CASE SCENARIO in MEDICAL SURGICAL NURSING

CHEST INJURY

Pre-Hospital Data

Marlin Ponce, a 19 years old student at OLFU, was going to her school to pay her dues at the
Accounting office, when suddenly a victim of stabbing while outside the campus. This all began when a
stranger approached her and asked her for some money which occurred immediately after this man saw
her. What started out as a verbal argument and she was refusing to give this stranger her money,
eventually resulted in a physical violence. Marlin sustained a single stab wound to the left chest in the
mid axillary line, just below the level of the nipple. She was transported to emergency department at
the nearby hospital NEDHI by the bystanders who witnessed the incidence. He was noted to be awake
and alert throughout the entire transport, but in an agony of the pain she was experiencing from the
stab wounds.

After several hours of observations, Marlin, at this time began complaining of a new subscapular pain, or
pain between the shoulder blades. The doctor was alarmed for the following reasons:

Patients with diaphragmatic injuries and irritation from the blood frequently exhibit referred pain in this
distribution. If the knife wound had projected inferiorly penetrating the diaphragm, there was also a
high likelihood of intra abdominal injuries. Therefore, it was decided that the patient required surgical
exploration, and the patient was taken to the operating room.

Emergency Room

Assessment:

The patient complained of some pain in her left chest and shortness of breath while she is moving from
the stretcher onto the examination table.

The nurse placed cardiac monitors, blood pressure-cuff and oxygen saturation probe on her. Vital signs
result as follows:

Heart rate- 8am 91b/min, 84b/min,72b/min, 101b/min, 64b/min, 92b/min, 71b/min, 89b/min, 62b/min

Blood Pressure- 140/90, 130/70, 120/80, 140/90, 130/70, 120/80, 140/90, 130/70, 120/80, 140/90

Respiratory rate – 26, 18, 30, 21. 18, 24, 35, 24, 20, 16, 35, 23, 30, 16, 18, 20

Temperature- 37.2 ‘C, 38.1, 36. 3, 37.2 ‘C, 38.2, 36. 5, 37.5 ‘C, 36.1, 36. 3, 37.2 ‘C, 36.1, 37. 3

I and O monitoring

9am total : I = NPO, IVF =160, urine =800 cc, BM =0, CTT out 200cc
1pm: Oral =NPO, IVF =160, urine = 760 cc, BM=1x, CTT output =300 cc

5pm: oral 120 cc of water , IVF =160,urine =700 cc, BM =0, CTT output =500 cc

9pm: oral 200 cc of milk , IVF=160 cc, urine =600 cc, BM =0 , CTT output=800cc

1am: oral = 100cc of water , IVF =160cc , urine =500 cc, BM=0 , CTT output = 550 cc

IVF: PNSS 1 L x 24, (drop factor 20) inserted @ cephalic vien Right hand , using 18 IVcatheter, started @
6am

Past Medical/Surgical History: Allergic Rhinitis, Asthma

Family History: Father is diabetic, Mother has hypertension

Medications: Medication for pain and antibiotic ( make your own order for pain and antibiotic) make an
drug study. Inhalers as needed

Allergy: Pain Medications such as IBUFROPEN (Alaxan, Gardan etc.)

Chest X-ray: Left sided hemo-pneumothorax

An upright CXR was done. Marlin need to be sat up because she had an isolated penetrating injury to the
chest, and the mechanism of injury did not warrant spinal precautions. Due to this isolated nature of her
injury a pelvis and lateral C-spine films were unfortunately not obtained.

Medication for pain and antibiotic (decide and make your own order for pain and antibiotic) make a
drug study.

Initial Survey:

Airway - There is patent airway as demonstrated by her ability to complain or talk.

Breathing -There is decreased breath sounds at the left base.

Oxygen mask with 100% FiO2 was placed; & an oxygen saturation of 98 % was obtained

Circulation – There is no active external bleeding observed

Exposure –The patient’s clothes were cut off and removed to examine for other injuries

Secondary Survey:

EENT: (-) lacerations, (-) hematomas, (-) fractures palpated

Neck: midline trachea, (-) JVD, (-) crepitus

Chest: clear on right, single stab wound to the left chest in the mid-axillary line in the 4th intercostal
space, no crepitus, no bleeding, decreased breath sounds at the left base

Cardiac: Normal RR, normal S1 and S2

Abdomen: soft, non-tender, non-distended, with presence of abdominal sounds

Extremities: warm to touch, (+) distal pulses

Neuro: GCS 15, (-) focal deficits, awake, GCS 13, GCS 14, GCS 13, GCS 14, GCS 15, GCS 15

Laboratory and other pertinent studies

Blood Work Ordered:

Coagulation panel

Complete blood count (CBC)

Arterial blood gas

Toxicology screen

QUESTIONS :

1. What is the best nursing diagnosis for Marlin’s case?

2. As the student nurse assigned to Marlin, how will you manage her pain?

3. What are the expected medications to be given to Marlin to alleviate her pain? Create at least 3 drug
studies.

4. What is the purpose of the Arterial blood gas analysis ordered by Marlin’s attending physician? How
will you prepare Marlin for this test?

5. What are the significance of the different blood (Coagulation panel, CBC etc.) work ordered by the
doctor?

6. Why is ABG is being ordered? State your reasons.

7. Which of these 2 diagnostic procedures does apply to Marlin’s case? Give your reasons.

A) Open laparotomy

B) Diagnostic Laparoscopy
8. If the knife wound had projected inferiorly penetrate the diaphragm, there is also a likelihood of
intra- abdominal injuries. Make 3 NCPs on this. Impaired Breathing pattern – ABG result with
oxygenation, Pain with pain scale of 8/10 on the operative site, Impaired physical mobility due to
presence of CTT 1 way bottle.

9. Using an schematic diagram, create a pathogenesis of what will be the effect of stab wound to her
lungs including possible complications.

10. What are important nursing management when dealing patients with CTT like Marlin? Explain the
rationale.