B. Etiology AND CLASSIFICATION1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity).Caused by: stab wounds, gunshot wounds.2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum).Caused by: blow, collision, explosion, deceleration, compression or seat belt (set-belt) (School of Medicine, 1995).
C. PathophysiologyJab / shot; blow, collision, explosion, deceleration, compression or seat belt (set-belt)-Abdominal Trauma-:1. Blunt abdominal trauma blood loss. Bruising / injury to the abdominal wall. damage organs. Pain irritation intestinal fluid2.Trauma penetrating abdominal The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death
1 & 2 causes:
Damage to skin integrity
Shock and hemorrhage
Damage to gas exchange
High risk of infection
Acute pain (Faculty, 1995).
D. SIGNS AND SYMPTOMS1. Penetrating trauma (trauma abdomen with penetration into the peritoneum cavity): The loss of all or part of the function of organs sympathetic stress response bleeding and blood clots Bacterial Contamination cell death2. Blunt trauma (trauma without penetrating into the abdominal cavity peritoneum). blood loss. Bruising / injury to the abdominal wall. damage organs. tenderness, pain of word, off pain and stiffness (rigidity) abdominal wall. irritation intestinal fluid (School of Medicine, 1995).
E. COMPLICATIONS Soon: hemorrhage, shock, and injury. Slow: infection (Smeltzer, 2001).
F. DIAGNOSTIC EXAMINATION rectal examination: presence of blood indicates abnormalities in the large intestine; kuldosentesi, the possibility of the presence of blood in the stomach, and catheterization, the blood showed a lesion in the urinary tract. Laboratory: hemoglobin, hematocrit, leukocytes and urine analysis. radiology: when indicated to do a laparotomy. IVP / sistogram: only when there is suspicion of urinary tract trauma. abdominal paracentesis: This action is done in blunt abdominal trauma who doubt that defects in the abdominal cavity or abdominal blunt trauma accompanied with severe head trauma, performed by using needle puncture no 18 or 20 which is inserted through the abdominal wall or underlined lower quadrant area middle under center with rubbing jar first. peritoneal Lavase: puncture and aspiration / flushing the abdominal cavity with saline fluid entering through a cannula inserted into the cavity of the peritoneum (School of Medicine, 1995).
G. MANAGEMENT Emergency Management; ABCDE.Installation NGT for gastric emptying and prevent aspiration. catheter to empty the bladder mounted and assess the urine comes out (bleeding). surgery / laparotomy (for penetrating trauma and blunt trauma in case of peritoneal stimulation: shock; bowel sounds are not audible; prolapsed viscera through a stab wound; blood in the stomach, bladder, rectum; intraperitoneal free air; lavase positive peritoneal; fluid free in abdominal cavity) (School of Medicine, 1995).
NURSING MANAGEMENTA. ASSESSMENTAssessment is the first step in the nursing process and basic overall (Boedihartono, 1994).Assessment of abdominal trauma patients (Smeltzer, 2001) are included:1. Penetrating Abdominal Trauma Get a history mechanism of injury; strength jab / shot; blunt force (punches). inspection abdomen for signs of injury before: puncture injuries, bruises, and a bullet exit.Auscultation presence / absence of bowel sounds and record baseline data so that changes can be detected. Absence of bowel sounds is an early sign of intraperitoneal involvement: if there are signs of irritation peritoneum, usually performed laparotomy (surgical incision into the abdominal cavity). Assess patients for progression of abdominal distension, move to protect, tenderness, stiffness or aching muscles loose, decreased bowel sounds, hypotension, and shock. Assess chest injury that often follow an intra-abdominal injury, injury-related observations. Record all physical signs during patient examinations.
2. Blunt abdominal trauma Get detailed history if possible (often can not be obtained, inaccurate, or false). get all possible data about the following things:• Method of injury.• Time of onset of symptoms.• What if the passenger traffic accidents (driver often suffers ruptured spleen or liver). Safety belt use / not, restrain the type used.• eat or drink last time.• bleeding tendency.• latest danmedikasi disease.• immunization history, with attention to tetanus.• Allergies. Do a quick check on the entire body pasienuntuk detect life-threatening problems.
EMERGENCY MANAGEMENT1. Started resuscitation procedures (repair of the airway, breathing, circulation) as indicated.2. Keep the patient on a gurney or stretcher board; motion can cause fragmentation clot in the large veins and cause massive hemorrhage.a) Ensure kepatenan airway and breathing as well as the stability of the nervous system.b) If the patient is comatose, dislocated neck to neck obtained after x-rays.c) Cut out clothes from the wound.d) Calculate the number of injuries.e) Determine the location of entrance and exit wounds.3. Assess signs and symptoms of hemorrhage. Hemorrhage often accompanies abdominal injuries, especially liver and spleen trauma.4. Control bleeding and blood volume defense until surgery is performed.a) Provide external compression on the bleeding wound and chest injuries dam.b) Put a large diameter catheter for IV fluid replacement quickly and improve circulation dynamics.c) Note the initial response syoksetelah incident happened to transfusion; This is often a sign of internal perdarrahan.d) The doctor may perform paracentesis to identify the bleeding site.5. Gastric aspiration with a nasogastric tube. This procedure helps detect ulcers, reducing contamination of the peritoneum cavity and prevent lung complications due to aspiration.6. Cover the abdominal viscera came out with a bandage sterile, moist saline dressings to prevent nkekeringan viscera.a) Fleksikan knee patients; protusi prevent further this position.b) Delay administration of oral fluids to prevent increased peristalsis and vomiting.7. Put settle urethral catheter to obtain assurance hematuria and monitor urine output.8. Maintain a continuous flow sheet of vital signs, urine output, central venous pressure readings of patients (if indicated), hematocrit value, and neurologic status.9. Prepare for paracentesis or peritoneum lavase when there is uncertainty about intraperitonium bleeding.10. Prepare sinografi to determine whether there is penetration of the peritoneum in cases of stab wounds.a) Stitches done around the wound.b) a small catheter is inserted into the wound.c) Agents contrast through a catheter inserted; indicate whether the x-ray penetration peritoneum has been done.11. Give tetanus prophylaxis according to regulations.12. Give broad spectrum antibiotics to prevent infection. trauma can lead to infection due to damage caused by a mechanical barrier, exogenous bacteria from the environment at the time of injury and diagnostic and therapeutic maneuvers (nosocomial infections).13. Prepare patients for surgery if there is evidence of shock, blood loss, presence of free air under the diaphragm, eviserasi, or hematuria.
ADVANCED CARE MANAGEMENT diruangB. Nursing DiagnosisNursing diagnosis is a unification of the problem of real or potential patients based on the data that has been collected (Boedihartono, 1994).Nursing diagnoses in patients with abdominal trauma (Wilkinson, 2006) are:1. Damage to skin integrity related to puncture injury.2. High risk of infection associated with impaired skin integrity.3. Acute pain associated with traumatic / discontinuity network.4. Activity intolerance related to general weakness.5. Barriers to physical mobility related to pain / discomfort, activity restriction therapy, and decreased strength / resistance.
C. INTERVENTION AND IMPLEMENTATIONIntervention is planning nursing actions that will be implemented to address the problem in accordance with the nursing diagnoses (Boedihartono, 1994).Implementation is the realization of management and nursing plans that had been developed at the planning stage (Effendi, 1995).And implementation of nursing interventions that occur in patients with abdominal trauma (Wilkinson, 2006) include:1. Damage to skin integrity is the state of one's skin that changes are not desirable.Goal: Achieve wound healing at the appropriate time.Results Criteria: - no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Assess skin and wound identification at this stage of development.R / know the extent of injuries facilitate the development of appropriate action.b. Assess the location, size, color, odor, and the number and type of wound fluid.R / identify the severity of the injury will facilitate intervention.c. Monitor the increase in body temperature.R / increased body temperature can be identified as the process of inflammation.d. Provide wound care with aseptic technique. Dressing the wound with sterile gauze and a dry, use paper tape.R / aseptic technique helps accelerate wound healing and prevent infection.e. If recovery does not occur collaboration further action, such as debridement.R / to be foreign or infected tissue is not widespread in other areas of normal skin.f. After debridement, dressing bandage as needed.R / dressing can be substituted one or two times a day depending on the condition of severe / not his wounds, to prevent infection.g. Collaboration antibiotics as indicated.R / antibiotics to kill pathogenic microorganisms useful in areas at risk of infection.
2. The risk of infection associated with inadequate peripheral defense, circulation changes, high blood sugar levels, invasive procedures and skin damage.Objective: infection does not occur / controlled.Criteria results: - there are no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a. Monitor vital signs.R / identify the signs of inflammation, especially when the body temperature rises.b. Perform wound care with aseptic technique.R / controlling the spread of pathogenic microorganisms.c. Perform maintenance on invasive procedures such as intravenous fluids, catheters, wound drainage, etc..R / to reduce the risk of nosocomial infection.d. If signs of infection collaboration for blood tests, such as hemoglobin and leukocytes.R / Hb decrease and increase in the number of normal leukocytes may result from the occurrence of the infection process.e. Collaboration for antibiotics.R / antibiotics to prevent the development of pathogenic microorganisms.
3. Pain is a sensory and emotional experience that is unpleasant and increased as a result of actual or potential tissue damage, described in terms of such damage; onset sudden or slowly from heavy to light intensity samapai can end in anticipation or less predictable and duration of six months.Purpose: The pain can be reduced or lost.Results Criteria: - Pain is reduced or lost- The client seemed calm.Intervention and Implementation:a. Approach the client and familyR / client relationship that makes both cooperative and familyb. Assess the level of intensity and frequency of painR / level of pain intensity and pain frequency scale showsc. Explain to the client the cause of painR / explanation would add to the knowledge of the client's paind. Observation of vital signs.R / to find out the client's developmente. Collaboration with the medical team in the delivery of analgesicsR / is dependent nursing actions, which serves to block the analgesic pain stimulation.
4. Activity intolerance is a condition is an individual who does not quite have the physiological or psychological energy to endure or meet the needs or daily activities desired.Purpose: The patient has enough energy to move.Criteria results: - Behavioral reveals the ability to meet the needs of self.- Patients expressed able to do some activities without assistance.- Coordination of muscle, bone and other limbs either.Intervention and Implementation:a. Plan adequate rest periods.R / reducing activity is not required, and the energy collected can be used for optimal activity secar necessary.b. Provide training activity gradually.R / stages are given to help the process of the activity slowly with energy saving but the exact purpose, early mobilization.c. Aids in meeting the needs of patients as needed.R / reduces energy consumption up to force the patient to recover.d. After reviewing the exercises and activities of the patient's response.R / keep the possibility of an abnormal response of the body as a result of the exercise.
5. Barriers to physical mobility is a limitation in self-reliance, beneficial physical movement of the body or a limb or more.Goal: patient will indicate the optimal level of mobility.Criteria results: - appearance of a balanced ..- Do the movement and displacement.- Maintaining optimal mobility that can be tolerated, with the characteristics: 0 = independent full 1 = require aid. 2 = requires assistance from another person for assistance, supervision, and teaching. 3 = needs help from others and aid. 4 = dependence; did not participate in the activity.Intervention and Implementation:a. Assess the need for health care and the need for equipment.R / identify the problem, facilitate intervention.b. Determine the patient's level of motivation to perform the activity.R / affecting the assessment of the ability of the activity is due to the inability or unwillingness.c. Teach and monitor patients in the use of tools.R / judge limits the ability of optimal activity.d. Teach and support patients in active and passive ROM exercises.R / maintain / increase muscle strength and endurance.e. Collaboration with a physical or occupational therapist.R / as a source suaatu planning to develop and maintain / improve patient mobility.
D. EVALUATIONAddalah evaluation stage on the nursing process in which the degree of success in achieving the goals of nursing assessed and the need to modify or nursing intervention defined purpose (Brooker, 2001).Evaluation expected in patients with abdominal trauma are:1. Achieve wound healing at the appropriate time.2. Infection does not occur / controlled.3. Pain can be reduced or lost.4. Patients have enough energy to move.5. Patients will show optimum level of mobility.
REFERENCESBoedihartono, 1994, Nursing Process in Hospital, Jakarta.Brooker, Christine. , 2001. Pocket Dictionary of Nursing Ed.31. EGC: Jakarta.Dorland, W. A. Newman. , 2002. Medical Dictionary. EGC: Jakarta.Faculty of medicine. , 1995. Science Lecture surgical set. Binarupa Literacy: JakartaNasrul Effendi, 1995, Introduction to Nursing Process, EGC, Jakarta.Smeltzer, Suzanne C. , 2001. Medical-Surgical Nursing Brunner and Suddarth Ed.8 Vol.3. EGC: Jakarta.