Acute Abdomen.pptx

The Acute Abdomen Nursing Development and Abdominal Anatomy Hollow organs Solid organs Hollow Organs  Stomach  Intestines  Bladder Solid organs  Liver  Spleen  Kidneys  Pancreas  GI : Assessment  Familiarize yourself with:  the anat...

The Acute Abdomen Nursing Development and Abdominal Anatomy Hollow organs Solid organs Hollow Organs  Stomach  Intestines  Bladder Solid organs  Liver  Spleen  Kidneys  Pancreas  GI : Assessment  Familiarize yourself with:  the anatomy,  organ function and interaction with other systems,  available tests,  labs and their interpretation. Be consistent in your approach.  GI : Assessment History  Chief complaint  S&S  Risk Factors  Current & Significant PMHx  Medications  Drug and alcohol  Allergies  GI & GU: Assessment  When assessing the abdomen the critical care nurse remembers that: A. Deep palpation should never be used. B. Deep palpation should be performed if spleenomegaly is present C. Normally, one should not be able to palpate the spleen. D. Normally, one should not be able to palpate the liver.  GI & GU: Assessment  When assessing the abdomen the critical care nurse remembers that: A. Deep palpation should never be used. B. Deep palpation should be performed if spleenomegaly is present C. Normally, one should not be able to palpate the spleen. D. Normally, one should not be able to palpate the liver. Assessment Physical Assessment 1. Inspection 2. Auscultation 3. Percussion 4. Palpation  Assessment Inspection  Skin color  Appearance of the abdomen  Size,shape, color, symmetry, distention, protuberance, rash, scaring, pulsation.  Pt positioning, expression  Stool & Urine: character, odor, color, blood Assessment Auscultation  Four quadrants  Bowel sounds  Friction rub over liver & spleen  Bruits over the abdominal aorta Assessment Percussion Normal Percussion sounds  Dullness: heard over solid organs and muscles.  Tympany: heard over most portions of the abdominal cavity. Abnormal Percussion sounds  Dullness: may be produced by intra-abdominal tumors or masses.  Shifting dullness may indicate presence of ascites. Percussion is also a very sensitive sign of peritonitis Percussion - Liver Assessment Palpation warn them  Gentle & Shallow make them  Palpating: comfortable  Rigidity take tension off the  Guarding abdominal wall  Pain or Pillow or bend the tenderness knees  Rebound Expose the entire tenderness abdomen  Masses Xiphoid to pubis  Hernias Direct & Rebound Tenderness Deep Palpation Liver Palpation  Assessment  A 24 year old restrained driver of a motor vehicle crash has arrived in the ED. After assessment, she is found to be hemodynamically stable, and an intra- abdominal injury is suspected. Which of the following is a rapid non-invasive tool for the confirmation of an intra-abdominal injury? 1. Computed tomography scan 2. Physical examination 3. Peritoneal lavage 4. Ultrasound  Assessment  A 24 year old restrained driver of a motor vehicle crash has arrived in the ED. After assessment, she is found to be hemodynamically stable, and an intra- abdominal injury is suspected. Which of the following is a rapid non-invasive tool for the confirmation of an intra-abdominal injury? 1. Computed tomography scan 2. Physical examination 3. Peritoneal lavage 4. Ultrasound  Assessment Signs  Kehr’s: (Ruptured Spleen )  Left shoulder pain with abdominal palpation  Gray-Turners: (retro peritoneal bleeding / pancreatitis)  Flank ecchymosis Cullen’s : (Blood in abdomen / Pancreatitis)  Periumbilical ecchymosis  Saegasser’s: (Splenic rupture)  Pain in neck w/ LUQ palpation  Balance’s: (Splenic Rupture)  Dullness on percussion w/ position change  GI & GU: Assessment Signs  Murphy’s: (Gallbladder)  Inhibition of inspiration on RUQ palpation  Rovsings: (Appendicitis)  RLQ pain on palpation of LLQ  Obturator: (Appendicitis)  Pain w/ flexion & internal rotation of R thigh  Psoas: (Appendicitis)  Pain w/ hyperextension of R hip  Acute Abdomen General name for presence of signs & symptoms of inflammation of the peritoneum (abdominal lining). History  What does pain feel like?  Steady pain - inflammatory process  Crampy pain - obstructive process History Was onset of pain gradual or sudden? Sudden = perforation, hemorrhage, infarct Gradual = peritoneal irritation, hollow organ distension History  Females  Last menstrual period?  Abnormal bleeding? In females, abdominal pain = Gyn problem until proven otherwise Physical Exam  General Appearance  Lies perfectly still  inflammation, peritonitis  Restless, writhing  obstruction  Abdominal distension?  Ecchymosis around umbilicus, flanks? Physical Exam  Bowel Sounds  Listen up to 5 minutes in each quadrant  Listen before feeling  Absent bowel sounds  ileus, peritonitis, shock Pancreatitis  Pancreatitis Two types:  Acute: excessive ethanol ingestion or by mechanical obstruction, trapping digestive enzymes in the pancreas  Chronic: digestive enzymes slowly destroy the pancreas and surrounding tissues.  Resultsin an inability to digest fats, proteins, and carbs properly.  Insulin production is affected.  Generally follows years of alcohol abuse  Pancreatitis S&S  Gray-Turners & Cullen’s signs  Severe upper abd pain that radiates through to the back  Epigastic tenderness  N&V  Low-grade fever  Hypotension  Signs of shock  Abdominal distension  Foul-smelling, fatty stool  Associated hyperglycemia & hypocalcaemia  Respiratory complications  Associated pleural effusion  atelectasis  Pancreatitis Diagnostic studies  Labs:  Lytes,calcium, magnesium, serum amylase (amylase peaks in 24 hours), lipase, CBC, LFT’s, Glucose  Imaging  ABD x-rays  US (for gallstones)  ABD CT (for critically ill patients)  CXR  Pancreatitis Therapeutic Interventions  Support ABC’s  Supplemental Oxygen  LR or NS IV  Blood replacement as indicated  NG to LIS  Analgesics* & Antiemetics  Antibiotics (for necrotizing pancreatitis)  Possible hospital admission  Possible surgery Diverticulitis GI & GU: Diverticulitis The Down & Dirty  Bowel inflammation  Affects sigmoid colon, diverticula sac  LLQ crampy pain (constant w/ diverticulitis, intermittent w/ diverticulosis), rigidity, distention, anorexia, occult blood in stool  Hydrate, analgesics, antispasmodics, antibiotics  Avoid straining ~ can result in diverticulitis with straining Cholecystitis  Cholecystitis  Inflammation of gall bladder  Commonly associated with gall stones  More common in 30 to 50 year old females  Nausea, vomiting; RUQ pain, tenderness; fever  Attacks triggered by ingestion of fatty foods Cholecystitis  Which assessment findings would be present in a patient with cholecystitis ? A. RUQ pain aggravated by deep breathing and increased WBC. B. Referred pain to right scapula and shoulder C. Murphy’s sign and temperature D. All of the above Cholecystitis  Which assessment findings would be present in a patient with cholecystitis ? A. RUQ pain aggravated by deep breathing and increased WBC. B. Referred pain to right scapula and shoulder C. Murphy’s sign and temperature D. All of the above  Cholecystitis S&S  Sudden onset of epigastric pain that radiates to the RUQ (especially following ingestion of fried or greasy foods)  Localized pain on palpation, with rebound tenderness  Pain referred to the right scapula  Anorexia  N&V  Low-grade fever: 38o  Mild jaundice  Murphy's sign (Inhibition of inspiration on RUQ palpation)  Cholecystitis Diagnostic Studies  U/S  ABD CT  Flat and upright ABD x-rays  CBC  Cholecystitis Interventions  NGT to LIS  LR or NS IVF  Antibiotics  Analgesics  Antiemetics  Possible surgery (cholecystectomy)  Low fat diet Gastroenteriti s  GI & GU: Gastroenteritis The Down & Dirty  Gastro can be:  Viral  Bacterial  Parasitic  Protozoan  Ask if the pt has had recent travel to a foreign country  #1 cause of dehydration in pediatric population  Crampy, colicky,abdominal pain, N/V, diarrhea, hyperactive bowel sounds  Electrolytes, stool exam for blood, culture, O&P Hydration!! Appendicitis  Appendicitis  Appendicitis is the most common cause of abdominal pain and abdominal surgery in the pediatric client.  Rare in pt’s < 2 years old  Appendicitis S&S  Pain originates in the periumbilical area and then localizes in the RLQ.  Preferred position is supine with the legs flexed  Rovsings: RLQ pain on palpation of LLQ  Obturator: Pain w/ flexion & internal rotation of R thigh  Psoas: Pain w/ hyperextension of R hip  Loss of appetite: if anorexia is not present, appendicitis is unlikely.  N&V occur  Febrile and tachycardic  RLQ guarding and pain with movement.  Rebound tenderness and abdominal rigidity (peritoneal sign) if ruptured.  Appendicitis Diagnostic Aids  Serial CBC’s (with left shift)  Renal P., Hepatic P., Bone P.  U/A  Abdominal U/S  Abdominal CT Scan (appy prep)  Abdominal CT scan  CXR (to rule out RLL pneumonia as the cause of pain)  Appendicitis Therapeutic interventions  NPO  IV Access  Medications  Analgesics  Antipyretics  Antibiotics  Question  A 4-month ole infant is brought to the ED by his parents, who have stated that the infant has been crying, drawing up his knees and having abnormal stools that have a “currant jelly” consistency. After examination, the physician orders a barium enema. The EN suspects that the infant most likely has: A. Appendicitis B. An intussusception C. An incarcerated hernia D. A foreign body obstruction  Question  A 4-month ole infant is brought to the ED by his parents, who have stated that the infant has been crying, drawing up his knees and having abnormal stools that have a “currant jelly” consistency. After examination, the physician orders a barium enema. The EN suspects that the infant most likely has: A. Appendicitis B. An intussusception C. An incarcerated hernia D. A foreign body obstruction Intussuscepti on  Intussusception  Telescoping of bowel segment near ileocecal valve  Occurs between 3m - 5 years of age  Unknown etiology  Complains of :  Spasmodic lower abd pain (colicky)  “currant jelly stool”  Treatment:  Air or barium enema fluoroscopy*  Analgesics  NGT  IVF  Prep for surgery Hepatic Injury  Hepatic Injury  A patient arrives to the ED with a GSW to the left lower quadrant. His vitals signs are 90/50, 130, 32. Upon admission, which intervention is warranted at this time? A. Abdominal CT B. Emergency exploratory laporatomy C. Diagnostic peritoneal lavage  Hepatic Injury  A patient arrives to the ED with a GSW to the left lower quadrant. His vitals signs are 90/50, 130, 32. Upon admission, which intervention is warranted at this time? A. Abdominal CT B. Emergency exploratory laporatomy C. Diagnostic peritoneal lavage  Hepatic Injury  When an individual sustains a penetrating abdominal wound, clinical signs of shock will occur after what percentage of blood volume is lost? A. 15% B. 25% C. 30% D. 50%  Hepatic Injury  When an individual sustains a penetrating abdominal wound, clinical signs of shock will occur after what percentage of blood volume is lost? A. 15% ADULTS B. 25% CHILDREN C. 30% D. 50%  Hepatic Injury  Liver is injured in about 19% of blunt or penetrating abdominal trauma cases.  The liver is looking for trouble b/c:  Of it’s anterior location,  It’s large size,  It’s denseness,  Of it’s relatively unprotected status,  and it is highly vascular (400-1000ml/min)  Clinical Manifestations  Abdominal wall muscle spasm and rigidity  Hypoactive or absent bowel sounds  Involuntary guarding  Rebound tenderness  RUQ pain  Signs of hypovolemic shock  Hepatic Injury Diagnostic Aids  CT  Liver enzymes  Angiography Therapeutic Interventions  Hydration  Urinary catheter  NGT  Antibiotics FYI: If there is evisceration - cover with saline gauze  Question  Patients with blunt abdominal trauma commonly have injuries to what internal organs? A. Pancreas and liver B. Pancreas and spleen C. Liver and spleen D. Kidneys and spleen  Question  Patients with blunt abdominal trauma commonly have injuries to what internal organs? A. Pancreas and liver B. Pancreas and spleen C. Liver and spleen D. Kidneys and spleen  Bowel Obstruction Bowel Obstruction  Blockage of inside of intestine  Interrupts normal flow of contents  Causes include adhesions, hernias, fecal impactions, tumors  Crampy abdominal pain; nausea, vomiting (often of fecal matter); abdominal distension Bowel Obstruction Q Upon auscultation of the abdomen, which would be indicative of early bowel obstruction? A. Decreased or absent bowel sounds B. Active or increased bowel sounds C. Increased BS above the obstruction , decreased BS below the obstruction Bowel Obstruction Q Upon auscultation of the abdomen, which would be indicative of early bowel obstruction? A. Decreased or absent bowel sounds B. Active or increased bowel sounds C. Increased BS above the obstruction , decreased BS below the obstruction Bowel Obstruction  Both small and large bowel can be affected  May be caused by a variety of reasons including:  Fecal impaction, hernia, adhesions,  Tumors, paralytic ileus, intussusception, volvulus,  gallstones,, abscesses or hematomas.  The immediate complication of a BO is dehydration S&S  N&V (fecal material)  Crampy pain that is wavelike and colicky  Abdominal distention  Constipation  Rectal blood and mucous, without fecal matter or flatus  Dehydration  Diffuse abdominal tenderness and rigidity Bowel Obstruction Diagnostic Studies  CBC,RP, HP, BUN & creatinine, amylase  ABD x-rays  Colonoscopy Therapeutic Interventions  Rehydration with crystalloid  NG to LIS  NPO  Abx  Urinary catheter  Treat / eliminate the cause Abdominal Trauma Penetrating & Blunt Injuries of the Abdomen  Closed injury (blunt)  Open injury (penetrating) Signs & Symptoms  Mechanism  Pain - pain upon palpation  Tachycardia  Shock  Bruising  Distended or rigid abdomen  Nausea & vomiting Care for Penetrating Injuries  Check for exit wounds.  Dry sterile dressing  Bulky dressing for impaled object Abdominal Evisceration  Internal organs or fat protrude through the open wound.  Never try to replace organs.  Cover with moist gauze, then sterile dressing.  Keep organs warm and moist.  Transport promptly. Question?