10.2 Care of Acute Abdomen, Ostomy Care & Gastrointestinal Bleeding

10.2 Care of Acute Abdomen, Ostomy Care & Gastrointestinal Bleeding

Care of the Patient with Acute Abdomen

An acute abdomen refers to a sudden, severe abdominal pain of non-traumatic origin requiring urgent medical or surgical evaluation. In Singapore emergency departments and surgical wards, prompt recognition of peritoneal signs and systemic deterioration is vital for nursing staff operating under Singapore Nursing Board (SNB) Practice Standards. Common underlying etiologies include acute appendicitis, acute diverticulitis, perforated peptic ulcer, acute cholecystitis, intestinal obstruction, and acute mesenteric ischemia.

Comprehensive Nursing Assessment

1. Symptom History & Pain Characterization: Utilize the PQRST model to assess pain location, onset, radiation, and aggravating/relieving factors. For example, pain starting periumbilically and migrating to the right lower quadrant (McBurney's point) strongly suggests acute appendicitis, whereas sharp epigastric pain radiating to the back suggests acute pancreatitis.
2. Abdominal Examination Sequence: Always follow the sequence of Inspection, Auscultation, Percussion, and Palpation (palpation is performed last to avoid altering bowel sounds or aggravating severe pain).
   • Auscultation: Auscultate all four quadrants. Bowel sounds may be hyperactive (early mechanical obstruction), hypoactive, or completely absent (paralytic ileus or generalized peritonitis). To document absent bowel sounds, the nurse must listen continuously for a full 5 minutes (1 to 2 minutes per quadrant).
   • Palpation for Peritoneal Signs: Assess for guarding (voluntary or involuntary abdominal muscle spasm), board-like rigidity (uncontrollable spasm of the abdominal wall), and rebound tenderness (Blumberg's sign: pain elicited upon sudden release of deep pressure). Board-like rigidity and rebound tenderness are classic signs of peritonitis resulting from bowel perforation or ruptured appendix.
3. Hemodynamic & Systemic Monitoring: Assess for early signs of septic or hypovolemic shock: tachycardia, hypotension, tachypnea, cool clammy peripheries, oliguria (< 0.5 mL/kg/h), and fever.

Immediate Nursing Interventions

• Maintain NPO Status: Place the patient on strict NPO (nothing by mouth) immediately to prepare for potential emergency surgical intervention or diagnostic imaging requiring sedation.
• Intravenous Access & Fluid Resuscitation: Establish two large-bore peripheral IV lines (18-gauge or 16-gauge) and initiate IV isotonic crystalloids (0.9% Normal Saline or Hartmann's solution) as prescribed to maintain organ perfusion.
• Gastric Decompression: Insert a large-bore nasogastric (NG) tube (Sump tube or Levin tube) to low intermittent suction if bowel obstruction, intractable vomiting, or severe abdominal distension is present.
• Pain Management Safety Warning: Withhold strong opioid analgesics until the surgical team completes the initial physical examination, as premature sedation may mask peritoneal signs and delay surgical decision-making. Once evaluated, administer prescribed IV analgesia promptly.
• Contraindicated Actions: Never administer laxatives or enemas to a patient with acute abdominal pain, as increased peristalsis can cause bowel perforation in acute appendicitis or intestinal obstruction. Avoid applying heat packs to the abdomen, which causes vasodilation and accelerates vascular congestion or appendix rupture.

Management of Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding is classified as Upper GI Bleeding (UGIB) or Lower GI Bleeding (LGIB) based on the location relative to the Ligament of Treitz (duodenojejunal junction).

Upper vs. Lower GI Bleeding Presentation

• Upper GI Bleeding (UGIB): Originates from the esophagus, stomach, or duodenum. Primary etiologies include peptic ulcer disease, esophageal varices (secondary to liver cirrhosis and portal hypertension), and Mallory-Weiss tears. Manifestations include:
  • Hematemesis: Vomiting of bright red blood (active profuse bleeding) or "coffee-ground" material (blood altered by gastric acid).
  • Melena: Black, tarry, foul-smelling stools resulting from digestion of blood proteins over ≥ 14 hours.
• Lower GI Bleeding (LGIB): Originates from the jejunum, ileum, colon, rectum, or anus. Primary etiologies include diverticulosis, arteriovenous malformations (angiodysplasia), colorectal carcinoma, inflammatory bowel disease, and hemorrhoids. Manifestations include:
  • Hematochezia: Passage of fresh, bright red or maroon blood per rectum.

Resuscitative & Pharmacologic Interventions

1. Airway & Hemodynamic Stabilization: Protect the airway in patients with active hematemesis (high aspiration risk). Place the patient in a recumbent position with elevated legs or left lateral recovery position if vomiting. Supplemental oxygen, continuous cardiac monitoring, and pulse oximetry are mandatory.
2. Pharmacologic Management:
   • For suspected variceal UGIB, initiate continuous IV Octreotide (Sandostatin) or Terlipressin to induce splanchnic vasoconstriction and decrease portal venous pressure.
   • Administer high-dose IV Proton Pump Inhibitor (pantoprazole 80 mg IV bolus followed by 8 mg/hr infusion) to maintain gastric pH > 6.0, stabilizing blood clot formation over ulcer beds.
3. Diagnostic Modalities: Emergency Esophagogastroduodenoscopy (EGD) within 24 hours is the diagnostic and therapeutic modality of choice for UGIB (band ligation for varices, hemoclip placement or thermal cautery for ulcers).

Blood Transfusion Protocols & Safety

In accordance with Ministry of Health (MOH) and Health Sciences Authority (HSA) Transfusion Guidelines:

• Independent 2-RN Bedside Verification: Prior to hanging Packed Red Blood Cells (PRBC) or fresh frozen plasma, two Registered Nurses must independently verify:
  1. Patient's full name and NRIC/FIN number against the blood bag label and transfusion form.
  2. ABO and Rh blood group matching.
  3. Unique unit serial number and crossmatch expiration date.
  4. Visual check of the blood unit for clots, discoloration, or gas bubbles.
• Transfusion Monitoring: Baseline vital signs must be recorded immediately before starting. The nurse must stay at the bedside for the first 15 minutes of infusion (infusing slowly at 1–2 mL/min). Repeat vital signs at 15 minutes, then hourly, and upon completion. Each unit of PRBC must be transfused within a maximum of 4 hours to prevent bacterial growth.
• Acute Transfusion Reaction Management: If fever, chills, rigors, dyspnea, urticaria, flank pain, or hypotension occur:
  1. Stop the transfusion immediately.
  2. Disconnect the blood tubing from the IV cannula; keep the IV line open with a fresh IV line and 0.9% Normal Saline.
  3. Report immediately to the attending physician and Blood Bank using ISBAR.
  4. Send the blood bag, administration set, and fresh patient blood/urine samples to the laboratory for workup.

Ostomy Care & Stomal Nursing Management

An ostomy is a surgically created opening (stoma) connecting an internal organ to the abdominal wall. Bowel ostomies include Ileostomy (end or loop ileostomy created from the distal small intestine) and Colostomy (ascending, transverse, descending, or sigmoid colostomy).

Clinical Assessment of Stoma Integrity

• Normal Appearance: A healthy stoma is pink to bright red, moist, and slightly edematous during the immediate postoperative period (resolving over 6 to 8 weeks). It protrudes approximately 1 to 3 cm from the abdominal surface.
• Abnormal Stoma Colors (Surgical Emergency):
  • Pale / Pinkish-White: Indicates severe anemia or compromised arterial perfusion.
  • Dusky, Dark Purple, or Black: Indicates venous congestion, ischemia, or stomal necrosis. The nurse must immediately notify the surgical team for urgent surgical re-intervention.
• Effluent Characteristics:
  • Ileostomy: Effluent is liquid to semi-liquid, continuous, rich in digestive enzymes (proteolytic enzymes causing severe skin excoriation), and high in sodium and water. Output can reach 1,000 to 1,500 mL/day initially. Patients are at high risk for dehydration and electrolyte imbalances (hyponatremia, hypokalemic metabolic acidosis).
  • Colostomy: Effluent consistency ranges from semi-liquid (ascending/transverse) to firm, formed stool (descending/sigmoid), with predictable elimination patterns.

Peristomal Skin Care & Pouching Techniques

• Wafer Sizing: The skin barrier (wafer) opening must be custom-cut to 1.5 to 2 mm (1/16 to 1/8 inch) larger than the actual stoma diameter. If cut too large, liquid effluent contacts bare skin, leading to severe irritant contact dermatitis. If cut too small, the wafer constricts stomal blood supply.
• Peristomal Hygiene: Clean peristomal skin with warm water; avoid oil-based soaps or moisturizing creams that interfere with pouch adhesion. Apply peristomal barrier powder or barrier film (e.g., Cavilon) for raw skin.
• Pouch Emptying: Empty the ostomy pouch when it is 1/3 to 1/2 full of gas or stool. Allowing the pouch to overfill places tension on the seal, causing leakage and skin breakdown.
• Stoma Therapy Specialist Referral: In Singapore public hospitals, collaborate early with Stoma Care Nurse Consultants (Enterostomal Therapists) for pre-operative stoma siting, appliance selection, and comprehensive patient/caregiver discharge education.

Clinical Summary Table: Upper vs. Lower GI Bleeding & Ostomy Care