Abdominal rigidity
Abdominal rigidity has been described as abnormal muscle tension or inflexibility of the abdomen, and as an abdominal muscle spasm with involuntary guarding. Rigidity is detected by palpation and may be voluntary or involuntary. Voluntary rigidity reflects the patient’s fear or nervousness upon palpation; involuntary rigidity reflects potentially life-threatening peritoneal irritation or inflammation. (See Recognizing voluntary rigidity.)
Involuntary rigidity most commonly results from GI disorders, but may also occur in pulmonary and vascular disorders and from the effects of insect toxins. It’s typically accompanied by fever, nausea, vomiting, and abdominal tenderness, distention, and pain.
Act Now: After palpating abdominal rigidity, quickly take the patient’s vital signs. Although he may not appear gravely ill or exhibit markedly abnormal vital signs, abdominal rigidity calls for emergency interventions.
Prepare to administer oxygen and to insert an I.V. line for fluid and blood replacement. The patient may require vasoactive medications to support blood pressure. He may also need an indwelling urinary catheter with careful monitoring of intake and output. Peritoneal lavage or abdominal paracentesis may be required.
A nasogastric tube may be necessary if abdominal rigidity is accompanied by abdominal distention; the tube relieves this distention. Because emergency surgery may be necessary, the patient should be prepared for laboratory tests and X-rays.
Assessment
History
If the patient’s condition allows further assessment, obtain a brief history; if you’re unable to obtain a history from the patient, consult the patient’s family. Ask when the abdominal rigidity began and whether it’s localized or generalized. Ask him whether the rigidity is accompanied by abdominal pain and, if so, whether the pain and rigidity developed at the same time. Using an established pain scale, ask the patient to rate the pain. Ask about variations. Has the pain increased, decreased, or remained unchanged ? Is it constant or intermittent? Is the location of the pain constant, radiating, or has it moved to a completely different location? Next, ask about possible aggravating or alleviating factors, such as position changes, coughing, vomiting, elimination, and walking.
Ask the patient about changes in bowel habits. Has he experienced increased flatulence, constipation, diarrhea, or changes in stool consistency? Note the date of the last bowel movement. Ask about changes in urinary habits. Has he developed urinary frequency, urgency, or pain? Has his urine changed color? Ask the female patient for the date of her last menses and whether changes have occurred in the menstrual cycle.
Physical examination
Inspect the abdomen for peristaltic waves, which may be visible in very thin patients. Check for a visibly distended bowel loop. Next, auscultate bowel sounds. Listen for systolic bruits over the abdominal aorta, renal artery, and iliac artery. Perform light palpation to locate the rigidity and determine its severity. Avoid deep palpation, which may exacerbate abdominal pain. Finally, check for poor skin turgor and dry mucous membranes, which indicate dehydration.
Pediatric pointers
Voluntary rigidity may be difficult to distinguish from involuntary rigidity in a young patient if associated pain makes him restless, tense, or apprehensive. In a child with suspected involuntary rigidity, your priority is early detection of dehydration and shock, which can rapidly become life threatening.
Abdominal rigidity in children can stem from gastric perforation, hypertrophic pyloric stenosis, duodenal obstruction, meconium ileus, intussusception, cystic fibrosis, celiac disease, and appendicitis.
Geriatric pointers
Advanced age and impaired cognition decrease pain perception and intensity in elderly patients. Weakening of abdominal muscles may decrease muscle spasms and rigidity. (See Accessory muscles: Locations and functions.) When accessory muscles are used, breathing requires extra effort. The accessory muscles — the sternocleidomastoid, scalene, pectoralis major, trapezius, internal intercostals, and abdominal muscles — stabilize the thorax during respiration. Some accessory muscle use normally takes place during such activities as singing, talking, coughing, defecating, and exercising. However, more pronounced use of these muscles might signal acute respiratory distress, diaphragmatic weakness, or fatigue. It may also result from chronic respiratory disease. Typically, the extent of accessory muscle use reflects the severity of the underlying cause.
Medical causes
Abdominal aortic aneurysm (dissecting)
Mild to moderate abdominal rigidity occurs with a dissecting abdominal aortic aneurysm, a life-threatening disorder. The rigidity is typically accompanied by constant upper abdominal pain that may radiate to the lower back or lower abdominal area; it may also manifest as severe chest pain. The pain may worsen when the patient lies down and decrease when he leans forward or sits up. Before rupture, the aneurysm may produce a pulsating mass in the epigastric area, accompanied by a systolic bruit over the aorta. However, the mass stops pulsating after rupture. Associated signs and symptoms include mottled skin below the waist, absence of femoral and pedal pulses, lower blood pressure in the legs than in the arms, and mild to moderate tenderness with guarding. Significant blood loss causes signs of shock, such as tachycardia, tachypnea, and cool, clammy skin.
Insect toxins
Insect stings and bites, especially black widow spider bites, release toxins that can produce abdominal rigidity and generalized, cramping abdominal pain. These toxins may also cause low-grade fever, nausea, vomiting, tremors, and localized pain and swelling. Some patients experience increased salivation, hypertension, paresis, and hyperactive reflexes. Children commonly are restless, have an expiratory grunt, and keep their legs flexed.
Mesenteric artery ischemia
Rigidity occurs in the central or periumbilical region and is accompanied by severe abdominal tenderness, fever, absence of bowel sounds, and signs of shock, including tachycardia, hypotension, and clammy skin. Other findings may include vomiting, anorexia, diarrhea, and constipation. Always suspect mesenteric artery ischemia in patients who are older than age 50 and have a history of heart failure, arrhythmias, cardiovascular infarct, or hypotension if they present with complaints of sudden, severe abdominal pain following 2 to 3 days of colicky periumbilical pain and diarrhea.
Peritonitis
Depending on the cause of peritonitis, abdominal rigidity may be localized (as seen with an acute appendicitis) or generalized (as seen with a perforated ulcer). Peritonitis also causes sudden and severe abdominal pain that can be localized or generalized. The patient with peritonitis generally exhibits abdominal tenderness with distention, rebound tenderness, guarding, hyperalgesia, hypoactive or absent bowel sounds, nausea, and vomiting. He may also experience fever, chills, tachycardia, tachypnea, and hypotension.
Pneumonia
In lower lobe pneumonia, abdominal rigidity is associated with severe referred upper abdominal pain and tenderness. The rigidity diminishes with inspiration. Other findings may include blood-tinged or rusty sputum, a dry and hacking cough, dyspnea, fever, sudden onset of chills, crackles, egophony, decreased breath sounds, and dullness on percussion.
Nursing considerations
Monitor the patient closely for tachycardia, hypotension, clammy skin, and decreased responsiveness — these signs may indicate the presence of a life-threatening condition. Position him as comfortably as possible, preferably in a supine position, with his head flat on the table, arms at his sides, and knees slightly flexed to relax the abdominal muscles. Withhold analgesics to avoid masking symptoms that may help determine the diagnosis. Monitor for changes in the pain assessment or the development of pain. Withhold food and fluids until surgery has been ruled out. Administer an I.V. antibiotic. Prepare the patient for diagnostic tests, which may include chest and abdominal X-rays, computed tomography scans, magnetic resonance imaging, peritoneal lavage, gastroscopy or colonoscopy, and blood, urine, and stool studies. A pelvic or rectal examination may also be done.
Patient teaching
Inform the patient that pain medications will be withheld until a definitive diagnosis is made because these agents can mask important symptoms. Reinforce proper positioning to maintain a relaxed abdominal area. Explain the procedures for all tests that are ordered. Prepare the patient for surgery, if indicated.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Abdominal cramps
» Next page: Abdominal distention (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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