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Introduction:

As nurses it is our responsibility to help patients deal

with their illness, prevent diseases, and promote general
health and well-being. When delivering direct care to patients
it is necessary to explore one’s clinical and diagnostic
reasoning in order to deliver quality health care by providing
proper treatment of an existing illness without delays that can
highly avoidwhich can prevent complications and further harm
to our patients. Clinical reasoning means using critical thinking
in health-care (Pesut & Herman, 1999). Bittner and Tobin
(1998) described critical thinking as “influenced by knowledge
and experience, using strategies such as reflective thinking as
a part of learning to identify the issues and opportunities, and
holistically synthesize the information in nursing practice.”

Diagnostic reasoning combines cognitive processes that

allows nurses to assess, gather data and analyse to
differentiate accurate diagnosis (Craven & Hirnle, 2003).
Diagnostic reasoning also comprises of finding clues that will
help determine the causes of the illness to be able to develop
a nursing management that will best meet the patient’s needs
(Resnick, 2016).

General Assessment and History:

With the application of these methods, a systematic and

organized approach is used to provide a quality care for a
patient with a chief complaint of abdominal pain in a timely
manner.

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The fFirst step to an accurate diagnosis is a

comprehensive history taking of the patient (Fawcett, 2012).
It is also necessary to establish rapport with the patient to
develop ease in asking important questions to ensure better
patient outcomes (Lang, 2012).

Mr. X (pseudonym), a 90 years old gentleman who is

alert and coherent and is well-groomed, and wearing clothes
appropriate to weather. He is from a Canadian descent without
any specific cultural considerations is living in an aged care
facility in Northland region since June 2017 has presented with
sudden acute abdominal pain which he first experienced three
(3) days ago. With presence of facial grimace while holding his
abdomen, he describes the pain as dull and sharp that is
worse when sitting. He voiced that the pain is intermittent
over the past three (3) days with pain score of 8/10 (1 as the
lowest and 10 as the highest) but after rest, lying down and
Paracetamol 1gm (pain medication) that his nurse is giving
him when needed, his pain score will come down to 3/10. He
also pointed that the pain is coming from the left quadrant of
his abdomen and the pain is not radiating.

Based on the chief complaint presented above, follow-up

questions has been done for more in-depth understanding of
Mr. X’s condition. When asked, he denies any problem with
swallowing, satiety, and no heartburn. There is no change in
his appetite and his weight remains stable in the last three (3)
months. Though he denies vomiting, and no evidence of
hematemesis (vomiting of blood) he voiced that he is feeling
nauseous and is dry retching at times in the past two (2)
days. It is also essential to ask about elimination, as it could
be a contributing factor for his abdominal pain (Craven &

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Hirnle, 2003). He denies problem in urinating such as dysuria

(painful urination) but has urinary frequency (increased urge
to urinate). He also denies any testicular pain. He does
complain of being constipated in the last few weeks. On the
other hand, no incidence of diarrhoea or melena (blood in
stool) has beenis reported.

For a thorough investigation, questions related to

cardiac system is also have also been inquired into as it may
be inter- related to Mr. X’s abdominal pain (Collier,
Heitkemper & Lewis, 1996). According to him, there is no
incident that he suffers from any chest pain, jaw pain or
weakness and numbness of any of his extremities or any
speech difficulty. Occasional shortness of breath (SOB) is
experienced especially with too much exertion. No episodes of
palpitation and dizziness that he can remember but collapsed
once while gardening in the heat of the summer prior to
admission to the resthome, nearly 3-4 years ago.

Other relevant data were gathered from Mr. X’s medical

file. He has Type 2 Non-insulin dependent diabetes mellitus
and hypertension. He does not have any known allergies to
any medications. He is currently on Terazosin, an alpha-1
adrenoceptor blocking agent that helps decrease blood
pressure and low dose Aspirin, to prevent blood clots. In the
past three (3) days, he is also taking as needed (PRN)
medications such as Paracetamol to relieve his abdominal pain
and laxsol for constipation. No hospitalization recorded in the
past year he’s admitted to the resthome, and no surgical
operations noted on his files. It was noted on his file that he’s
an occasional drinker and he used to be a heavy smoker, who
smokes a pack a day until he was fifty (50) years old. Since

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admission to the facility on 2017, he’s been less active and

living a sedentary lifestyle. He prefers to stay in his room most
of the time watching TV or reading newspapers. Nutrition
wise, he is on diabetic and high fibre diet, eating 3x a day with
snacks in between and with good hydration. Childhood
illnesses and family history remains unknown as nothing was
noted on his file and Mr. X has vague memory with regards to
these. He has annual flu vaccine. He has nNo trips abroad
since 2000. He has strong family ties, and his children make a
point to visit him regularly every week.

Diagnostic Considerations:

When working out on the cause of Mr. X’s chief

complaint, we need to find clues before coming up with a
diagnosis. Considering his age, abdominal pain is one of the
most common presenting complaint in elderly (Khoujah,
Martinez, Pham & Sprangler, 2014). Conditions that may be
considered based on data gathered from presenting complain
and comprehensive history taking of the patient are bowel
obstruction, diverticulitis, and abdominal aortic aneurysm
(AAA).

Mr. X’s intermittent abdominal pain, accompanied with

other classic symptoms such as nausea and constipation that
is not relieved with by taking laxsol for couple of days, may
suggest he’s suffering from bowel obstruction (Phelps, 2017).

Diverticulitis is very common with older patients. With

Mr. X’s case, he presented with pain on the left quadrant of
his abdomen, together with his nausea, increase urge to

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urinate and constipation it is also more likely he may be

suffering from diverticulitis (Persons, 2017).

Abdominal aortic aneurysm (AAA) is a disease most

associated solely with elderly population, mostly male, with
acute abdominal pain (Khoujah et al., 2014). Taking into
consideration the patient’s old age of 90, sedentary lifestyle,
his old habits of being a heavy smoker and having
hypertension, he is at high risk of experiencing AAA (Bosley &
Macon, 2017).

Physical Examination:

After a comprehensive history taking, a thorough

physical examination is needed to gather more information to
come up with accurate diagnosis. Physical examination is
composed of analysing bodily function using the IPPA
techniques; inspection, palpation, percussion and auscultation.

To start with, a JACCO assessment is done. This stands

for jaundice, anaemia, cyanosis, clubbing and oedema. When
checked Mr. X conjunctiva appears to be nice and pink on both
sides and the sclera is not at all yellow which means there is
no evidence of jaundice is. There is are also no obvious signs
of cyanosis on his mouth. When hands are assessed, colour is
even, there is no blue tinged on fingernails and there are
palmar creases present which are darker than the other part
of the palm which means anaemia is less likely. His fingernails
formed a diamond when put together which means there is
absence of clubbing. There is also no signs of oedema when
both upper and lower extremities where checked. These are all
normal findings (Bickley & Szilagyi, 2017).

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Vital signs is are essential as this indicate the current

physiological state of the patient (Castledine, 2013). Blood
pressure of 148/98 mmHg and pulse rate of 101 beats per
minute are slightly elevated compared to his baseline range
may be related to his pain. Respiratory rate of 22 cycles per
minute, blood sugar level 60 mg/dl and oxygen saturation on
air of 96% are within normal range for elderly. Temperature of
38°C is raised and most often indicates infection or illness
(Hall, Hurst & Walker, 1990). Moreover, his body mass index
is twenty-three (2)3 which falls under normal range
(https://www.kiwicover.co.nz/your-health/bmi). No loss of
appetite and weight remains stable.

Let’s start with the abdominal examination. Upon

inspection of Mr. X’s mouth there were no ulcerations found,
hands were slightly warm to touch due to high temperature
but no there was no sweating. Next is his abdomen, there
were no visible surgical scars, bruising, or lumps nor increase
of veins that may be cause problem on circulation. It is just
noted that abdomen is mildly distended without guarding or
rebound. Since the patient is suffering from abdominal pain,
light palpation is done while on supine position and noticed
that it is firm and rigid but unable to palpate any mass or any
presence of hernia. It is also noted that upon palpation, the
pain is isolated on the left lower quadrant of the abdomen
where the colon is located (Hoehn & Marieb, 2006). Patient
appears to be uncomfortable but in no acute distress. Upon
percussion dull, lower pitched bowel sounds were heard on the
left quadrant of abdomen which may suggest that a mass or
faeces is present on this area (Craven & Hirnle, 2003). Upon
auscultation using the stethoscope it is evident that there is

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hypoactive bowel sounds every 15-30 mins on each quadrant.

This findings often indicate constipation and may need further
investigation to confirm (Hall et al., 1990).

It is imperative to include perirectal exam with patients

with abdominal pain. Failure to do so may increase the chance
of misdiagnosis (Galland & Manimaran, 2004). Upon
inspection, skin is intact and non-reddened which is a normal
findings. However, upon palpation, presence of hard stool is
prominent that may suggest faecal impaction (Obokhare,
2012).

Consequently is the cardiac examination. To begin with,

is the inspection of the skin while patient is ideally at 30-45
degrees, it is noted that it is well perfused, no sweating, no
signs of cyanosis but is warm to touch and a bit flushed due to
high temperature recorded earlier. No laboured breathing is
noted. Normal findings with capillary refills, also no signs or
haemorrhage when fingernail beds when checked. When the
pulses were checked and compared, both were equal and
regular but fast. Next to inspect was the chest, no signs of
surgical scars, no pulsations were visible and all these findings
are normal (Bickley et al., 2017). Following this, is tothere is a
need to check if there isare a visible signs of chest palpation,
wherein no palpable murmurs or thrills was found. It is then
followed by auscultation, using both the bell and diaphragm of
the stethoscope to listen the heart on four region, namely
aortic, pulmonic, tricuspid and mitral area. No extra sounds
between heartbeats (s1 and s2) were heard. These extra
sounds were referred to as heart murmurs. Usually when
there is a heart murmur there is a heart valve problem (Fong,
2013). Jugular venous pressure is measured as 3 centimeters.

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Between 0-4cm is in normal range. Elevated JVP indicates

abnormal right heart dynamics. It typically suggests fluid
overload (Chiaco, Parikh & Fergusson, 2013).

Differential Diagnosis:

With new data gathered from thorough physical

examination, it is substantial to come up of three (3) most
accurate diagnosis that may causing Mr. X’s sudden acute
abdominal pain.

First is small-bowel obstruction. Though no evidence of

any abdominal surgeries or presence of hernia which are the
most common cause for elderly, findings such rigid and mild
distended abdomen without guarding or rebound, pain upon
palpation and dull lower pitched bowel sounds heard upon
percussion supports this diagnosis. Furthermore, presence of
hard stool upon rectal exam coincides with this diagnosis.
Faecal obstruction is one of the most common causes of lower
gastrointestinal obstruction and this is associated with chronic
or severe constipation that is more rampant on elderly
(Obokhare, 2012).

Second is diverticulitis. Abdominal pain that was isolated

on the left lower quadrant of the abdomen where colon is
located highly suggests this diagnosis (Phelps, 2017). In
addition, abdominal distentiondistension, absent of bowel
sounds and fever supports this diagnosis (Shahedi, 2017).

Third is Aortic abdominal aneurysm. The only new

symptom from our physical examination that can further
support this diagnosis is Mr. X’s pulse rate of 101 beats per

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minute increased from his baseline heart rate. No evidence of

clammy or sweaty skin nor evidence of trauma or other
scarring or bruising that may indicate damage to abdomen nor
of shock which are most common symptoms accompanying
abdominal pain (Boskey et al., 2017).

Diagnostic Tests:

Further evaluation is needed to determine the medical

cause for Mr. X’s acute abdominal pain. Appropriate
diagnosing testing like radiography, laboratory studies, and
computerized tomography (CT scan) are likewise suggested.
Based on our differential diagnosis for acute abdominal pain,
imaging plays an important part to be able to give an accurate
diagnosis

Radiography imaging plays a higher part in diagnosis of

elderly patients suffering with abdominal pain rather than in
younger ones. This is more helpful for elderly because of the
wide differential diagnosis. For instance, plain abdominal films
for Mr. X suggestsa plain abdominal film for Mr. X suggests
bowel obstruction or ileus on the sigmoid colon as interpreted
by radiologist. According to Ranmarine (2017), it showed in a
study of 103 patients with suspected SBO, the sensitivity of
plain radiography was reported to be 75%, with a specificity of
53%.

Laboratory studies can narrow down differential

diagnosis. Most abdominal lab test are done to test general
physiology. With Mr. X’s case, complete blood count (CBC),
blood urea nitrogen and creatinine, electrolytes, cardiac
enzymes and liver function tests and urinalysis were done. All

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results are normal except with leucocytosis/increased WBC

both in blood and urine results (Jahnes, Mills & Panebianco,
2011). However, according to Bryan (2017), leucocytosis
result in laboratory studies has a poor sensitivity and
specificity especially with elderly population.

CT scan is considered to be the gold standard to rule out

and in the diagnoses such as small bowel obstruction, AAA and
diverticulitis with a sensitivity of 94% and specificity of 96%
(Megibow, 1994). While this is more accurate compared to
the other diagnostic tests, it is also more informative except
with cholecystitis, which the result will be less useful to
confirm or repudiate this certain diagnosis (Boermeester,
Lameris, Randem & Stoker, 2009). This specific diagnostic
imaging also is capable of detecting complications that are not
visible on plain imaging (Ramnarine, 2017).

Abdominal CT scan result for Mr. X shows acute

inflammatory enlargement of the proximal descending colon
just inferior to the splenic flexure. Presence of small bowel
dilation and presence air-fluid levels, colonic wall thickening of
> 5mm, colonic obstruction which is most likely suggest small
bowel obstruction secondary to sigmoid diverticulitis (Snyder,
2004).

Diagnostic Reasoning:

Gastrointestinal and elimination, both bladder and

bowel, symptoms are mainly the emphasis of health care
providers dealing with acute abdominal pain in elderly.
Nevertheless, cardiac symptoms should also take into
consideration, as well as patient’s age gender, diet, lifestyle

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and past history. Data gathered from comprehensive history

taking, physical examination together with necessary
diagnostic test results were analysed in order to come up with
the precise diagnosis in a timely manner. In this case, we can
assure that systematic process is done and required treatment
and interventions were rendered to be able to guarantee
quality care is delivered to the patient.

Mr. X’s general appearance as well-groomed without

notable facial grimace and not in any acute distress but
appears to be uncomfortable as evidenced by holding his
abdomen confirms his verbal complaints of sudden acute and
intermittent abdominal pain. Together with his old age,
nausea, constipation, abdominal distention and his chief
compliant, it is most likely associated with bowel obstruction
and diverticulitis.

Bowel obstruction is gastrointestinal condition associated

with intestinal contents were unable to pass normally through
the bowel (Collier et al., 1996). This obstruction leads to
proximal dilation of the intestine due to build-up of
gastrointestinal secretions and swallowed air (Ranmarine,
2017).

Diverticulitis refers to the presence of peridiverticular

inflammation and infection which mostly affects the elderly
population. As diverticula is form, thickened colon wall follows.
With low dietary fibre, it decreases the bulk of the stool
combined with narrowed lumen due to thickened sigmoid
colon, causes high intraluminal pressures and retention of
stool and bacteria in the diverticulum. This causes

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inflammation and usually spreads on the surrounding area of

the intestines (Collier et al., 1996).

To further scrutinize the data gathered, both bowel

obstruction and diverticulitis share mostly the same signs and
symptoms as discussed earlier on this paper. If we’re going to
include the diagnostic test findings, we’re going to come up a
more defined diagnosis. Abnormal findings from laboratory
studies together with the abnormal findings in his vital signs;
heart rate of 101 beats per minute and fever of 38 degrees
Celsius which shows presence of infection and inflammation
which coincides with our definition of diverticulitis. The plain
abdominal radiography result shows bowel obstruction or ileus
which is also a positive finding for diverticulitis. Lastly, CT scan
result supports the signs and symptoms found through
comprehensive history taking and thorough physical
examination that come up with final diagnosis of small bowel
obstruction secondary to sigmoid diverticulitis. With this
necessary treatment will be given to Mr. X and recovery will
be expected.

Although Mr. X is at high risk for abdominal aortic

aneurysm due to gender age and history of heavy smoking
when younger, absence of aneurysm in CT scan results and
laboratory studies; normal liver function tests and normal CBC
including MCV and MCH on blood tests ruled out AAA
altogether (Rahimi, 2017).

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Conclusion:

Morbidity and mortality for elderly patients with acute

abdominal pain is relatively high, thus, coming up with the
right diagnosis promptly using diagnostic reasoning process
together with clinical thinking is important and of the essence.
Factors that affect diagnostic reasoning includes how accurate
the data collected and how it will be analysed. Just with Mr.
X’s case, comprehensive history taking and thorough physical
examination suggest that his abdominal pain is caused by
either bowel obstruction, diverticulitis or AAA. With these
three (3) differential diagnosis, specific diagnostic testing were
done to be able to rule out and confirm the incorrect from the
right diagnosis. From this process of elimination, diagnostic
testing were done in a timely and cost-effectively manner. The
findings from the diagnostic testing done with Mr. X then ruled
out AAA as the real cause for his abdominal pain and
confirmed that it is caused by small bowel obstruction
secondary to sigmoid diverticulitis. As nurses, combining our
knowledge, skills, and experience in diagnostic reasoning has
a big impact in coming up with an accurate patient’s diagnosis
in a timely and efficient manner.

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