Situation: A 38-year-old man comes to the outpatient clinic with epigastric pain for the past 2 months. He takes no regular medicines and has no known drug allergies. Three weeks later he is admitted with sudden, severe epigastric pain that spread across his whole abdomen 2 hours ago. His abdomen is rigid and board-like, and he lies still with his knees drawn up. What should the nurse do FIRST?

Sudden severe pain spreading across the abdomen with board-like rigidity suggests a perforated ulcer with peritonitis, a surgical emergency. The nurse keeps the client nothing by mouth, notifies the provider at once, and prepares for nasogastric suction, intravenous fluids, antibiotics, and surgery.

Clinical picture

A 38-year-old man with 2 months of epigastric pain now presents with sudden severe pain that has spread across the entire abdomen within 2 hours. The abdomen is rigid and board-like, and he lies still with knees drawn up. These are classic signs of perforated peptic ulcer with secondary peritonitis.

Why this is a surgical emergency

When a peptic ulcer erodes through the full thickness of the stomach or duodenal wall, gastric acid, digestive enzymes, and luminal contents spill into the sterile peritoneal cavity. This chemical contamination triggers intense inflammation, and within hours bacterial translocation leads to secondary bacterial peritonitis. The board-like rigidity reflects involuntary guarding of the abdominal wall muscles over the inflamed peritoneum — the body's attempt to splint the area and limit movement. The patient's still posture with knees flexed reduces tension on the peritoneum and relieves pain.

Perforation with peritonitis is a time-dependent emergency; early recognition and prompt source control are the cornerstones of effective management. The WSES guidelines emphasize that intra-abdominal infections are major contributors to non-trauma deaths in emergency departments, and that delays in adequate source control worsen outcomes ^[1].

Priority nursing actions

The first nursing action is to keep the patient nothing by mouth (NPO) and notify the surgeon immediately. Oral intake must be stopped because any food or fluid entering the stomach will continue to leak through the perforation into the peritoneal cavity, worsening contamination. Antacids and oral omeprazole are inappropriate at this stage — they do not close the perforation and may increase gastric volume, leading to more leakage. Ambulation is contraindicated because movement aggravates peritoneal irritation and may spread contaminated fluid throughout the abdomen.

After notifying the surgeon, the nurse prepares for nasogastric suction to decompress the stomach, intravenous fluid resuscitation, broad-spectrum antibiotics, and urgent surgical repair. These interventions align with the WSES framework of early recognition, adequate source control, and appropriate antimicrobial therapy ^[1].

Watch out! Do not give oral medications or encourage ambulation when peritonitis is suspected. Oral intake worsens peritoneal contamination, and movement increases pain and spreads infection.

Key point! Board-like rigidity plus sudden diffuse abdominal pain equals perforation until proven otherwise. The nurse's first move is NPO plus immediate provider notification, not symptom relief with antacids.

Assessment finding	Clinical meaning	Nursing implication
Sudden severe pain spreading across abdomen	Perforation with spillage of gastric contents	Treat as surgical emergency; do not delay
Board-like rigidity	Diffuse peritoneal inflammation and involuntary guarding	Strongly suggests peritonitis; prepare for surgery
Lying still with knees drawn up	Position that reduces peritoneal tension and pain	Avoid movement; keep patient comfortable and NPO
History of 2 months epigastric pain	Likely chronic peptic ulcer disease now complicated	Reinforces perforation as the acute event

The correct first action is therefore to keep the patient NPO and notify the surgeon now, because source control — not oral medication or ambulation — is what determines survival in perforated ulcer with peritonitis ^[1].