EMERGENCY NURSING CARE OF PATIENTS WITH ABDOMINAL TRAUMA
EMERGENCY NURSING CARE OF PATIENTS
EMERGENCY NURSING CARE OF PATIENTS
WITH ABDOMINAL TRAUMA
A. BASIC CONCEPT OF DISEASE
1. DEFINITION
· Trauma is an injury or involuntary or psychological or emotional harm (Dorland, 2002: 2111)
· Abdominal trauma is an injury to the abdomen, can be blunt and penetrating trauma and trauma intentional or unintentional (Smeltzer, 2001: 2476)
2. Etiology / FACTORS CAUSE
Based on the mechanism of trauma, divided into 2, namely:a) Blunt TraumaA direct blow, let the door hit the steering wheel or car parts are sinking into the collision, can cause compression trauma or crush injury to the viscera organs. It can damage solid organs and hollow organs, and can lead to rupture, especially distended organs (eg uterus of pregnant women), and resulted in bleeding and peritornitis. Trauma pull (shearing injury) to the viscera organ is actually a crush injury that occurs when a safety device (eg, type of seat belt lap belt or shoulder safety components) are not used properly. Patients who were injured in a motorcycle collision can occur traumatized decelerasi where unequal movement between the parts and the fixed to the moving parts, such as rupture or ruptured liver spleen (the organ that moves) ligamentnya section (which is fixed to the organ). Use of water-bag does not prevent people from experiencing abdominal trauma. In patients who undergo laparotomy because of blunt trauma, the organ that is most often subject to lien (40-55%), liver (35-45%), and colon (5-10%). In addition, 15% of them had retroperitoneal hematoma.b) sharp TraumaStab wound or gunshot wound (low speed) will cause tissue damage due to laceration or cut. Gunshot wound at high speed will cause the transfer of kinetic energy greater the viscera organ, with additional effects such as temporary cavitation, and can be broken into fragments that cause other damage. Puncture wounds of the common hepatic (40%), small bowel (30%), diaphragm (20%), and colon (15%). Gunshot wounds cause greater damage, which is determined by the bullet traveling away, and how much kinetic energy as well as the possibility of ricochets by bone organ, as well as the effect of the bone fragments. Gunshot wounds most commonly affects the small intestine (50%), colon (40%), liver (30%) and abdominal blood vessels (25%).(American College of Surgeons Committee of Trauma, 2004: 145)
3. SIGNS AND SYMPTOMS
- Lacerations, bruises, ecchymosis- Hypotension- Absence of bowel sounds- Hemoperitoneum- Nausea and vomiting- The sign "Bruit" (sounds abnormal vascular auscultation pd, pd usually carotid artery),- Pain- Bleeding- Impairment of consciousness- Shortness- Sign Kehrs is pain on the left side caused by bleeding limfa.Tanda there when the patient in recumbent position.- Mark Cullen was ecchymosis periumbulikal on peritoneal hemorrhage- Grey-Turner sign is ecchymosis on the side of the body (waist) in retroperitoneal bleeding.- Sign coopernail is ecchymosis of the perineum, scrotum or labia on pelvic fracture- Signs balance is blunt voice that settled the area in the upper left quadrant when performed percussion on lymph hematoma(Scheets, 2002: 277-278)
4. Pathophysiology and TREE PROBLEM
When an external force blasted on the human body (due to traffic accidents, assault, sporting accidents and falls from a height), then the severity of trauma is the result of interactions between factors - physical factors of the strength of the body's tissues. Severe trauma that occurred related to the ability of a static object (which bumped) to hold the body. Impact on the place because of the difference in the movement of the body tissues will cause tissue disruption. It is also characteristic of the surface of the body is also an important stop. Trauma is also dependent on the viscosity of elastitisitas and body tissues. Elasticity is the ability of the network to return to the previous state. Viscosity is the network's ability to maintain its original shape despite collision. Tolerance body withstand the impact depends on both the state .. Severity of the trauma that happens depends on how much force would be able to pass through the existing network resilience. Another component that must be considered in weighing trauma is the position of the body relative to the impact surface. This can occur intra-abdominal organ injury caused by several mechanisms:
Increased intra-abdominal pressure is sudden and severe by the compressive force from the outside like a clash of the steering wheel or seat belt that is located incorrectly can result in rupture of solid organ or hollow organ.
Intra-abdominal organ wedged between the anterior abdominal wall and the bone structure of the vertebrae or the thoracic wall.
Occur force sudden acceleration-deceleration force can cause torn on organ and vascular pedicle.
5. CLASSIFICATION
Based mechanism, namely:a) Blunt Trauma- Usually caused by motor vehicle accidents.- Other factors such as sudden falls and trauma- Results of crush injury and traumatic deceleration of the solid organs (due to bleeding) or intestine (due to perforation and peritonitis)- Lymph and the liver is the organ most frequently involvedb) sharp Trauma- Usually caused by stab, stab or gun shot.- It may be connected with the chest, diaphragm and retroperitoneal injuries in the system.- Liver and small intestine is the most common organ damage.- Puncture wound may be menenbus wall peritoneum and often damaging conservatively, however injuries from gun shots and investigation always requires surgery to control early intraperitoneal injury.
6. DIAGNOSTIC EXAMINATION / SUPPORT
Ø Diagnostic
a) Blunt Trauma
1. Diagnostic peritoneal lavage
DPL is invasive procedure that can be done quickly meaningful change plans for the next patient, and is considered 98% sensitive for bleeding intraretroperitoneal. Should be carried out by a surgical team for patients with multiple blunt trauma with abnormal hemodynamics, especially when encountered:
Changes in sensorium-trauma capitis, alcohol intoxication, drug addiction.
Changes in sensation spinal trauma
Injury to adjacent organs-lower ribs, pelvis, lumbar vertebra
Diagnostic tests are not clear
Predicted aka tone lost contact with the patient in a rather long time, anesthesia for extraabdominal injury, X-Ray examination of the old instance Angiography
The existence of lap-belt sign (abdominal wall contusion) with suspicion of bowel injury
DPL is also indicated in patients with normal hemodynamic values encountered something like the above and the facilities here are not memiliiki ultrasound or CT scan. One of the contraindications for DPL is a clear indication for laparotomy. The relative contraindications include previous abdominal surgery, morbid obesity, which further shirrosis, and the presence of coagulopathy before. Can be worn open or closed technique (Seldinger) in infraumbilikal by trained physicians. In patients with pelvic fractures or pregnant women, the better we do supraumbilikal to prevent pelvic hematoma or endanger the enlarged uterus. The presence of fresh blood aspiration, gastrointestinal contents, vegetable fiber or bile coming out, through the tube DPL in patients with abnormal henodinamik show strong indications for laparotomy. If there is no fresh blood (> 10 cc) or liquid stool, carried 1000cc lavage with Ringer Lactate (in children 10cc/kg). After the mixed liquid by pressing or doing Rogg-oll, fluids are recovered and examined in the laboratory for gastrointestinal contents, fiber and bile. (American College of Surgeons Committee of Trauma, 2004: 149-150)Test (+) in blunt trauma when 10 ml or more of blood macroscopic (gross) at the initial aspiration, erythrocytes> 100,000 mm3, leukocytes> 500/mm3 or painting gram (+) for bacteria, bacteria or fiber. Whereas when DPL (+) on the sharp trauma when 10 ml or more of blood macroscopic (gross) at the initial aspiration, the red blood cells 5000/mm3 or more. (Scheets, 2002: 279-280)
2. FAST (Focused Assessment Sonography in Trauma)
Individuals who are well trained to use ultrasound to detect the presence of hemoperitoneum. With the specialized equipment in the hands of those who are experienced, ultrasound possess sensitivity, acuity for meneteksi specifitas and intra-abdominal fluid is proportional to the DPL and CT Abdominal Ultrasound provides proper way, noninvansive, accurate and inexpensive to detect hemoperitorium, and can be repeated at any time. Ultrasound can be used as a bedside diagnostic tool dikamar resuscitation, that simultaneously with the execution of several other therapeutic and diagnostic procedures. Use the same indication with indication of DPL. (American College of Surgeons Committee of Trauma, 2004: 150)3. Computed Tomography (CT)Used to obtain information regarding organ damage and the level of damage, and also to diagnose pelvic trauma or difficult retroperineal diagnosed with a physical exam, FAST, or DPL. (American College of Surgeons Committee of Trauma, 2004: 151)b) Sharp Trauma
Lower thorax injuries
For asymptomatic patients with suspicion on the diaphragm and upper abdominal structures required physical examination and photographs over the thorax, thoracoskopi, laparoscopy or CT scan.
Local wound exploration and DPL serial examinations compared to the front abdominal stab wounds. For patients who are relatively asymptomatic (except for pain due to a puncture), an option that is not invasive diagnostic examination is a diagnostic examination series within 24 hours, MPAs and diagnostic laroskopi.
Physical examination diagnostic serial compared to double or triple contrast in the flank or back injury
For asymptomatic patients no diagnostic options include serial physical examinations, CT with contrast double or triple, or DPL. With serial diagnostic examination for patients who are initially asymptomatic became symptomatic, we get the sharpness especially in detecting and intraperineal retroperinel injury to the anterior wound behind linea axillaries. (American College of Surgeons Committee of Trauma, 2004: 151)
Radiological examination
1. X-Ray examination for screening of blunt trauma
X-rays for screening is Ro-photograph lateral cervical, thorax and pelvis AP AP in patients with blunt trauma multitrauma. Abdominal x-ray photograph three positions (supine, semi-erect and lateral decubitus) is useful to see free air under the diaphragm or the air outside diretroperitoneum lumen, which if there is a hint for the second laparotomy performed. Suggests the possibility of the loss of the psoas shadow retroperitoneal injury
2. X-Ray examination for screening sharp trauma
Patients with stab wounds do not require abnormal hemodynamic X-ray examination in patients with stab wounds above the umbilicus or suspected thoracoabdominal injuries with abnormal hemodynamics, upright chest x-ray photo useful to rule out the possibility of hemo or pneumothorax, or for documentation of intraperitoneal free air. In patients who hemodinamiknya normal, mounting clips on entry and exit wound from a gunshot wound to show the course of the bullet and the retroperitoneal air on abdominal x-ray photograph sleep.
3. Examination with special contrast
Urethrografi
As previously mentioned, must be performed before catheter urine urethrografi if we suspect a ruptured urethra. Examination urethrografi used with catheters no. # 8-F balloon pumped with 1.5-2cc in naviculare fossa. Entered 15-20 cc of diluted contrast. Done taking pictures with oblique projection with a little pull on the pelvis.
Sistografi
Bladder rupture intra-or extraperitoneal best determined by examination or CT-Scan sistografi sistografi. Catheter, urethra and then mounted 300 cc water-soluble contrast in kolf as high as 40 cm above the patient and allowed contrast flow into the plume or until (1) the flow stops (2) patients spontaneously straining, or (3) the patient felt sick. X-rays taken AP, oblique and post-voiding photo. Another way is with a CT Scan (CT cystogram) is particularly useful to obtain additional information about the kidneys and pelvis. (American College of Surgeons Committee of Trauma, 2004: 148)
CT Scan / IVP
Whenever there is a CT Scan facility, then all patients with hematuria and suspected hemodynamically stable urinary system can be examined by CT scan with contrast and can set the degree of kidney injury. When there is no CT Scan facility, the alternative is IVP examination.Here I use A dose of 200mg / kg bw kidney contrast. Do bolus injection of 100 cc solution Jodine 60% (standard 1.5 cc / kg, 30% if used 3.0 cc / kg) with 2 pieces of 50 cc syringe is injected in 30-60 seconds. 20 min after injection when will acquire visualization calyx on X-Ray. When one side of the non-visualization, chances are renal agenesis, thrombosis and rupture a.renalis interested, or parenchyma which suffered massive damage. Nonvisualisasi both require further investigation with CT Scan + contrast, or renal arteriography or renal exploration; whichever is taken depending on the facilities they have.
Gastrointestinal
Injury to gastrointestinal structure that is located retroperitoneal (duodenum, ascending colon, colon descendens) will not cause peritonitis and can not be detected by DPL. Whenever there is suspicion, examination with CT scan with contrast or RO-examination of the upper GI track for photo-and lower GI tract with contrast should be performed.(American College of Surgeons Committee of Trauma, 2004:149)
Laboratory examination
Complete blood count to look for abnormalities in the blood itself
Decrease in hematocrit / hemoglobin
Increased liver enzymes: alkaline phosphate, SGPT, SGOT,
Coagulation: PT, PTT
MRI
Angiography for possible damage to the hepatic vein
CT Scan
Chest radiographs indicate an increased diaphragm, the possibility of pneumothorax or rib fracture VIII-X.
Scan lymph
Ultrasonogram
Increased serum or urine amylase
Increased serum glucose
Increased serum lipase
DPL (+) for amylase
Improvements WBC
Increased serum amylase
Serum electrolytes
AGD
(,2000:49 ENA-55)
7. COMPLICATIONS
Venous Thrombosis
Pulmonary embolism
Stress ulceration and bleeding
Pneumonia
Pressure ulceration
Atelectasis
Sepsis
(Paul, revised on July 28, 2008)
Pancreas: Pancreatitis, Pseudocyta formation, pancreatic-duodenal fistula, and bleeding.
Spleen: changes in mental status, tachycardia, hypotension, cold akral, diaphoresis, and shock.
Intestine: intestinal obstruction, peritonitis, sepsis, necrotic bowel, and shock.
Kidney: Acute renal failure (ARF)
(Catherino, 2003: 251-253)
8. TREATMENT AND THERAPY MANAGEMENT emergency
- Patients who are unstable or patients with obvious signs of trauma indicating intra-abdominal (peritoneal examination, injury diaphragm, abdominal free water, evisceration) should be immediately performed surgery- Blunt trauma must be observed and has managed the non-operative based on clinical status and degree of injury seen on CT- Provision of analgesic drugs as indicated- Provision of O2 as indicated- Perform ETT intubation for installation if needed- Trauma penetration:ü Do surgery under the above indicationsü Most GSW require surgery depending on the depth of penetration and engagement intraperitonealü stab wound can be explored locally in the ED (under sterile conditions) to demonstrate peritoneal disorders; when the peritoneum intact, the patient can be sewn and issuedü stab wound with intraperitoneal injury requiring surgeryü The outside of the body support must be cleaned or removed by surgery(Catherino, 2003: 251)
B. Nursing care BASIC CONCEPTS
1. ASSESSMENT
1) Subjective Data
History of present illness:
a) Pain in RUQ, hypochondriac or epigastric region (injury to the liver)b) Pain in the left upper quadrant (LUQ), Kehr sign (pain in the left upper quadrant radiating to the left shoulder) on injured lymphaticc) Pain in the epigastric area or the back, possibly asymptomatic unless there is peritonitis, signs may not be discovered until 12 hours after the injury to the pancreas injuryd) abdominal pain, nausea and vomiting in intestinal injurye) The mechanism of blunt or sharp trauma injuries
Medical history:
- The tendency to hemorrhage- Allergy- Diseases of the liver / hepatomegaly with liver injury2) Objective dataPrimary DataA: Airway: No airway obstructionB: Breathing (respiratory): There is dyspnoea, use of accessory muscles of breathing and nasal flaring.C: Circulation (circulation): hypotension, bleeding, signs of "Bruit" (pd auscultation sounds abnormal blood vessels, usually pd carotid artery), Cullen sign, Grey-Turner sign, sign Coopernail, balance marks., Tachycardia, diaphoresisD: Disability (disability): pain, loss of consciousness, Kehr signSecondary dataE: Exposure: There is an injury (trauma blunt trauma atu sharp) on the abdominal area depending on where trauma
F: Five intervension / vital signs: Vital signs: hypotension, tachycardia, attach heart monitors, pulse oximetry, note the abnormal lab resultsLab results:
Complete blood count to look for abnormalities in the blood itself
Decrease in hematocrit / hemoglobin
Increased liver enzymes: alkaline phosphate, SGPT, SGOT,
Coagulation: PT, PTT
MRI
Angiography for possible damage to the hepatic vein
CT Scan
Chest radiographs indicate an increased diaphragm, the possibility of pneumothorax or rib fracture VIII-X.
Scan lymph
Ultrasonogram
Increased serum or urine amylase
Increased serum glucose
Increased serum lipase
DPL (+) for amylase
Improvements WBC
Increased serum amylase
Serum electrolytes
AGD
G: Give comfort (PQRST):a) Pain in RUQ, hypochondriac or epigastric region (injury to the liver),b) Pain in the left upper quadrant (LUQ), Kehr sign (pain in the left upper quadrant radiating to the left shoulder) on injured lymphaticc) Pain in the epigastric area or the back, possibly asymptomatic unless there is peritonitis, signs may not be discovered until 12 hours after the injury to the pancreas injuryd) Pain in the abdomenIts perceived acute pain occurs suddenly and can be caused by blunt trauma or sharp trauma.H: Head to toe:Inspection:- The existence of ecchymosis- The hematomaAuscultation:- Decrease / absence of bowel soundsPalpation:- Swelling in the abdomen- The spasms in abdomen- The future of the abdomen- TendernessPercussion:- Voice dullnessI: posterior surface Inspection: Assess if there is an injury to the spine (spinal)
Nursing Diagnosis
PK Bleeding
PK: Hypovolemic Shock
Acute pain b / d agent physical injury (trauma blunt / sharp) is characterized by pain, diaphoresis, dyspnea, tachycardia
Anxious b / d surgical procedures characterized by patient anxiety, fear, nervousness, trembling, tense face
Ineffective breathing pattern b / d of hyperventilation is characterized by tightness, dyspnea, use of accessory muscles of breathing, nasal breathing cupung
Damage to skin integrity b / d trauma sharp / blunt marked by a hematoma, ecchymosis, open wounds, injury to the abdomen
Risk of infection b / d bacterial invasion
Nursing Plan / EMERGENCY intervension
Dx 1: PK BleedingObjectives: After nursing care for 2 x 4 hours expected bleeding can be stopped / resolvedOutcomes:
Signs of bleeding (-)
Normal vital signs (pulse = 60-100 x / minute, BP = 110-140/70-90 mmHg; Temperature = 36, 5-37, 50 C, and RR = 16-24 x / min)
CRT <2 seconds
Akral warm
Intervention:Independent:1) Monitor the TTVIdentifying the patient's condition.2) Monitor signs of bleeding.Identify bleeding, helps in providing appropriate interventions.3) Monitor signs of circulation changes to the peripheral tissues (CRT and cyanosis).Knowing the adequacy of blood flow.Collaboration:1) Monitor the results of the laboratory (platelets).As an indicator of blood-clotting platelets.2) Collaboration of IV fluids (crystalloid fluid NS / RL) as indicated.Help meet the fluids in the body.3) Give the anticoagulant drug, ex: LMWH (Low molecule With Heparin).Prevent further bleeding.4) Give blood transfusion.Help meet the need for blood in the body.5) Perform surgery if necessary as indicatedHelp to stop the bleeding by covering the wound areaDx 2: Acute pain b / d agent physical injury (trauma blunt / sharp) is characterized by pain, diaporesis, dyspnea, tachycardiaObjective: After the action is done nursing for 2 x 10 min expected pain experienced by the patient controlledOutcomes:
Patients reported reduced pain
Patients seemed to relax
TTV within normal limits (TD 140-90/90-60 mmHg, pulse 60-100 x / min, RR: 16-24 x / min, temperature 36, 5-37, 50 C)
Patients can use the non-analgesic techniques for dealing with pain.
Intervention:Independent:
Assess pain comprehensively covers the location, characteristics, duration, frequency, quality, pain intensity and precipitation factors.
Influence the choice / control intervention effectiveness.
Evaluation of increased irritability, muscle tension, restlessness, changes in vital signs.
Non-verbal clues of pain or discomfort requiring intervention.
Provide comfort measures, such as changes in position, massage.
Alternative measures to control pain
Teach use of non-analgesic techniques (progressive relaxation, breathing exercises in, imagination visualization, therapeutic touch, acupressure)
Refocus attention, improve self-control and can improve muscle strength; may increase self-esteem and coping skills.
Provide a comfortable environment
Lower the pain stimulus.Collaboration:
Give medications as indicated: muscle relaxants, for example: dantren; analgesic
Needed to relieve spasm / muscle pain.Dx 3: Anxious b / d patient surgical procedures characterized by anxiety, fear, nervousness, trembling, tense faceObjective: Having given nursing care for 2 x 10 min expected decrease patient anxietyOutcomes:
Agitated patients reduced
Said scared and nervous reduced
Not appear shaky
Intervention:Independent:
Identification of the level of anxiety and the perception of clients such as fear and anxiety, and a sense of concern.
Assess the client's level of knowledge of the disaster facing surgery and treatment to be performed.
Give the client a chance to express his feelings.
Pay attention and answer all questions to help the client express his feelings.
Observation sign - a sign of anxiety both verbal and non-verbal.
Provide a description of any action in accordance with the procedure surgical preparation.
Give moral support and therapeutic touch.
Provide a description of the use of simple language and purpose of the surgical treatment such action to the clients and their families.
4 Dx: Ineffective breathing pattern b / d of hyperventilation is characterized by tightness, dyspnea, use of accessory muscles of breathing, nasal flaringObjectives: After askep for 1 x 10 minute expected effective breathing patterns of patients returningOutcomes:
Patients reported shortness reduced
Dyspnea (-)
The use of accessory muscles (-)
Nasal flaring (-)
Intervention:Independent:
Monitor the tightness or dyspnea
To determine the state of the patient breathing
Monitor respiratory effort, chest expansion, regularity of breathing, breath lobe and the use of accessory muscles
To determine the degree of disturbance, and determine appropriate interventions
Give semifowler position if there are no contraindications
To improve chest wall expansion
Teach clients a deep breath
To increase comfortCollaboration
Give O2 as indicated
To meet the needs of O2
Intubation if respiratory aids and prepare worsen ventilator mounting as indicated
To help breathing adequately4. EVALUATIONDx 1: Bleeding can be stopped / resolvedDx 2: Pain patient controlledDx 3: Anxious patients reducedDx 4: patient's breathing pattern back effectively
A. BASIC CONCEPT OF DISEASE
1. DEFINITION
· Trauma is an injury or involuntary or psychological or emotional harm (Dorland, 2002: 2111)
· Abdominal trauma is an injury to the abdomen, can be blunt and penetrating trauma and trauma intentional or unintentional (Smeltzer, 2001: 2476)
2. Etiology / FACTORS CAUSE
Based on the mechanism of trauma, divided into 2, namely:a) Blunt TraumaA direct blow, let the door hit the steering wheel or car parts are sinking into the collision, can cause compression trauma or crush injury to the viscera organs. It can damage solid organs and hollow organs, and can lead to rupture, especially distended organs (eg uterus of pregnant women), and resulted in bleeding and peritornitis. Trauma pull (shearing injury) to the viscera organ is actually a crush injury that occurs when a safety device (eg, type of seat belt lap belt or shoulder safety components) are not used properly. Patients who were injured in a motorcycle collision can occur traumatized decelerasi where unequal movement between the parts and the fixed to the moving parts, such as rupture or ruptured liver spleen (the organ that moves) ligamentnya section (which is fixed to the organ). Use of water-bag does not prevent people from experiencing abdominal trauma. In patients who undergo laparotomy because of blunt trauma, the organ that is most often subject to lien (40-55%), liver (35-45%), and colon (5-10%). In addition, 15% of them had retroperitoneal hematoma.b) sharp TraumaStab wound or gunshot wound (low speed) will cause tissue damage due to laceration or cut. Gunshot wound at high speed will cause the transfer of kinetic energy greater the viscera organ, with additional effects such as temporary cavitation, and can be broken into fragments that cause other damage. Puncture wounds of the common hepatic (40%), small bowel (30%), diaphragm (20%), and colon (15%). Gunshot wounds cause greater damage, which is determined by the bullet traveling away, and how much kinetic energy as well as the possibility of ricochets by bone organ, as well as the effect of the bone fragments. Gunshot wounds most commonly affects the small intestine (50%), colon (40%), liver (30%) and abdominal blood vessels (25%).(American College of Surgeons Committee of Trauma, 2004: 145)
3. SIGNS AND SYMPTOMS
- Lacerations, bruises, ecchymosis- Hypotension- Absence of bowel sounds- Hemoperitoneum- Nausea and vomiting- The sign "Bruit" (sounds abnormal vascular auscultation pd, pd usually carotid artery),- Pain- Bleeding- Impairment of consciousness- Shortness- Sign Kehrs is pain on the left side caused by bleeding limfa.Tanda there when the patient in recumbent position.- Mark Cullen was ecchymosis periumbulikal on peritoneal hemorrhage- Grey-Turner sign is ecchymosis on the side of the body (waist) in retroperitoneal bleeding.- Sign coopernail is ecchymosis of the perineum, scrotum or labia on pelvic fracture- Signs balance is blunt voice that settled the area in the upper left quadrant when performed percussion on lymph hematoma(Scheets, 2002: 277-278)
4. Pathophysiology and TREE PROBLEM
When an external force blasted on the human body (due to traffic accidents, assault, sporting accidents and falls from a height), then the severity of trauma is the result of interactions between factors - physical factors of the strength of the body's tissues. Severe trauma that occurred related to the ability of a static object (which bumped) to hold the body. Impact on the place because of the difference in the movement of the body tissues will cause tissue disruption. It is also characteristic of the surface of the body is also an important stop. Trauma is also dependent on the viscosity of elastitisitas and body tissues. Elasticity is the ability of the network to return to the previous state. Viscosity is the network's ability to maintain its original shape despite collision. Tolerance body withstand the impact depends on both the state .. Severity of the trauma that happens depends on how much force would be able to pass through the existing network resilience. Another component that must be considered in weighing trauma is the position of the body relative to the impact surface. This can occur intra-abdominal organ injury caused by several mechanisms:
Increased intra-abdominal pressure is sudden and severe by the compressive force from the outside like a clash of the steering wheel or seat belt that is located incorrectly can result in rupture of solid organ or hollow organ.
Intra-abdominal organ wedged between the anterior abdominal wall and the bone structure of the vertebrae or the thoracic wall.
Occur force sudden acceleration-deceleration force can cause torn on organ and vascular pedicle.
5. CLASSIFICATION
Based mechanism, namely:a) Blunt Trauma- Usually caused by motor vehicle accidents.- Other factors such as sudden falls and trauma- Results of crush injury and traumatic deceleration of the solid organs (due to bleeding) or intestine (due to perforation and peritonitis)- Lymph and the liver is the organ most frequently involvedb) sharp Trauma- Usually caused by stab, stab or gun shot.- It may be connected with the chest, diaphragm and retroperitoneal injuries in the system.- Liver and small intestine is the most common organ damage.- Puncture wound may be menenbus wall peritoneum and often damaging conservatively, however injuries from gun shots and investigation always requires surgery to control early intraperitoneal injury.
6. DIAGNOSTIC EXAMINATION / SUPPORT
Ø Diagnostic
a) Blunt Trauma
1. Diagnostic peritoneal lavage
DPL is invasive procedure that can be done quickly meaningful change plans for the next patient, and is considered 98% sensitive for bleeding intraretroperitoneal. Should be carried out by a surgical team for patients with multiple blunt trauma with abnormal hemodynamics, especially when encountered:
Changes in sensorium-trauma capitis, alcohol intoxication, drug addiction.
Changes in sensation spinal trauma
Injury to adjacent organs-lower ribs, pelvis, lumbar vertebra
Diagnostic tests are not clear
Predicted aka tone lost contact with the patient in a rather long time, anesthesia for extraabdominal injury, X-Ray examination of the old instance Angiography
The existence of lap-belt sign (abdominal wall contusion) with suspicion of bowel injury
DPL is also indicated in patients with normal hemodynamic values encountered something like the above and the facilities here are not memiliiki ultrasound or CT scan. One of the contraindications for DPL is a clear indication for laparotomy. The relative contraindications include previous abdominal surgery, morbid obesity, which further shirrosis, and the presence of coagulopathy before. Can be worn open or closed technique (Seldinger) in infraumbilikal by trained physicians. In patients with pelvic fractures or pregnant women, the better we do supraumbilikal to prevent pelvic hematoma or endanger the enlarged uterus. The presence of fresh blood aspiration, gastrointestinal contents, vegetable fiber or bile coming out, through the tube DPL in patients with abnormal henodinamik show strong indications for laparotomy. If there is no fresh blood (> 10 cc) or liquid stool, carried 1000cc lavage with Ringer Lactate (in children 10cc/kg). After the mixed liquid by pressing or doing Rogg-oll, fluids are recovered and examined in the laboratory for gastrointestinal contents, fiber and bile. (American College of Surgeons Committee of Trauma, 2004: 149-150)Test (+) in blunt trauma when 10 ml or more of blood macroscopic (gross) at the initial aspiration, erythrocytes> 100,000 mm3, leukocytes> 500/mm3 or painting gram (+) for bacteria, bacteria or fiber. Whereas when DPL (+) on the sharp trauma when 10 ml or more of blood macroscopic (gross) at the initial aspiration, the red blood cells 5000/mm3 or more. (Scheets, 2002: 279-280)
2. FAST (Focused Assessment Sonography in Trauma)
Individuals who are well trained to use ultrasound to detect the presence of hemoperitoneum. With the specialized equipment in the hands of those who are experienced, ultrasound possess sensitivity, acuity for meneteksi specifitas and intra-abdominal fluid is proportional to the DPL and CT Abdominal Ultrasound provides proper way, noninvansive, accurate and inexpensive to detect hemoperitorium, and can be repeated at any time. Ultrasound can be used as a bedside diagnostic tool dikamar resuscitation, that simultaneously with the execution of several other therapeutic and diagnostic procedures. Use the same indication with indication of DPL. (American College of Surgeons Committee of Trauma, 2004: 150)3. Computed Tomography (CT)Used to obtain information regarding organ damage and the level of damage, and also to diagnose pelvic trauma or difficult retroperineal diagnosed with a physical exam, FAST, or DPL. (American College of Surgeons Committee of Trauma, 2004: 151)b) Sharp Trauma
Lower thorax injuries
For asymptomatic patients with suspicion on the diaphragm and upper abdominal structures required physical examination and photographs over the thorax, thoracoskopi, laparoscopy or CT scan.
Local wound exploration and DPL serial examinations compared to the front abdominal stab wounds. For patients who are relatively asymptomatic (except for pain due to a puncture), an option that is not invasive diagnostic examination is a diagnostic examination series within 24 hours, MPAs and diagnostic laroskopi.
Physical examination diagnostic serial compared to double or triple contrast in the flank or back injury
For asymptomatic patients no diagnostic options include serial physical examinations, CT with contrast double or triple, or DPL. With serial diagnostic examination for patients who are initially asymptomatic became symptomatic, we get the sharpness especially in detecting and intraperineal retroperinel injury to the anterior wound behind linea axillaries. (American College of Surgeons Committee of Trauma, 2004: 151)
Radiological examination
1. X-Ray examination for screening of blunt trauma
X-rays for screening is Ro-photograph lateral cervical, thorax and pelvis AP AP in patients with blunt trauma multitrauma. Abdominal x-ray photograph three positions (supine, semi-erect and lateral decubitus) is useful to see free air under the diaphragm or the air outside diretroperitoneum lumen, which if there is a hint for the second laparotomy performed. Suggests the possibility of the loss of the psoas shadow retroperitoneal injury
2. X-Ray examination for screening sharp trauma
Patients with stab wounds do not require abnormal hemodynamic X-ray examination in patients with stab wounds above the umbilicus or suspected thoracoabdominal injuries with abnormal hemodynamics, upright chest x-ray photo useful to rule out the possibility of hemo or pneumothorax, or for documentation of intraperitoneal free air. In patients who hemodinamiknya normal, mounting clips on entry and exit wound from a gunshot wound to show the course of the bullet and the retroperitoneal air on abdominal x-ray photograph sleep.
3. Examination with special contrast
Urethrografi
As previously mentioned, must be performed before catheter urine urethrografi if we suspect a ruptured urethra. Examination urethrografi used with catheters no. # 8-F balloon pumped with 1.5-2cc in naviculare fossa. Entered 15-20 cc of diluted contrast. Done taking pictures with oblique projection with a little pull on the pelvis.
Sistografi
Bladder rupture intra-or extraperitoneal best determined by examination or CT-Scan sistografi sistografi. Catheter, urethra and then mounted 300 cc water-soluble contrast in kolf as high as 40 cm above the patient and allowed contrast flow into the plume or until (1) the flow stops (2) patients spontaneously straining, or (3) the patient felt sick. X-rays taken AP, oblique and post-voiding photo. Another way is with a CT Scan (CT cystogram) is particularly useful to obtain additional information about the kidneys and pelvis. (American College of Surgeons Committee of Trauma, 2004: 148)
CT Scan / IVP
Whenever there is a CT Scan facility, then all patients with hematuria and suspected hemodynamically stable urinary system can be examined by CT scan with contrast and can set the degree of kidney injury. When there is no CT Scan facility, the alternative is IVP examination.Here I use A dose of 200mg / kg bw kidney contrast. Do bolus injection of 100 cc solution Jodine 60% (standard 1.5 cc / kg, 30% if used 3.0 cc / kg) with 2 pieces of 50 cc syringe is injected in 30-60 seconds. 20 min after injection when will acquire visualization calyx on X-Ray. When one side of the non-visualization, chances are renal agenesis, thrombosis and rupture a.renalis interested, or parenchyma which suffered massive damage. Nonvisualisasi both require further investigation with CT Scan + contrast, or renal arteriography or renal exploration; whichever is taken depending on the facilities they have.
Gastrointestinal
Injury to gastrointestinal structure that is located retroperitoneal (duodenum, ascending colon, colon descendens) will not cause peritonitis and can not be detected by DPL. Whenever there is suspicion, examination with CT scan with contrast or RO-examination of the upper GI track for photo-and lower GI tract with contrast should be performed.(American College of Surgeons Committee of Trauma, 2004:149)
Laboratory examination
Complete blood count to look for abnormalities in the blood itself
Decrease in hematocrit / hemoglobin
Increased liver enzymes: alkaline phosphate, SGPT, SGOT,
Coagulation: PT, PTT
MRI
Angiography for possible damage to the hepatic vein
CT Scan
Chest radiographs indicate an increased diaphragm, the possibility of pneumothorax or rib fracture VIII-X.
Scan lymph
Ultrasonogram
Increased serum or urine amylase
Increased serum glucose
Increased serum lipase
DPL (+) for amylase
Improvements WBC
Increased serum amylase
Serum electrolytes
AGD
(,2000:49 ENA-55)
7. COMPLICATIONS
Venous Thrombosis
Pulmonary embolism
Stress ulceration and bleeding
Pneumonia
Pressure ulceration
Atelectasis
Sepsis
(Paul, revised on July 28, 2008)
Pancreas: Pancreatitis, Pseudocyta formation, pancreatic-duodenal fistula, and bleeding.
Spleen: changes in mental status, tachycardia, hypotension, cold akral, diaphoresis, and shock.
Intestine: intestinal obstruction, peritonitis, sepsis, necrotic bowel, and shock.
Kidney: Acute renal failure (ARF)
(Catherino, 2003: 251-253)
8. TREATMENT AND THERAPY MANAGEMENT emergency
- Patients who are unstable or patients with obvious signs of trauma indicating intra-abdominal (peritoneal examination, injury diaphragm, abdominal free water, evisceration) should be immediately performed surgery- Blunt trauma must be observed and has managed the non-operative based on clinical status and degree of injury seen on CT- Provision of analgesic drugs as indicated- Provision of O2 as indicated- Perform ETT intubation for installation if needed- Trauma penetration:ü Do surgery under the above indicationsü Most GSW require surgery depending on the depth of penetration and engagement intraperitonealü stab wound can be explored locally in the ED (under sterile conditions) to demonstrate peritoneal disorders; when the peritoneum intact, the patient can be sewn and issuedü stab wound with intraperitoneal injury requiring surgeryü The outside of the body support must be cleaned or removed by surgery(Catherino, 2003: 251)
B. Nursing care BASIC CONCEPTS
1. ASSESSMENT
1) Subjective Data
History of present illness:
a) Pain in RUQ, hypochondriac or epigastric region (injury to the liver)b) Pain in the left upper quadrant (LUQ), Kehr sign (pain in the left upper quadrant radiating to the left shoulder) on injured lymphaticc) Pain in the epigastric area or the back, possibly asymptomatic unless there is peritonitis, signs may not be discovered until 12 hours after the injury to the pancreas injuryd) abdominal pain, nausea and vomiting in intestinal injurye) The mechanism of blunt or sharp trauma injuries
Medical history:
- The tendency to hemorrhage- Allergy- Diseases of the liver / hepatomegaly with liver injury2) Objective dataPrimary DataA: Airway: No airway obstructionB: Breathing (respiratory): There is dyspnoea, use of accessory muscles of breathing and nasal flaring.C: Circulation (circulation): hypotension, bleeding, signs of "Bruit" (pd auscultation sounds abnormal blood vessels, usually pd carotid artery), Cullen sign, Grey-Turner sign, sign Coopernail, balance marks., Tachycardia, diaphoresisD: Disability (disability): pain, loss of consciousness, Kehr signSecondary dataE: Exposure: There is an injury (trauma blunt trauma atu sharp) on the abdominal area depending on where trauma
F: Five intervension / vital signs: Vital signs: hypotension, tachycardia, attach heart monitors, pulse oximetry, note the abnormal lab resultsLab results:
Complete blood count to look for abnormalities in the blood itself
Decrease in hematocrit / hemoglobin
Increased liver enzymes: alkaline phosphate, SGPT, SGOT,
Coagulation: PT, PTT
MRI
Angiography for possible damage to the hepatic vein
CT Scan
Chest radiographs indicate an increased diaphragm, the possibility of pneumothorax or rib fracture VIII-X.
Scan lymph
Ultrasonogram
Increased serum or urine amylase
Increased serum glucose
Increased serum lipase
DPL (+) for amylase
Improvements WBC
Increased serum amylase
Serum electrolytes
AGD
G: Give comfort (PQRST):a) Pain in RUQ, hypochondriac or epigastric region (injury to the liver),b) Pain in the left upper quadrant (LUQ), Kehr sign (pain in the left upper quadrant radiating to the left shoulder) on injured lymphaticc) Pain in the epigastric area or the back, possibly asymptomatic unless there is peritonitis, signs may not be discovered until 12 hours after the injury to the pancreas injuryd) Pain in the abdomenIts perceived acute pain occurs suddenly and can be caused by blunt trauma or sharp trauma.H: Head to toe:Inspection:- The existence of ecchymosis- The hematomaAuscultation:- Decrease / absence of bowel soundsPalpation:- Swelling in the abdomen- The spasms in abdomen- The future of the abdomen- TendernessPercussion:- Voice dullnessI: posterior surface Inspection: Assess if there is an injury to the spine (spinal)
Nursing Diagnosis
PK Bleeding
PK: Hypovolemic Shock
Acute pain b / d agent physical injury (trauma blunt / sharp) is characterized by pain, diaphoresis, dyspnea, tachycardia
Anxious b / d surgical procedures characterized by patient anxiety, fear, nervousness, trembling, tense face
Ineffective breathing pattern b / d of hyperventilation is characterized by tightness, dyspnea, use of accessory muscles of breathing, nasal breathing cupung
Damage to skin integrity b / d trauma sharp / blunt marked by a hematoma, ecchymosis, open wounds, injury to the abdomen
Risk of infection b / d bacterial invasion
Nursing Plan / EMERGENCY intervension
Dx 1: PK BleedingObjectives: After nursing care for 2 x 4 hours expected bleeding can be stopped / resolvedOutcomes:
Signs of bleeding (-)
Normal vital signs (pulse = 60-100 x / minute, BP = 110-140/70-90 mmHg; Temperature = 36, 5-37, 50 C, and RR = 16-24 x / min)
CRT <2 seconds
Akral warm
Intervention:Independent:1) Monitor the TTVIdentifying the patient's condition.2) Monitor signs of bleeding.Identify bleeding, helps in providing appropriate interventions.3) Monitor signs of circulation changes to the peripheral tissues (CRT and cyanosis).Knowing the adequacy of blood flow.Collaboration:1) Monitor the results of the laboratory (platelets).As an indicator of blood-clotting platelets.2) Collaboration of IV fluids (crystalloid fluid NS / RL) as indicated.Help meet the fluids in the body.3) Give the anticoagulant drug, ex: LMWH (Low molecule With Heparin).Prevent further bleeding.4) Give blood transfusion.Help meet the need for blood in the body.5) Perform surgery if necessary as indicatedHelp to stop the bleeding by covering the wound areaDx 2: Acute pain b / d agent physical injury (trauma blunt / sharp) is characterized by pain, diaporesis, dyspnea, tachycardiaObjective: After the action is done nursing for 2 x 10 min expected pain experienced by the patient controlledOutcomes:
Patients reported reduced pain
Patients seemed to relax
TTV within normal limits (TD 140-90/90-60 mmHg, pulse 60-100 x / min, RR: 16-24 x / min, temperature 36, 5-37, 50 C)
Patients can use the non-analgesic techniques for dealing with pain.
Intervention:Independent:
Assess pain comprehensively covers the location, characteristics, duration, frequency, quality, pain intensity and precipitation factors.
Influence the choice / control intervention effectiveness.
Evaluation of increased irritability, muscle tension, restlessness, changes in vital signs.
Non-verbal clues of pain or discomfort requiring intervention.
Provide comfort measures, such as changes in position, massage.
Alternative measures to control pain
Teach use of non-analgesic techniques (progressive relaxation, breathing exercises in, imagination visualization, therapeutic touch, acupressure)
Refocus attention, improve self-control and can improve muscle strength; may increase self-esteem and coping skills.
Provide a comfortable environment
Lower the pain stimulus.Collaboration:
Give medications as indicated: muscle relaxants, for example: dantren; analgesic
Needed to relieve spasm / muscle pain.Dx 3: Anxious b / d patient surgical procedures characterized by anxiety, fear, nervousness, trembling, tense faceObjective: Having given nursing care for 2 x 10 min expected decrease patient anxietyOutcomes:
Agitated patients reduced
Said scared and nervous reduced
Not appear shaky
Intervention:Independent:
Identification of the level of anxiety and the perception of clients such as fear and anxiety, and a sense of concern.
Assess the client's level of knowledge of the disaster facing surgery and treatment to be performed.
Give the client a chance to express his feelings.
Pay attention and answer all questions to help the client express his feelings.
Observation sign - a sign of anxiety both verbal and non-verbal.
Provide a description of any action in accordance with the procedure surgical preparation.
Give moral support and therapeutic touch.
Provide a description of the use of simple language and purpose of the surgical treatment such action to the clients and their families.
4 Dx: Ineffective breathing pattern b / d of hyperventilation is characterized by tightness, dyspnea, use of accessory muscles of breathing, nasal flaringObjectives: After askep for 1 x 10 minute expected effective breathing patterns of patients returningOutcomes:
Patients reported shortness reduced
Dyspnea (-)
The use of accessory muscles (-)
Nasal flaring (-)
Intervention:Independent:
Monitor the tightness or dyspnea
To determine the state of the patient breathing
Monitor respiratory effort, chest expansion, regularity of breathing, breath lobe and the use of accessory muscles
To determine the degree of disturbance, and determine appropriate interventions
Give semifowler position if there are no contraindications
To improve chest wall expansion
Teach clients a deep breath
To increase comfortCollaboration
Give O2 as indicated
To meet the needs of O2
Intubation if respiratory aids and prepare worsen ventilator mounting as indicated
To help breathing adequately4. EVALUATIONDx 1: Bleeding can be stopped / resolvedDx 2: Pain patient controlledDx 3: Anxious patients reducedDx 4: patient's breathing pattern back effectively
