Abdominal trauma

51 Abdominal trauma




Overview/pathophysiology


Abdominal trauma accounts for nearly 7 million emergency department visits in the United States annually and often causes serious injury to major organs. It is essential to understand the mechanism of the injury (blunt, penetrating, or combination) and the abdominal organs affected to avoid complications in the recovery period. Astute serial assessments in the posttraumatic period may prevent serious consequences and avoid life-threatening situations. Abdominal injuries often are associated with multisystem trauma. See also discussions in “Pneumothorax/Hemothorax,” p. 120; “Spinal Cord Injury,” p. 306; and “Traumatic Brain Injury,” p. 333.


Knowledge of the injury mechanism and location assist the nurse in anticipating specific injuries to abdominal organs. Abdominal trauma, along with thoracic and musculoskeletal trauma, especially below the fourth rib, should heighten the nurse’s awareness of specific organ assault. Solid organs (liver, kidneys, and spleen) tend to fracture and bleed with trauma; hollow organs (stomach and intestines) may collapse or rupture, releasing caustic substances into the peritoneum. Injury also may result from movement of organs within the body, particularly at the transition between rigidly fixed and mobile organs. Injury to the urinary bladder is not common but may be associated with pelvic fractures. Rectal and vaginal examinations are necessary to assess for injury and bleeding.


Blunt trauma may be caused by falls, assaults, motor vehicle collisions, or sports injuries and involve direct transmission of energy to solid or hollow organs, most commonly affecting the spleen and liver. Splenic injury should be suspected in the presence of left lower rib fractures. Rupture may not be immediately obvious, reinforcing the need for ongoing assessments. Pain radiating to the left shoulder (Kehr’s sign) may indicate blood beneath the diaphragm from splenic bleeding. Pain radiating to the right shoulder may indicate injury to the liver. Other organs that may be affected by blunt trauma include the kidneys and, occasionally, the pancreas and small and large intestines. Bleeding is the most common complication, resulting in increased morbidity and mortality. Abdominal vessels are injured in about 10% of blunt abdominal trauma patients and can quickly lead to shock and death if not recognized. Signs of blood loss may not be evident initially. For example, young healthy patients may lose up to 50% of their blood volume and appear stable.


Gunshot, stabbing, or impalement may cause penetrating trauma, and the external appearance of the wound does not accurately represent internal damage. If the lower esophagus, stomach, or intestines are injured by penetration, complications from release of irritating gastric and intestinal fluids into the peritoneum and free air below the diaphragm may occur. Penetrating injuries to the solid organs may cause fatal damage if not identified early.




Assessment


As with all trauma patients, immediate life-threatening problems are identified and treatment is initiated before the more detailed secondary and focused assessments can be completed.


Caution: Recently injured patients should be evaluated for peritoneal signs (generalized abdominal pain or tenderness, guarding of abdomen, abdominal wall rigidity, rebound tenderness, abdominal pain with movement or coughing, abdominal distention, and decreased or absent bowel sounds) at hourly intervals. The health care provider must be notified immediately if the patient develops peritoneal signs, evidence of shock, gastric or rectal bleeding, or gross hematuria.











Diagnostic tests

















Angiography:


Performed to evaluate injury to spleen, liver, pancreas, duodenum, and retroperitoneal vessels. Caution: Ensure adequate hydration and monitor urine output closely for 24-48 hr following angiography because the large amount of contrast used may cause renal failure, especially in older adults or in patients with preexisting cardiovascular or renal disease. Decreased urinary output and increased blood urea nitrogen (BUN) and creatinine may indicate contrast-associated acute tubular necrosis.





Nursing diagnosis:


Ineffective breathing pattern

related to pain from injury or surgical incision, chemical irritation of blood or bile on pleural tissue, and diaphragmatic elevation caused by abdominal distention


Desired Outcome: Within 24 hr of admission or surgery, patient is eupneic with respiratory rate (RR) 12-20 breaths/min and clear breath sounds.




























ASSESSMENT/INTERVENTIONS RATIONALES
Assess quality of breath sounds, RR, presence/absence of cough, and sputum characteristics. Individuals sustaining abdominal trauma are likely to be tachypneic, with the potential for poor ventilatory effort. If not reversed, this could result in atelectasis and pneumonia.
Monitor oximetry readings q2-4h; report significant findings. O2 saturation 92% or less usually signals need for supplemental oxygen.
Administer supplemental oxygen as prescribed. Monitor and document effectiveness. Supplemental O2 is delivered until patient’s arterial blood gas or oximetry values while breathing room air are acceptable.
Encourage and assist patient with coughing, deep breathing, incentive spirometry, and turning q2-4h. These measures help prevent pneumonia and atelectasis.
Administer analgesics at dose and frequency that relieves pain and associated impaired chest excursion. Reducing pain will enable full chest excursion for better oxygenation.
Instruct patient in methods to splint abdomen. This information will help the patient reduce pain on movement, coughing, and deep breathing, which in turn will aid the respiratory effort.
For additional interventions, see “Perioperative Care” Ineffective Breathing Pattern, p. 46.  
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Abdominal trauma

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