Acute Abdominal Pain: Manage Without Delay

Chris Pasero, MS, RN-BC

Disclosures

August 02, 2013

Treatment Options for Acute Abdominal Pain

It is important to remember that treatment of pain is a high priority for patients and their families, and attention to optimal pain relief may result in improved patient and family satisfaction with the ED experience.[20] An interesting study of 147 patients who presented with pain in the ED showed that they had high expectations for pain relief, but only one third asked for pain medication.[21] A high expectation for pain relief coupled with a reluctance to request pain medication underscores the importance of nurses advocating for patients who have pain. An encouraging finding in this study was that 71% of the patients received an analgesic whether they requested it or not, which is an improvement over previous research,[1,20] but this still left more than one fourth of the patients with no analgesic administration.

Accepted guidelines recommend a multimodal analgesic regimen for severe acute abdominal pain.[9,22,23] Multimodal analgesia combines analgesics with different underlying mechanisms of action, with the goal of improved pain relief with lower opioid doses than would be possible with an opioid-only treatment plan. Lower opioid doses result in fewer opioid-induced adverse effects, such as nausea, constipation, sedation, and respiratory depression.[23] Multimodal analgesia for acute pain includes the administration of nonopioids (acetaminophen and a nonsteroidal anti-inflammatory drug) as the foundation of the treatment plan. Acetaminophen, ketorolac, and ibuprofen are available in IV formulations[24] and are appropriate when oral intake is contraindicated, such as in patients with abdominal pain of unknown origin.[19] The nonopioids should be followed with a first-line IV opioid, such as morphine, hydromorphone, or fentanyl.[23]

Pain Management: Case Outcome

The patient in this scenario is experiencing severe nontraumatic abdominal pain of unknown origin. Despite the nurse and the nursing supervisor providing the physician with research and accepted guidelines that support the administration of analgesia during diagnosis, the physician refused to provide pain management orders until after examining the patient and reviewing the laboratory work and CT scan results. The patient was diagnosed with appendicitis and scheduled for a laparotomy.

The nurse promptly administered 3 mg of IV morphine to the patient, which reduced her pain intensity from 10 to 5 within 10 minutes. Subsequently, IV acetaminophen was given in the preoperative holding room, which reduced the patient's pain intensity to 3.

The nurse documented the incident carefully in the medical record. The nursing supervisor talked with the medical staff director, who was agreeable to the formation of a multidisciplinary task force represented by nursing, pharmacy, and medicine to develop an evidence-based policy with the goal of preventing similar incidents in the future.

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