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Community Health Centre Clinical Practice Guidelines for Primary abdominal pain

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					                                                                         Primary Health Care Services
                                                               Date of last review       2009

             Community Health Centre Clinical Practice Guidelines for Primary Care Nurses

                                             Abdominal pain


1. Presentation:
          Client presents with abdominal pain.

2. Purpose:
         To evaluate pain located in the abdominal area.

3. Definition
            Presence of abdominal pain

4. Etiology:
          Pain located within the abdominal region of unknown etiology. May be simple to complex in origin.
          Causes may range from trivial to immediately life threatening, requiring rapid diagnosis and surgery.
          These may include ruptured abdominal aortic aneurysm (AAA), perforated viscus, mesenteric ischemia,
          and ruptured ectopic pregnancy. Others (eg, intestinal obstruction, appendicitis, severe acute
          pancreatitis) are also serious and nearly as urgent.
                                   Fig. 1

Location of abdominal pain and possible causes.
5. Signs and Symptoms:
    Pain (mild to severe)
    Complaints of abdominal distension
    fever
    protracted vomiting,
    syncope or presyncope
    Hemoptysis, hematuria, blood in stool (occult or frank)
    Infants, young children, and some elderly people may have difficulty localizing the pain and may appear
          agitated and/or confused

6. Assessment:

            History

       Pain : quality (pain scale 1 to 10), location, onset and duration, radiation
       Factors that exacerbate or improve symptoms such as food, antacids, exertion, defecation
       Associated symptoms including fevers, chills, weight loss or gain, nausea, vomiting, diarrhea, constipation,
           hematochezia, melena, jaundice, change in the color of urine or stool, change in the diameter of stool

       Last bowel movement, if passing gas rectally
       Last micturition
       Past medical and surgical history, including risk factors for cardiovascular disease and details of previous
            abdominal surgeries
       Family history of bowel disorders
       Alcohol intake
       Last food intake
       Intake of medications including over the counter medications such as acetaminophen, aspirin, and NSAIDs
       Menstrual, contraceptive and pregnancy history

                      Physical
            The physical examination will vary depending upon the location and chronicity of the patient's
            symptoms. However, a typical examination will include:

       Measurement of blood pressure, pulse, and temperature
       Examination of the eyes and skin for jaundice
       Urine screen
       Auscultation (presence or absence of bowel sounds) percussion and palpation of the abdomen

7. Intervention:

            Severe abdominal pain (pain scale 8-10 out of 10)
            In patients with severe abdominal pain, symptoms that suggest surgical or emergent conditions include
            fever, protracted vomiting, syncope or presyncope, and evidence of gastrointestinal tract blood loss,
            signs of shock (hypotension, tachycardia)

            *All pediatric and cognitively impaired adults should be referred immediately

       Dial 9-911 immediately, request an ambulance and notify the on-site physician if any. At no time should
        transport of the patient be delayed for treatment. Treatment will continue en route as per EMS protocols.
       Continue complete assessment
       Keep patient NPO
       start IV NaCl 0.9% (18 gauze catheter for adult if possible)
       For adults with signs of shock( tachycardia,hypotension,diaphoresis,pallor)
           o O² 100% non rebreather.
           o Bolus NaCl 0.9% 500 ml- 1 L,
           o Reassess,
           o Repeat bolus to total of 2 L, Maintain systolic BP > 100 mmHg

       For pediatric with signs of shock (Prolonged capillary refill (>2 seconds) is a sign of decreased tissue
        perfusion and is more beneficial as a sign of shock in children than in adults. Persistent tachycardia is the
        most reliable indicator of shock in children.)
           o Give oxygen at 12-15 L/min by non-rebreather mask with reservoir; keep oxygen saturation >97%.
           o Give 20 mL/kg IV fluid rapidly as a bolus over 20 minutes
           o Reassess for signs of continuing shock
           o If shock persists, continue to administer fluid in 20 mL/kg boluses, and reassess after each bolus
       Following departure of the patient, contact the emergency department of the receiving hospital to advise
        that the patient is being transported and to give a detailed report to the receiving nurse.


   Mild to moderate abdominal pain
    Give nothing by mouth until the diagnosis is clear
    If patient presents urinary symptoms, obtain urinalysis and urine culture as per urinary symptoms guideline.
    For female of child bearing age, obtain urine pregnancy test
    Refer to on-site physician if available.
    If no physician available in the facility refer to the nearest emergency room with a written report of the
       patient assessment.

8. Referral to Physician:
             Patient who presents with abdominal pain must be seen by a physician.

9. Follow-up:
     Discharge instructions for abdominal pain
     For more information: call Tele-Care (811).
                                         FRAMEWORK FOR DECESION-MAKING



        Severe abdominal pain 8-10 out of 10                             Mild to moderate pain

                 Dial 9-911 immediately,                               All patient with abdominal pain
           Notify the on-site physician if any.                        must be seen by a physician.
                             ↓
            Continue complete assessment
                             ↓                                       NPO until the diagnosis is clear
                    Keep patient NPO                                                  ↓
                             ↓                                             If urinary symptoms,
                      IV NaCl 0.9%                                  obtain urinalysis and urine culture
             (18 gauze for adult if possible)                                         ↓
                             ↓                                       For female of child bearing age
                      If Signs shock                                   Obtain urine pregnancy test
           adult                         pediatric                                    ↓
-O² 100% non- rebreather       -O²at 12-15 L/min by non-          Refer to on-site physician if available,
-Bolus 500ml- 1 L              rebreather mask keep O²        Otherwise refer to the nearest emergency room
-Reassess,                     sat >97%                                               ↓
-Repeat boluses to total of     -Bolus 20 mL/kg IV fluid                Document and give report
2 L,                           rapidly over 20 minutes
-Maintain syst.                -Reassess for signs of
 BP > 100 mmHg                 continuing shock
                               -If shock persists, continue
                               to administer boluses in 20
                               mL/kg
                               -Reassess after each
                               boluses
                                              Abdominal pain
                               DISCHARGE INSTRUCTIONS/PATIENT INFORMATION

Most of the causes of abdominal pain are not serious and can be readily diagnosed and treated. However, abdominal
pain can also be a sign of a serious illness. It is important to be able to recognize symptoms that are severe and know
when to call a doctor.
Whether it is a mild stomach ache, sharp pain or stomach cramps, abdominal pain has numerous causes.
These include:

   Indigestion
   Constipation
   Stomach "flu"
   Menstrual cramps
   Food poisoning
   Food allergies
   Gas
   Lactose intolerance
   Ulcers
   Pelvic inflammatory disease
   Hernia
   Gallstones
   Kidney stones
   Endometriosis
   Crohn's disease
   Urinary tract infection
   Gastroesophageal reflux disease (GERD)

If your abdominal pain is severe or if it is accompanied by any of the following symptoms, contact your doctor
or Emergency Room as soon as possible:

   Fever
   Inability to keep food down for several days
   Inability to pass stool, especially if you are also vomiting
   Vomiting blood
   Bloody stools
   Difficulty breathing
   Painful or unusually frequent urination
   The pain occurs during pregnancy
   The abdomen is tender to the touch
   The pain is the result of an injury to the abdomen in the previous days
   The pain lasts for several days

For more information:     Contact Tele-Care at 811
                                      NURSES PRACTICE GUIDELINES
                                              Abdominal Pain

PATIENTS WITH ABDOMINAL PAIN MUST BE REFERRED TO PHYSICIAN

SIGNS AND SYMPTOMS
Pain scale: ____ on scale of 1 to 10
Pain location:    RUQ     LUQ      RLQ     LLQ
   Epigastric     Peri-umbilical   Supra-pubic   Lt flank   Rt flank
  Other_________________________________________________________________________________________
Pain radiation: ___________________________________________________________________________________
Factors that exacerbate or improve symptoms: __________________________________________________________
   _____________________________________________________________________________________________
Associated symptoms:
   Diaphoresis     Pallor Fever Chills        Nausea      Constipation Jaundice
   Vomiting ____________________________________________________________________________________
   Diarrhea______________________________________________________________________________________
   Other________________________________________________________________________________________

ASSESSMENT
Last bowel movement______________________________________________________________________________
    Passing gas rectally    Alcohol intake  Pain medication: ______________________________________________
Menstrual and contraceptive history: __________________________________________________________________
Medical and surgical history: ________________________________________________________________________
Vital signs: Temp______BP_______________Resp___________________Pulse______________________________
    Bowel sounds by auscultation_____________________________________________________________________
    Capillary refill_______________________ Weight___________________________________________________
Allergies no      yes _____________________________________________________________________________
_______________________________________________________________________________________________

NURSING INTERVENTIONS
   911     NPO     O²____________      IV____________________________________________________________
   IV boluses___________________________________________________________________________________
   Urine analysis and culture obtained  Pregnancy test_________________________________________________
   Revaluation___________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

    Discharge instructions sheet given and explained to patient ____________________________________________

Nurse’s signature:                                               Date: _________________________________
                                                  REFERENCES

Medscape, Evaluation of Acute Abdominal Pain Reviewed CME/CE
      News Author: Laurie Barclay, MDCME Author: Penny Murata, MD Release Date: April 18, 2008. Retrieved
      September 2, 2008 from http://www.medscape.com/viewarticle/573206

  The Merck Manual, Gastrointestinal disorders, acute abdominal pain September 2007 by Parswa Ansari, MD.
     Retrieved September 2, 2008 from
     http://www.merck.com/mmpe/sec02/ch011/ch011b.html#sec02-ch011-ch011b-395

Up to Date 2008. Diagnostic approach to abdominal pain in adults. Retrieved September
       2, 2008 from
       http://www.uptodate.com/online/content/topic.do?topicKey=pri_gast/4946

WebMD Home. Digestive Disorders Health Center, Digestive Diseases: Abdominal Pain
     Edited by Cynthia Dennison Haines, MD on March 01, 2006.Retrieved on September 8, 2008 from
     http://www.webmd.com/digestive-disorders/abdominal-pain


CTAS Implementation Guidelines, 2008 Revised CTAS Implementation Guidelines.

       Retrieved on September 8, 2008 from
       http://www.caep.ca/template.asp?id=B795164082374289BBD9C1C2BF4B8D32#guidelines

Province of New Brunswick, Provincial Medical Protocol, Policy and Procedure Manual,
       Adult Protocol: Non-trauma Shock, Last Updated: July 2007

Health Canada, Pediatric Clinical Practice Guidelines for Nurses in Primary Care, Date
Modified: 2005-03-17. Retrieved in September 11, 2008 from
        http://www.hc-sc.gc.ca/fniah-spnia/pubs/services/_nursing- infirm/2001_ped_guide/chap_20b-eng.php#20-10

				
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