A nurse is caring for a client with peritonitis and observes a rigid, board-like abdomen upon palpation. The nurse recognizes this finding as:
A.
Rebound tenderness
B.
Paralytic ileus
C.
Abdominal compartment syndrome
D.
Guarding
The Correct answer and Explanation is:
The correct answer is D. Guarding.
Explanation:
Guarding is a clinical finding in which the abdominal muscles contract involuntarily during palpation, causing the abdomen to feel rigid or board-like. This reaction is often an indicator of peritoneal irritation or inflammation. In the context of peritonitis, which is an inflammation of the peritoneum (the lining of the abdominal cavity), guarding occurs as a protective mechanism by the body to minimize discomfort and prevent further irritation. The involuntary contraction of the abdominal muscles can make the abdomen feel firm or rigid to the touch.
Here’s a detailed breakdown of why guarding is the correct answer and how it compares to other options:
- Rebound Tenderness (A): Rebound tenderness refers to the pain that occurs when pressure applied to the abdomen is suddenly released. This sign is associated with peritoneal irritation, but it is distinct from guarding. Rebound tenderness indicates irritation of the peritoneum, but it does not describe the rigidity of the abdomen.
- Paralytic Ileus (B): Paralytic ileus is a condition where there is a lack of peristalsis in the intestines, leading to a cessation of bowel movements and potentially abdominal distention. While a paralytic ileus can cause abdominal discomfort, it does not typically present with a rigid, board-like abdomen. The rigidity seen in guarding is not characteristic of paralytic ileus.
- Abdominal Compartment Syndrome (C): Abdominal compartment syndrome occurs when there is increased intra-abdominal pressure due to conditions such as trauma or massive fluid resuscitation. This condition may cause distention and pain but is associated with severe, progressive symptoms and elevated abdominal pressures, rather than just rigidity upon palpation.
- Guarding (D): Guarding is a physical examination finding where the abdominal muscles contract in response to palpation due to pain or discomfort, leading to a rigid, board-like feel of the abdomen. In peritonitis, this is a protective response to the inflammation and irritation of the peritoneum.
In summary, guarding is the correct answer because it specifically describes the rigid, board-like abdomen observed in patients with peritonitis due to the involuntary contraction of the abdominal muscles in response to pain.