Abdominal trauma accounts for approximately 15% of all trauma-related deaths. Intra-abdominal trauma is usually not a single organ system injury; as more organs are injured, the risks of organ dysfunction and death climb. The abdominal cavity contains solid, gas-filled, fluid-filled, and encapsulated organs. These organs are at greater risk for injury than are other organs of the body because they have few bony structures to protect them. Although the last five ribs serve as some protection, if they are fractured, the sharp-edged bony fragments can cause further organ damage from lacerations or organ penetration.
Abdominal trauma can be blunt or penetrating. Blunt injuries occur when there is no break in the skin; they often occur as multiple injuries. In blunt injuries, the spleen and liver are the most commonly injured organs. Injury occurs from compression, concussive forces that cause tears and hematomas to the solid organs such as the liver, and deceleration forces. These forces can also cause hollow organs such as the small intestines to deform; if the intraluminal pressure of hollow organs increases as they deform, the organ may rupture. Deceleration forces such as those that occur from a sudden stop in a car or truck may also cause stretching and tears along ligaments that support or connect organs, resulting in bleeding and organ damage. Examples of deceleration injuries include hepatic tears along the legamentum teres (round ligament that is the fibrous remnant of the left umbilical vein of the fetus, originates at the umbilicus, and may attach to the inferior margin of the liver), damage to the renal artery intima, and mesenteric tears of the bowel.
Penetrating injuries are those associated with foreign bodies set into motion. The foreign object penetrates the organ and dissipates energy into the organ and surrounding areas. The most commonly involved abdominal organs with penetrating trauma include the intestines, liver, and spleen. Complications following abdominal trauma include profuse bleeding from aortic dissection or other vascular structures, hemorrhagic shock, peritonitis, abscess formation, septic shock, paralytic ileus, ischemic bowel syndrome, acute renal failure, liver failure, adult respiratory
distress syndrome, disseminated intravascular coagulation, and death.
At least half of the cases of blunt abdominal trauma are caused by motor vehicle crashes (MVCs). These injuries are often associated with head and chest injuries as well. Other causes of blunt injury include falls, aggravated assaults, and contact sports. Penetrating injuries can occur from gunshot wounds, stab wounds, or impalements.
Nursing care plan assessment and physical examination
For patients who have experienced abdominal trauma, establish a history of the mechanism of injury by including a detailed report from the pre-hospital professionals, witnesses, or significant others. AMPLE is a useful mnemonic in trauma assessment: Allergies; Medications; Past medical history; Last meal; Events leading to presentation. Information regarding the type of trauma (blunt or penetrating) is helpful. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient was restrained, the patient’s position in the vehicle, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine whether the patient was wearing a helmet. In cases of traumatic injuries from falls, determine the point of impact, the distance of the fall, and the type of landing surface. If the patient has been shot, ask the paramedics or police for ballistics information, including the caliber of the weapon and the range at which the person was shot.
The patient’s appearance may range from anxious but healthy to critically injured with a full cardiopulmonary arrest. If the patient is hemorrhaging from a critical abdominal injury, he or she may be profoundly hypotensive with the symptoms of hypovolemic shock. The initial evaluation or primary survey of the trauma patient is centered on assessing the airway, breathing, circulation, disability (neurological status), and exposure (by completely undressing the patient). Lifesaving interventions may accompany assessments made during the primary survey in the presence of life- and limb-threatening injuries. The primary survey is followed by a secondary survey, a thorough head-to-toe assessment of all organ systems. The assessment of the injured patient should be systematic, constant, and with re-evaluation.
When you inspect the patient’s abdomen, note any disruption from the normal appearance such as distension, lacerations, ecchymoses, and penetrating wounds. Inspect for any signs of obvious bleeding such as ecchymoses around the umbilicus (Cullen sign) or over the left upper quadrant, which may occur with a ruptured spleen (although these signs usually take several hours to develop). Note that Grey-Turner’s sign, bruising of the flank area, may indicate retroperitoneal bleeding. Inspect the perineum for accompanying urinary tract injuries that may lead to bleeding from the urinary meatus, vagina, and rectum. If the patient is obviously pregnant, determine the fetal age and monitor the patient for premature labor.
Auscultate all four abdominal quadrants for 2 minutes per quadrant to determine the presence of bowel sounds. Although the absence of bowel sounds can indicate underlying bleeding, their absence does not always indicate injury. Bowel sounds heard in the chest cavity may indicate a tear in the diaphragm. Trauma to the large abdominal blood vessels may lead to a friction rub or bruit. Bradycardia may indicate the presence of free intraperitoneal blood. Percussion of the abdomen identifies air, fluid, or tissue intra-abdominally. Air-filled spaces produce tympanic sounds as heard over the stomach. Abnormal hyper-resonance can indicate free air; abnormal dullness may indicate bleeding. When you palpate the abdomen and flanks, note any increase in tenderness that can be indicative of an underlying injury. Note any masses, rigidity, pain, and guarding. Kehr’s sign—radiating pain to the left shoulder when you palpate the left upper quadrant—is associated with injury to the spleen. Palpate the pelvis for injury.
Changes in lifestyle may be required, depending on the type of injury. Large incisions and scars may be present. If injury to the colon has occurred, a colostomy, whether temporary or permanent, alters the patient’s body image and lifestyle. The sudden alteration in comfort, potential body image changes, and possible impaired functioning of vital organ systems can often be overwhelming and lead to maladaptive coping.
Nursing care plan primary nursing diagnosis: Ineffective breathing pattern related to pain and abdominal distension.
Nursing care plan intervention and treatment plan
The initial care of the patient with abdominal trauma follows the ABCs of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion include the establishment of an effective airway and a supplemental oxygen source, support of breathing, control of the source of blood loss, and replacement of intravascular volume. Titrate intravenous fluids to maintain a systolic blood pressure of 100 mm Hg; over-aggressive fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.
Surgical intervention is needed for specific injuries to organs. Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years. Esophageal injury is often managed with gastric decompression with a nasogastric tube, antibiotic therapy, and surgical repair of the esophageal tear. Gastric injury is managed similarly to esophageal injury, although a partial gastrectomy may be needed if extensive injury has occurred. Liver injury may be managed nonoperatively or operatively, depending on the degree of injury and the amount of bleeding. Patients with liver injury are apt to experience problems with albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation, resistance to infection, and nutritional balance. Management of injuries to the spleen depends on the patient’s age, stability, associated injuries, and type of splenic injury. Because removal of the spleen places the patient at risk for immune compromise, splenectomy is the treatment of choice only when the spleen is totally separated from the blood supply, when the patient is markedly hemodynamically unstable, or when the spleen is totally macerated. Treatment of pancreatic injury depends on the degree of pancreatic damage, but drainage of the area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage from pancreatic enzymes. Small- and largebowel perforation or lacerations are managed by surgical exploration and repair. Preoperative and postoperative antibiotics are administered to prevent sepsis.
Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to eliminate gastrointestinal feedings for extended periods of time, depending on the injury and the surgical intervention required. Total parenteral nutrition may be used to provide nutritional requirements.
The most important priority is the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. Be prepared to assist with endotracheal intubation and mechanical ventilation by maintaining an intubation tray within immediate reach at all times. Maintain a working endotracheal suction at the bedside as well. If the patient is hemodynamically stable, position the patient for full lung expansion, usually in the semi-Fowler position with the arms elevated on pillows. If the cervical spine is at risk after an injury, maintain the body alignment and prevent flexion and extension by using a cervical collar or other strategy as dictated by trauma service protocol.
The nurse is the key to providing adequate pain control. Encourage the patient to describe and rate the pain on a scale of 1 through 10 to help you evaluate whether the pain is being controlled successfully. Consider using nonpharmacologic strategies, such as diversionary activities or massage, to manage pain as an adjunct to analgesia.
Emotional support of the patient and family is also a key nursing intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the ABCs, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives and keep them updated as to the patient’s response to therapy. Notify the physician if the family needs to speak to her or him about the patient’s progress. If blood component therapy is essential to manage bleeding, answer the
patient’s and family’s questions about the risks of hepatitis and human immunodeficiency virus
Nursing care plan discharge and home health care guidelines
Provide a complete explanation of all emergency treatments and answer the patient’s and family’s questions. Explain the possibility of complications to recovery, such as poor wound healing, infection, and bleeding. Explain the risks of blood transfusions, and answer any questions about exposure to blood-borne infections. If needed, provide information about any follow-up laboratory procedures that might be required after discharge. Provide the dates and times that the patient is to receive follow-up care with the primary healthcare provider or the trauma clinic. Give the patient a phone number to call with questions or concerns. Provide information on how to manage any drainage systems, colostomy, intravenous therapies, or surgical wounds.