Abdominal Discomfort (including Abdominal Pain, Distention)

Also Consider:  Constipation, Diarrhea, Nausea/Vomiting, Rectal Bleeding, Vomiting Blood

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

2. Evaluate Symptoms and Signs

• If Pain:  exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent

• Acute mental status change

• Not eating or drinking as much as usual

• Acute decline in ADL abilities

• Jaundice

• Respiratory: New cough, abnormal lung sounds

• GI: Nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, scrotal pain, urinary retention / Bladder scan

• Appearance of any vomited material, presence of occult blood

• Rectal check for impaction, appearance of stool

• Fingerstick glucose (patients with diabetes)

3. Take Action using SBAR Report:

• Immediately notify the medical staff & resident representative

  • Abrupt onset of severe pain or distention, OR 

  • With fever >101.3, rebound tenderness, persistent vomiting, or GI bleeding 

• Notify medical staff & resident representative within the next 16 hours. 

  • Moderate diffuse or localized pain, unrelieved by antacids or laxatives, or 

  • Persistent nausea without vomiting

• Notify medical staff on the next business day 

  • Moderate diffuse or localized pain, unrelieved by antacids or laxatives, or 

  • Persistent nausea without vomiting

• Notify medical staff at the next regular rounds 

  • Gradual increase in abdominal girth not associated with acute symptoms, OR 

  • more than occasional discomfort (but not persistent) 

4. Implement Management Plan

• Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days

• Offer fluids frequently if nausea/vomiting allow

• Place on Intake & Output monitoring

• Place on 24-hour report for 2-3 days

• Record all episodes of vomiting or diarrhea

• Obtain lab results (if ordered), and notify medical as needed of:

  • Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)

  • WBC > 12,000 or neutrophils > 90%

  • Abnormal X-ray results

  • Positive C. Diff

  • Urine results suggest infection and symptoms or signs present

• Monitor meal acceptance

• Assure bowel regularity

• Resume normal diet and discontinue prn nausea and pain medications when symptoms are resolved

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with resident representative daily

2025-04-19