BACHELOR OF SCIENCE IN NURSING:

RLE 312 Case Scenario: Chest Injury

PRE HOSPITAL HISTORY:

SOP, a 19 year 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. SOP sustained a single
stab wound to the left chest in the mid -axillaries line, just below the level of the nipple. She
was transported to emergency department at the nearby hospital NEDHI by the by standers
who witnessed the incidence. She 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, SOP, 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 results as follows:

Heart rate- 91/min
Blood Pressure- 129/71
Respiratory rate - 26
Temperature- 37.2 ‘C

Past Medical/Surgical History: Allergic Rhinitis, Asthma

Family History: The patient’s family history has hypertension in her mother side, diabetes
mellitus on the father side, but there are no other medical illnesses indicated.

Medications: Inhalers as needed

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

INITIAL LABORATORY RESULT:

Chest X-ray: Left sided hemo-pneumothorax
An upright CXR was done. SOP 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.

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, with 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

Laboratory and other pertinent studies

Blood Work Ordered:
Type and screen
Coagulation panel
Complete blood count (CBC)
Arterial blood gas
Toxicology screen

QUESTIONS :
1. What is the best nursing diagnosis for SOP case?
2. As the student nurse assigned to SOP, how will you manage her pain?
3. What is the purpose of the Arterial blood gas analysis ordered by SOP’s attending
physician? How will you prepare Marlin for this test?
4. What are the significance of the different blood ( Coagulation panel, CBC etc. )work ordered
by the doctor?
5. Why is that ABG is better indicator of hemorrhage than haematocrit? State your reasons.
6. Which of these 2 diagnostic procedures does apply to SOP’s case? Give your reasons.
A) Open laparotomy
B) Diagnostic Laparoscopy
7. If the knife wound had projected inferiorly penetrate the diaghragm, there is also a likelihood
of intra abdominal injuries. Make 2 NCPs on this.