C
E
1.5
ANCC/AACN
Abdominal
Downloaded from https://journals.lww.com/nursing by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FRWkQAwAvKUd/7pC7mas8C3iDwGw1L073UhREQRD5sg= on 03/16/2020
CONTACT
HOURS
Hidden in the abdomen, life-threatening injuries can elude
detection. Find out how to evaluate your patient’s condition
and prevent further harm.
BY CYNTHIA BLANK-REID, RN, CEN, MSN
OFTEN INVOLVING multiple
injuries, abdominal trauma can
lead to hemorrhage, hypovolemic
shock, and death. Yet even a seri-
ous, life-threatening abdominal
injury may not cause obvious signs
and symptoms, especially in cases
of blunt trauma.
To detect ominous changes in a
patient’s condition, you need to
perform frequent, ongoing assess-
ments and interpret your findings
correctly. Key responses to decrease
mortality and morbidity include
aggressive resuscitation efforts,
adequate volume replacement,
early diagnosis of injuries, and sur-
gical intervention if warranted.
Setting priorities
As always, your primary priorities
are to maintain the patient’s airway,
breathing, and circulation. Next,
perform a rapid neurologic exami-
nation and assess him head to toe
to identify obvious injuries and
signs of prolonged exposure to
heat or cold. Ask the patient (or
his family, emergency personnel, or
bystanders) about his history—
allergies, medications, preexisting
medical conditions, when he last
ate, and events immediately pre-
ceding or related to his injury.
36 Nursing2004, Volume 34, Number 9
If your patient sustained blunt
trauma, as in a motor vehicle crash
(MVC), keep his neck and spine
immobilized until X-rays rule out a
spinal injury. If his viscera are pro-
truding, cover them with a sterile
dressing moistened with 0.9%
sodium chloride solution to pre-
vent drying. The following inter-
ventions are routine for a patient
with abdominal trauma:
• Insert two large-bore intravenous
(I.V.) lines to infuse 0.9% sodium
chloride or lactated Ringer’s solu-
tion, according to facility protocol.
• Control the patient’s pain without
sedating him, so you can continue
to assess his injuries and ask him
questions. Generally, I.V. analgesics
such as morphine can adequately
manage pain without sedation.
• Insert an indwelling urinary
catheter, unless you suspect a uri-
nary tract injury. For example,
bloody urine or a prostate gland
found to be in a high position dur-
ing a rectal exam could indicate
damage to the urinary tract. If the
patient is to have a rectal examina-
tion, delay catheter insertion until
afterward.
• Draw blood specimens stat for
baseline lab values. (Appropriate
tests are listed later in this article.)
• Insert a gastric tube to decom-
press the patient’s stomach, prevent
aspiration, and minimize leakage
of gastric contents and contamina-
tion of the abdominal cavity. This
also gives you access to gastric
contents to test for blood.
• Administer tetanus prophylaxis
and antibiotics as ordered.
Assessing abdominal injuries
Blunt injuries suffered during an
MVC can be especially difficult to
detect. A penetrating abdominal
injury, such as a stab wound, caus-
es more obvious damage that com-
monly involves hollow organs such
as the small bowel. (To review the
various types of trauma, see Forces
behind Abdominal Injury.)
If your patient is stable, perform
a complete assessment using
inspection, auscultation, percus-
sion, and palpation. If he’s unsta-
ble, you may have to rely on
inspection and auscultation alone.
Inspection. Look for and docu-
ment obvious abnormalities,
including distension, contusions,
abrasions, lacerations, penetrating
wounds, and asymmetry. If the
patient was in an MVC, look for a
contusion or abrasion across his
lower abdomen, known as the
“seat belt sign.” Areas of purple
discoloration should make you
suspicious. Ecchymosis around the
umbilicus (Cullen’s sign) or flanks
(Grey-Turner’s sign) may indicate
retroperitoneal hemorrhage, but
www.nursing2004.com
 trauma Dealing with the damage
these signs may not appear for
hours or days.
Auscultation. If resuscitation
efforts aren’t under way, auscultate
your patient’s baseline bowel
sounds and listen for abdominal
bruits. Always auscultate before
percussion and palpation because
those procedures can change the
frequency of bowel sounds. Listen
to all four quadrants of his abdo-
men and his thorax.
The absence of bowel sounds
could be an early sign of intraperi-
toneal damage. Bowel perforation
and the spread of blood, bacteria,
and chemical irritants can cause
diminished or absent bowel
sounds. Bowel sounds in the chest
may signal a ruptured diaphragm
with herniation of the small bowel
into the thoracic cavity. Abdominal
bruits (vascular sounds due to tur-
bulent blood flow that resemble
systolic heart murmurs) might sig-
nal an arterial injury or aneurysm.
Before you percuss and palpate
your patient’s abdomen, ask him to
point to painful areas and be sure
to examine them last. If his pain is
severe, skip percussion and palpa-
tion; diagnostic studies such as
ultrasound and computed tomog-
raphy (CT) studies are necessary to
evaluate his abdomen.
Percussion. In a normal
MARTENS & KIEFER

abdomen, percussion elicits dull

sounds over solid organs and fluid-
filled structures (such as a full blad-
der) and tympany over air-filled

www.nursing2004.com Nursing2004, September 37

areas (such as the stomach). The
following findings are abnormal:
• Pain with light percussion sug-
gests peritoneal inflammation.
• Fixed dullness in the left flank
and shifting dullness in the right
flank while the patient is lying on
his left side (Ballance’s sign) signal
blood around the spleen or spleen
injury.
• Dullness over regions that nor-
mally contain gas may indicate
accumulated blood or fluid.
• Loss of dullness over solid organs
indicates the presence of “free air,”
which signals bowel perforation.
Palpation. Begin gently palpat-
ing your patient’s abdomen in an
area where he hasn’t complained of
pain. Palpate one quadrant at a
time for involuntary guarding, ten-
derness, rigidity, spasm, and local-
ized pain. Keep in mind that these
signs and symptoms might not be
present if he has competing pain
from another injury, a retroperi-
toneal hematoma, spinal cord
injury, or decreased level of con-
sciousness or if he’s under the
influence of drugs or alcohol.
Generalized discomfort during pal-
pation may signal peritonitis. An
abdominal mass might be a collec-

Pinpointing key injuries

Signs and symptoms of injury
Liver • peritoneal irritation
• diaphragm elevated on right side
• lower right rib fracture
• hypotension, tachycardia
• low to normal central venous
pressure (CVP)
• right upper quadrant guarding
Spleen • pain in left upper quadrant
• Ballance’s sign
• Kehr’s sign (referred shoulder
pain from blood or another irritant
in the peritoneal cavity)
• peritoneal irritation
• hypotension, tachycardia
• low to normal CVP
• rigid abdomen
Pancreas • epigastric pain, tenderness,
guarding
• Grey-Turner’s sign
• late signs 12 to 36 hr after injury
Stomach, • abdominal pain, guarding
duodenum, • peritoneal signs of inflammation
mesentery, and (increased pain with deep inspira-
small bowel tion or jarring)
• absent bowel sounds
• blood in nasogastric tube
• shock
Large intestine, • peritonitis
rectum • pain and tenderness during rectal
exam
Vascular • hemodynamic instability
(inferior vena
cava, portal
vein, and aorta)
Kidney • ecchymosis over flank or 11th or
12th rib
• flank or abdominal tenderness on
palpation
Diagnostic test abnormalities
• elevated white blood cell (WBC)
count
• decreased hemoglobin and
hematocrit (H&H) levels
• elevated liver enzymes
• abnormal coagulation studies,
including increased clotting and
prothrombin times
• decreased H&H levels
• elevated WBC count
• elevated WBC count
• elevated amylase levels
• free air on abdominal films
• free air on abdominal films
• positive fecal occult blood test
• increased WBC count
• decreased H&H levels
• hematuria (absence of blood in • infection
urine doesn’t rule out renal injury) • renal failure
Complications
• disseminated intravascular
coagulation and other clotting
problems
• sepsis
• pulmonary complications
• intra-abdominal abscess
• liver failure
• overwhelming postsplenectomy
infection or fulminate pneumo-
coccal bacteremia
• wound infection
• subdiaphragmatic abscess
• pulmonary complications
• hypovolemic shock
• delayed hemorrhage
• cutaneous or enteric fistula
• pancreatic pseudocyst
• abscess
• delayed hemorrhage
• diabetes/pancreatic insufficiency
• traumatic pancreatitis
• ileus
• peritonitis
• pulmonary complications
• ischemic bowel syndrome
• gastric fistulas
• incisional infection, abscess
• intestinal obstruction
• colocutaneous fistula
• bowel ischemia
• thrombus
• dehiscence from failed
anastomosis
• infection
• vascular-enteric fistula

38 Nursing2004, Volume 34, Number 9 www.nursing2004.com

 tion of blood or fluid. (See
“Assessing the Abdomen” in the Forces behind abdominal injury
May issue of Nursing2003 for more Blunt trauma, a force to the abdomen that doesn’t leave an open wound, commonly
occurs with motor vehicle crashes or falls. Compression and shearing are examples.
on assessment techniques.)
Your patient also may need an
internal examination by an autho-
rized practitioner. A rectal exami-
nation can help pinpoint injury to
the urinary tract or pelvis. A vagi-
nal examination can reveal a vagi-
nal injury or the presence of a for-
eign body, such as bone from a
pelvic fracture.

Signs of internal injuries

Certain telltale signs can help you
sort out the many internal injuries
that can occur with abdominal
trauma. For example, a victim of Compression is the result of a direct blow, such as being thrust against a steering wheel or
an MVC can sustain a lap belt seat, or with pressure from a seat belt.
injury that deserves special atten-
tion. When a quick stop whips the Shearing is common during
upper torso forward, the seat belt rapid deceleration in a motor
above the bony pelvic girdle can vehicle crash as a portion of
momentarily trap the viscera tissue continues to move for-
ward while another portion
against the spine and impose
remains stationary. Here, the
shearing and compression injuries
liver has torn away from the
to the gut and mesentery. Most portal vein.
common in this situation are
mesenteric hematoma, devascular-
ization of the bowel, severe damage
leading to rupture of the bowel
wall, bruising, and hemorrhage of
the abdominal wall that follows the Penetrating trauma causes an open wound, such as from a gunshot or stabbing. The solid
belt pattern. organs—diaphragm, spleen, liver, pancreas, and kidneys—can bleed profusely when injured.
Signs and symptoms of lap belt The hollow organs—stomach, gallbladder, duodenum, large intestine, small intestine, and blad-
der—generally don’t bleed significantly but are more likely to cause peritonitis if damaged.
injury usually develop slowly and
may be overshadowed by other
injuries. Any MVC victim who has
ecchymosis in the imprint of a seat
belt on his abdomen or develops
late abdominal pain, distension,
paralytic ileus, or slow return of
gastrointestinal function should be
evaluated for abdominal injuries.
Spleen injury is usually associat-
ed with blunt trauma. Fractures of
ribs 10 to 12 on the left should
raise your suspicion of spleen dam-
age, which ranges from laceration
of the capsule or a nonexpanding
hematoma to ruptured subcapsular A gunshot can damage multiple organs A stab wound is typically more localized
hematomas or parenchymal lacera- because of high bullet velocity or fragment- and may be less damaging.
tion. The most serious types of ing. The patient needs surgery to repair the
BIRCK COX

injury are a severely fractured injured tissues and remove bullet fragments.
spleen or vascular tear that causes

www.nursing2004.com Nursing2004, September 39

splenic ischemia and massive
blood loss. (See Pinpointing Key
Injuries for more details.)
Liver injury is common because
of the liver’s size and location.
Severity ranges from a controlled
subcapsular hematoma and lacera-
tions of the parenchyma to hepatic
avulsion or a severe injury of the
hepatic veins. Because liver tissue
is very friable and the liver’s blood
supply and storage capacity are
extensive, a patient with liver
injuries can hemorrhage profusely
and may need surgery to control
the bleeding.
The most common kidney
injury is a contusion from blunt
trauma; suspect this type of injury
if your patient has fractures of the
posterior ribs or lumbar vertebrae.
Other renal injuries include lacera-
tions or contusion of the renal
parenchyma caused by shearing
and compression forces; the deeper
a laceration, the more serious the
bleeding. Deceleration forces may
damage the renal artery; collateral
circulation in that area is limited,
so any ischemia is serious and may
trigger acute tubular necrosis.
Hollow organ injuries, which
can occur with blunt or penetrat-
ing trauma, most commonly
involve the small bowel. Decelera-
tion with shearing may tear the
small bowel, generally in relatively
fixed or looped areas.
Blunt forces cause most bladder
injuries. The bladder rises into the
abdominal cavity when full, so it’s
more susceptible to injury. If a dis-
tended bladder ruptures or is per-
forated, urine is likely to escape
into the abdomen. If the bladder
isn’t full when ruptured, urine may
leak into the surrounding pelvic
tissues, vulva, or scrotum.
Taking a look inside
Today’s technology helps pinpoint
the location, nature, and severity of
abdominal injuries. The medical
team can use diagnostic test results
to grade the patient’s injuries
according to several classification
systems, then target treatments to
specific organs, evaluate the
patient’s responses, and monitor
him for complications.
The approaches commonly used
to diagnose and grade abdominal
injuries include ultrasound, CT,
diagnostic peritoneal lavage, and
video-assisted laparoscopy. An
Inside View of Trauma reviews what
each technique involves.
If the patient’s hemodynamic sta-
tus is unstable or diagnostic testing
reveals a severe injury, such as a
deep laceration of the liver, spleen,
kidney, or pancreas, the surgeon
will perform an exploratory laparot-
omy. He’ll assess the abdomen and
pelvis, then base the surgical inter-
ventions on the extent of injury, the
organ involved, and the patient’s
other injuries, clinical condition,
age, and comorbid conditions.

An inside view of trauma Lab studies shed light

The following diagnostic methods are used to evaluate and classify abdomi- The following lab work is consid-
nal trauma: ered basic for evaluating a victim
Ultrasound is a common tool in EDs because it’s portable, noninvasive, of abdominal trauma:
and usable during resuscitation. Focused abdominal sonography for trauma • Urinalysis detects blood as a
(FAST) is close to 100% specific and 98% accurate in evaluating blunt abdom- sign of urinary tract injury. A
inal trauma. It can detect 100 ml or more of fluid or blood in the pericardium,
urine toxicology screen is routine
abdomen, and pelvis and it lets you visualize the spleen and liver. Interpreting
to check for substances that could
the results may be difficult when obesity, subcutaneous emphysema, or
diaphragm or bowel injuries are involved. (To learn more about FAST, see Eye
mask or mimic an injury. Women
on Diagnostics in the February issue of Nursing2004.) of childbearing age should have a
Abdominal computed tomography (CT) can reveal specific injury sites, urine pregnancy test as well.
the degree of injury and bleeding, and many retroperitoneal injuries that • A baseline complete blood cell
don’t show on ultrasound. The patient must be hemodynamically stable so he count can help clinicians identify
can be moved from the ED and lie quietly for the test. A CT scan is only mar- injury sites, the extent of injuries,
ginally sensitive for detecting injuries to the diaphragm, pancreas, and hollow and complications. For example,
organs and may pose additional risks if used with contrast media. an elevation in white blood cells
Diagnostic peritoneal lavage (DPL) is usually performed in the ED on may indicate a ruptured spleen.
patients who are hemodynamically unstable. A peritoneal dialysis catheter is
(See “How to Manage Spleen
inserted through a small incision just below the umbilicus and a liter of
Trauma without Surgery” in the
warmed lactated Ringer’s or 0.9% sodium chloride solution is infused.
Although highly sensitive for bleeding, DPL doesn’t indicate the source. If you
January issue of Nursing2002.) An
remove the fluid and it appears bloody or you can’t read a paper through it, increase in immature neutrophils
consider the results positive. False negatives are possible if the patient has (a shift to the left) may signal
adhesions or retroperitoneal hemorrhage. acute infection.
Video-assisted diagnostic laparoscopy has helped reduce the number of Even when the patient is bleed-
laparotomies performed to evaluate abdominal trauma. The clinician inserts a ing, his initial hemoglobin and
tiny camera through a small incision in the abdomen to evaluate the organs. hematocrit (H&H) results may be
Misplacing the trocar, however, could cause an injury. normal due to volume loss and
hemoconcentration. Once fluid

40 Nursing2004, Volume 34, Number 9 www.nursing2004.com

resuscitation is under way, H&H
values can decrease significantly,
so monitor serial measurements.
A patient in hypovolemic shock
may have a normal hematocrit
level simply because not enough
time has passed for hemodilution
to occur. The best gauge of success
for resuscitation or nonoperative
management is the patient’s clinical
condition.
• Arterial blood gases can reveal
abnormalities such as metabolic
acidosis.
• Prothrombin time, international
normalized ratio, and activated par-
tial thromboplastin time screen for
coagulopathy.
• Electrolyte, blood urea nitrogen,
and creatinine levels screen for
underlying renal problems and
provide a baseline.
• A type and crossmatch may be
needed for blood replacement.
• Serum amylase and lipase levels,
when persistently elevated, may
indicate injury to the pancreas or
bowel.
The best way to document your
patient’s lab values is on a flow
sheet. This helps you see subtle or
ambiguous changes that might go
unnoticed if documented out of
context with other lab reports.
Ongoing vigilance
Even if your initial abdominal
assessments are inconclusive, main-
tain a high degree of suspicion and
repeat your assessments for any
trauma victim. If you note changes
in his vital signs, level of conscious-
ness, lab results, pain level, or
abdominal assessments, notify his
primary care provider right away.
Abdominal trauma remains a
serious and deadly threat. By
becoming adept at identifying dan-
ger signs and changes in your
patient’s condition, you’ll ward off
potential complications and help
him heal.
SELECTED REFERENCES
Abbasakoor, F., and Vaizey, K.: “Pathophysiol-
ogy and Management of Bowel and Mesen-
teric Injuries Due to Blunt Trauma,” Trauma.
5(4):199-214, October 2003.
ACEP Clinical Policies Committee, Clinical
Policies Subcommittee on Acute Blunt Ab-
dominal Trauma: “Clinical Policy: Critical Is-
sues in the Evaluation of Adult Patients Pre-
senting to the Emergency Department with
Acute Blunt Abdominal Trauma,” Annals of
Emergency Medicine. 43(2):278-290, February
2004.
Hoff, W., et al.: “Practice Management Guide-
lines for the Evaluation of Blunt Abdominal
Trauma: The EAST Practice Management
Guidelines Work Group,” The Journal of
Trauma, Injury, Infection, and Critical Care.
53(3):602-611, September 2002.
Schulman, C.: “Emergency Care Focus: A
FASTer Method of Detecting Abdominal
Trauma,” Nursing Management. 34(9):47-49,
September 2003.
Wotherspoon, S., et al.: “Abdominal Injury
and the Seat-Belt Sign,” Emergency Medicine.
13(1):61-65, March 2001.
Cynthia Blank-Reid is a trauma clinical nurse special-
ist at Temple University Hospital and clinical adjunct
associate professor at the College of Nursing and
Allied Health Professions of Drexel University, both in
Philadelphia, Pa.
The author has disclosed that she has no significant
relationship with or financial interest in any com-
mercial companies that pertain to this educational
activity.

To take this test online, visit http://www.nursingcenter.com/ce/nursing.

CE Test
Abdominal trauma: Dealing with the damage
Instructions:
• Read the article beginning on page 36.
• Take the test, recording your answers in the test answers
section (Section B) of the CE enrollment form. Each question
has only one correct answer.
• Complete registration information (Section A) and course
evaluation (Section C).
• Mail completed test with registration fee to: Lippincott
Williams & Wilkins, CE Group, 333 7th Avenue, 19th Floor,
New York, NY 10001.
• Within 3 to 4 weeks after your CE enrollment form is received,
you will be notified of your test results.
• If you pass, you will receive a certificate of earned contact
hours and an answer key. If you fail, you have the option of
taking the test again at no additional cost.
• A passing score for this test is 12 correct answers.
• Need CE STAT? Visit http://www.nursingcenter.com for
immediate results, other CE activities, and your personalized CE
planner tool.
• No Internet access? Call 1-800-933-6525 for other rush service
options.
• Questions? Contact Lippincott Williams & Wilkins: 646-674-
6617 or 646-674-6621.
Registration Deadline: September 30, 2006
Provider Accreditation:
This Continuing Nursing Education (CNE) activity for 1.5 contact
hours is provided by Lippincott Williams & Wilkins, which is
accredited as a provider of continuing education in nursing by
the American Nurses Credentialing Center’s Commission on
Accreditation and by the American Association of Critical-Care
Nurses (AACN 00012278, CERP Category A). This activity is also
provider approved by the California Board of Registered Nursing,
Provider Number CEP 11749 for 1.5 contact hours. LWW is also
an approved provider of CNE in Alabama, Florida, and Iowa and
holds the following provider numbers: AL #ABNP0114, FL
#FBN2454, IA #75. All of its home study activities are classified
for Texas nursing continuing education requirements as Type I.
Your certificate is valid in all states. This means that your certifi-
cate of earned contact hours is valid no matter where you live.
Payment and Discounts:
• The registration fee for this test is $11.95.
• If you take two or more tests in any nursing journal published
by LWW and send in your CE enrollment forms together, you may
deduct $0.75 from the price of each test.
• We offer special discounts for as few as six tests and institu-
tional bulk discounts for multiple tests. Call 1-800-933-6525 for
more information.

www.nursing2004.com Nursing2004, September 41

 C E 1.5
ANCC/AACN CONTACT HOURS

Abdominal trauma: Dealing with the damage

GENERAL PURPOSE To provide nurses with an overview of abdominal injury, including its manifestations, diagnosis, and management. LEARNING
OBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Indicate the pathophysiology and associated signs and symp-
toms of abdominal injury. 2. Indicate physical assessments and diagnostic studies for abdominal injury. 3. Identify nursing interventions for abdominal injury.

1. What’s the first priority in caring for the b. spleen injury. d. intestinal injury.
patient with abdominal injury? 12. Which of the following complications is
a. Perform a rapid head-to-toe assessment. 7. Which hollow organ is more commonly most often associated with splenectomy?
b. Maintain airway, breathing, and circulation. injured? a. pneumococcal bacteremia
c. Establish large-bore I.V. access. a. stomach c. bladder b. thrombus
d. Control the patient’s pain with I.V. analgesics. b. small intestine d. large intestine c. vascular-enteric fistula
d. renal failure
2. Ecchymosis around the umbilicus may indi- 8. Which statement about the baseline com-
cate plete blood cell count following abdominal 13. Which statement about complications of
a. seat belt injury. c. retroperitoneal bleeding. injury is correct? abdominal trauma is correct?
b. contusions. d. urinary tract injury. a. The initial hematocrit level is usually high when a. Liver injury can trigger an elevated CVP.
hypovolemic shock is present. b. Referred shoulder pain indicates a positive Grey-
3. A bruit heard during auscultation of the b. A decrease in immature neutrophils may indi- Turner’s sign.
abdomen might indicate cate infection. c. Hematuria always occurs with renal injury.
a. spread of chemical irritants. c. A drop in the WBC count may indicate spleen d. Dehiscence of the anastomosis may follow vas-
b. stomach herniation into the thoracic cavity. rupture. cular injury repair.
c. rupture of the diaphragm. d. Hemoglobin and hematocrit values can be nor-
d. an arterial injury or aneurysm. mal despite bleeding. 14. The FAST diagnostic tool
a. is very accurate in obese patients.
4. Which statement correctly describes percus- 9. Which serum lab study reflects pancreatic b. doesn’t allow visualization of the spleen and
sion findings in abdominal injury? injury? liver.
a. Ballance’s sign indicates blood around the liver. a. blood urea nitrogen c. amylase c. can detect as little as 100 ml of blood.
b. Tympany is heard over regions with accumulated b. creatinine d. electrolytes d. is 98% accurate in evaluating penetrating
fluid or blood. abdominal trauma.
c. Dullness over solid organs indicates “free air.” 10. Which statement correctly describes forces
d. Pain on light percussion indicates peritoneal that cause abdominal injury? 15. Unlike ultrasound, an abdominal CT scan
inflammation. a. Shearing occurs with rapid deceleration. can detect injuries
b. Most blunt trauma occurs with sports injuries. a. to the diaphragm.
5. Lap belt injuries c. Hollow organs generally bleed profusely. b. in the retroperitoneal area.
a. usually manifest immediately after the trauma. d. A compression injury occurs with forward c. of the pancreas.
b. entrap viscera against the abdominal wall. motion and stationary forces. d. to hollow organs.
c. cause shearing and compression trauma to the
intestines. 11. Which of the following is associated with 16. Which statement about DPL is correct?
d. often lead to splenic laceration and hemorrhage. liver injury? a. The patient must be hemodynamically stable.
a. Kehr’s sign b. A small camera is inserted through a tiny incision.
6. If your patient has lumbar vertebral frac- b. lower right rib fracture c. The fluid to be instilled should be warmed.
tures, assess him for c. Grey-Turner’s sign d. The procedure can identify the source of bleeding.
a. renal injury. c. liver injury. d. pain in the left upper quadrant

✄ ✄
ENROLLMENT FORM Nursing2004, September, Abdominal trauma: Dealing with the damage
A. Registration Information: ❑ LPN ❑ RN ❑ CNS ❑ NP ❑ CRNA ❑ CNM ❑ other ___________________
Last name ____________________________ First name ________________________ MI _____ Job title __________________________________ Specialty _________________________________
Type of facility ____________________________________ Are you certified? ❑ Yes ❑ No
Address _______________________________________________________________________________
Certified by ___________________________________________________________________________
City _______________________________________ State _________________ ZIP ______________ State of license (1) __________________________ License # ___________________________
State of license (2) __________________________ License # ___________________________
Telephone ____________________ Fax ____________________ E-mail ____________________
Social Security # _____________________________________________________________________
Registration Deadline: September 30, 2006 ❑ From time to time, we make our mailing list available to outside organizations to announce special offers.
Contact hours: 1.5 Pharmacology hours: 0.0 Fee: $11.95 Please check here if you do not wish us to release your name and address.

B. Test Answers: Darken one circle for your answer to each question.
a b c d a b c d a b c d a b c d
1. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 16. ❍ ❍ ❍ ❍
2. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 12. ❍ ❍ ❍ ❍
3. ❍ ❍ ❍ ❍ 8. ❍ ❍ ❍ ❍ 13. ❍ ❍ ❍ ❍
4. ❍ ❍ ❍ ❍ 9. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍
5. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍
C. Course Evaluation* D. Two Easy Ways to Pay:
1. Did this CE activity's learning objectives relate to its general purpose? ❑ Yes ❑ No ❑ Check or money order enclosed (Payable to Lippincott Williams & Wilkins)
2. Was the journal home study format an effective way to present the material? ❑ Yes ❑ No ❑ Charge my ❑ Mastercard ❑ Visa ❑ American Express
3. Was the content relevant to your nursing practice? ❑ Yes ❑ No
Card # _____________________________________________ Exp. date __________________
4. How long did it take you to complete this CE activity?___ hours___minutes
5. Suggestion for future topics __________________________________________________________ Signature _______________________________________________________________________
*In accordance with the Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of the CE offering may be submitted directly to the Iowa Board of Nursing.