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Ferlanda Pierrelus.

The Upper Right Quadrant

The patient complains of upper right abdomen ache. One of the most common reasons patients seek medical attention is abdominal pain. Inquire about the pain’s onset, location, duration, characteristics, and aggravating and alleviating variables (Dunphy, Winland-Brown, Porter, & Thomas, 2019). Following that, examining the patient’s previous medical history would offer a baseline. Inquire about the patient’s current appetite, sickness, bowel and urine function, and fill out a pharmaceutical requisition.

The clinician can inquire about the level of pain by asking the patient to rate the pain on a scale of 1–10, but keep in mind that pain in older persons may be dulled regardless of the underlying disease (Kennedy-Malone, L., Martin-Plank, L., & Duffy, E., 2019). Compile a list of past abdominal surgeries. Inquire about drug or alcohol abuse. Inquire about any jaundice, heart illness, or peripheral vascular disease in the past. Examine all current drugs.

The physical examination of the abdomen begins with an inspection, checking for general symmetry while the patient is lying down. The practitioner can divide the belly into four quadrants by imagining a vertical line from the sternum to the pubis passing through the umbilicus and a horizontal line drawn across the umbilicus. In addition to being familiar with the underlying organ systems and referred pain in the four quadrants, the nurse practitioner should be familiar with anatomical landmarks such as epigastric, periumbilical, suprapubic, and McBurney’s point, which is one-third of the distance between the right anterior superior iliac spine and the umbilicus (Kennedy-Malone, Plank, & Duffy, 2019). Examine carefully for scars, lesions, dilated veins, or other marks. If surgical scars are discovered, evaluate the patient’s surgical history if it has not been recorded. Ascertain whether the abdomen is concave or protuberant. Is there an umbilical hernia, abdominal wall hernia, incisional hernia, or inguinal hernia? Is there any abdominal bloating? Look at the umbilicus. Examine the patient for indications of jaundice, perspiration, and skin temperature. Other objective findings would concentrate on abdominal evaluation. Begin by listening to the bowl noises. Tachycardia, tachypnea, and hypertension are all symptoms of acute pain (Kennedy-Malone, Plank, & Duffy, 2019). Light palpation detects abdominal masses and enlarged organs such as the liver, spleen, kidneys, and tender areas; always palpate in a quadrant away from the specified spot (Kennedy-Malone et al., 2019).

The practitioner may consider appendicitis, diverticulitis, acute pancreatitis, and perforated peptic ulcer as differential diagnoses (Kennedy-Malone et al., 2019). A complete blood count (CBC), liver function tests, and amylase are all laboratory tests that may be ordered to assist narrow down the diagnosis. An abdominal x-ray, ultrasonography, and a CT scan are all possible radiology exams. The x-ray could show a blockage, whereas the CT could show appendicitis (Dunphy et al., 2019). The patient may be diagnosed with cholecystitis based on the presentation of RUQ pain, low-grade temperature, nausea and vomiting, and the absence of rebound tenderness (Kennedy-Malone et al., 2019).

Acute episodes necessitate hospitalization in preparation for cholecystectomy; at this time, antibiotics are administered intravenously and are chosen to target enteric infections. Agents such as amoxicillin/clavulanic acid or ceftriaxone, and metronidazole are used in simple instances where there is no penicillin allergy, evidence of multi-organ involvement, or other hospital-acquired illness (Kennedy-Malone et al., 2019). Laparoscopic cholecystectomy should be performed within 24 to 48 hours, and postponing surgery to resolve inflammation is no longer recommended. Supportive measures such as analgesics and antiemetics may be administered (Kennedy-Malone et al., 2019).

Infection, severe drug responses and interactions, and changes in functional and mental state are all potential risks of cholecystectomy treatment (Kennedy-Malone et al., 2019). To avoid problems, encourage patients with chronic cholecystitis and those who cannot have surgery to report early signs and symptoms of an acute attack. Patients should also be informed that, despite past cholecystectomy, gallstones might return in the common bile duct (Kennedy-Malone et al., 2019).

If acute cholecystitis is suspected, surgical consultation is required. A gastroenterologist should be consulted in the case of the frail older adult who is not a surgical candidate or in the clinical scenario of choledocholithiasis. It is strongly advised to consult a gastroenterologist for examination through ERCP, MRI, or endoscopic ultrasonography (Kennedy-Malone et al., 2019).

References

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. F.A. Davis Company.

Kennedy-Malone, L., Plank, L. M., & Duffy, E. G. (2019). Advanced practice nursing in the care of older adults. F.A. Davis Company.