Introduction The abdomen can

Introduction
The abdomen can be injured in many types of trauma; injury may be confined to the abdomen or be accompanied by severe, multisystem trauma. The nature and severity of abdominal injuries vary widely depending on the mechanism and forces involved, thus generalizations about mortality and need for operative repair tend to be misleading.
Injuries are often categorized by type of structure that is damaged:
* Abdominal wall
* Solid organ (liver, spleen, pancreas, kidneys)
* Hollow viscus (stomach, small intestine, colon, ureters, bladder)
* Vasculature
Some specific injuries due to abdominal trauma are discussed elsewhere, including those to the liver, spleen and GU tract.
Etiology
Abdominal trauma is typically also categorized by mechanism of injury:
* Blunt
* Penetrating
Blunt trauma may involve a direct blow (eg, kick), impact with an object (eg, fall on bicycle handlebars), or sudden deceleration (eg, fall from a height, vehicle crash). The spleen is the organ damaged most commonly, followed by the liver and a hollow viscus (typically the small intestine).
Penetrating injuries may or may not penetrate peritoneum and if they do, may not cause organ injury. Stab wounds are less likely than gunshot wounds to damage intra-abdominal structures; in both, any structure can be affected. Penetrating wounds to the lower chest may cross the diaphragm and damage abdominal structures.
Classification:
Injury scales have been devised that classify organ injury severity from grade 1 (minimal) to grades 5 or 6 (massive); mortality and need for operative repair increase as grade increases. Scales exist for the liver, spleen, and kidneys.
Associated injuries:
Blunt or penetrating injury that affects intra-abdominal structures may also damage the spine and/or pelvis. Patients who experience significant deceleration often have injuries to other parts of the body, including the thoracic aorta.

Learning Objectives:
This study aims to provide an information and to give an example for how to plan a care for a patient diagnosed with blunt abdominal injury
Patient’s Profile:
Age: 21
Status: Single
Sex: Male
Religion: Islam
Date and Place of Birth: 11/29/1992/ Metro Manila
Date Admitted: 11- Aug – 2014
Time of Admission: 12:30am
Initial Diagnosis: Blunt Abdominal Injury sec to Trauma (06 Aug 2014)
Patient’s Health History
Patient came in w/ no airway obstruction, speaks in sentences, O2 sat of 97%; no difficulty of breathing but tachypneic at 28cpm; BP of 130/70mmHg w/ no episodes of hypotension; GCS 15 with both pupils equally reactice to light and accomodation. No other external sign of physical injury on back, axillae and groin.

PAST MEDICAL HISTORY
(-) HPN
(-) DM
(-) Bronchial Asthma
(-) Asthma
(-) thyroid dse
(-) PTB
(-) Food/drug allergy
FAMILY HISTORY

(-) HPN
(-) DM
(-) Bronchial Asthma
(-) PTB
(-) CA- father

PERSONAL AND SOCIAL HISTORY
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use
Anatomy and Physiology
1. esophagus
A 25-30 cm long muscular tube that connects the pharynx to the stomach.
Transports food from the mouth to the stomach.
2. kidney
A bean-shaped organ, ~12 cm long and 6 cm wide.
Filters blood, regulates blood pressure and electrolyte levels, among other functions.
3. liver
A large, reddish-brown organ with multiple, equally-sized lobes. It weighs ~1.5 kg.
Removes toxins from blood arriving from the small intestine, synthesizes proteins,
and produces bile (used for digestion).
4. stomach
Further digests food using muscular contractions that mix the food with acids and
protein-digesting enzymes.
A hollow, muscular organ with sphincters on either end that act as “valves” for
receiving food and regulating its release.
5. large intestine
A 1.5-meter long tube, much wider than the small intestine (> 5 cm wide).
Connected to the exit end of the small intestine on one end and the rectum on the
other.
Absorbs water from the nutrient-depleted digested material. Provides a fertile
environment for bacterial flora essential for vitamin production.
6. small intestine
A 5-meter long tube, ~3 cm wide. It is connected along its length to a thin membrane
called the mesentery, which serves as its blood supply.
Further digests food by mechanically mixing the “chyme” (fluid ejected by the
stomach) and absorbing nutrients.
7. spleen
Part of the lymphatic system. About ~11 cm long and weighs ~200 g. Purplish gray.
Synthesizes antibodies and removes antibody-coated bacteria. Performs many other
functions related to fighting disease and infection.
8. gallbladder
Small, hollow sack that receives and stores bile produced by the liver.
Releases bile (up to 50 mL) into the small intestine when fatty foods have entered the
digestive tract.
9. pancreas
Has four prominent features referred to as the head, neck, body, and tail. Located
below the stomach and about one-third of the stomach’s size.
Secretes pancreatic juice that helps dissolve food. Also produces chemicals for the
endocrine system (hormones).

Pathophysiology
Trauma

Hypovolemic Shock

Tissue Injury

Increase Sympathetic nervous system activity

Decrease Gut perfusion

Cellular Perfusion

Cell Death

Inflammation

Increase Capillary permiablity

Edema Formation

Increase Intra- abdominal pressure

Gordon’s Functional Health System
HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN
Before:
The patient said that he has a weak resistance to cold and has an allergic rhinitis. He took vitamins everday and usually self-medicate if he doesn’t felling well.

During:
The patient is bed ridden but still conscious and coherent. The patient is generally weak but can follow commands. The patient was hospitalized because of abdominal pain secondary to trauma.

NUTRITIONAL- METABOLIC PATTERN
Before:
The patient said that he eats 4x a day and drinks more than 8 glasses of water a day.
During:
The patient is currently receiving her nutrition through IV fluids and NGT. The patient has edema on the left arm.

ELIMINATION PATTERN
Before:
The patient has a normal bowel movement. Voided 1x a day with normal consistency.
The patient eliminates through a urinary catheter and defecates on an adult diaper. The patient has a normal hourly urine output but did not defecate throughout the shift.

ACTIVITY-EXERCISE PATTERN
Before:
The patient exercise regularly.
The patient is generally weak. The patient can follow commands but cannot speak because of tracheostomy.

SLEEP-REST PATTERN
Before:
The patient usually has 6 – 7 hours of sleep a day with 1 hour nap during noon.
During:
The patient seems restless. The patient have not had a good sleep since the start of our shift.

COGNITIVE PERCEPTUAL PATTERN
Before:
The patient doesn’t have any problem with vision either or hearing. But said that he has a high tolerance to pain.
During:
The patient can establish eye contact when called, and is able to respond with a smile. He wrote what he wants in a whiteboard.
SELF-PERCEPTION / SELF-CONCEPT PATTERN
The patient is aware about his condition. He is cooperative on the procedures done to him.

ROLE RELATIONSHIP
The patient is with his parents and brother during the shift, he had other visitors that came during the shift. The patient is living with his family.

SEXUALITY REPRODUCTIVE
The patient’s was not comfortable disclosing information about his sexual relationship.

COPING-STRESS TOLERANCE
The patient mostly relies on his family. When he is stress he surfs on the internet or play games on his Ipad.

VALUE-BELIEF PATTERN
He was born a Roman catholic because it was his father’s religion but decides to change into Muslim his mother’s religion.

LABORATORY RESULT

ARETERIAL BLOOD GAS PARAMETERS RESULT NORMAL RANGE INTERPRETATION pH 7.47 7.35-7.45 mmHg
Partially compensated
Respiratory Alkalosis PaCO2 33.6 35-45 mmHg PaO2 81 80-100 mmHg HCO3 24.1 22-26 mEq/L O2Sat 99.8% 95-100% FiO2 40% Low level is due to inadequate oxygen.

COMPLETE BLOOD COUNT RESULT NORMAL VALUES INTERPRETATION Hemoglobin 135 120-160 Normal Hemoglobin Hematocrit 0.39 0.37-0.45 Decreased in hematocrit indicates blood loss. The patient may be at risk for hypovolemia. RBC Count 4.84 4.0-5.4 Normal WBC Count 9.87 4.0-10.0 Normal Differential Count Segmenters 0.80 0.55-0.65 An increased amount of segmenters may indicate ongoing bacterial infection. Lymphocytes 0.11 0.25-0.35 Decreased lymphocytes puts the patient at risk for viral infection. Eosinophils 0.01 0.02-0.04 Normal eosinophils indicate no allergic reaction and parasite infection. Monocytes 0.08 0.03-0.06 Increased monocytes indicates phagocytic activities. Basophils 0.00 0.00-0.01 Normal basophils indicate no allergic reaction. MCV 80.2 80-100 The red blood cells of the patient are of the normal size. MCH 27.4 26-32 The mass of hemoglobin in each RBC are normal. MCHC 35 32-36 The proportion of RBC to hemoglobin are normal. RDW 15.2 11-15 An increase in RDW may indicate anemia. Platelet Count 137 130-400 Normal platelet count indicates normal clotting formation.
Course in the Ward:

14 – Sept. – 14

Post – op Pain
D> with complaints of mild tolerable abdominal pain.
>With on-going Ketoralac and tramadol drip infusing well.
A> observed pain characteristics, monitored accordingly. Maintained on above pain medication insfusion.
> Suctioned secretions as needed
R> No complaints of pain

15 – Sept. – 14

Ineffective Airway Clearance
D > with ET to mech vent
> O2 sat of 90%
A > assessed for respiration status; maintained on moderate high back rest; CPT with nebulization done.; monitored signs and symptoms of respiratory distress and excacerbration.
> Suctioned secretions as needed
> Extubated by Dr. Sta. Ana
> Hooked to 02 inhalation via face mask @ 5-6 LPM.
R > latest 02 saturation 99% ; for continuity of care.
16- Sept – 14

Impaired skin integrity
D > post- op abdominal incision with dry and intact dressing, with JP on left side, with NGT and with IFC to urine bag.
A> Decreased skin integrity; maintaned and observed aseptic technique. Monitored urine output; WOF for signs and sypmtoms of infection.
> Turned side to side with interval
R> For continuity of care.
17 – Sept. – 14

Serum electrolyte imbalance
D > post- op abdominal incision with dry and intact dressing
> with JP left on negative pressure with serosanginous output; with NGT to bedside bottle; with IFC to urine bag with adequate output.
A> Maintained on KCL drip of PNSS 1L x KVO
> Given due meds
> Done NGT feeding every 2 hours.
> Output taken and recorded accurately.
R > for continuity of care.

DISCHARGE PLANNING
MEDICATIONS:
* Advice client to continue taking medications needed (noting on medication that should not be able to discontinue abruptly) to maintain a normal functioning of the body and maintain homeostasis. The staff nurse made sure that the patient’s guardian understood how to administer her medications and was familiar with their possible adverse effects by having them explain back what they had heard, in their own words. The treatment regimen ordered by the doctor must be followed strictly.
* Advice the client as well as her guardian to observe any reaction towards the given medication and signs that needs to call the attention of the physician.
* Always instruct the client as well as her guardians the proper dosage of the drug to be given, frequency, and routine of administration.
* Also instruct relatives on some drug’s precautions before administration to prevent adverse reactions of drug.
EXERCISE:
* Discuss to the client as well as to her guardian the importance of developing a program of exercise and relaxation techniques as tolerated that is suitable to the client’s daily activity and appropriate to the client’s age.
* Breathing exercise must be taught to the client.
TEACHING:
* A teaching plan that affect client’s holistic wellness should be done in order to maintain an environment that is conducive for health promotion.
* Control of exposure to possible infectious agent in the patient’s environment.
* Teaching the client’s guardians regarding the signs and symptoms that may require a visit to the physician.
OPD SCHEDULE:
* Proper referral is best for health care provider to evaluate condition of the client, whether it is improving or not. Also, for early diagnosis of any other underlying conditions. It has been recommended that follow up checkup must be done 1 to 2 days after discharge.
DIET:
* Proper execution of client’s diet is very important so informing and instruction client about proper meals to be given to the client and increasing oral fluid and protein intake is important.
*

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