startling pierce 1

8/9/2019 Startling Pierce 1

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Startling pierce

A case presentation brought by

TEAM OR

JENIFER JOY MONTES DIAMA

ROMELYN Y. CANDAZA

HILDA E. FUSELERO


2/19

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


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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18/19


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GENERIC/BRAND

DOSAGE/ROUTE


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.

startling pierce 1

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