• Obtain STAT bedside blood glucose level if Pt has diabetes.
• Test emesis/NG drainage and/or stool for occult blood.
• Administer antiemetic and pain medication if ordered.
• Insert NG tube and initiate nasogastric suctioning as ordered.
• Perform bladder scan and/or insert urinary catheter as ordered.