ED nurse initiated Rx of the patient with abdominal pain

see also:

• EM nursing
• nurse initiated ED treatment
• ED nurse initiated analgesia

• patients with abdominal pain often waiting excessive long periods in ED waiting rooms awaiting a cubicle to be free
• their time to diagnosis could be reduced and their symptoms partly relieved by nurse initiated ED Rx, although it is recognised that these presentations can be complex and warrant timely medical assessment to properly exclude important red flags.
• the following is a suggested framework for ED's who have nurses accredited to undertake ED nurse initiated treatment including the ordering of pathology tests.

• see also: basic nursing assessment common to all pathways
• patient should be kept nil orally until notified otherwise by medical staff
• patients with vomiting and diarrhoea need to be considered infectious until proven otherwise, and infection precautions instituted
• most elderly patients are normally dehydrated, acute illness exacerbates this, increasing falls risk and delirium risk, and nearly all will benefit from 1L N saline over 2 hours as soon as possible - exceptions are acute blood loss where blood transfusion is more appropriate, and those on fluid restriction (eg. dialysis patients or florid cardiac failure)

• hypotension
• pregnancy
• epigastric pain radiating through to back, particularly in the elderly (?AAA)
• ECG changes suggestive of AMI
• fever
• severe pain
• haematemesis or melaena
• blood glucose > 25 or diabetic with ketones in urine
• acutely altered mental state - see sepsis / septicaemia

• DDx includes biliary disease, pancreatitis, gastritis, peptic ulcer, AAA, AMI, lower lobe pneumonia, pyelonephritis
  • see also: the patient with acute abdominal pain in the ED
• ECG if diabetic or elderly
• DO NOT give non-steroidal anti-inflammatory drugs (NSAIDs) unless it is clear gastritis or peptic ulcer is not the cause of the pain
• iv access, commence N Saline 2hrly rate
• take blood for FBE, U&E, LFTs, lipase, glucose, and
  • if child-bearing age, a HCG
  • if on warfarin, an INR
  • if GIT bleeding, coagulation profile plus group and hold

• DDx includes diverticulitis (esp. LIF), appendicitis (RIF), ovarian cyst, ectopic pregnancy, PID, dysmenorrhoea, UTI, pyelenephritis (esp. if flank pain and fever), renal colic, urinary retention, bowel obstruction, sigmoid volvulus (nursing home residents), and constipation.
  • see also: the patient with acute abdominal pain in the ED
• iv access, commence N Saline 2hrly rate
• take blood for FBE, U&E, glucose, CRP, and:
  • if child-bearing age, and not already had an US confirmed pregnancy, a HCG
  • if on warfarin, an INR
  • patients with known AF should also be considered for a serum lactate level (discuss with ED doctor)
• urinalysis and urine pregnancy test (if child bearing age and not known to be pregnant)
• consider bladder scan to exclude retention if unable to void