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CASE STUDY- ABDOMINAL BLUNT INJURY

CASE STUDY- ABDOMINAL BLUNT INJURY

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Published by: Elrex Belino on Apr 10, 2011
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01/17/2015

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I.

INTRODUCTION

Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups. Identification of serious intra-abdominal pathology is often challenging. Many injuries may not manifest during the initial assessment and treatment period. Mechanisms of injury often result in other associated injuries that may divert the physician's attention from potentially life-threatening intra-abdominal pathology. The most common causes of blunt abdominal trauma are from motor vehicle accidents and automobile-pedestrian accidents. In a large review of operating room deaths in which blunt trauma accounted for 61% of all injuries, abdominal trauma was the primary identified cause of death in 53.4% of cases. Most studies indicate that peak incidence occurs in persons aged 14-30 years. A review of 19,261 patients with blunt abdominal trauma revealed equal incidence of hollow viscus injuries in both children and adults.

RATIONALE LEARNING OBJECTIVES a. Cognitive


To acquire knowledge about abdominal blunt injury To identify the risk factors that have been linked to this health problem, the signs and symptoms, and its clinical manifestations

To determine the previous and present clinical history of the patient and its relation to present illness.

b. Psychomotor • To practice the chosen profession by means of knowing the patient’s condition To provide proper nursing management and reinforcement with regards this condition • To use the appropriate nursing process for effectiveness and achievement of nursing care c. Behavioral

Ariel Tria. 1987 Lumangbayan. San Teodoro Single Filipino Catholic August 12.M. San Teodoro (8). 2010. d. its effect to every individual.S.D. .• To acquire positive attitude about abdominal blunt injury. 2010 1:40 PM Gastric Perforation R to Blunt Abdominal Injury Admission Diagnosis: R/O Blunt Abdominal Injury Principal Operation Procedure: Exploratory Laparotomy. CLINICAL SUMMARY a. Gastrorrhaphy Admitting Physician: Dr. M. its manifestations. HISTORY OF PRESENT ILLNESS Prior to confinement the patient was riding on his motorcycle when stumbled hitting a wall in Lumangbayan. and appropriate nursing actions and interventions • To be able to interact to the patient with rapport and therapeutic communication II. San Teodoro at 11:10 am on August 12. CHIEF COMPLAINT His chief complaint is abdominal pain. necessary treatment. b. Oriental Mindoro September 2. 81233 22 y/o Male Lumangbayan. GENERAL DATA Name: Hospital number: Age: Gender: Address: B-day: B-place: Civil status: Nationality: Religion: Date of admission: Time of admission: Principal Diagnosis: B.

e. PHYSICAL ASSESSMENT A. HEAD-TO-TOE ASSESSMENT DATE: BP: mmHg PR: bpm RR: cpm T: AREAS ASSESS °C TECHNIQUE USED NORMAL FINDINGS SIGNIFICANT FINDINGS ANALYSIS AND INTERPRETATION . f. PR bpm. and BP: mmHg. PAST MEDICAL HISTORY According to the patient. III. GENERAL APPEARANCE The patient was conscious.Admission vital signs at OMPH were as follows: T: °C. Lying on bed wearing maroon shorts and maroon jersey with IVF of D5LR 1L at 250cc level regulated at 24gtts/min inserted at left metacarpal vein with Jackson Pratz drain inserted to right connected to one way bottle. RR: cpm. FAMILY HISTORY g. he was admitted when he was 15 years of age at Oriental Mindoro Provincial Hospital with a health problem of pneumonia.

Face is soft.SKIN Inspection. Head should be free from scalp flaking. Eyelashes are evenly distributed and direction of curl is upwards Has the ability to blink. and Pigmentation of the skin. NAILS Inspection Blanch test Capillary refill 3 seconds. should have proper distribution of hair with healthy hair. Skin return To shape when pinched. Skin color varies depending on race. Corneal Facial grimacing is a sign of physiological response. palpation EYE STRUCTURE AND VISUAL CAPACITY Inspection Pale conjunctiva Significant sign of low blood that affects tissue perfusions . Poor arterial circulation SKULL AND FACE Inspection. Capillary Refill 2 seconds Symmetrical in size and shape. nutrition. roughing and crackling of skin HEAD Inspection Can accommodate facial expression with no lesion. roughed. Corneas are brownish. sun exposure. Palpation Intact. Normal cephalic Drying. Nails are smooth. and Crackled. Pale complexion of skin Dry skin Due to decrease oxygenation Poor hygiene Moist. smooth Dry. no nodules should not be palpated Eyebrows hair are evenly distributed and aligned.

EARS AND HEARING Inspection. can identify different smell or odor. No lesions. TEETH AND GUMS TONGUE/FL OOR OF THE MOUTH Inspection Teeth and gums are complete and aligned well. patent nostril. Palpation sensitivity has a good reflex. tenderness. Decibels test. Palpation Buccal mucosa is pale Indication of poor oral hygiene. Both ears have no inflammation. No tenderness palpated. Ears are symmetrical size and position. Tongue is pinkish and has a maximum range of movement. with maximum head . No signs of tenderness Ears are not obstructed and glossy Can perceive high pitch and low pitch sounds No tenderness on the outer ear No septal deviation. NOSE AND SINUSES Inspection MOUTH Inspection. No signs of redness or swelling Teeth are not properly aligned. Inner lips and buccal mucosa are pinkish and moist. palpation No palpable mass or nodules. Ears can perceive high pitch and low pitch sounds. NECK Inspection. in midline. Pupils equally round reactive to light and accommodation.

Thyroid glands are symmetrical and no enlargement. smooth. POSTERIOR THORAX Inspection Centrally located. rhythmic and effortless respiration Full symmetric excursion Normal breath sounds Symmetrical No chest pain Inspection Palpation Auscultation Symmetric Apical pulse present with a rate of 89 bpm HEART Auscultation Lubb dub sound was auscultated Heart rate must be 60-100. Lubbdubb sound was auscultated Heart rate is 83 bpm. full and symmetric chest expansion Normal breath sounds Quiet. masses or nodules. Normal Normal BREAST AND Inspection. painless Centrally located and rise freely with swallowing Normal Inspection Palpation Auscultation B. No palpable lymph nodes. No murmurs and abnormal sounds. Not palpable Not palpable Normal Inspection At midline At midline Normal CRICOTHYR OID CARTILLAG E THORAX A.LYMPHNOD ES TRACHEA Inspection movement and good muscle strength. ANTERIOR THORAX Chest symmetric Skin intact. Palpation Symmetric and equal in size and Normal .

3 seconds. globular No lesion. His body temperature is 37. He has a pale complexion of skin. rough and crackled.5° C. complete. BP 90/60 mmHg. REVIEW OF SYSTEMS LEVEL INTEGUMENTARY SYSTEM FINDINGS His skin was dry. Palpation Inspection. Respiratory rate was 15 cpm. inflammation and swelling. nontender. Capillary refill . Normal B. RESPIRATORY SYSTEM CARDIOVASCULAR SYSTEM .83 bpm. soft. Radial pulse . swelling. Limbs are complete.AXILLAE shape No palpable tenderness masses or nodules ABDOMEN UPPER AND LOWER EXTREMITIE S Inspection. Palpation Flat. No lesion. Good peripheral pulses Normal Have good reflex. Apical pulse .62 bpm. Chest wall symmetrical in expansion. inflammations. Good peripheral pulses are palpated.

meat. Whenever he feels pain or slight weakness he endures it and consults a doctor if it’s too much body weakness with dizziness. All joints function. His usual breakfast is bread and milk. he complains of body weakness. During hospitalization The patient stated that for him. IV. He has loss of appetite but eats ¼ of the foods serve by the dietary service which is usually rice. He masturbates once a day and three times a week.GASTROINTESTINAL/DIGESTIVE SYSTEM GENITOREPRODUCTIVE SYSTEM MUSCULOSKELETAL SYSTEM NEUROLOGIC SYSTEM He has a normal bowel sounds with irregular gargling noises with a rate of 10/secs. He stated that he would cooperate and pursue just to get well. He would also pray and pray until he gets well. He doesn’t eat vegetables. inihaw and street foods. He can answer questions related to her condition and can recall other matters regarding him. coherent and well oriented to time and place. No reports of pain in his sexual organ. The client was thin. 2010 Health perception/ Health management Prior to hospitalization The patient perceived that he is healthy when he is not ill. fish and vegetables. He is sexually active. His appetizer was . While his meal for lunch and dinner is always rice. health is when a person has no any kind of illness and he can do his daily activities well. FUNCTIONAL ASSESSMENT DATE: July 16. The patient was conscious. Nutrition/metabolism He was able to eat 3 times a day.

He usually lies and sits on his bed. As a teenager his daily activities are playing basketball 1 to 2 hours per day with his friends. He has more time of sleep during hospitalization than the ordinary days. Cognitive/ Perceptual Still. He didn’t experience any kind of mental illness. His answers were direct to the point. He is the only child of his parents. It has a noxious odor and black color. He wasn’t able to do his usual activities. He drinks 5-7 glasses of water a day. His mental ability is in good condition. He hasn’t experience any kind of mental illness. He takes a little walk whenever he feels boredom. He has a good pattern of urination. The black stool turns into yellowish one and with normal odor. washing the dishes and cooking. He is responsible by helping his parents in doing household chores like cleaning surroundings. date and place. He has no memory gap or no memory loss. Whenever he experiences Activity and Exercise He defecates once a day. He loves soda. He masturbates twice a week. He has no memory gap or memory loss. He sleeps at 7 in the evening and wakes up at seven in the morning. His illness makes him sad . He spent 8-10 hours of sleep. He has a good pattern of urination. date and place. He was also an alcoholic drinker approximately 1 bottle of gin occasionally. He usually sleeps at 10 or 11 o’ clock in the evening and wakes up at 8 or 9 o’ clock in the morning.Elimination banana cue. He was circumcised when he was in the 4th grade. He was still oriented with time. He also considers this as an exercise pattern. Sleep/Rest pattern Role/relationship pattern Sexuality/ reproductive Coping/Stress He never experienced coitus. salty foods and junk foods. He has a normal pattern of defecation. He naps at day time for an hour. He was a cigarette smoker two years ago with an estimated 2 packs per week. He voids 5-6 times at an estimated amount of half of an 8 oz. He is sexually active. He watches television during vacant hours. He thinks that he is a burden to his family. He’s oriented with the time. glass per voiding. He voids daily 5-6 times at an estimated amount of half glass per voiding.

because he and his family had to sacrifice lots of things just to make him well. He goes to church occasionally with his family.Tolerance Values and Beliefs emotional problems he chooses to keep quiet instead of sharing it with somebody because it makes him feel more comfortable. . The patient prays for his early recovery.

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