Surgery and Surgical

nursing
ACUTE ABDOMEN

MR SANDWE T.K
Specific Objectives
1. Define acute abdomen
2. Outline the common causes of acute abdomen
3. Outline the signs and symptoms of acute abdomen
4. Mention the investigations used to diagnose acute
abdomen
5. Describe the management of acute abdomen ( pre and
post-operative)
6. Outline the complications of acute abdomen
MR SANDWE T.K
DEFINITION
• Acute abdomen is described as severe abdominal
pain that sets in suddenly which usually donates signs
and symptoms of intra-abdominal disease usually
treated by emergency surgical operation to avoid
complications or to save life.
• any delay in diagnosis of acute abdomen can
adversely affect the outcome

MR SANDWE T.K
CAUSES
• Inflammatory conditions such as peritonitis,
appendicitis (perforated) perforated diverticulitis,
• Mechanical obstruction of intestines by worms, food
bolus, volvulus, intussusception etc.
• Vascular; perforated peptic ulcer, perforated
appendix, perforated bowel etc.

MR SANDWE T.K
Other Causes …………….
• Neoplastic; growths that obstruct movement of food
along the gastrointestinal tract e.g. intraluminal
intestinal growths.
• Traumatic; ruptured spleen, ruptured aorta, ruptured
ectopic pregnancy, ruptured urinary bladder

MR SANDWE T.K
Signs and symptoms

• Sudden onset of pain

• Pain which is:
• Colicky in intestinal obstruction
• Sharp and persistent , diffuse and agonising – in
peritonitis

MR SANDWE T.K
• Abdominal guarding due to severe pain
• Hard woody abdominal wall due to hyper excited
peritoneum
• Abdominal tenderness due to the disease process
• Rebound tenderness i.e. when you press your hands
on the abdomen and when you release the hand the
patient experiences severe pain.

MR SANDWE T.K
• Peristaltic movements may be visible in case of obstruction
• Nausea and vomiting due to gastrointestinal disturbance and
excessive peristalsis.
• Boborygymy - exaggerated bowel sounds – mumbling sounds
• Constipation alternating with diarrhoea
• Signs of shock due to excessive vomiting and or diarrhoea

MR SANDWE T.K
• Generalizes abdominal tenderness in inflammatory
causes.
• Constipation, most common in occlusive cases

MR SANDWE T.K
INVESTIGATIONS
• HISTORY
• Obtain as detailed a history as possible regarding the time of
onset, duration, intensity, and character of pain, as well as
any associated symptoms.
• Also, ascertain the time course and acuteness of onset by
asking the following questions;
• Did the pain begin suddenly or did it grow in intensity?

MR SANDWE T.K
• Is it steady or crampy, dull and aching, or sharp and
stabbing?
• Did it occur after or before meal
• Did it awaken the patient from sleep?
• How well is it localized, and has the location changed?
• It is associated with nausea and vomiting, and if so, did these
symptoms begin before or after the pain?
• Does anything make the pain worse or better?
MR SANDWE T.K
PHYSICAL EXAMINATION

• Observation for the patient’s body habit and facial

expression.
• -peritonitis: unwillingness to change posture, hip flexion
with the knees down up, shallow breathing
• -colicky pain: intense movements to alleviate pain.
• Inspection of the abdomen: localized or generalized
distension, visible peristalsis, hernia bulges
• Auscultation, bowel sounds are head, if no sounds are head:
paralytic ileus or complete obstruction
MR SANDWE T.K
• Percussion: absence of hepatic dullness: perforation
• Palpation: superficial, gentle of all quadrants, first at the
least painful areas, after this deeper.
• -have the patient laugh, cough, distend or maximally reduce
his/her abdominal girth.

MR SANDWE T.K
INVESTIGATIONS
• Complete blood count, white blood cell differential,
• Urinalysis
• Serum amylase ( urine)
• Beta human chorionic gonadotropin in females- Pregnant
test should be done on women of child bearing age
• BUN, creatinine and glucose.
• Liver function test in upper abdominal
• Abdominal x-ray
MR SANDWE T.K
PRE OPERATIVE MANAGEMENT

• Acute abdomen is a surgical emergency and thus it requires

quick surgical intervention. All preparations should thus be
made within the shortest period.

MR SANDWE T.K
Pre Operative Management of patient
with Acute Abdomen
• Pre operative Objectives
• To ensure that Surgery is performed as soon as possible in order
to decrease the risk of complications.
• To correct or prevent fluid and electrolyte imbalance and
dehydration by giving intravenous fluids before surgery
• To relieve pain by giving analgesia
• To prepare the patient physically, emotionally, psychologically so
as to enable him withstand the effects of surgery.

MR SANDWE T.K
ENVIRONMENT
• Nurse the patient in a clean environment
• It should a quiet room
• Well ventilated
• Enough lighting

MR SANDWE T.K
RESUSCITATION

• Check the vital functions ensuring the ABCs immediately

after getting relevant history directing your interventions
towards the suspected and or confirmed anomalies with
reference to the gotten history. Open an intravenous line at
this time for intravenous fluids and or administration of
blood

MR SANDWE T.K
• A Ryles (nasogastric) tube should be inserted to deflate the
abdomen and for post-operative aspiration.
• A urethral catheter should be inserted to drain the urinary
bladder and to prevent accidental injury to the bladder as it
becomes an abdominal organ when full.

MR SANDWE T.K
PSYCHOLOGICAL CARE

• Explain the type of operation, why the patient need to go for

operation and what to expect post operatively.
• Reassure patient and his relatives to gain cooperation
• Allow patients to verbalize and answer her calmly.
• Give psychological care to the patient while preparing him for surgery
if conscious. If unconscious emphasis is directed to the relatives both
during preparing the patient and when he is in theatre.
• To allay anxiety
• Fear of the prognosis

MR SANDWE T.K
CONSENT FORM

• Quickly explain the importance of signing the consent to the

patient if conscious.
• Let the patient sign if conscious, above 18 years and in a sound
state mentally.
• Relative to sign the consent form, If no relative available the
surgeon can sign on the patient’s behalf. Prior to signing an
informed consent, the patient should:Be told in clear and simple
terms by the surgeon what is to be done ( drawings or
audiovisual aids may help )Be aware of the risks, possible
complications, disfigurement, and removal of parts
MR SANDWE T.K
Purpose of consent
• To protect the patient against unauthorized procedures
• To protect the surgeon and hospital against legal action by a
patient who claims that an authorized procedure was done

MR SANDWE T.K
PHYSICAL PREPARATION
• The patient should be shaved from the nipple line to the end
of the thighs to prevent microorganisms from entering the
incision site as hair harbours microorganisms. It is advisable
to use a hair clipper for shaving to avoid cuts.
• Inspect the abdomen for distension, masses, scar etc.
• Auscultate bowel sounds( diminished- complete obstruction
• Observe the vomitus and measure.

MR SANDWE T.K
Immediate Preparation

• Ensure that prescribed pre medications if any are given

within the shortest period. Remove all dentures or
prostheses, jewels. Ensure that the laboratory results,
radiological results are collected and put together in the
patient’s file, no time to bath the patient in such as
emergency but just wipe, label the patient for identification

MR SANDWE T.K
• Remove jewelry, identify properly, and place in the hospital
safe, if wedding ring cannot be removed, tie with gauze
bandage fastened around wrist
• Remove contact lenses, have patient void immediately
before leaving for the operating room. Measure amount and
note time of voiding; record.
• Continue to support the patient emotionally and correct any
misconceptions he may have

MR SANDWE T.K
Observations

• Take vital signs more frequently i.e. every 15 minutes till patient is
stable. Then duration changes as condition stabilizes
• Record vital sign for baseline data to compare post operatively
• Depending on the cause of acute abdomen, the patient may be in
shock and there is need of resuscitating him or her before she goes
to theatre. The foot end of the bed is elevated to promote blood
flow to the vital organs of the body such as lungs, brain and the
heart.
• The patient is covered with extra linen to keep him or her warm
• Commence intravenous fluids
MR SANDWE T.K
INVESTIGATIONS/ASSESSMENT

• Make a very quick appraisal of the patient’s physical condition

• Consider haemoglobin count, grouping and cross matching
• Random blood sugar test may be done
• Do bleeding and clotting time on patient
• Abdominal X – ray should be done within the shortest possible
time which might reveal the presence of gases in the
abdomen. Since patient is very sick, portable x-ray can be done

MR SANDWE T.K
Bowel preparation
• Stop intake of food immediately and keep the patient nil
orally.
• Put up IV fluid line and charts to monitor intake and output
• Insert NGT for aspiration of abdominal contents and in order
prevent aspiration during surgery
BLADDER PREPARATION
• A urethral catheter should be inserted to drain the urinary
bladder and to prevent accidental injury to the bladder as it
becomes an abdominal organ when full.
MR SANDWE T.K
• Premedication
• Administer all premedication e.g. prescribed pre operative
Antibiotic to combat infection during operation.
• Purposes
• To facilitate the administration of any anesthetic and to
relax the patient
• To minimize respiratory tract secretions and changes in
heart rate and to reduce anxiety
MR SANDWE T.K
GOWNING

• Gown the patient if the gown is within reach and ready

TRANSPORTING PATIENT TO THE OPERATING ROOM
• Wheel the patient to theatre on a theatre trolley. At the
operating theatre hand over to the theatre staff or receiving
nurse giving relevant details such as patient’s name, age, sex,
diagnosis and proposed surgery, what was done being an
emergency, the latest observations etc.
• Complete chart and preoperative check list; include laboratory
reports and x-rays as required in the operating room
MR SANDWE T.K
POST OPERATIVE CARE
AIMS
• To ensure patient airway.
• To prevent complication after surgery
• To enhance healing

MR SANDWE T.K
Environment
• The patient who has undergone an abdominal surgery
will be in the surgical ward acute bay for close
monitoring.
• All sources of infection should be eliminated by
ensuring that the room is clean.
• The room should be well ventilated and well lit to
allow stale air out and for easy visibility respectively.
• All resuscitative equipment should be by bedside
MR SANDWE T.K
Cont…
• A bed cradle may be used to lift off the linen from the
incision site. This will allow for easy observation and
also prevents undue pressure being exerted on the
wound.
• Ensure that all the tubings are in the functional
position and patent

MR SANDWE T.K
POSITION - Supine position with head to side for
easy drainage of secretions.
• As soon as patient recovers from the effects of
anaesthesia they can assume the position of their
choice
• 2 hourly turnings to prevent pressure sore
formation

MR SANDWE T.K
Observations
• TPR and BP for base line data and note any deviation
from normal
• Observe the wound for haemorrhage, swelling, pus at
the site of incision.
• Naso gastric tube remains in situ to continuously
aspitrate the stomach content and keep it empty.
• Aspiration of the stomach is important because it assists in
the prevention of paralytic ileus and it also helps in the quick
return of the peristalsis.
MR SANDWE T.K
• Monitor secretion dark red colour first 12hrs,then light
yellowish brown or greenish because of presence of
bile. If dark red colour continue inform the doctor
• Check NGT for patency if obstructed with mucus or
blood clot clear if or inform the doctor.
• Observe the intravenous line for any infiltration of fluids into
the tissues or extravasation as well as signs of phlebitis.
Observe the return of peristalsis by auscultating the
abdomen
MR SANDWE T.K
HYGIENE MEASURES

• Initially in the first 24 hours the patient will not be disturbed

however, oral care should be done to moisten the buccal
mucosa and promote salivation.
• When the patient has stabilised, bed baths are provided to
remove dirt from the body, to refreshen the patient and
improve his self esteem. Shower baths can be given as the
patient improves.

MR SANDWE T.K
Psychological Care
• Reassure the client that the health staff are doing
everything possible to ensure quick recovery.
• Allow the patient ventilate his/her fears and ask
questions
• Involve relatives and friends so that patient can have
sense of belonging and love.
• Explain each and every procedure to allay anxiety.

MR SANDWE T.K
Rest
• Minimize noise, wear rubber shoes, oil trolley wheels,
minimize visitors, speak in low tones.
• Promote clustered nursing care to promote rest and
relieve pain.
• Analgesics to relieve pain hence promote rest

MR SANDWE T.K
Wound Care
• Use aseptic technique when cleaning the wound to
promote healing. The doctor will change the first
dressing after 24hrs thereafter daily dressing are done
to prevent infection.
• Advise patient not to be touching the wound to
prevent wound infection
• Change linen whenever soiled to prevent infection

MR SANDWE T.K
• Exercises - Passive range of motion exercise are done to
prevent deep vein thrombosis and pressure sore
formation.
Elimination - Offer bedpans and urinals to promote
excretion
• Change soiled linen for comfort
• Monitor I & O to maintain fluid volume
MEDICATION - Antibiotics are given as prescribed to
combat infection MR SANDWE T.K
Pain Management
• The surgeon may prescribe injection morphine 10mgs
TDS or Pethidine 50 – 100mgs 8hourly X 2 days
intramuscularly and it should be given accordingly as
ordered. Explain the action and importance of these
pain medications.
• As pain reduces, mild pain killers can be given to the
patient e.g. Panadol 500mgs tds
• Give other prescribed drugs according to prescription
MR SANDWE T.K
Nutrition
• Patient will be nil per oral initially and will maintained of
IV fluids such as Normal saline to restore electrolytes and
body fluids.
• The nasogastric tube normally will be removed in the
next 24 hours or day 1 after surgery if there are no
complications.
• As soon as sounds bowel return, the patient can be given
sips of water if tolerated semi fluids until the assume the
full meals. MR SANDWE T.K
• Patient will fed mixed diet containing proteins for
quick wound healing and repair, carbohydrates for
energy and vitamins for tissue repair and improved
immunity.
• Serve in small amounts to promote appetite

MR SANDWE T.K
HEALTH EDUCATION
• Avoid weight lifting in the next 6 months to allow
maximum healing.
• Explain to the patient on the importance of review for
close monitoring and ensuring complete recovery. If
discharged with sutures, he has to visit the nearest
health center for suture removal.

MR SANDWE T.K
• Explain the importance of good nutrition for quick recovery, wound
healing and general restoration of body energy reserves.
• Emphasize on the need to be vigilant with hygiene so as to prevent
contamination of the wound which may lead to infection and delayed
wound healing.
• Explain on the importance of visiting the health centre as soon as he
experiences any abdominal disturbance even before the review date to
identify and recommend early treatment.
• Explain the importance of drug compliance to ensure completion of the
course of antibiotics and prevent drug resistance, prevention of infection
and ensure complete recovery
MR SANDWE T.K
COMPLICATIONS
• Haemorrhage
• Post operative wound infection
• Evisceration-The process whereby tissue or organs that
usually reside within a body cavity are displaced outside
that cavity, usually through a traumatic disruption of the
wall of the cavity; evisceration of bowel
• Pulmonary complications-General anesthesia and surgery
are the main causes of postoperative respiratory
complications
MR SANDWE T.K
• Dehiscence-is a surgical complication in which a wound
ruptures along a surgical incision
• Deep vein thrombosis
• Paralytic ileus-Obstruction of the intestine due to paralysis of
the intestinal muscles.
• Hernia

MR SANDWE T.K
 THE END
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MR SANDWE T.K