# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630275  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

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?

## 보기

1. Give 30 mL of antacid and recheck his pain in 30 minutes
2. Keep him nothing by mouth and notify the surgeon now **✔ 정답**
3. Give his next scheduled oral omeprazole dose right away
4. Help him walk in the hallway to pass trapped intestinal gas

**정답: 2**

## 해설

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.

## 심화 해설

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].References (research sources)

- [1]The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.GuidelineSartelli M, Chichom-Mefire A, Labricciosa FM, Hardcastle T, Abu-Zidan FM, Adesunkanmi AK, Ansaloni L, Bala M, Balogh ZJ, Beltrán MA, Ben-Ishay O, Biffl WL, Birindelli A, Cainzos MA, Catalini G, Ceresoli M, Che Jusoh A, Chiara O, Coccolini F, Coimbra R, Cortese F, Demetrashvili Z, Di Saverio S, Diaz JJ, Egiev VN, Ferrada P, Fraga GP, Ghnnam WM, Lee JG, Gomes CA, Hecker A, Herzog T, Kim JI, Inaba K, Isik A, Karamarkovic A, Kashuk J, Khokha V, Kirkpatrick AW, Kluger Y, Koike K, Kong VY, Leppaniemi A, Machain GM, Maier RV, Marwah S, McFarlane ME, Montori G, Moore EE, Negoi I, Olaoye I, Omari AH, Ordonez CA, Pereira BM, Pereira Júnior GA, Pupelis G, Reis T, Sakakhushev B, Sato N, Segovia Lohse HA, Shelat VG, Søreide K, Uhl W, Ulrych J, Van Goor H, Velmahos GC, Yuan KC, Wani I, Weber DG, Zachariah SK, Catena F. (2017) · DOI: 10.1186/s13017-017-0141-6

## 임상 시나리오

Perforated Ulcer: First Nursing ActionsRecognize the acute abdomen and activate surgical response
Sudden severe epigastric pain spreading across the whole abdomen with board-like rigidity and a still, knees-drawn-up posture indicates perforated peptic ulcer with secondary peritonitis.

The first priority is to keep the patient NPO and notify the surgeon immediately. Oral intake must stop because any food or fluid entering the gastrointestinal tract worsens peritoneal contamination.

Prepare for nasogastric suction, intravenous fluids, broad-spectrum antibiotics, and urgent surgical source control. Delays in source control increase mortality in intra-abdominal sepsis.

CautionDo not give oral antacids, oral medications, or encourage ambulation. These actions delay definitive care and may worsen peritoneal irritation or contamination.

## 핵심 개념

- **board-like rigidity** — Involuntary abdominal wall muscle guarding over inflamed peritoneum, a classic sign of peritonitis.
- **perforated peptic ulcer** — Full-thickness erosion through stomach or duodenal wall allowing luminal contents to spill into the peritoneal cavity.
- **peritonitis** — Inflammation of the peritoneum from chemical and bacterial contamination, often presenting as severe pain and rigidity.
- **NPO** — Nothing by mouth; withholding oral intake to prepare for surgery and prevent further contamination.
- **source control** — Surgical or interventional elimination of the contamination source, the definitive treatment for perforation.

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