Abdominal and Urologic Trauma

CHAPTER 32 Abdominal and Urologic Trauma



Melody R. Campbell, RN, MSN, CEN, CCRN, CCNS



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Abdominal Injuries


Liver

Spleen

Gastric

Pancreatic/Duodenal

Small Bowel/Large Bowel

Specific Urologic Injuries


Renal

Bladder

Urethra


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)


2. Focused assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Mechanism of injury (see Chapter 30)
(1) Blunt force: motor vehicle crash, fall, struck pedestrian, motorcycle crash

(2) Penetrating force: gun shot or stab wounds

b) Pain: PQRST (see Chapter 9)

c) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness

b) Past surgical procedures

c) Substance and/or alcohol use/abuse

d) Last normal menstrual period: female patients of childbearing age

e) Current medications
(1) Prescription

(2) Over-the-counter/herbal

f) Allergies

g) Immunization status

3) Psychological/social/environmental
a) Stress factors
(1) Lifestyle

(2) Coping patterns

(3) Precipitating event

(4) Significant others involved in traumatic event

b) Possible/actual victim of assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Level of distress/discomfort

2) Inspection
a) Abdominal distention/flatness

b) Symmetry

c) Contour (flat, rounded, herniation)

d) Abrasions, contusions, open wounds, lacerations

e) Ecchymosis, “seat belt sign”

3) Auscultation
a) Bowel sounds: normal, decreased, or absent

b) Breath sounds: normal, absent, crackles

4) Palpation/percussion: all four quadrants of the abdomen
a) Abdominal tenderness

b) Rigidity/guarding

c) Peritoneal irritation

3. Diagnostic procedures


a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Liver function tests (aspartate aminotransaminase [AST], alanine aminotransferase [ALT], lactate dehydrogenase [LDH], alkaline phosphatase)

4) Serum amylase, lipase

5) Type and crossmatch

6) Serial hematocrits

7) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT)

8) Urinalysis; pregnancy test in female patients of childbearing age

b. Imaging studies

1) Abdominal flat plate radiograph

2) Chest radiograph

3) Focused Assessment Sonography for Trauma (FAST) (Table 32-1)
a) Detects bleeding within the chest or abdominal cavity

b) Four areas of the abdomen are examined
(1) Hepatorenal fossa

(2) Splenorenal fossa

(3) Pericardial sac

(4) Pelvis (Fig. 32-1)

(5) As little as 100 mL of fluid can be detected, but examination is usually considered positive when there is at least 200 to 500 mL of fluid noted

(6) Injuries of the small and large bowel as well as retro/introperitoneal trauma are unable to be diagnosed with the use of FAST

4) Cystography

5) Retrograde urethrography

6) Intravenous pyelogram (IVP)

7) Angiography
a) Identifies active bleeding

b) Interventionalists can then embolize, stent, or coil to treat the injury

8) Abdominal/pelvic/thoracic computed tomography (CT) scan (see Table 32-1)
a) Oral contrast is usually not administered in the resuscitative phase

b) IV contrast assists in diagnosis of active bleeding; a blush on the CT is an indication of active bleeding with possible need for embolization or operative intervention

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Gastroscopy or endoscopy

3) Sigmoidoscopy/proctoscopy/colonoscopy

4) Diagnostic peritoneal lavage (DPL) (see Table 32-1)
a) Identifies intraabdominal bleeding

b) Following decompression of the bladder and the stomach, a peritoneal catheter is inserted into the abdomen below the umbilicus

c) Withdrawal of gross red blood is considered positive

d) If gross blood is not noted, 1 L of isotonic crystalloid solution is infused through the catheter. The lavage fluid is then allowed to passively drain back out by gravity and is sent to the laboratory for analysis

e) Presence of red or white blood cells, bile, amylase, food fiber, or feces is noted. DPL may be performed in the unstable patient who has experienced blunt force injury


Table 32-1 COMPARISON OF DIAGNOSTIC TESTS

image

image

FIGURE 32-1 The Focused Assessment Sonography for Trauma (FAST) examination consists of ultrasound views of four sites: pericardial, perihepatic (right upper quadrant), perisplenic (left upper quadrant), and pelvic.


(From Macdougall, D. B. [2005]. Abdominal trauma. In Emergency Nurses Association [Ed.], Sheehy’s manual of emergency care (6th ed). St. Louis, MO: Mosby. Courtesy of William Mallon, MD.)



B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Risk for deficient fluid volume


2. Ineffective tissue perfusion


3. Acute pain


4. Anxiety/fear


5. Risk for infection



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluids/blood products/medications

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes, and modify nursing care plan as appropriate


3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatrics


a. Growth or development related

1) Because of greater fluid needs related to body surface area, fluid, fluid/electrolyte, and acid-base balance are more precarious

2) Acidosis develops more rapidly

3) Children can compensate for a 25% blood loss by increasing their heart rate and peripheral vascular resistance, thereby maintaining normal systolic blood pressure. Blood pressure is an unreliable early indicator of shock in children

4) The abdominal muscles are thinner, weaker, and less developed. The liver is more easily injured because it lies anteriorly and is less protected by the ribs. The kidneys are mobile and are not protected by fat

b. “Pearls”

1) The hollow and solid abdominal organs are more prone to injury than in adults

2) Intra-abdominal injury can result from airbag deployment

3) Abdominal injuries may be the result of child maltreatment

2. Geriatrics


a. Aging related

1) There is a loss of pulmonary reserve with aging; the cardiovascular system is not as responsive

2) The older adult has a decreased ability to adjust to extremes of temperature; care should be taken to minimize body exposure and maintain normothermia

3) Peristalsis and gastric motility slow with aging. Older adults often have preexisting malnutrition and anemia

b. “Pearls”

1) Shock may be present in the presence of normal vital signs

2) Urine output may not be a reliable indicator of overall tissue perfusion because the older adult has a decreased ability to concentrate urine

3) Any degree of hypoxemia is detrimental in the older adult

4) Gastric motility and emptying slow with the aging process



II. SPECIFIC ABDOMINAL INJURIES



A. Liver


The liver is one of the most commonly injured organs in the abdomen. Blunt force is more often the cause of liver injury. Penetrating injury can cause both minor lacerations and severe damage to the parenchyma resulting in rapid blood loss. Liver injuries are graded on a scale from 1 to 5, with type 1 being the least severe injury. Injury to the liver affects its functions, including blood storage (up to 500 mL) and filtration, secretion of bile, conversion of glucose into glycogen, synthesis and breakdown of fats and temporary storage of fatty acids, and synthesis of serum proteins (globulins, albumin) that aid in the regulation of blood volume and essential clotting factors (fibrinogen and prothrombin). Because blood flow through the liver at any one time is approximately 30% of the cardiac output, and blood is also stored within the liver, there is a great potential for significant blood loss with liver injuries. Liver injury should be suspected in any patient with lower chest or abdominal injury on the right side of the body.




1. Assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Pain (see Chapter 9): in right upper quadrant (RUQ), hypochondriac, or epigastric region

b) Mechanism of injury (see Chapter 30)

2) Past medical history
a) Current or preexisting diseases/illness
(1) Bleeding tendencies

(2) Liver disease or enlarged liver

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: alert to confusion, coma

(2) Possible hypotension, tachycardia

(3) Moderate to severe distress/discomfort

b) Inspection
(1) Abrasions, contusions, open wounds, lacerations

(2) Ecchymosis over right lower chest wall/RUQ abdomen

(3) Abdominal distention

c) Auscultation
(1) Bowel sounds: normal to decreased or absent

(2) Breath sounds: normal to decreased or absent on right side

d) Palpation
(1) Right lower chest wall tenderness

(2) Abdominal tenderness

(3) Rebound tenderness

(4) Rigid abdomen specifically in RUQ

2) Diagnostic procedures
a) CBC with differential

b) Serial hematocrits

c) Type and crossmatch

d) Coagulation profile: PT, PTT

e) Urinalysis; pregnancy test in female patients of childbearing age

f) Liver enzymes: elevated alkaline phosphate, ALT, AST

g) Abdominal radiograph: flat plate (portable)

h) Chest radiograph: may indicate right pneumothorax or fractured ribs

i) FAST

j) Abdominal CT scan

k) Possible DPL: positive for blood

l) Angiography

2. Analysis: differential nursing diagnoses/collaborative problems


a. Deficient fluid volume

b. Ineffective tissue perfusion: peripheral

c. Acute pain

d. Anxiety/fear

e. Risk for infection

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen

c. Establish IV access for administration of crystalloid fluids/blood products/medications

1) Insert two large-caliber IV catheters

2) Infuse warmed normal saline solutions

3) Infuse warmed blood products as needed

d. Prepare for/assist with medical interventions

1) Institute cardiac and pulse oximetry monitoring

2) Insert gastric tube and attach to suction as indicated

3) Insert indwelling urinary catheter as indicated

4) Maintain normothermic body temperature

5) Assist with collection and maintenance of physical and forensic evidence as indicated (see Chapter 43)

6) Assist with hospital admission, preparation for the operating suite, or transfer to an institution providing a higher level of care

e. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Antibiotics

4) Tetanus immunization

4. Evaluation and ongoing monitoring (see Appendix B)


a. Level of consciousness

b. Hemodynamic status

c. Breath sounds and pulse oximetry

d. Cardiac rate and rhythm

e. Pain relief

f. Intake and output


B. Spleen


The spleen is the abdominal organ most frequently injured by blunt force, and it is associated with fractures of the left 10th through 12th ribs. Penetrating forces may also cause injury to the spleen. An injury grading system similar to that developed for liver injuries, with a scale of 1 to 5, is used to describe injury to the spleen. Grades 1 through 3 are less severe, whereas grades 4 and 5 usually require operative intervention. The spleen plays a role in immune competence, filtration of blood, and removal of blood-borne bacteria. It also stores up to 200 mL of blood. Because of the spleen’s important role in immunity, intervention is aimed at spleen or partial spleen salvage.




1. Assessment


a. Subjective data collection

1) History of present injury/chief complaint
a) Pain (see Chapter 9)
(1) Left upper quadrant (LUQ)

(2) Referred to left shoulder (Kehr’s sign)

b) Mechanism of injury (see Chapter 30)

2) Past medical history
a) Current or preexisting diseases/illness
(1) Bleeding tendencies

b) Medications

c) Allergies

d) Immunization status

b. Objective data collection

1) Physical examination
a) General appearance
(1) Level of consciousness, behavior, affect: alert to confusion, comatose

(2) Possible hypotension, tachycardia

(3) Moderate to severe distress/discomfort

b) Inspection
(1) Abrasions, contusions, open wounds, lacerations

(2) Ecchymosis over left lower chest wall/LUQ abdomen

(3) Abdominal distention

c) Auscultation
(1) Bowel sounds: normal to decreased or absent

(2) Breath sounds: normal to decreased or absent on left side

d) Palpation
(1) Lower left chest wall tenderness

(2) Abdominal tenderness

(3) Rebound tenderness

(4) Rigid abdomen specifically in LUQ

2) Diagnostic procedures
a) CBC with differential

b) Serial hematocrits

c) Type and crossmatch

d) Urinalysis; pregnancy test in female patients of childbearing age

e) Chest radiograph (portable): may indicate left pneumothorax or fractured left 10th through 12th ribs

f) Abdominal radiograph: flat plate (portable)

g) FAST

Related posts:

  1. Genitourinary Emergencies
  2. Shock Emergencies
  3. Professionalism and Leadership
  4. Cardiovascular Emergencies

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Abdominal and Urologic Trauma

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