A 44-year-old man presents to the emergency department (ED) with epigastric and mid-back pain for the past 1 week, which he describes as burning, gnawing, and cramping. He rates pain as a 5 on a 0-to-10 scale between meals, which is relieved by eating but then returns again 2-3 hours later. Changes in dietary choices have not helped with pain. He has been taking calcium carbonate antacids 2-3 tabs in the middle of the night due to epigastric pain, waking him from sleep. He has also had nausea and vomiting during this time, has vomited two times today, and reports blood tinge with each occurrence. His last bowel movement was 2 days ago. He reports urinary frequency, having to void every 1-2 hours during the day, and having urine that is dark and concentrated. He reports a constant, dull headache and feeling more fatigued than usual, especially with activity, but is still able to perform his activities of daily living (ADLs) as usual.
Physical assessment findings
Pain to epigastric area with palpation
Vital signs:
BP: 135/86 mm Hg
HR: 102 bpm
RR: 20 breaths/min.
pO2 94% on room air
Temperature: 99.0oF (37.2oC)
Abdomen is soft, nonbloated
done
That’s right!
Rationale:
Potential Condition: This client’s symptoms are indicative of a duodenal ulcer. A duodenal ulcer is a chronic circumscribed break in the duodenal mucosa that scars with healing; it may develop from an infection with Helicobacter pylori and increased gastric acid secretion. Classic symptoms are localized epigastric pain that occurs when the stomach is empty and is relieved by food or antacids; clients with a bleeding ulcer may have hematemesis and melena, and significant blood loss may result in dizziness and syncope. With significant bleeding, clients may show hypotension and tachycardia. It occurs approximately twice as often in men as in women. Pain related to a gastric ulcer occurs with eating (not between meals) and would typically be located in the left upper quadrant. GERD is a complex of symptoms of esophagitis, including burning pain in mid-epigastrium or behind lower sternum that radiates upward, or heartburn. GERD occurs 30-60 min after eating and is aggravated by lying down or bending over. Inflammation of the gallbladder is termed cholecystitis; the primary symptom is abrupt pain in the right upper quadrant of the abdomen that may radiate to the right shoulder or scapula that lasts 2-4 hours after eating fatty foods, alcohol, or caffeine. The client will demonstrate a positive Murphy sign. Relevant Cue: This client has pain that is relieved (not worsened by food) and that occurs 2-3 hours after a meal; these are classic symptoms associated with a duodenal ulcer. The client having a bowel movement 2 days ago is within normal limits. Urinary frequency, dysuria, urgency, and suprapubic pain may indicate a urinary tract infection. His urine may be more concentrated if dehydration is occurring with the vomiting but is not specifically associated with duodenal ulcers. Additional Supporting Cue: Hematemesis may occur with a bleeding duodenal ulcer. Often, the pain with a duodenal ulcer is burning, gnawing, and/or cramping pain to the epigastric area. Clients with cirrhosis, among other issues, frequently report fatigue and dark urine, tan-colored stools, and ascites. Fatigue does not necessarily indicate a duodenal ulcer. Clients with a duodenal ulcer may have hypotension and tachycardia; this client’s blood pressure is higher than normal limits and may be associated with hypertension. His report of a constant, dull headache is not commonly linked to duodenal ulcers.
1720
A 17-year-old female client is brought to the emergency department (ED) by her mother. She reports dull pain around the umbilicus, which started 20 minutes ago. She has had constant nausea since the pain started.
1728
Client vomits; she tells the nurse her pain was worse right before she vomited.
1735
BP: 118/76 mm Hg
HR: 98 bpm
RR: 20 breaths/min.
pO2: 97%
Temp.: 100.2oF (37.9oC)
1738
Client tells the nurse her pain is now more severe, sharp and colicky, and localized to her right lower abdomen.
1740
Client has guarding with even light palpation of the abdomen; abdomen is stiff. She has rebound tenderness to the right lower quadrant.
one
That’s right!
Rationale:
This client’s signs and symptoms are indicative of appendicitis. Clients with appendicitis typically initially present with periumbilical or epigastric pain, which is colicky; this pain later becomes localized to the right lower quadrant, often at McBurney point. Clients with appendicitis often have nausea, vomiting, and fever. Pain is often worse right before vomiting and also with coughing or movement. An inflamed appendix may cause irritation of the lateral iliopsoas muscle. The nurse would perform an iliopsoas test by asking the client to lie supine and then place a hand over the lower right thigh. The nurse would then ask the client to raise the right leg, flexing at the hip, while the nurse pushes downward. Pain with this technique would be considered a positive psoas sign, indicating irritation of the iliopsoas muscle (which would indicate possible irritation of the appendix). The nurse would perform an obturator muscle test for suspected appendicitis. The nurse would ask the client to lie in a supine position and to flex the right leg at the hip and knee to 90 degrees. The nurse would hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially. Pain in the right hypogastric region is a positive sign, indicating irritation of the obturator muscle due to appendix irritation. Several other tests are used to test for appendicitis including Aaron, Rovsing, and Markle. A positive Murphy sign is associated with cholecystitis. Clients with pancreatitis may show a positive Grey Turner sign and positive Cullen sign. A positive Kehr sign would be associated with renal calculi. Clients with peritonitis would likely have a positive Ballance sign. Clients with cholecystitis typically present with severe, unrelenting right upper quadrant or epigastric pain, which may be referred to the right subscapular area. Clients with biliary stones often have episodic, severe, right upper quadrant, or epigastrium pain lasting 15 minutes to several hours.
Patient Data
History and Physical
3 years prior to assessment (PTA) – 30-year-old male client presents to healthcare provider with nonspecific abdominal pain, nausea and vomiting, diarrhea, and decreased appetite in recent few weeks. He admits to drinking three to five beers per day, more on the weekends. He is also a one to two packs per day (ppd) cigarette smoker for the past 9 years. Healthcare provider educates on dehydration and alcoholic liver disease and strongly advises lifestyle changes, including smoking cessation and stopping all alcohol intake, to avoid further liver damage.
1 year PTA – Client presents to healthcare provider seeking medical attention related to blood in vomitus this week. He has had 26-pound weight loss since last visit. He reports swelling to lower legs and rounding of abdomen. He reports being more tired every day with activity but having difficulty sleeping due to itchy skin and continues with generalized abdominal pain rating a 2-3 on a 0-to-10 pain scale most days. Significant physical assessment findings include more noticeable vasculature to abdomen, spider angiomas to bilateral legs, yellow discoloration of skin, and also enlargement of liver 3 cm below right costal margin. Client continues with three beers per day alcohol intake and reports that he has decreased smoking to one-half ppd. He is diagnosed with alcoholic liver disease, and healthcare provider orders client to stop all alcohol intake to prevent further disease progression, referring the client to alcoholics anonymous.
Present day – Client presents with increasing fatigue and reports that he is now unable even to walk out to his mailbox and back into his home without feeling so fatigued that he must sit for 30 or more minutes afterward. Intakes are minimal because of a feeling of abdominal fullness and generalized abdominal pain. He reports constant nausea and occasional vomiting, which is unrelieved by medications. He has had an additional 17-pound weight loss since last visit. He is noted to be shivering and itching constantly throughout visit. He reports stools that are clay colored and that urine is darker and tea colored. Significant physical assessment findings include worsening jaundice since last visit and gaunt appearance to face and upper body. He has faint purple bruising to multiple areas on arms and legs, generalized edema to all extremities. Significant ascites are noted, and increased vasculature to abdomen persists.
one
That’s right!
Rationale:
This client’s assessment and history indicate cirrhosis. Cirrhosis is commonly caused by hepatitis C or alcoholic liver disease. Clients may be asymptomatic, but others report jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, and fatigue. Clients may have prominent abdominal vasculature and cutaneous spider angiomas. The liver is initially enlarged (generally 2-3 cm below the costal margin) with a firm (not soft), nontender border on palpation; as scarring progresses, liver size is reduced and generally cannot be palpated. Ascites is common. Clients with a long-standing history of alcoholism are at risk.Cholecystitis is characterized by pain in the right upper quadrant, which is abrupt and severe and lasts for 2-4 hours. Clients with appendicitis usually have periumbilical or epigastric pain, which later becomes localized to the right lower quadrant, often at McBurney point. A positive psoas sign would alert the nurse to appendicitis. Hydronephrosis is dilation of the renal pelvis and calyces caused by an obstruction of urine flow. Clients with acute obstruction may have intermittent, severe pain with nausea and vomiting; costovertebral angle tenderness may be present.