1. King Dome Of Saudi Arabia – Tabuk AL-Ghad International Medical Sciences Collages – Female section Nursing

3. Out Line Introduction of acute abdominal pain. Identification of Acute abdominal pain. Classification of acute abdominal pain and character of each one. Description the causes of abdominal pain. Know the most people whose risk of acute abdominal pain. Explanation the sings and symptoms of abdominal pain Actions the nursing process of abdominal pain. Discussions the Pharma treatment of abdominal pain. Conclusion the lecture. References.

4. Objectives At the end of this lecture the student will be able to : Defined the acute abdominal pain. Classified the acute abdominal pain know the character of each type. Descripted the causes pf pain. Knowing the most people whose risk of acute abdominal pain. Explained the sings and symptoms of abdominal pain. Dealing Nursing process with abdominal pain. Discuss the medical treatment of abdominal pain. summery of lecture. References.

5. Introduction Severe abdominal pain that comes on quickly, however, almost always indicates a significant problem. It may be the sole indicator of the need for surgery. people react to pain differently.

6. Definition Of Abdominal Pain

7. The term 'acute abdomen' represents a rapid onset of severe symptoms that may indicate life-threatening intra- abdominal pathology.

8.   Visceral pain  Somatic pain  Referred pain Types of Abdominal Pain

9. Type of abdominal pain Visceral pain comes from the organs within the abdominal cavity (which are called the viscera). The viscera's nerves do not respond to cutting, tearing, or inflammation. Instead, the nerves respond to the organ being stretched (as when the intestine is expanded by gas) or surrounding muscles contract. Character of Viscera Pain : Visceral pain is typically vague. Dull nauseating

10. Con.. Types Somatic pain comes from the membrane (peritoneum) that lines the abdominal cavity (peritoneal cavity). Unlike nerves in the visceral organs, nerves in the peritoneum respond to cutting and irritation (such as from blood, infection, chemicals, or inflammation). The character of somatic pain : Somatic pain is sharp and fairly easy to pinpoint.

11. Cont,, Types R eferred pain is pain perceived distant from its source.The results from convergence of nerve fibers at the spinal cord. Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm

12. Causes the abdominal Pain Acute cholecystitis. Acute cholecystitis Acute appendicitis. Acute appendicitis Acute pancreatitis. Acute pancreatitis Ectopic pregnancy. Ectopic pregnancy Diverticulitis. Diverticulitis Peptic ulcer disease. Peptic ulcer disease Pelvic inflammatory disease. Pelvic inflammatory disease Intestinal obstruction, including paralytic ileus (adynamic obstruction). Intestinal obstruction

14. Immediately life-threatening disorders [Causes ] Require rapid diagnosis and surgery : Ruptured abdominal aortic aneurysm Perforated stomach or intestine Blockage of blood flow to the intestine (mesenteric ischemia) Ruptured ectopic pregnancy

15. Serious disorders that are nearly as urgent : Intestinal obstruction Appendicitis Sudden (acute) inflammation of the pancreas (pancreatitis) GastroenteritisGastroenteritis. Acute intestinal ischaemia/infarction or vasculitisAcute intestinal ischaemia/infarction or vasculitis. Gastrointestinal (GI) haemorrhage. Renal colic or renal tract pain. Acute urinary retentionAcute urinary retention. Abdominal aortic aneurysmAbdominal aortic aneurysm.

16. The 'Top 5' medical causes of an acute abdomen to consider in older patients are – Inferior myocardial infarction.myocardial infarction – Lower-lobe pneumonia/pulmonary embolism causing pleurisy.pneumoniapulmonary embolism - Diabetic ketoacidosis – Pyelonephritis. Pyelonephritis – Inflammatory bowel disease. Inflammatory bowel disease

17. The People risk Newborns Infants Young children Older people Third trimester of pregnancy.

20. Sings and Symptoms

21. Most Warning sings and symptoms In people with acute abdominal pain, certain symptoms and characteristics are cause for concern : Severe pain Signs of shock (for example, a rapid heart rate, low blood pressure, sweating, and confusion) Signs of peritonitis (for example, constant pain that doubles the person over and/or pain that worsens with gentle touching or with bumping the bed) Swelling of the abdomen

23. Assessment Note whether the patient looks ill, septic or shocked. Note whether they are lying still (think peritonitis) or rolling around in agony (think intestinal, biliary or renal colic)? Assess and manage Airway, Breathing and Circulation (ABC) as a priority. In an emergency department setting: if there are signs that the patient is shocked or acutely unwell, assess quickly but carefully and arrange any early investigations. In a community setting: make arrangements for rapid transfer to hospital for further assessment.

24. History Demographic details, occupation, recent travel, history of recent abdominal trauma. Pain: Onset (including whether new pain or previously experienced). Site (ask the patient to point), localised or diffuse. Nature (constant/intermittent/colicky). Radiation. Severity. Relieving/aggravating factors (eg, if worsened by movement/coughing, suspect active peritonitis; pancreatitis is relieved by sitting forward).

25. Cont,, History Associated symptoms: Vomiting and the nature of vomitus. Hematemesis or melaena. Stool/urine colour. New lumps in the abdominal region/groins. Eating and drinking - including when the patient's last meal occurred. Bowels - including presence of diarrhoea, constipation and ability to pass flatus

26. Cont,,, History Fainting, dizziness or palpitations. Fever/rigors. Rash or itching. Urinary symptoms. Recent weight loss. Past medical and surgical history/medication.

27. Question Potential Responses and Indications Where is the pain? Location of abdominal pain and possible causes. What is the pain like? Acute waves of sharp constricting pain that “take the breath away” (renal or biliary colic)  Waves of dull pain with vomiting (intestinal obstruction)  Colicky pain that becomes steady (appendicitis, strangulating intestinal obstruction, mesenteric ischemia)  Sharp, constant pain, worsened by movement (peritonitis) Tearing pain (dissecting aneurysm) Dull ache (appendicitis, diverticulitis, pyelonephritis) Have you had it before? Yes suggests recurrent problems such as ulcer disease, gallstone colic, diverticulitis.

28. Was the onset sudden? Sudden: “Like a light switching on” (perforated ulcer, renal stone, ruptured ectopic pregnancy, torsion of ovary or testis, some ruptured aneurysms) Less sudden: Most other causes How severe is the pain? Severe pain (perforated viscus, kidney stone, peritonitis, pancreatitis) Pain out of proportion to physical findings (mesenteric ischemia) Does the pain travel to any other part of the body? Right scapula (gallbladder pain) Left shoulder region (ruptured spleen, pancreatitis) Pubis or vagina (renal pain) Back (ruptured aortic aneurysm, pancreatitis, sometimes perforated ulcer) What relieves the pain? Antacids (peptic ulcer disease) Lying as quietly as possible (peritonitis)

29. What other symptoms occur with the pain? Vomiting precedes pain and is followed by diarrhea (gastroenteritis) Delayed vomiting, absent bowel movement and flatus (acute intestinal obstruction; the delay increases with a lower site of obstruction) Severe vomiting precedes intense epigastric, left chest, or shoulder pain (emetic perforation of the intra- abdominal esophagus)

30. Physical examination Pulse, temperature and blood pressure. Assess respiratory rate and pattern. Patients with peritonitis may take shallow, rapid breaths to reduce pain. If there is altered consciousness, check Glasgow Coma Scale (GCS) or AVPU (Alert, Voice response, Pain response, Unconscious) scale.

31. Inspection: – Look for evidence of anemia/jaundice. – Look for visible peristalsis or abdominal distension. – Look for signs of bruising around the umbilicus (Cullen's sign - this can be present in haemorrhagic pancreatitis and ectopic pregnancy) or flanks (Grey Turner's sign - this can be present in retroperitoneal haematoma). – Assess whether the patient is dehydrated (skin turgor/dry mucous membranes).

32. Auscultation – Auscultate the abdomen in all four quadrants. – Absent bowel sounds suggest paralytic ileus, generalised peritonitis or intestinal obstruction. High-pitched and tinkling bowel sounds suggest subacute intestinal obstruction. – Intestinal obstruction can also present with normal bowel sounds. – If there is reason to suspect aortic aneurysm, listen carefully for abdominal and iliac bruits.

33. Percussion – Percuss the abdomen to assess whether swelling/distension might be due to bowel gas or ascites. – Patients who display tenderness to percussion are likely to have generalized peritonitis and this should act as a red flag for serious pathology. – Assess for shifting dullness and fluid thrill. – Percussion can also be used to determine the size of an abdominal mass/extent of organomegaly.

34. Palpation: – Palpate the abdomen gently, then more deeply, starting away from the pain and moving towards it. – Feel for masses, tenderness, involuntary guarding and organomegaly (including the bladder). – Test for rebound tenderness. – Examine the groins for evidence of herniae. – Always examine the scrotum in men, as pain may be referred from unrecognised testicular pathology. – Check supraclavicular and groin lymph nodes.

35. Further examination: – Perform rectal or pelvic examination as needed, with an appropriate chaperone in attendance. – Check lower limb pulses if there could be an abdominal aortic aneurysm. – Dipstick urine and send for culture if appropriate. – In a woman of childbearing age, assume that she is pregnant until proven otherwise - perform a pregnancy test. – Examine any other system that might be relevant - eg, respiratory, cardiovascular.

36. Investigation ( Diagnostic Test ) blood tests CBC :, amylase, glucose, clotting, and occasionally calcium; arterial blood gas. Blood cultures. Pregnancy test in women of childbearing age. Urinalysis. Radiology - abdominal X-ray (supine), CXR (erect looking for gas under the diaphragm), intravenous pyelogram (IVP), CT scan, ultrasound scan, as appropriate. Consider ECG and cardiac enzymes. Laparoscopy

37. In Emergency Department suspect abdominal pain Analgesia Apply oxygen as appropriate. Intravenous (IV) fluids: set up immediately if the patient is shocked and the equipment is available. Send blood for group and save/crossmatch and other blood tests as appropriate. Consider passing a nasogastric (NG) tube if severe vomiting occurs, there are signs of intestinal obstruction or the patient is extremely unwell and there is danger of aspiration.

38. Medication Analgesia Antiemetic Antibiotics

39. Summary Abdominal pain is a common presentation in the outpatient setting and is challenging to diagnose. Abdominal pain is the presenting complaint in 1.5 percent of office-based visits and in 5 percent of emergency department visits. Although most abdominal pain is benign, as many as 10 percent of patients in the emergency department setting and a lesser percentage in the outpatient setting have a severe or life-threatening cause or require surgery. Therefore, a thorough and logical approach to the diagnosis of abdominal pain is necessary.

40. References http://patient.info/doctor/acute-abdomen http://www.merckmanuals.com/professional/gastroi ntestinal-disorders/acute-abdomen-and-surgical- gastroenterology/acute-abdominal-pain