UNIVERSITY OF THE CORDILLERAS

College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@bcf.edu.ph
Website: www.bcf.edu.ph

BLUNT ABDOMINAL TRAUMA

A Case Presented to the

College of Nursing

In Partial Fulfillment of the requirements in the Course

(Virtual Duty (Surgery/Operating Room))

Submitted By:

Abeer, Mahmud

Anablon, Jhemaima

Bersalona, Nestle Gay

Bin Qursain, Saleh Faroq

Dalog, Jasjine Khyla

Escobar, Alyssa Julia

Galliasto, Nezelyn

Lachaona, Jian Emmanuel

Sito, Antonette

Soriano, Edeniel

Tuyishimire, Liliane

(Date: 25-NOVEMBER-2021)

Noted and Approved for Presentation:

Name of Case Presentation Adviser or Panel/s

________________________
Signature of panel / Date

________________________
Signature of panel / Date

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ABSTRACT:
Around the world, blunt abdominal trauma is a prominent cause of morbidity
and mortality. Accidents, injuries, and other conditions that cause a person to
become wounded are inevitable. The term "blunt abdominal trauma" refers to
an injury to a person's abdomen. Where the abdominal wall, solid organs, hollow
viscus, or vasculature can be injured. In the case of the patient, she was sent to
the emergency room with generalized abdominal pain and left shoulder-tip pain
due to intraperitoneal bleeding caused by a tear in the splenic capsule after
being kicked by her horse during her fall. The diagnosis was confirmed after a
computed tomography (CT) scan.

TITLE:
INTRAPERITONEAL BLEEDING Secondary to BLUNT ABDOMINAL TRAUMA

AUTHOR’S INFORMATION:
The authors, aspiring nurses, namely: Abeer, Mahmud; Anablon, Jhemaima;
Bersalona, Nestle Gay; Bin Qursain, Saleh Faroq; Dalog, Jasjine Khyla; Escobar,
Alyssa Julia; Galliasto, Nezelyn; Lachaona, Jian Emmanuel; Sito, Antonette;
Soriano; Edeniel; and Tuyishimire, Lilian, are all third-year student nurses from the
University of the Cordilleras.

BACKGROUND:
Intraperitoneal bleeding is a frequent complication that occurs after traumatic
abdominal trauma and can be life-threatening. This occurs in the abdominal
cavity after a tear or rupture of the abdominal wall, solid organs, hollow viscus, or
vasculature. This is a prevalent ailment that affects people of all ages, although
treatment choices and treatment courses differ.

CASE DESCRIPTION

HISTORY
You are called urgently to the resuscitation room for a trauma call. An 18-year-old
girl has fallen from her horse. During her descent, the horse kicked her, and she is
now complaining of generalized abdominal pain and left shoulder-tip pain.

EXAMINATION
She is talking and examination of her chest is normal. The oxygen saturations are
100 per cent on 24 per cent oxygen. Initially, her pulse rate is 110/min with a blood
pressure of 84/60 mmHg. She is slightly drowsy and her Glasgow Coma Score
(GCS) is 14. On examination of the abdomen, there is an abrasion on the left side
beneath the costal margin with tenderness in the left upper quadrant. There is no
evidence of any other injuries and the urinalysis is clear. The patient is given 2 L of
intravenous fluids and the blood pressure improves to 130/90 mmHg. As the patient
has now become stable, a CT scan of the chest and abdomen is obtained. The
On returning to the emergency department, the patient becomes increasingly
agitated. The nurse informs you that her blood pressure is now 80/60 mmHg and
the pulse rate is 130/min.

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 TABLE OF CONTENTS

I. Introduction 1
II. Statement of Objectives 2
A. General Objectives 2
B. Specific Objectives 2
III. Patient’s Profile 2
IV. Chief Complaints 2
V. Present History of Illness 2
VI. Past History of Illness 3
VII. Family Health History 3
VIII. Health Assessment 3
A. General Survey 3
B. Head to Toe Assessment 3
C. 13 areas of Assessment 4
IX. Diagnostics 8
X. Comprehensive Pathophysiology 10
XI. Treatment/Management 11
A. Drugs 11
B. IV Fluids 18
C. Surgery 19
XII. Nursing Care Plans 20
A. Prioritization of Problems 20
a. List of Problems 20
b. Basis for Prioritization 20
B. Nursing Care Plans 22
a. NCP 1 22
b. NCP 2 25
c. NCP 3 27
d. NCP 4 31
e. NCP 5 34
C. Discharge Plan 36
XIII. Learning Insights 37
XIV. List of References 39

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I. INTRODUCTION

Abdominal trauma is defined as any injury to the abdomen that is either restricted
to the abdomen or is accompanied by severe, multisystem trauma. Since the type and
severity of abdominal injuries varies greatly depending on the mechanism and forces
involved, generalizations concerning mortality and the necessity for operational
treatment are sometimes deceptive. Injuries are usually categorized according to the
sort of structure that has been damaged namely: abdominal wall, solid organ (liver,
spleen, pancreas, kidneys), hollow viscus (stomach, small intestine, colon, ureters,
bladder), or vasculature.

Abdominal traumatic injuries are classified as either blunt force or penetrating.

When an object strikes the abdomen or the abdomen strikes against an object, blunt
force trauma occurs. During a car collision, for example, this is a regular occurrence. The
abdominal organs can be injured at three different moments after forceful trauma. A fast
shift in organ momentum and speed might cause first damage. Shearing forces can
cause organs to rip at their bases or at the junction between two organs when organs or
nearby structures suddenly decelerate at different speeds (typically owing to connective
tissues). Shearing pressures put solid and hollow organs, as well as the vasculature, at
danger. Organs can then be crushed when a blunt item is forced on them, or when
organs are squashed against solid bodily structures. Crushing is especially dangerous to
the spleen, kidneys, and liver. Finally, external compression from acute trauma generates
an increase in internal pressure, especially in hollow organs. Hollow organs rupture as a
result of this, expelling their contents into the abdominal cavity.

Blunt abdominal trauma can affect persons of all ages and is linked with a high
rate of morbidity. Thousands of patients with traumatic abdominal injuries visit emergency
rooms each year, resulting in a significant rise in healthcare costs. Internal organ damage
from blunt abdominal trauma can result in internal bleeding, contusions, or injuries to the
gut, spleen, liver, and intestines. Extra-abdominal injuries, such as extremities injuries, can
also be present. Because the symptoms aren't always apparent, diagnosing them can
be challenging and time-consuming. Aside from pain, the patient may also have rectum
hemorrhage, fluctuating vital signs, and peritonitis. A physical examination may reveal
lap belt marks, ecchymosis, abdominal distention, silent bowel noises, and palpable
tenderness. Abdominal stiffness, guarding, and rebound soreness may be present if
peritonitis is present.

Abdominal trauma, both blunt and penetrating, is a leading cause of morbidity

and death in the United States, due to the difficulty in recognizing apparent signs early.
The spleen and liver are the most often affected organs in blunt abdominal trauma, with
an 8.5 percent death rate. Vehicles are involved in nearly three-quarters of all blunt
abdominal trauma injuries. Males account for about two-thirds of all injuries, with a peak
frequency among patients aged 14 to 30.

In a study in over 2 decades ago, between 1995 and 1999, 538 pediatric patients
with traumatic injuries aged 0 to 18 years were hospitalized to the Philippine General
Hospital. There were 296 cases of blunt trauma, 234 cases of penetrating injuries, and 9
cases of blast injuries. With 423 instances, males outnumber females in all age categories.
There were more blunt traumas in individuals aged 0 to 12, and more penetrating injuries
in those aged 13 and over. The most prevalent cause of blunt trauma is a motor vehicle
accident, which occurs 99 percent of the time with the patient as a pedestrian. The head
is the most commonly affected area. There were 71 blunt abdominal trauma cases out
of 538 total traumatic injuries. The male to female ratio is about equal. The most prevalent
cause of blunt abdominal injuries among pedestrians is a motor vehicle accident. Falling
from great heights and child abuse followed. Skeletal injuries were the most prevalent
related damage, with the kidney being the most commonly injured intra-abdominal
organ. There were just 38 patients that were operated on. The others were dealt with in
a non-operative manner. There were three cases of morbidity and four cases of death.
Unfortunately, all of the patients died as a result of severe blood loss.

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II. STATEMENT OF OBJECTIVES OF THE CASE
A. General Objectives
This case analysis aims to increase the understanding and knowledge of
student nurses on how to care for patients with Blunt Abdominal Trauma

B. Specific Objectives
Specifically, this case analysis aims to:
1. Define Blunt Abdominal Trauma and its effects to the person’s
body during the accident.
2. Illustrate the pathophysiology of Blunt Abdominal Trauma and in
relation to the signs and symptoms specifically observed in the
patient.
3. Describe the common signs and symptoms of Blunt Abdominal
Trauma.
4. Discuss the medical interventions for the management of Blunt
Abdominal Trauma.
5. Formulate appropriate nursing care plans suited for the patient
based on the assessment findings
6. Identify care measures to be given to the patient and family to
promote continuity of care and independence after discharge.

III. PATIENT PROFILE

Name PATIENT X
Age 18
Gender Female
Civil Status Single
Address Baguio City
Nationality Filipino
Ethnic Ilocano
Background
Religion Christian
Date of September 9, 2021
Admission
Time of 8:00 am
Admission
Ward Emergency Room; Bed 2
Admitting Abdominal trauma
Diagnosis
Chief Generalized abdominal pain and left shoulder-tip pain
Complaints
Final Diagnosis Ruptured Spleen - intraperitoneal bleeding

IV. CHIEF COMPLAINTS

An 18-year-old states that she has fallen from her horse. The patient said
that during her descent, the horse kicked her, and she is now complaining of
generalized abdominal pain, tenderness in the left upper quadrant, and left
shoulder-tip pain. The patient has sustained a tear in the splenic capsule, causing
intraperitoneal bleeding. The CT scan shows the fractured spleen with surrounding
haematoma. The shoulder-tip pain described is known as Kehr’s sign, and is
indicative of blood in the peritoneal cavity causing diaphragmatic irritation. The
patient was diagnosed with RUPTURED SPLEEN-INTRAPERITONEAL BLEEDING. The
physician recommended exploratory laparotomy and splenectomy for the
patient for medical-surgical management.

V. PRESENT HISTORY OF ILLNESS

The patient had been in her normal state of health until a few moments ago
when she fell from her horse and got kicked by it at the same time during her
descent. The patient reported that she is experiencing generalized abdominal
pain and left shoulder-tip pain. There are no urinary symptoms. On inspection, the

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 patient's splenic capsule had torn, resulting in intraperitoneal bleeding. Kehr's sign
is a symptom of blood in the peritoneal cavity causing diaphragmatic irritation, as
represented by the shoulder-tip ache leading to her diagnosis of ruptured spleen-
intraperitoneal bleeding.

VI. PAST HISTORY OF ILLNESS

Patient X was admitted at the Baguio General Hospital when she is 5 years
due to LBM. Aside from that, she also got a common sickness like cough, runny
nose, and fever, but manage it with over-the-counter drugs like, Solmux for cough,
Neozep for runny nose, and paracetamol for fever. Her mother mentioned that
her daughter is a fully immunized child. The patient has no history of any adult
major illnesses and past childhood illnesses, surgical history, and there are no
allergies and drug reaction on any medications. No prior injuries and
hospitalizations. She got her first menstrual period when she is 13 years old and with
an interval of 28-30 days and her bleeding usually lasts an average of 6 days. She
also experiences dysmenorrhea during menstruation.

VII. FAMILY HEALTH HISTORY

The patient claims that her father's present illness is hypertension and cirrhosis.
The mother has a remarkable medical history of extensive medical conditions such
as hypertension, angina, and transient ischemic accidents. Both the patient's
maternal grandparents had a history of type 2 diabetes. Other members of the
family currently experience no other present illness.

VIII. HEALTH ASSESSMENT

A. General Survey
The patient was received awake and lying on bed with ongoing IVF of
D5LRs 2 L regulated at 27 gtts per minute on the right arm. Patient looks drowsy
and needs assistance when changing positions. She wears a neat gown, with no
body and breath odor. Patient is oriented to the current time and date. The
patient verbalized that she is 5 feet tall and weighs 45 kilograms.

B. Head to Toe Assessment

1. Head The head was normocephalic and symmetrical without
deformities, masses, or tenderness upon palpation. Hair is
well distributed and there is no presence of dandruff
during inspection.
2. Eyes The patient was able to distinguish different colors. Pupils
were equally round and reactive to light. Extraocular
matter was intact and was able to follow the 6 cardinal
gazes. The conjunctiva was moist and light pink in color.
3. Ears The ears were symmetrical and in line with the outer
canthus of the eyes, with a minimal amount of cerumen.
During the assessment of the watch tick test, the client was
able to hear ticking in both ears. There were no nodules,
swelling, or tenderness in the mastoid area.
4. Nose and sinuses The nose was symmetrical in shape, with the septum
located midline and no noted discharges. The patient was
able to distinguish the scent of coffee and alcohol. The
frontal, sphenoid, ethmoid, and maxillary sinuses were free
of inflammation, tenderness, or nodules.
5. Mouth Lips are pinkish in color and symmetrical. The oral mucosa
was moist but reddish brown in color. Tonsils were
bilaterally present and not inflamed. The uvula was
located midline and no dentures were noted.
6. Neck The patient was able to move his neck in different
directions without complaining of pain. Carotid pulses
were symmetrical with strong palpable pulses. Superficial
cervical lymph nodes were palpable and non-tender. The

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 thyroid gland and trachea were midline with no
inflammation.
7. Chest The patient had a normal chest configuration and
symmetrical chest wall expansion upon breathing. The
breathing pattern was even in depth and rate, with no
crepitus present. No crackles or wheezes were noted upon
auscultation.
8. Cardiac The patient had an abnormal heart rate of 110/min with a
blood pressure of 84/60 mmHg.
9. Breast/Chest The patient was negative for mastitis. The skin color was
similar to the rest of the body. Nipples were symmetrical
and darker in color.
10. Abdomen There is an abrasion on the left side beneath the costal
margin with tenderness in the left upper quadrant.
11. Genitals There is no lesion noted and there is no presence of
bleeding.
12. Musculoskeletal The patient was assessed with full ROM and muscle
strength of 5/5 on both the right and left upper extremities
and moderate ROM and muscle strength of 3/5 on the
lower extremities.
13. Integumentary The patient has good skin turgor. Nails were pinkish, clean
and trimmed with a capillary refill time of 1-2 seconds
when pressure is applied to the nail bed. The skin is warm
to the touch, and there are no lesions or bruises to be
found.

C.13 Areas of Assessment

1. Psychosocial and Psychological Status:

Patient X is an 18-year-old female. According to her, she was born

on July 5, 2003, a resident of Baguio City, a Filipino citizen and a Christian.
She is the youngest child among the three children. Patient X speaks
Ilocano and is single.

She falls under the fifth stage of Erik Erikson's theory of psychosocial
development is identity vs. role confusion, and it occurs during
adolescence, from about 12-18 years. During this stage, adolescents
search for a sense of self and personal identity, through an intense
exploration of personal values, beliefs, and goals. During adolescence, the
transition from childhood to adulthood is most important. Children are
becoming more independent, and begin to look at the future in terms of
career, relationships, families, housing, etc. The individual wants to belong
to a society and fit in.

2. Mental and Emotional Status:

Patient X is very drowsy but is conscious and well orientated to time,

place and person. She can identify things and answer the questions being
asked. She can recall recent and remote memories she experienced. She
is able to read and write and she can understand and speak Tagalog and
English. She is very responsive and collaborative. She is cooperative while
performing the interview. The patient seems to be agitated whenever she
is asked a question, claiming that she is in pain.

3. Environmental Status:

Patient X is well-oriented to the environment and is familiar with the

room set-up. She is in the emergency room and it is adequately ventilated and
well-lit. Her bed is located near the window. The table is just near the bed, the
comfort room is 7-8 steps away from the bed. She looks drowsy and needs
assistance when changing positions. The floor is well maintained and not
slippery. No scatter rugs were seen. Bed rails are available and social
distancing is being observed. She wears a neat gown, with no body and

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breath odor. Prior to hospitalization, she was engaged in house riding and
was athletic.

4. Sensory Status

a. Visual Status:

There is no visual deficit; the sclera is anicteric with pinkish

palpebral conjunctivae; no nasoaural discharge; no cervical
lymphadenopathy. Pupils are normal and are reactive to light.

b. Auditory Status:

Patient X is really responsive to noises; there are no

abnormalities or discharges from the ears noted. Ears are
symmetrical and have a normal appearance on both sides.

c. Olfactory Status:

The nose was symmetrical in shape, with the septum located

midline and no noted discharges. The patient was able to distinguish
the scent of coffee and alcohol. The frontal, sphenoid, ethmoid, and
maxillary sinuses were free of inflammation, tenderness, or nodules.

d. Gustatory Status:

Patient X has a good gag reflex and her lips appear to be

pinkish and hydrated, aligned with her ethnicity, and the tongue
looks good.

e. Tactile Status:

Facial sensations are intact and symmetrical on both sides.

The patient was able to perceive hot and cold, including smooth
and rough objects, using a ballpen. She responds to stimuli and can
feel pain by way of pinching her skin.

5. Motor Status

Patient X is in a lying position and is able to undergo limited

movement only. She is also not comfortable with her condition because of
the deformity of the left shoulder tip pain and a generalized abdominal
pain. She needs assistance when performing activities of daily living. She
tried to perform activities alone if she can, but admitted that she is scared
due to her condition.

6. Thermoregulatory Status:

Patient X has a normal body temperature of 36.5 Celsius.

Date Time Temperature

September 9, 2021 7:00am 36.4o C
11:00am 36.5o C
2:00pm 36.8o C
September 10, 2021 7:00am 36.7o C
11:00am 37.0o C
2:00pm 37.0o C

7. Respiratory Status:

The patient has a symmetrical chest wall expansion and clear breath
sounds. The respiratory rate was 22, which is normal.

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 Date Time RR SPO2
September 9, 7:00am 26 91
2021 11:00am 24 92
2:00pm 12 93
September 10, 7:00am 19 95
2021 11:00am 20 94
2:00pm 21 95

8. Circulatory Status:

The patient has a dynamic pericardium and the heart rate is 130
bpm. Her initial blood pressure was 84/60 mmHg, which is very low, and
later, the patient’s blood pressure improved to 130/90 mmHg. Lastly, the
patients’ blood pressure decreased to 80/60 mmHg.

Date Time CR BP
September 9, 7:00am 110 84/60
2021 11:00am 80 130/90
2:00pm 130 80/60
September 10, 7:00am 83 80/60
2021 11:00am 82 110/70
2:00pm 80 110/80

9. Nutritional Status:

Patient X has good nutrition and enough intake of a well-balanced

diet. She usually consumes 2-3 meals a day. Prior to admission, the patient
normally drinks 7–8 glasses of water a day and usually skips breakfast or
dinner. Her diet usually consists of rice, processed foods, and soup. There
are no cultural or religious dietary restrictions reported by the patient. The
patient denied any indigestion or vomiting and was eating by herself.

10. Elimination Status:

The patient has the normal frequency of urine (3x a day) and stool
(1x a day) and the normal frequency of their amount and color. It doesn't
have practices to aid elimination. No changes due to health problems.

11. Sleep, Rest and Comfort Status:

The patient claims that she normally sleeps 6–7 hours a day. During
her stay at the hospital, she was only able to get 4–5 hours of sleep. She said
that she was not able to sleep comfortably because of the noise and the
lights at the hospital, and that she was not used to being in a room with a
lot of people and sleeping with the lights turned on.

12. Fluids and Electrolytes Status:

The patient usually drinks 7–8 glasses of water daily. On the right arm,
the patient received an IVF of D5LRs (2 L) regulated at 27 gtts per minute.
She claimed that she did not have any feelings of thirst. Her skin turgor was
normal, and she had a moist mouth and mucous membranes. She did not
show any signs of dehydration.

13. Integumentary Status:

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 The patient has good skin turgor. Nails were pinkish, clean and
trimmed with a capillary refill time of 1-2 seconds when pressure is applied
to the nail bed. The skin is warm to the touch, and there are no lesions or
bruises to be found.

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IX. DIAGNOSTICS

DIAGNOSTIC DESCRIPTION OF THE SIGNIFICANCE/ DATE OF PROCEDURE FINDINGS IMPLICATIONS

PROCEDURE PROCEDURE PURPOSE
OF THE PROCEDURE
CT SCAN Imaging During a CT scan, you lie CT scan allows doctors November 9, 2021 CT scans can detect CT scans use X-rays,
procedure that uses a in a tunnel-like machine to see inside your body. bone and joint which produce ionizing
combination of X-rays while the inside of the It uses a combination of - The entire procedure problems, like complex radiation. Research
and computer machine rotates and X-rays and a computer may take anywhere bone fractures and shows that this kind of
technology to produce takes a series of X-rays to create pictures of from 20 minutes to one tumors. If you have a radiation may damage
images of the inside of from different angles. your organs, bones, and hour condition like cancer, your DNA and lead to
the body. It shows These pictures are then other tissues. It shows heart disease, cancer
detailed images of any sent to a computer, more detail than a emphysema, or liver
part of the body, where they're combined regular X-ray. You can masses, CT scans can
including the bones, to create images of get a CT scan on any spot it or help doctors
muscles, fat, organs and slices, or cross-sections, part of your body. see any changes. They
blood vessels. of the body. show internal injuries and
bleeding, such as those
caused by a car
accident.
Focus Abdominal The sonographer gently Doctors order an November 9, 2021 The patient was placed Complications of
Sonographic Technique presses the transducer abdominal ultrasound supine. Focused abdominal injuries can
against your stomach when they're concerned abdominal sonography be acute (e.g.,
area, moving it back about symptoms such as for trauma (FAST|) was bleeding) or delayed
and forth. The device abdominal pain, performed, which takes (e.g., abscess,
sends signals to a repeated vomiting, no more than 5 min, the obstruction or ileus,
computer, which abnormal liver or kidney following four standard delayed hematoma
creates images that function tests, or a views should be rupture). The abdominal
show how blood flows swollen belly. Abdominal obtained: examination does not
through the structures in ultrasound tests can (a) reliably indicate the
your abdomen. A show the size of the Epigastric region severity of abdominal
typical ultrasound exam abdominal organs and transverse views to injury.
takes about 30 minutes can help evaluate assess the left lobe of
to complete. It's usually injuries to or diseases of the liver.
painless. the abdominal organs.
(b)
Right hypochondrium
longitudinal views to
Page | 8
assess the right lobe of
the liver, the right kidney,
and the Morison pouch.

(c)
Left hypochondrial
longitudinal views to
assess the left kidney,
the spleen, and the
lienorenal space.

(d)
Suprapubic transverse
and longitudinal views to
assess the urinary
bladder and Douglas
pouch.

In addition to these four

views, right and left
longitudinal views of the
lower thoracic cage are
acquired to rule out
pleural effusion.

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X. COMPREHENSIVE PATHOPHYSIOLOGY

Precipitating Factors: Predisposing Factors:

Accident, abdominal pain. Age, gender and hobbies.

ABDOMINAL TRAUMA
Acute Pain
LUQ Pain, tenderness.

Hemodynamically unstable: Grimacing

Ineffective breathing
BP: 80/90 mmHg; PR: 130/min; (+)
pattern
agitation
Guarding
behavior
Tachypnea
Performed CT Scan and FAST

Evidence of intraperitoneal bleeding Risk for hypovolemic

and tear in the splenic capsule shock

Surgery: Acute pain

Laparatomy,
splenectomy
Risk for infection

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XI. TREATMENT
A. Drugs
DRUG NAME MECHANISM OF ACTION INDICATION / ADVERSE EFFECT NURSING RESPONSIBILITIES
CONTRAINDICATION

GENERIC: The action of propofol INDICATIONs: CNS: BEFORE:

PROPOFOL involves a positive modulation To induce general Dystonic or choreiform - Observe 10 rights of drug
BRAND: of the inhibitory function of anesthesia movement administration.
DIPRIVAN the neurotransmitter gama- CV: DURING:
CLASS: aminobutyric acid (GABA) CONTRAINDICATION: bradycardia, hypotension, - Note respiratory rate, depth,
THERAPEUTIC through GABA-A receptors. Hypersensitivity; use hypertension, decreased and rhythm and size of
HYPNOTICS cautiously in patients who are cardiac output pupils in patients receiving
hemodynamically unstable META: repeated doses.
PHARMACOLOGIC: SOURCE: hyperlipidemia - If signs of CNS hyperactivity
PHENOL DERIVATIVES Propofol: Uses, Interactions, DRUG TO DRUG INTERACTION: RESPI: are present, consult
Mechanism of Action | Inhales anesthetics; opioids; Apnea, respiratory acidosis physician before
DOSAGE: DrugBank Online. (n.d.). sedatives DERM: administering drug.
10mg/mL DrugBank. Retrieved Rash, pruritus - Monitor vital signs closely.
September 9, 2021, from DRUG TO FOOD INTERACTION: MISC: - Schedule deep breathing,
ROUTE: https://go.drugbank.com/dru _________________ Burning or stinging at coughing, and changes in
IV gs/DB00818 DRUG TO HERB INTERACTION: injection site position at intervals to help
_________________ to overcome respiratory
_________________ depressant effects.
DRUG TO LIFESTYLE - Discontinue drug if
INTERACTION: hypersensitivity reactions
Alcohol use occur.
AFTER:
- Teach patient about drug’s
side effect.
- Promote comfort measures.
- Assess patient's condition
thereafter the therapy.
GENERIC: Binds with opioid receptors in INDICATIONs: CNS: BEFORE:
FENTANYL the CNS, altering perception Adjunct to anesthesia; Asthenia, clouded - Observe 10 rights of drug
BRAND: of and emotional response to preoperative medication sensorium, confusion, administration.
SUBLIMIZE pain. CONTRAINDICATION: euphoria, sedation, DURING:
CLASS somnolence, anxiety,
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THERAPEUTIC CLASS: SOURCE: Contraindicated in patients depression, dizziness, - Monitor vital signs and
OPIOID ANALGESICS Comerford, K. C., & intolerant to drug. hallucinations, headache, observe patient for signs of
PHARMACOLOGIC: Durkin, M. T. (2020). Nursing DRUG TO DRUG INTERACTION: nervousness, seizures skeletal and thoracic muscle
OPIOID AGONIST 2020 drug handbook (15th ed., Amiodarone; CV: (depressed respirations)
DOSAGE: Vol. 1). Philadelphia: Wolters Benzodiazepines; CNS Arrhythmias, chest pain, rigidity and weakness.
50mcg/ml Kluwer. depressants hypertension hypotension, - Watch carefully for
ROUTE: DRUG TO FOOD INTERACTION: DVT, PE respiratory depression and
IV _________________ GI: for movements of various
DRUG TO HERB INTERACTION: Abdominal pain, groups of skeletal muscle in
St. John’s wort constipation, vomiting, extremities, external eye,
anorexia, diarrhea, dyspepsia, and neck during
DRUG TO LIFESTYLE dry mouth, ileus, nausea postoperative period. These
INTERACTION: DERM: movements may present
Alcohol use Pruritus, diaphoresis, patient management
erythema problems; report promptly.
RESPI: AFTER:
Respiratory depression, - Promote comfort measures.
apnea, hypoventilation, - Assess patient's condition
dyspnea, cough, URI, thereafter the therapy.
bronchitis
EENT:
Swelling, pharyngitis, dry
eyes, strabismus, ptosis,
epistaxis, nasal discomfort,
rhinorrhea, nasal congestion,
post nasal drip, rhinitis
GU:
Urine retention
MUSCO:
Skeletal muscle rigidity
MISC:
Physical dependence

GENERIC: May inhibit prostaglandin INDICATIONs: CNS: BEFORE:

KETOROLAC synthesis to produce anti- Short-term management of Dizziness, headache, - Observe 10 rights of drug
BRAND: inflammatory, analgesic, and moderately severe, acute drowsiness, sedation administration.
TORADOL antipyretic effects. pain CV:

Page | 12
CLASS CONTRAINDICATION: Arrhythmias, edema, - Assess patient's need for prn
THERAPEUTIC CLASS: Hypersensitivity hypertension, palpitations medication.
NON-STEROIDAL ANTI- SOURCE: DRUG TO DRUG INTERACTION: GI: - Assess first the patient
INFLAMMATORY DRUGS Comerford, K. C., & Salicylates; Probenecid; ACE Dyspepsia, GI pain, nausea, before administering this
PHARMACOLOGIC: Durkin, M. T. (2020). Nursing inhibitors constipation, diarrhea, drug: know the history and
NON-STEROIDAL ANTI- 2020 drug handbook (15th DRUG TO FOOD INTERACTION: flatulence, peptic ulceration,
physical condition of the
INFLAMMATORY DRUGS ed., Vol. 1). Philadelphia: _________________ stomatitis, vomiting, GI
DOSAGE: Wolters Kluwer. DRUG TO HERB INTERACTION: hemorrhage patient.
1 ampule White willow; Garlic; Ginger; EENT:
DURING:
ROUTE: Horse chestnut; Red clover; Nasal discomfort, rhinalgia,
- Monitor urine output.
IVP Feverfew; Dong quai rhinitis, throat irritation
GU: - Monitor for S&S of GI distress
DRUG TO LIFESTYLE Renal failure or bleeding.
INTERACTION: HEMA: - Inform patient to report any
Alcohol use; smoking Decreased platelet signs of itching, swelling in
adhesion, prolonged the ankles, sore throat, easy
bleeding time, purpura bruising, etc.
DERM:
- Monitor for fluid retention
Rash, urticaria, diaphoresis
MISC: and edema in patients
Pain at injection site AFTER:
- Teach patient about drug’s
side effect.
- Promote comfort measures.
Assess patient's condition
thereafter the therapy.
GENERIC: NSAID (non-steroidal anti- INDICATIONs: CNS: headache, dizziness, - Monitor for desired effect.
IBUPROFEN inflammatory drug) that is a Rheumatoid arthritis; drowsiness, nervousness, - Monitor blood pressure
BRAND: pain reliever and fever osteoarthritis aseptic meningitis closely during treatment.
ADVIL Mild to moderate pain; - Monitor allergies
reducer. Ibuprofen is the
CLASS: Moderate to severe pain as CV: hypertension, arrhythmias - Stay alert for GI bleeding
active ingredient in a range
adjunct to opioid analgesics; and ulcers, especially for
THERAPEUTIC of over-the-counter (OTC) Fever reduction; Primary EENT: amblyopia, blurred long term therapy.
ANALGESIC, ANTI-PYRETIC medicines. Ibuprofen is dysmenorrhea; Juvenile vision, tinnitus - Watch out for GI upset,
ANTI INFLAMMATORY classed as non-steroidal anti- arthritis; adverse CNS (such as
inflammatory drug (NSAID). Fever reduction; pain relief GI: nausea, vomiting, headache and drowsiness),
PHARMACOLOGIC: Body chemicals called constipation, dyspepsia, and hypersensitivity
CONTRAINDICATION: reaction.
Page | 13
 NONSTREROIDAL ANTI- prostaglandins produce pain
INFLAMMATORY DRUG and fever. Advil is an
(NSAID) ibuprofen-based pain reliever
brand that blocks the body's
DOSAGE:
production of these
400 mg
prostaglandins, therefore
ROUTE: reducing pain and fever.
ORAL
SOURCE: McGraw-Hill (2013).
Nurse’s Drug Handbook (7th
edition). McGraw-hill
education.
GENERIC: Binds to opioid receptors in
MORPHINE SULFATE CNS, altering perception of
BRAND: painful stimuli. Causes
RAXANOL generalized CNS depression,
CLASS: decreases cough reflex, and
reduces GI motility
THERAPEUTIC
OPOID ANALGESIC, SOURCE: McGraw-Hill (2013).
ANTITUSSIVE Nurse’s Drug Handbook (7th
Hypersensitivity to drug or
other NSAIDs.; Perioperative
use in coronary artery bypass
graft surgery
DRUG TO DRUG INTERACTION:
__________________
DRUG TO FOOD INTERACTION:
_________________
INDICATIONs:
Mild to moderately severe
pain
CONTRAINDICATION:
Hypersensitivity to drug, its
components, or other opioids
abdominal discomfort, GI
bleeding
GU: cystitis, hematuria,
azotemia, renal failure
Hematologic: anemia,
prolonged bleeding time,
aplastic anemia, neutropenia,
pancytopenia,
thrombocytopenia,
leukopenia, agranulocytosis
Hepatic: hepatitis
Metabolic: hyperglycemia,
hypoglycemia
Respiratory: bronchospasm
Skin: rash, pruritus, urticaria,
Stevens- Johnson syndrome
Other: edema, allergic
reactions including
anaphylaxis
CNS: confusion, sedation,
malaise, agitation, euphoria,
floating feeling, headache,
hallucinations, unusual
dreams, apathy, mood
changes
CV: hypotension,
bradycardia, peripheral
Patient teaching:
- Tell patient to take oral drug
with full glass of water, with
food, or after meals to
minimize GI upset
- To help prevent esophageal
irritation, instruct patient to
avoid lying down for 30 to
60 minutes after taking
dose.
- Instruct patient to
immediately report irregular
heartbeats, black tarry
stools, vision changes,
unusual tiredness, yellowing
of skin or eyes, change in
urination pattern, difficulty
breathing, finger or ankle
swelling, weight gain,
itching, rash, fever, or sore
throat
- Caution patient to avoid
driving and other hazardous
activities until the knows
how drug affects
concentration, alertness,
and balance.
- Monitor vital signs and CNS
status.
- Assess pain level and
efficacy of pain relief.
- Evaluate patient for adverse
reactions.
- Stay alert for overdose signs
and symptoms, such as CNS
and respiratory depression,
Page | 14
 edition). McGraw-hill Respiratory depression, severe vasodilation, reduced GI cramping, and
PHARMACOLOGIC: education. bronchial asthma, peripheral resistance constipation.
OPOID AGONIST hypercarbia - Assess other drugs in
Paralytic ileus or suspected EENT: blurred or double vision, patient’s drug regimen for
DOSAGE: paralytic ileus miosis, reddened sclera those that could cause
20 mg/mL DRUG TO DRUG INTERACTION: additive or adverse
__________________ GI: nausea, vomiting, interactions.
ROUTE: constipation, decreased - Monitor patient for signs and
ORAL DRUG TO FOOD INTERACTION: gastric motility symptoms of drug
_________________ dependence or tolerance.
GU: urinary retention, urinary
tract spasms, urinary urgency Patient teaching
- Teach patient to minimize
Respiratory: suppressed adverse GI effects by taking
cough reflex, respiratory doses with food or milk.
depression - Tell patient to notify
prescriber promptly if he
Skin: flushing, sweating experiences shortness of
breath or difficulty
Other: physical or breathing or if nausea,
psychological drug vomiting, or constipation
dependence, drug tolerance become pronounced.
- Caution patient to avoid
driving and other hazardous
activities until he knows how
drug affects concentration,
alertness, vision,
coordination, and physical
dexterity.
- Instruct patient to move
slowly when sitting up or
standing, to avoid dizziness
or light-headedness from
sudden blood pressure
decrease.
- As appropriate review all
other significant and life-

Page | 15
 threatening adverse
reactions and interactions,
especially those related to
the drugs, herbs, and
behaviors mentioned
above.
GENERIC: Pain relief may result from INDICATIONs: Hematologic: - Observe for acute toxicity
ACETAMINOPHEN inhibition of prostaglandin Mild to moderate pain thrombocytopenia, hemolytic and overdose. Signs and
BRAND: synthesis in CNS, with caused by headache, muscle anemia, neutropenia, symptoms of acute toxicity
TYLENOL subsequent blockage of pain ache, backache, minor leukopenia, pancytopenia areas follows—Phase1:
CLASS: impulses. Fever reduction may arthritis, common cold, Nausea, vomiting, anorexia,
result from vasodilation and toothache, or menstrual Hepatic: jaundice, malaise, diaphoresis.
THERAPEUTIC increased peripheral blood cramps or fever. hepatotoxicity o Phase 2: Right upper
ANALGESIC, ANTIPYRETIC flow in hypothalamus, which quadrant pain or
dissipates heat and lowers CONTRAINDICATION: Metabolic: hypoglycemic tenderness, liver
PHARMACOLOGIC: body temperature. Hypersensitivity to drug coma enlargement, elevated
SYNTHETIC NON-OPOID bilirubin and hepatic
PAMINOPHENOL DERIVATIVE SOURCE: McGraw-Hill (2013). DRUG TO DRUG INTERACTION: Skin: rash, urticaria enzyme levels, prolonged
Nurse’s Drug Handbook (7th __________________ prothrombin time, oliguria
DOSAGE: edition). McGraw-hill Other: hypersensitivity (occasional). Phase 3:
500 mg education. DRUG TO FOOD INTERACTION: reactions (such as fever) Recurrent anorexia, nausea,
_________________ vomiting, and malaise;
ROUTE: jaundice; hypoglycemia;
ORAL coagulopathy;
encephalopathy; possible
renal failure and
cardiomyopathy. Phase 4:
Either recovery or
progression to fatal
complete hepatic failure.

Patient teaching
- Caution parents or other
caregivers not to give
acetaminophen to children
younger than age 2 without
consulting prescriber first.

Page | 16
- Tell patient, parents or other
caregivers not to use drug
concurrently with other
acetaminophen containing
products or to use more
than 4,000 mg of regular
strength acetaminophen in
24 hours.
- Inform patient, parents, or
other caregivers not to use
extra strength caplets in
dosages above 3,000 mg
(six caplets) in 24 hours
because of risk of severe
liver damage.
- Advise patient, parents, or
other caregivers to contact
prescriber if fever or other
symptoms persist despite
taking recommended
amount of drug.
- Inform patients with chronic
alcoholism that drug may
increase risk of severe liver
damage.
- As appropriate, review all
other significant and life-
threatening adverse
reactions and interactions,
especially those related to
the drugs, tests, and
behaviors mentioned
above.

Page | 17
 B. IV Fluids
IV Fluids Classification Components Use and effects Nursing Responsibility
Isotonic Crystalloid Fluid Balanced/ Buffered solution Na Cl 0.9% ⚫ Use with caution in patients ⚫ Properly label the IV Fluid
Na 150mmol/L with heart failure, edema or ⚫ Solution containing
Cl 150mmol/L hypernatremia. dextrose should be used
⚫ Used for initial volume with caution in patients
Ringer’s Lactate (Hartmaan’s resuscitation ⚫ Observe aseptic technique
solution) ⚫ Use cautiously in renal and when changing IV Fluid
Na 131mmol/L cardio patients ⚫ Discard unused portion
K 5mmol/L
Ca 2mmol/L
Cl 111mmmol/L
HCo3 29mmmol/L

Dextrose 5%
50g/L
200kcal/L

Page | 18
 C. Surgery
Procedure Description and Indication Nursing Care / Responsibility
Exploratory Laparotomy Exploratory is an open surgery of the abdomen to view the organs and 1. Monitor consciousness, vital signs, CTV, intake
tissue inside. and output
2. To observe and record color and amount of
Indication: drainage
⚫ Blunt abdominal trauma + hypotension + positive FAST or clinical 3. Sterile wound care.
evidence of intra peritoneal bleeding.
⚫ Penetrating trauma: e.g.: gun shoot/ abdominal evisceration
⚫ Peritonitis
⚫ Free air, retroperitoneal air or rupture of hemidiaphragm after blunt
trauma
⚫ Organ specific injury-on CT scan
Splenectomy Splenectomy is the surgical removal of the spleen. ⚫ Remove N-G tube and the suction drain when
drainage is minimal
Indications: ⚫ Provide patient education leaflet
⚫ Pneumonic; TRASH-TV ⚫ Ensure antibiotic plan and immunization plan
⚫ Torsion; wandering spleen
⚫ Rupture; trauma
⚫ Adjunctive to surgery; pancreatectomy, gastrectomy, staging of HL
⚫ Swellings; splenomegaly, hypersplenism, portal hypertension
⚫ Haematological disorders; RBC disorder- spherocytosis, Hbss,
thalassemia, WBC disorders- leukaemia, myelofibrosis, PLATELET
disorders-idiopathic thrombocytopenic purpura.
⚫ Tumor: haemangiomas, hemangiosarcoma, lymphoma
⚫ Vascular anomalies: aneurysm of the splenic artery, splenic vein
thrombosis

Page | 19
XII. NURSING CARE PLANS
A. Prioritization of Problems
A.1. List of Problems
PREOPERATIVE
Ineffective Breathing Pattern
Acute Pain
POST OPERATIVE
Acute Pain
Risk for Hypovolemic Shock
Risk for Infection

A.2. Basis for Prioritization

Nursing Problem Rank Nursing Diagnosis Justification

PREOPERATIVE
INEFFECTIVE 1 INEFFECTIVE According to the
BREATHING PATTERN BREATHING PATTERN ABC’s we should
related to pain from initially prioritize the
injury breathing of the
patient before
anything else. In
emergencies, the
ABCs serves as a
first aid and
minimizes further
injuries. Further,
Maslow’s Hierarchy:
The physiologic
needs states that
breathing is
fundamental to life
and our body’s
cells would die
without it
ACUTE PAIN 2 ACUTE PAIN related to This is the second
trauma to tissue as priority because it
evidenced by muscle may create
guarding and rebound changes in comfort
tenderness and disrupt typical
routines, which can
influence an
individual's
physiological
requirements,
which if not
addressed, can
cause the physical
body to struggle to
function, according
to Abraham
Maslow's hierarchy
of needs.
After stabilizing a
patient, we can
now address the
pain felt because
these injuries when
Page | 20
 not properly
managed can lead
to more severe
problems.
POST OPERATIVE
ACUTE PAIN 3 ACUTE PAIN related to Medical problems
presence of post such as
operative surgical pneumonia, deep
incision as evidenced vein thrombosis,
by verbal report of infection, and
pain, guarding delayed healing, as
behavior and facial well as the
mask development of
chronic pain, can
result from poor
post-operative
acute pain
treatment. As a
result, it is critical
that all surgical
patients have
proper pain
treatment.
RISK FOR 4 RISK FOR According to
HYPOVOLEMIC HYPOVOLEMIC SHOCK Maslow’s hierarchy
SHOCK secondary to of needs, this would
abdominal trauma as fall under safety
manifested by severe needs on health
internal blood loss and wellness.
This is fourth to be
prioritized because
risk for shock
related to extreme
blood loss may
lead to various
complications and
would then lead to
death.
RISK FOR INFECTION 5 RISK FOR INFECTION According to
related to post Maslow’s hierarchy
operative incision of needs, this would
also fall under
safety needs on
health and wellness
but it is fifth priority
because it
progresses slowly
and could
intervene faster
because this can
be monitored
easily.

Page | 21
 A. Nursing Care Plans
NCP 1: INEFFECTIVE BREATHING PATTERN related to pain from injury
ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
PROBLEM
Subjective: Abdominal trauma is an STO: Dx. STO:
injury to the abdomen. ❖ Assessed quality of ❖ Individuals sustaining Goal met.
Objective: Within 1-2 hrs. of
Signs and symptoms breath sounds, RR, abdominal trauma are Within 1-2 hrs. of
performing nursing presence/absence of likely to be tachypneic, effective nursing
• Abrasion on the left include abdominal pain, interventions the patient
side beneath the tenderness, rigidity, and cough, and sputum with the potential for interventions, the patient
is eupneic with pulse characteristics. poor ventilatory effort. the patient is eupneic
costal margin with bruising of the external rate (PR) 60-100
tenderness in the left If not reversed, this with pulse rate (PR) 60-
abdomen. breaths/min and clear
upper quadrant; could result in 100 breaths/min and
Complications may breath sounds.
• Slightly drowsy atelectasis and clear breath sounds.
include blood loss and pneumonia.
LTO:
infection.
Within 24 hrs of ❖ Assessed for upper ❖ Pain can result from LTO:
Initial V/S: performing nursing abdominal pain. shallow breathing Goal met.
PR: 110 bpm interventions, the patient Within 24-72 hours of
will: ❖ Monitored oximetry ❖ O2 saturation 92% or effective nursing
BP: 84/60 mmhg
The patient will exhibit readings q2-4h; report less usually signals interventions, the patient
Sat.: 90% an effective breathing significant findings. need for supplemental was able to exhibit an
pattern with oxygen oxygen. effective breathing
saturation within the pattern with oxygen
Nursing Diagnosis: normal range. ❖ Encouraged and assist ❖ These measures help saturation within the
patient with coughing, prevent pneumonia normal range and rests
INEFFECTIVE BREATHING - Rest and conserve deep breathing, and and atelectasis. and conserves energy
PATTERN related to pain energy by limiting turning q2-4h. by limiting activities and
from surgical incision activities and remaining remaining in bed and
in bed and then slowly then slowly increasing
increasing activities. Tx. activities.

❖ Ensured adequate ❖ Patients with

hydration; may require abdominal pain may
intravenous fluids have a diminished
appetite, be NPO, or
not want to drink fluids.

Page | 22
 Assess and promote
appropriate fluid
balance, which may
require notifying the
provider of a
decreased oral intake
and the need for
intravenous fluids to
maintain fluid balance.

Edx.
❖ Educated patient or ❖ These allow sufficient
significant other on mobilization of
proper breathing, secretions. Deep
coughing, and breathing exercises
splinting methods. facilitates maximum
expansion of the lungs
and smaller airways,
and improves the
productivity of cough.
Splinting reduces chest
discomfort and an
upright position favors
deeper and more
forceful cough effort
making it more
effective.

❖ Educated the patient ❖ These measures allow

about pursed-lip the patient to
breathing, abdominal participate in
breathing, performing maintaining health
relaxation techniques, status and improve
performing relaxation ventilation.
techniques, taking
prescribed

Page | 23
medications (ensuring
the accuracy of dose
and frequency and
monitoring adverse
effects), scheduling
activities to avoid
fatigue, and provide
for rest periods.

Page | 24
NCP 2: ACUTE PAIN related to trauma to tissue as evidenced by muscle guarding and rebound tenderness
ASSESSMENT EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
PROBLEM
Subjective: First, tissue damage STO: Dx: STO:
" She complaints of release chemical After 1 hour of effective ❖ Assessed the nature ❖ Provide information to Fully met:
generalized abdominal mediators, such as nursing interventions, the and location of the aid in determining The patient has verbally
pain and left shoulder - prostaglandins, patient will be able to patient’s pain, the choice or effectiveness stated she was relieved
tip pain." as verbalized bradykinin, serotonin, verbally state relieve presence or absence of interventions. and experienced
by the patient’s mother. substance P, and and decrease pain to of distention. decreased pain level to
histamine. These 4/10. 4/10.
❖ Conducted frequent ❖ Decreasing
Objective: substances then
checks of the patient’s responsiveness may
• Slightly drowsy activate nociceptors, LTO: level of responsiveness. offer a clue to an LTO:
• Facial grimacing resulting in transduction, After 8 hours of effective increasing electrolyte Fully Met:
• Guarding behavior or the generation of an nursing interventions, the imbalance or The patient was able to
• Pain scale of 9/10 action potential (an patient will be able to impending shock. mage the pain with a
• Vital sign as follows: electrical impulse). In the manage the pain with a rating of 1/10 in the pain
PR- 110/min second process, rating of 1/10 in the pain Tx: scale of 1 to 10, wherein
BP- 89/60 mmHg transmission the action scale of 1 to 10, wherein ❖ Provided comfort ❖ To alleviate pain by 10 is the highest.
potential moves from 10 is the highest. measures such as promoting non-
the site of injury along repositioning the pharmacological pain
afferent nerve fibers to patient slowly and management.
Nursing Diagnosis: keeping the patient in
ACUTE PAIN related to nociceptors at the spinal
semi-Fowler’s position.
trauma to tissue as cord. Release of
evidenced by muscle substance P and other
❖ Provided comfort ❖ Promotes relaxation
guarding and rebound neurotransmitters carry measures such as and may enhance
tenderness. the action potential massage, back rubs, patient’s coping
across the cleft to the and deep breathing. abilities by refocusing
dorsal horn of the spinal attention.
cord, from where it
ascends the ❖ Administered ❖ Promotes comfort by
spinothalamic tract to analgesics as blocking impulses.
the thalamus and the indicated.
midbrain. Finally, from
the thalamus, fibers send Edx: ❖ Electrolytes help move
electrical signals
the nociceptive
Page | 25
message to the ❖ Educated the patient throughout your body
somatosensory cortex, to drink plentiful fluid and protein helps in
parietal lobe, frontal and eat protein rich building and repairing
lobe, and the limbic food. your body.
system, where the third
nociceptive process, ❖ To lessen the anxiety
and relax the mind of
then perception occurs.
the patient.
❖ Educated the patient
Source: with necessary
Wuhrman, E. and diagnostic test and
Cooney, F., (2011). treatments.
Acute Pain: Assessment
and Treatment. . (), pp.

Page | 26
NCP 3: ACUTE PAIN related to presence of post operative surgical incision as evidenced by verbal report of pain, guarding behavior and facial mask
ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
PROBLEM
Subjective: The patient had an STO: Dx: STO:
The patient claimed that intraperitoneal bleeding After 3 hours of nursing ❖ Reviewed ❖ Presence (Goal Met)
she is experiencing pain because her spleen interventions the client intraoperative or of narcotics and Within 3 hours of nursing
at the surgical site with a ruptured. She had given will be able to: recovery room droperidol in system interventions the client
pain scale of 6. exploratory laparotomy, a) Report pain is record for type of potentiates narcotic was able to report that
Objective: a surgery to open up the relieved with a pain anesthesia and analgesia, whereas the pain is relieved with
➢ Vital signs: abdomen. This is used scale of 0-3. medications patients anesthetized a pain scale of 3, has a
RR: 20 cpm when an abdominal b) Normal vital signs previously with Fluothane and stable vital sign, no
PR: 102 bpm injury needs emergency c) No facial grimace administered. Ethrane have no facial grimaces and
BP: 110/90 mmHg medical care which led noted residual analgesic acknowledged the
➢ (+) guarding her to feel pain of d) Acknowledge health effects. In addition, health teaching
behavior incision after the surgery. teaching intraoperative local/
➢ (+) grimace ACUTE PAIN, is an regional blocks have LTO:
➢ Restlessness unpleasant sensory and LTO: varying duration, e.g., (Goal Met)
observed. emotional experience Within 72 hours of nursing 1–2 hr for regionals or Within 72 hours of
arising from actual or interventions the patient up to 2–6 hr for locals. effective nursing
Nursing Diagnosis: potential tissue damage will: interventions, the patient
ACUTE PAIN related to or described in terms of a) achieve timely ❖ Noted patient’s age, ❖ Approach to was able to achieved
presence of post such damage wound healing weight, coexisting postoperative pain timely wound healing,
operative surgical (International b) Free from infection medical or management is based free from infection and
incision as evidenced by Association for the Study c) Able to move psychological on multiple variable was able to move
verbal report of pain, of Pain); sudden or slow without much conditions, factors. without much assistance
guarding behavior and onset of any intensity assistance from idiosyncratic from others
facial mask. from mild to severe with others. sensitivity to
an anticipated or analgesics, and
predictable end and a intraoperative
duration of greater (>3) course.
months. (NANDA)
❖ Evaluated pain ❖ Provides information
SOURCE/S: regularly (every 2 hrs about need for or
Doenges, M., noting effectiveness of
Moorhouse, M.F. & Murr, characteristics, interventions. Note: It
A. (2019). Nurse’s Pocket location, and may not always be
intensity (0–10 scale). possible to eliminate

Page | 27
Guide (15th edition). F.A.
Davis Company.
N.A. (2020). Exploratory
Laparotomy. Saint
Luke’s.
https://www.saintlukeskc
.org/health-
library/exploratory-
laparotomy
William C. Shiel Jr., MD,
FACP, FACR (2020). Why
is exploratory
laparotomy done?
Medicin Net.
https://www.medicinen
et.com/why_is_an_explo
ratory_laparotomy_done
/article.htm
Tx:
pain; however,
analgesics should
reduce pain to a
tolerable level
❖ Assessed vital signs, ❖ Changes in these vital
noting signs often indicate
tachycardia, hyperte acute pain and
nsion, and increased discomfort. Note: Some
respiration, even if patients may have a
patient denies pain slightly lowered BP,
which returns to normal
range after pain relief
is achieved.
❖ Assessed causes of ❖ Discomfort can be
possible discomfort caused or aggravated
other than operative by presence of non-
procedure. patent indwelling
catheters, NG tube,
parenteral lines
(bladder pain, gastric
fluid and gas
accumulation, and
infiltration of IV fluids or
medications).
❖ Repositioned as ❖ May relieve pain and
indicated: semi- enhance circulation.
Fowler’s; lateral Sims’. Semi-Fowler’s position
relieves abdominal
muscle tension and
arthritic back muscle
tension, whereas
lateral Sims’ will relieve
dorsal pressures.
Page | 28
 ❖ Administered ❖ Useful for mild to
medication NSAIDs moderate pain or as
as ordered. adjuncts to opioid
therapy when pain is
moderate to severe.
Allows for a lower
dosage of narcotics,
reducing potential for
side effects.

❖ Provided regular oral ❖ Reduces discomfort

care, occasional ice associated with dry
chips or sips of fluids mucous membranes
as tolerated. due to anesthetic
agents, oral restrictions.

❖ Provided additional ❖ Improves circulation,

comfort measures: reduces muscle tension
backrub, heat or and anxiety associated
cold application with pain. Enhances
sense of well-being.
Edx:
❖ Encouraged use of ❖ Relieves muscle and
relaxation emotional tension;
techniques: deep- enhances sense of
breathing exercises, control and may
guided imagery, improve coping
visualization, music. abilities.

❖ Educated the client ❖ To prevent having an

about the proper infection.
wound care

❖ Encouraged ❖ To stimulate
ambulation such as contractions of the
intestines and prevent

Page | 29
walking within post-operative
individual limits complications.

Page | 30
NCP 4: RISK FOR HYPOVOLEMIC SHOCK secondary to abdominal trauma as manifested by severe internal blood loss
ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME
PROBLEM
Subjective: Hypovolemic shock STO: Dx: STO:
“I cannot breathe, my occurs when there is Within 30 minutes - 1 ❖ Assess the client's heart ❖ To evaluate the (Fully Met)
chest hurts. What is fluid loss. This results in hour of effective nursing rate and blood patient's response to Within 30 minutes-1 hour
happening? I am the drop in arterial blood interventions, the patient pressure the treatment of effective nursing
confused!” as verbatim pressure which activates will be able to: interventions, the patient
by the pt. the body’s - Have warm and dry ❖ Assess the client's ❖ To characterize pulse has warm and dry skin,
compensatory skin central and peripheral waveform regained her strength,
Objective: mechanism in attempt - Regain her strength pulses and acquired 40% of the
• Vital Signs: to increase the body’s - Acquire 40% of the lost lost blood from her
- BP: 80/60mmHg intravascular volume. blood from her body ❖ Assess the respiratory ❖ To characterize rapid, body.
- PR: 130bpm Diminished venous return rate, rhythm, and shallow respirations
- RR: 33cpm occurs as a result in LTO: auscultate breath and adventitious (Partially Met)
- Temp: 36.0°C arterial blood pressure. Within 24-48 hours of sounds breath sounds such as Within 30 minutes-1 hour
- Spo2: 95% Preloading or filling effective nursing crackles and wheezing of effective nursing
• agitated pressure then is reduced. interventions, the client which is included in interventions, the patient
• weak and thready pulse Thus, stroke volume and will: shock. has warm and dry skin,
• cold or clammy skin. cardiac output is - Maintain an regained her strength,
• pale skin decreased. Reduced adequate cardiac ❖ Monitor oxygen ❖ To maintain an oxygen but did not acquire 40%
• rapid and shallow mean arterial pressure output saturation and arterial saturation of the lost blood from
breathing follows as the cardiac - Have a heart blood gases her body or vice versa.
• sweating output gradually rate of 60-100
• dilated pupils decreases. And as the beats per ❖ Monitor cardiac output ❖ Cardiac output (Not Met)
tissue perfusion provides an objective Within 30 minutes-1 hour
minute with
decreases, the delivery number to guide of effective nursing
regular rhythm
Nursing Diagnosis: of nutrients and oxygen therapy interventions, the patient
- Acquire a normal
RISK FOR HYPOVOLEMIC to the cells are has cold clammy skin,
blood pressure of
SHOCK secondary to decreased, which could ❖ Assess skin color, ❖ Cool, pale, clammy restless and did not
abdominal trauma as ultimately lead to 120/80 mmHg temperature, and skin is an indication of acquire 40% of the lost
manifested by severe multiple organ - Acquire 100% of the moisture low cardiac output blood from her body.
internal blood loss dysfunction syndrome. lost blood from her and desaturation
NANDA defined Risk for body with complete Tx:
Shock as the WBC and platelet ❖ Provide electrolyte ❖ Electrolyte imbalance LTO:
susceptibility to an count replacement as may cause (Goal Met)
inadequate blood flow prescribed dysrhythmias

Page | 31
to the body’s tissues that ❖ Administer fluid and ❖ To maintain an Within 24-48 hours of
may lead to life- blood replacement adequate circulating effective nursing
threatening cellular therapy as prescribed blood volume interventions, the patient
dysfunction, which may by the physician maintained an
compromise health. adequate cardiac
Edx: output, a heart rate of
SOURCE/S: ❖ Educate the patient ❖ Proper nutritional 60 -100 beats per minute
Aprn Bc, M. D. E., Crrn, and family members needs help the patient with regular rhythm, a
M. M. R. M. F., & Bsn for adequate recover fast normal blood pressure of
Rn, A. M. C. (2019). nutritional needs of the 120/80 mmHg and
Nurse’s Pocket client acquired 100% of the
Guide: Diagnoses, lost blood from her body
Prioritized ❖ Encourage the patient ❖ To avoid the with complete WBC and
Interventions and to avoid heavy and recurrence of such platelet count.
Rationales (Fifteenth excessive chores complications
ed.). F.A. Davis (Partially Met)
Company. Within 24-48 hours of
Belleza, R. M. N. (2021, effective nursing
February 11). interventions, the patient
Hypovolemic Shock. maintained an
Nurseslabs. adequate cardiac
https://nurseslabs.c output, a heart rate of
om/hypovolemic- 60 -100 beats per minute
shock/ with regular rhythm, a
normal blood pressure of
120/80 mmHg and did
not acquire 100% of the
lost blood from her body
with complete WBC and
platelet count.
or vice versa.

(Not Met)
Within 24-48 hours of
effective nursing
interventions, the patient
did not maintain an

Page | 32
 adequate cardiac
output, a heart rate
higher than 60 -100
beats per minute with
regular rhythm, a higher
blood pressure of 120/80
mmHg and did not
acquire 100% of the lost
blood from her body
with complete WBC and
platelet count.

Page | 33
NCP 5: RISK FOR INFECTION related to post operative incision.

ASSESSMENT EXPLANATION OF THE OBJECTIVE INTERVENTION RATIONALE EXPECTED OUTCOME

PROBLEM
SUBJECTIVE: Patient X is diagnosed STO: Dx: STO:
‘I just had my surgery 6 with abdominal trauma, Within 15 minutes of ❖ Assess signs of ❖ Fever may indicate Within 15 minutes of
hours ago’ making her undergo a nursing intervention, the infection especially infection. nursing intervention,
surgery in order to treat patient will identify risk temperature.
OBJECTIVE: it. The decision to suture factors that are present Goal met:
T-36.3C depends on the nature and have a partial Tx: The patient had
SPO2:95% of the wound the time understanding about ❖ Maintain aseptic ❖ Regular wound identified risk factors that
technique when dressing promotes fast
BP :110/70 since the injury was infection control. are present and had a
changing healing and drying of
RR:18bpm sustained the degree of partial understanding
dressing/caring wounds.
-patient looks weak in contamination. about infection control.
wound.
appearance
-Clean and intact Reference: ❖ Keep area around ❖ Wet area can be Goal partially met if:
abdominal dressing. Brunner & suddarth’s LTO: wound clean and dry. lodge area of The patient hadn’t
textbook of Medical- Within 24 hours of nursing bacteria. identified risk factors that
NURSING DIAGNOSIS: surgical Nursing 11
th infection, the patient will are present and had a
RISK FOR INFECTION edition by Smeltzer, have a full ❖ Administer antibiotics ❖ Antibiotic will help kill partial understanding
related to post Bare, Hinkle, cheever understanding of as ordered by the and stop the about infection control.
operative incision. infection control and will physician. proliferation and
be free from any signs growth of the bacteria Goal unmet if:
and symptoms of which could cause the patient hadn’t
related to infection. infection. identified risk factors that
Edx: are present and had a
❖ Educate the patient ❖ Knowledge of ways to partial understanding
about appropriate reduce or eliminate about infection control.
cleaning, disinfecting germs reduce the
and sterilizing items. likelihood of
-It can reduce stress and
transmission.
regain strength
❖ Encourage adequate ❖ It can reduce stress
rest -To prevent further
and regain strength
complications

Page | 34
❖ Advice to report any ❖ To prevent further LTO:
problems complications Within 24hours of nursing
intervention,

Goal met:
The patient had a full
understanding of
infection control and is
free from any signs and
symptoms of related to
infection.

Goal partially met if:

the patient had a full
understanding of
infection control and is
NOT free from any signs
and symptoms of
related to infection.

Goal unmet if:

the patient had not had
a full understanding of
infection control and is
not free from any signs
and symptoms of
related to infection.

Page | 35
 B. Discharge Plan
A. Eat a nutritious diet high in vitamin C, protein, and zinc to
promote wound healing.
❖ Citrus fruits and green vegetables such as broccoli and
Brussels sprouts are rich in vitamin C.
❖ Meats and milk products are high in protein and zinc.
DIET/NUTRITION B. Have an increased fluid intake of 6-8 glasses of water a day
as it is another frequent home treatment recommendation
thus limiting also the intake of caffeine.
A. Limit Movement
For 4 to 8 weeks after your surgery, or until your doctor tells you
otherwise, do not lift, pull, or push anything that weighs more than 10
pounds. Do not perform any movement or exercises that use your
abdominal muscles, such as sitting straight up from a lying position.
B. Get Plenty of Rest
Sleep is very important when healing after surgery. If you are having
trouble sleeping, try using a body positioner or pillow. Keeping a
pillow between your knees or under your stomach will help you sleep
more comfortably after surgery. Place the body positioner under the
ACTIVITY back to support the spine as you on lie on your side, reducing
pressure on the sacrum. If you’re trying a new sleeping position, a
supportive head pillow can help too.
C. NO SMOKING
For 2 weeks after surgery because it will delay the wound healing.
A. Take medication as prescribed by the doctor
MEDICATION B. POSTOPERATIVE MEDICATION
Ibuprofen — 400 mg; PO
A. Keep the wound clean and dry for the first 72 hours. Your
health care provider will tell you when you can shower.
When having a shower, do not let the spray go directly onto any
incision until it is well healed. Avoid baths, swimming pools and hot
tubs until your incision is well healed.
B. When should you call your family doctor or health care
provider?
Call your family doctor or health care provider right away if you
have:
WOUND CARE • a wound that is more red, swollen or hot
• a wound that has green or yellow drainage
• a wound that smells bad
• bleeding that does not stop with pressure
• pain that is not getting better
• a feeling of hardness or fullness around the wound
• any incision opens
• a fever over 38.3°C or 101°F

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XIII. LEARNING INSIGHTS
1. Abeer, Mahmud
- The abdomen can be injured in many types of trauma; injury may be
confined to the abdomen or be accompanied by severe, multisystem
trauma. The nature and severity of abdominal injuries vary widely depending
on the mechanism and forces involved, thus generalizations about mortality
and need for operative repair tend to be misleading. Blunt trauma may
involve a direct blow, impact with an object, or sudden deceleration. The
spleen is the organ damaged most commonly, followed by the liver and a
hollow viscus (typically the small intestine). What makes this case interesting is
how it is broad and has so much for us to learn as student nurses making us
provide the best care to such kind of cases. As a future nurse, my role for such
cases would be begin with an assessment of the abdomen. The abdominal
assessment is often less than effective due to the often-subtle signs and
symptoms and the other distracting injuries a patient may have. Observing
the abdomen for contusions, abrasions and distension or penetrating
wounds. Consider that wounds above the umbilicus could have thoracic
implications. Auscultating for bowel sounds and bruits. Absent bowels sounds
should be considered in conjunction with other assessment data. Bruits may
indicate injury to a great vessel, liver or spleen. Assessing for guarding or
rigidity, keeping in mind the older adult often has more subtle signs of
peritoneal irritation than their younger counterparts.
2. Anablon, Jhemaima
- This case presentation provides us an opportunity to developed further into
the state of thinking critically. It was a challenging case for me but still
wanted to learn as much as I can. This actually gave me a clear discussion
specially what causes this condition, but there are certain details I don't
understand. Furthermore, I learned how to deal in this condition and what to
prioritized.
3. Bersalona, Nestle Gay
- As a nursing student, this case study develops my reflective and critical
thinking. In this case study, I learned that we really need a deep
understanding and a lot of patience, I learned how to handle or how we
treated our patients in this kind of situation. In making our case study it makes
me realize how communication and working together important is.
4. Bin Qursain, Saleh Faroq
- I learned that it is possible for a person who has an accident to be in danger,
even if no visible symptoms appear on the body. It is possible that internal
bleeding or damage to organs may occur. I learned what to do from x-rays
or internal examination and how you can take care of the patient and give
the appropriate treatment.
5. Dalog, Jasjine Khyla
- This case analysis and case presentation is still something new to me – to us
despite us having one last semester. Even if we had done one, I would still
consider ourselves beginners nearing to competent in skill. Making this output
very challenging yet exciting. Moreover, the case given to us was very
informative on our part even if we weren’t able to witness it firsthand, but
nonetheless, I was able to gather and gain new knowledge for my
betterment. But because of the current situation for us not being able to see
or witness this phenomenon, we were able to work more as a group and
show our strengths, weaknesses and limitations that we have for the
betterment and improvement of our group. Initially, I thought that we will not
be able to finish this with how we have finished it with all our efforts and
perseverance – but we were able to finish it with some confidence that we
have made a good, even if not the best, case study. This will also serve as our
baseline or steps for our future better case studies and presentations. I can’t
wait to learn more from the comments and suggestions of our panelists.
6. Escobar, Alyssa Julia
- Making a case presentation is hard and challenging but I gained in-depth
knowledge while doing this case presentation. This research helped me to
improve my skills in providing high-quality patient care, documentation,
develop a management, critical thinking skills and decision-making. I believe
Page | 37
 that this case presentation will help us students to provide quality patient care
and we must be able to solve problems and overcome daily challenges.
7. Galliasto, Nezelyn
8. Lachaona, Jian Emmanuel
- The case study has broadened my knowledge about ruptured spleen -
intraperitoneal bleeding. I learned about ruptured spleen's pathophysiology,
symptoms, treatment, prevention, and, importantly, managing patients with
ruptured spleen. I also learned that as nurses, it is our job to evaluate, screen,
make referrals, know the proper use of medications and interventions,
encourage and educate patients to perform an appropriate self-care, reach
a certain level of activity according to their goal, and enhance their quality
of life. The study also helps me develop my critical thinking skills and patient
care. I will apply everything I learned in my future duties and educate others
about ruptured spleen - intraperitoneal bleeding.
9. Sito, Antonette
- It's a fascinating case study that will be useful as I begin working in a hospital.
This case allows me to gain new knowledge and good learning about
abdominal trauma, which is very helpful for me to enriched my
understanding about it and how it may take place to someone else. It’s tricky
task to complete this case study as we have limited data but we do need to
gather more information, but it's also extremely valuable because it helps me
to better comprehend. Furthermore, I believe it is significant if we, as student
nurses, attempt to assess and care for patients in the actual setting.
10. Soriano, Edeniel
- In studying the case of our patient. I was able to conclude that A blunt
abdominal injury is a direct blow to the abdomen without an open wound.
Organs such as your pancreas, liver, spleen, or bladder may be injured. Your
intestines may also be injured. These injuries may cause internal bleeding. As
a healthcare provider, I have to watch her closely to see if your injury is mild
and your condition is stable. A blunt abdominal injury is treated depending
on how severe your injury is. Mild injuries, such as bruising and soreness, will be
monitored for a short time. Giving medicine to decrease swelling and pain. I
learned that symptoms of severe injuries may not appear for up to 8 hours.
Severe injuries, such as damage to organs, blood vessels, and bones, may
need surgery depending on the situation.
11. Tuyishimire, Liliane
- I'm grateful that I enrolled in this subject and are given chance to have
educational.
- I've learned a lot about our case presentation we focused on giving health
education regarding on blunt abdominal trauma and as well as
recommendations on how to prevent most of what we taught were on basic
among the society and we taught about how the society can learn how to
avoid it, I learned that it's helpful because i learned a lot about Abdominal
trauma.

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XIV. LIST OF REFERENCES
Abdominal Trauma-Introduction | Trauma Victoria. (n.d.). Major Trauma Guidelines &
Education. https://trauma.reach.vic.gov.au/guidelines/abdominal-
trauma/introduction
Aprn Bc, M. D. E., Crrn, M. M. R. M. F., & Bsn Rn, A. M. C. (2019). Nurse’s Pocket Guide:
Diagnoses, Prioritized Interventions and Rationales (Fifteenth ed.). F.A. Davis
Company.
Belleza, R. M. N. (2021, February 11). Hypovolemic Shock. Nurseslabs.
https://nurseslabs.com/hypovolemic-shock/
Blunt abdominal injuries in children. (n.d.). HERDINPlus.
https://www.herdin.ph/index.php?view=research&cid=34732
Comerford, K. C., & Durkin, M. T. (2020). Nursing 2020 drug handbook (15th ed.,
Vol. 1). Philadelphia: Wolters Kluwer.
Doenges, M., Moorhouse, M.F. & Murr, A. (2019). Nurse’s Pocket Guide (15th edition). F.A.
Davis Company.
Legome, E. L., MD. (2021, June 11). Blunt Abdominal Trauma: Practice Essentials,
Pathophysiology, Etiology. Medscape.
https://emedicine.medscape.com/article/1980980-
overview#:%7E:text=Blunt%20abdominal%20trauma%20usually%20results,colorect
um%2C%20diaphragm%2C%20and%20pancreas.
McGraw-Hill Nurses Drug Handbook, Seventh Edition (McGraw-Hill’s Nurses Drug
Handbook) 7th (seventh) Edition by Schull, Patricia published by McGraw-Hill
Professional (2013) (7th ed.). (2013). McGraw-Hill Education / Medical.
N.A. (2020). Exploratory Laparotomy. Saint Luke’s.
https://www.saintlukeskc.org/health-library/exploratory-laparotomy
O'Rourke MC, Landis R, Burns B. Blunt Abdominal Trauma. [Updated 2021 Jul 28]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-
. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431087/
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., PhD, & Cheever, K. H., PhD. (2008). Brunner &
Suddarth’s Textbook of Medical Surgical Nursing, 11th Edition (2 Volumes) (11th
ed.). Lippincott Williams & Wilkins.
Van, P. Y. (2021, November 17). Overview of Abdominal Trauma. MSD Manual
Professional Edition. https://www.msdmanuals.com/professional/injuries-
poisoning/abdominal-trauma/overview-of-abdominal-trauma
William C. Shiel Jr., MD, FACP, FACR (2020). Why is exploratory laparotomy done?
Medicin Net.
https://www.medicinenet.com/why_is_an_exploratory_laparotomy_done/article.
htm

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