Primary Nursing Diagnosis

Ineffective breathing pattern related to pain and abdominal distension

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

H PLANNING AND IMPLEMENTATION Collaborative

The initial care of the patient with abdominal trauma follows the ABCs of resuscitation. Measures to ensure adequate oxygenation and tissue perfusion include the establishment of an effective airway and a supplemental oxygen source, support of breathing, control of the source of blood loss, and replacement of intravascular volume. Titrate intravenous fluids to maintain a systolic blood pressure of 100 mm Hg; over-aggressive fluid replacement may lead to recurrent or increased hemorrhage and should be avoided prior to surgical intervention to repair damage. As with any traumatic injury, treatment and stabilization of any life-threatening injuries are completed immediately.

SURGICAL. Surgical intervention is needed for specific injuries to organs. Diaphragmatic tears are repaired surgically to prevent visceral herniation in later years. Esophageal injury is often managed with gastric decompression with a nasogastric tube, antibiotic therapy, and surgical repair of the esophageal tear. Gastric injury is managed similarly to esophageal injury, although a partial gastrectomy may be needed if extensive injury has occurred. Liver injury may be managed nonoperatively or operatively, depending on the degree of injury and the amount of bleeding. Patients with liver injury are apt to experience problems with albumin formation, serum glucose levels (hypoglycemia in particular), blood coagulation, resistance to infection, and nutritional balance. Management of injuries to the spleen depends on the patient's age, stability, associated injuries, and type of splenic injury. Because removal of the spleen places the patient at risk for immune compromise, splenectomy is the treatment of choice only when the spleen is totally separated from the blood supply, when the patient is markedly hemodynamically

10 Abdominal Trauma unstable, or when the spleen is totally macerated. Treatment of pancreatic injury depends on the degree of pancreatic damage, but drainage of the area is usually necessary to prevent pancreatic fistula formation and surrounding tissue damage from pancreatic enzymes. Small- and large-bowel perforation or lacerations are managed by surgical exploration and repair. Preoperative and postoperative antibiotics are administered to prevent sepsis.

NUTRITIONAL. Nutritional requirements may be met with the use of a small-bore feeding tube placed in the duodenum during the initial surgical procedure or at the bedside under fluoroscopy. It may be necessary to eliminate gastrointestinal feedings for extended periods of time, depending on the injury and the surgical intervention required. Total parenteral nutrition may be used to provide nutritional requirements.

Pharmacologic Highlights

Medication or

Drug Class Dosage

Description

Rationale

Histamine-2 blockers Varies with drug

Ranitidine (Zantac); cimetidine (Tagamet); famotidine (Pepcid); nizatidine (Axid)

Block gastric secretion and maintain pH of gastric contents above 4.0, thereby decreasing inflammation

Other Therapies: Narcotic analgesia to manage pain and limit atelectasis and pneumonia, and antibiotic therapy as indicated.

Independent

The most important priority is the maintenance of an adequate airway, oxygen supply, breathing patterns, and circulatory status. Be prepared to assist with endotracheal intubation and mechanical ventilation by maintaining an intubation tray within immediate reach at all times. Maintain a working endotracheal suction at the bedside as well. If the patient is hemodynamically stable, position the patient for full lung expansion, usually in the semi-Fowler position with the arms elevated on pillows. If the cervical spine is at risk after an injury, maintain the body alignment and prevent flexion and extension by using a cervical collar or other strategy as dictated by trauma service protocol.

The nurse is the key to providing adequate pain control. Encourage the patient to describe and rate the pain on a scale of 1 through 10 to help you evaluate whether the pain is being controlled successfully. Consider using nonpharmacologic strategies, such as diversionary activities or massage, to manage pain as an adjunct to analgesia.

Emotional support of the patient and family is also a key nursing intervention. Patients and their families are often frightened and anxious. If the patient is awake as you implement strategies to manage the ABCs, provide a running explanation of the procedures to reassure the patient. Explain to the family the treatment alternatives and keep them updated as to the patient's response to therapy. Notify the physician if the family needs to speak to her or him about the patient's progress. If blood component therapy is essential to manage bleeding, answer the patient's and family's questions about the risks of hepatitis and human immunodeficiency virus (HIV) transmission.

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