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MedSurg Chapter60:3
Noninflammatory Intestinal Disorders:3
Question | Answer |
---|---|
Abdominal Trauma | Injury to structures located between the diaphragm and pelvis; blunt or penetrating force to abdomen |
Causes of Abdominal Trauma-Blunt | Motor Vehicle AccidentsFallsAggravated AssaultsContact Sports |
Causes of Abdominal Trauma-Penetrating | Gunshot woundsStabbingImpalement with an objects |
Most common injured site | LIVER- in both blunt and penetrating traumaSpleen- most commonly injured organ in blunt abdominal trauma |
Priority Nursing Assessment | Mental StatusVital SignsSkin perfusion- most reliable clinical guide in assess hypovolemic shock |
Shock | Mild Shock- Pale, Cool, and Moist skinModerate Shock- Diaphoresis is more marked and urine output ceasesSevere Shock-Changes in mental status- manifested by agitation, disorientation, recent memory losss |
Cullen's Sign | Ecchymosis around the umbilicus- may signify internal bleedingEcchymosis in distribution of lap seat shoud be reported to the health care provider immediate-occult injury to bowel |
Turner's sign | Ecchymosis on either flank- May indicate retroperitoneal bleeding into abdominal wallAusculate for bruits- indicate renal artery injury |
Ballance's Sign | Resonance over right flank with the client lying on the left side; ruptured spleen |
Kehr's Sign | Left shoulder pain resulting from diaphragmatic irritation, may be present with splenic injury |
Emergency Care: Abdominal Trauma | Placement of at least two large-bore IV catheters in UPPER extremitiesAnalgesics are NOT prescribed during this time |