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8/9/2019 Startling Pierce 1
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fe
Startling pierce
A case presentation brought by
TEAM OR
JENIFER JOY MONTES DIAMA
ROMELYN Y. CANDAZA
HILDA E. FUSELERO
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INTRODUCTION
For every moment one turns around anymore, one is flooded with violent news flashing
before their eyes. Headlines sweep across the screen and newspapers as violence outbreaks at
community once again. We seem not to be able to escape hearing, or seeing such horrific news
any more. But since we are medical front liners, we need to be open minded to all things
regarding in all races, ethnic, age or stability in life,, as we ought for our profession, which is to
save lives.
Violence is a generic term used to describe a variety of destructive behaviors which cause
harm to people. It is powerful, it is dominators which destroy morale, motivation, performance as
well as it makes people very ill and if theyre unfortunate enough, they DIE.
What characteristic is being used by a person who is provoked to succumb to violence
to the extent that their life is also threatened? These are the so called projectiles. Projectiles
often cause injuries or a life threatening condition in humans. A fundamental point to remember
regarding blunt and penetrating trauma is that a patient who has been stabbed may also have
been beaten and kicked and subsequently has sustained both blunt and penetrating injury to the
body
In addition to this, some violent people who have intact mentality and dont have any
history of any mental illness often subject them to being under the influence of prohibited drugs
and alcohol.
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GENERAL OBJECTIVE
After the case presentation ended the participant would be able to gain knowledge about
the linkage of effects of injury to the body, demonstrate adequate skills in analyzing the nursing
process and appreciate the importance of nurses role in providing appropriate management.
SPECIFIC OBJECTIVE
y Can present anatomy and physiology and tackle the pathophysiology of foreign
substance that causes injury.
y Relate the significance of laboratory results of the clients condition or the disease
process.
y Identifies all operation being done to the patient, know the responsibilities and
safety precautions.
y Identify classification, indication, mechanism of action, special precaution, side
effects, and nursing responsibilities in administration of drugs.
NURSING HISTORY
PATIENT X, 23 years of age, single, a college undergraduate was rush in the Emergency
Room and admitted direct thru the Operating Room due to stab wound, without intravenous fluid
and was transferred via stretcher STAT. The blood in the patients clothes was evidence that the
patient had wound and it had been bleeding but not profusely because the blood had solidified in
the wound site. Aside from the feature of wound, the patient had also complaining of pain in the
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HISTORY OF PRESENT ILLNESS
According to the bystander who brought him in the hospital, the patient was in the social
gathering of a friend. They where drinking liquor and the conversation went from cool to hot
topics that triggered the sudden violence. One of the bystanders who brought him was his
neighbor one who also contacted his relatives while the patient was directly admitted to the
operating room, June 03 2010. PNSS 1L x kvo attached at Right metacarpal vein to serve as the
blood line, and D5LR 1L in the left metacarpal vein to serve as the mainline; and a Foleycatheter inserted and has been attached at the urine bag.
The present diagnosis of the patient isstab wound T9-T10 IAL left
PAST MEDICAL HISTORY
According to the clients brother he has immunization of BCG, DPT, OPV, HEPA B, and
MEASLES. He has a history of chicken fox when he was a grade school. This is his second time
of hospitalization. His first hospitalization was last 2006 brought about by gang fight.
FAMILY MEDICAL HISTORY
There is no known familial disease in his both maternal and paternal family except for
hypertension, originated from his mother.
LIFESTYLE
According to the brother, patient X was a positive smoker who can light a 4 5 cigarettes
a day. He can consume large amount of alcohol in a sitting and a drug addict who uses different
d h th b th did t ll ti th id d H l l t t i ht d 10
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SOCIAL HISTORY
He belongs to a consanguineal family. He is single, TESDA trainee in the division of
airconditioning. He didnt complete the 2nd
year college agricultural in Mindanao Norte Dame
Tacorong College. Theyre residing in a rented house in PNR site FTI WBTC, with 2 rooms; 1
for the client and his brother and 1 for the family of her sister together with her children and
husband including the husbands mother.
Their monthly income is below minimum. The brother said he only earns 125 150 a day
in the construction at maharlika village. The patient also earns 200 300 when he is asked to
drive a tricycle for his kumpare.
PHYSICAL ASSESSMENT
GENERAL SURVEY
The patient is fully awake, lying in the stretcher; he is under alcohol abuse, dress
appropriately though the patients clothes is soaked in blood from the fight he encountered, with
appearance of labile emotions, not pallor though weak looking; he has slender body built with a
flabby abdominal girth and approximately in the height of 54. He is Conscious, coherent, and
conversant to time and date. Has pain in the left part of the abdomen with initial vital sign has
been taking in the monitor around 5:05 pm with a BP of 120/80 mmHg, pulse rate of 82 bpm and
a respiratory of 30 bpm. The doctor ordered chest x-ray and CBC with blood type cross
matching.
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REVIEW OF SYSTEM
y SKIN-skin is light brown in color, mole noted in the back of ear, bruises noted on the
upper arm, warm to touch and with good skin turgor.
y MOUTH the lips is somewhat darken in color, dry and cavities noted with cracks in the
front tooth.
y ANTERIORCHEST skin is same with all body parts thorax rises and falls in unison
with respiratory cycle some blood from wound site noted. And noted 30 breaths per
minute
y HEART cardiac rate of 82 beats per minute
y ABDOMEN abdomen is round symmetrical flabby abdominal girth, stab wound noted
in 11 12 intercostals space mid clavicular line.
y UPPEREXTREMITIES same from the skin bruises from the deltoid to elbow joint. No
deformity noted
y LOWEREXTREMITIES knees are align with each other and do not protrude medially
or laterally. But minor wound seen in the archiles site.
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ANATOMY AND PHYSIOLOGY
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SPLEEN
Spleen is an important organ that is
considered as a part of the lymphatic
system. This organ is present in almost
all vertebrates, including humans and
dogs, and it performs several significant
functions in their body. The humanspleen is located in the upper left part of
the abdomen, just below the diaphragm
and behind the stomach. It is a small
organ, not larger than the size of a fist.
The average human spleen is about 12
cm in length, 7cm in height, 4cm thick
and it weighs 150 gm approximately.
The human spleen is a soft organ, which
is dark purple in color. The tissues of
this organ can be classified into two
types, white pulp and red pulp, which
are responsible for performing some specific functions. It is concerned with producing
lymphocytes, which is a type of white blood cell. So, spleen is an integral part of the human
immune system, as the lymphocytes are responsible for producing antibodies to fight against the
foreign invaders. Antibodies are mainly associated with the destruction of the bacteria, virus or
any other microorganisms or germs that can cause several diseases. Another important feature
about the function of the spleen is that while filtering the blood, i.e. while destroying the old red
blood cells, it saves some important components like iron from them. Iron is stored in the spleen
as bilirubin and ferritin. Iron preserved in this way is then transported to the bone marrow, which
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STOMACH
The stomach is a pouch-like organ that lies in the upper left part of the abdominal cavity, justunder the diaphragm and next to the liver.
Functions The stomach has five functions:
y digestion of food
y secretion of gastric juices as well as mucus which helps to coat its lining, preventingerosion by gastric juices
y
secretion of gastric hormonesy regulation of the rate at which partially digested food is delivered to the small intestine
y absorption of small quantities of water and dissolved substances. It does not absorb verywell, except in the case of alcohol. Consumption of alcohol on an empty stomach will
quickly increase blood levels.
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PATHOPHYSIOLOGY
Penetrating trauma
to the (spleen,
stomach)
HemorrhageDecreased
hemoglobin,
hematocrit & RBC
Increased
neutrophils
Signifies
infection from
foreign body
Increased heart rate (to
compensate for blood
loss)
Increased RR resulting
to blood pooling in the
lungs area & as part of
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LABORATORY RESULTS
MCH 32 pg 28 33
MCHC 34 % 32 -38
WBC High 21,900 mm3 4,800 10, 800
NEUTROPHILS High 19, 272 2,00 7, 500
LYMPHOCYTES 1,533 1, 500 4, 000
MONOCYTES High 1, 095 200 800
EOSINOPHILS 0 40 500
BASOPHILS 0 10 - 100
Interpretation:
Decrease in hemoglobin, hematocrit and RBC is related to persistent blood loss due to the
stab wound. Increase in neutrophils indicates presence of infection related to foreign body (knife)
ABO RH blood grouping
Type of exam Abnormal flag Result Reference range
HEMOGLOBIN Low 5.4 g/dl 13.0 -18.0
HEMATOCRIT Low 15.9 % 40.0 52.0
RBC Low 1.71 nl/ mm3 4.70 5.40
MCV 93 fl 80 100
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MEDICAL SURGICL INTERVENTION
1. vital signs monitoring- to continually monitor clients health status
2. IVF therapy implemented to maintain the fluid and electrolyte balance of the body which
sustain bodily function on the optimum level
y D5LR- a physiologic solution used for infusion into the circulation. In
additions to essential ions it also contains glucose
y PNSS a way to replace water at correct electrolyte deficit. It provides
medium for IV drug administration.
3. Foley catheter insertion allow drainage of urine in order to lessen the pain of patient
when in surgery, sudden puncture of the bladder, and to empty the bladder for operation.
4. O2 inhalation therapy inhalation (5 Lpm) via T- piece
5. Medications:
y Cefuroxime 1.5 TIV q8 antibiotic, pre operative prophylaxis
y Ketorolac 30 mg TIV q8 x 6 doses analgesic, anti inflammatory; short
term pain management
y Tramadol 100 mg TIV q8 hold if BP less than 90/60 for severe pain
y Metronidazole 500 mg TIV q8 antibiotic for anaerobic bacteria
y Ranitidine 50 mg TIV q8 while on NPO then D/c once fully awake a
histamine H2 receptor antagonist that inhibits stomach acid production
6. Chest x ray of posterior and anterior view of chest and abdomen for viewing of organs
that has been affected by the stab wound and to detect how the extent of wound reached.
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SURGICAL INTERVENTION
1.The patient underwent E. Ex Lap (exploratory laparotomy) + splenorrhaphy + repair +Diaphragmatic Vent + Peritoneorrhapy + Gastrorrhaphy + chest thoracotomy tube (CTT)
left insertion.
y Exploratory laparotomy is a method of abdominal exploration, a diagnostic tool
that allows physicians to examine the abdominal organs.
y
Splenorrhaphy- surgical repair of spleen
y Diaphragmatic vent-
y Peritoneorraphy- surgical repair of peritoneum
y Gastrorrhapy- suture of stomach for repair
y Chest thoracotomy tube - Exchange of oxygen and carbon dioxide in the lungs
depends on effective ventilation and adequate circulation of blood through bothlungs. And getting the secretions, such as , blood air or pus
2. Blood transfusion Transfusions are given to restore lost blood, to improve clotting time,
and to improve the ability of the blood to deliver oxygen to the body's tissues.
3. CBC and Blood type cross matching - establishes compatibility or incompatibility of a
donor's and a recipient's blood. It's the best antibody detection test available for avoiding
lethal transfusion reactions. C bc for complete blood count if the patient can sustain the
surgery
4. General anesthesia - a state of total unconsciousness resulting from general anesthetic drugs
Post operative Diagnosis
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NURSING CARE PLAN
CUES Assessment Scientific
Interference
Goal of care Nursing
Intervention
Rationale Evaluation
> cardiac outputdecrease
-
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DRUG STUDY
GENERIC/BRAND
DOSAGE/ROUTE
CLASSIFICATION ACTIONS INDICATIONS CONTRAINDICATIONS ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
G = ranitidine
hydrochloride
B = ranitidine
50 mg T. I.V
> histamine H2
receptor
>Competitively
inhibits action
of histamine on
the H2 at
receptor sites of
parietal cells,
decreasing
gastric acid
secretion.
> Duodenal and
gastric ulcer
(shorterm
treatment);
pathologic
hypersecretory
conditions.
> contraindicated in
patient hypersensitive to
drug and those with acute
porphyria.
> Use cautiously in
patient with hepatic
dysfunction. Adjust
dosage in patients with
impaired renal function.
> Headache,
malaise,
vertigo, blurred
vision,
jaundice,
burning and
itching at
injection site.
>assess patient for
abdominal pain. Note
presence of blood in
emesis, stool, or gastric
aspirate.
>ranitidine may be
added to total
parenteral nutrition
solution.
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GENERIC/BRAN
D
DOSAGE/ROUTE
CLASSIFICATION ACTIONS INDICATIONS CONTRAINDICATIONS ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
G = cefuroxime
sodium
B = ceftin
1.5 g T. I.V
> anti infective/
antibiotic
>second
generation
cephalosporin
that inhibits cell
wall synthesis,
promoting
osmotic
instability;
usually
bactericidal.
> pre
prophylaxis /
perioperative
prevention
> contraindicated in
patient hypersensitive to
drug or other
cephalosporin.
> use cautiously in
patient with
hypersensitivity to
penicillin because of
possibility of cross-
sensitivity with otherbeta lactam antibiotics..
> nausea,
anorexia,
vomiting,
diarrhea,
temperature
elevation,
urticaria.
>obtain specimen for
culture and sensitivity
test before giving first
dose. Ask patient or
relatives if there is a
sensitivity in penicillin
or other cephalosporin
drugs.
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GENERIC/BRAND
DOSAGE/ROUTE
CLASSIFICATION ACTIONS INDICATIONS CONTRAINDICATIONS ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
G =tramadol
B = tramadol 100
mg T. I.V
>Analgesic >A centrally
acting synthetic
analgesic
compound not
chemically
related to
opiates that is
thought to bindto opioid
receptors and
inhibit reuptake
or
norepinephrine
and serotonin.
>Moderate to
moderately
severe pain
>Contraindicated in
patients with
hypersensitivity to drug
or with acute intoxication
from alcohol, hypnotics,
centrally acting
analgesics, opioids, or
psychotropic drugs.
>dizziness,
vertigo,
headache,
somnolence,
CNS
stimulation,
anxiety,
confusion,coordination
disturbance,
nervousness,
sleep disorder,
visual
disturbances.
>Use cautiously in
patients at risk for
seizures or respiratory
depression; in patients
with increased
intracranial pressure or
head injury.
>Monitor respiratorystatus. Withhold dose
and notify doctor if
respirations decrease or
rate is below 12 bpm.