Question

A client presents to the Emergency Room after a motor vehicle accident. The client denies hitting their head; however, they do report pain in the left upper quadrant of their abdomen, and their breathing is labored with a respiratory rate of 28. Normal bowel sounds are auscultated. During the interview, the client states he has black, sticky stools weekly. (20 points)

• Discuss how the nurse will assess the client’s abdomen, including any significant landmarks and techniques.
• Describe the expected bowel sounds that are auscultated during the assessment and their meaning.
• Upon assessment, a mass in the upper left quadrant is palpated and the client states there is sensitivity when this is done. Discuss how the potential cause of this mass and how the nurse should proceed with the assessment
• Identify additional assessment questions the nurse ask regarding the client’s statement of black, sticky stools.
• The provider orders for the client to get 1. 5 L of normal saline via intravenous infusion over 8 hours. How many mL total will the client receive?

Answer 1

ABDOMINAL ASSESSMENT BY THE NURSE:As in basics of any trauma management, the nurse in the emergency room must first assess the trauma patient for adequacy of airway,breathing and circulationABC.The abdominal examination begins with providing patient privacy and explaining the procedure to the patient and taking patient's consent.Appropriate hand hygeine and ensuring stable hemodynamic status should be taken care of before starting the abdominal examination.

The patient is placed supine and an general enquiry of bowel and bladder habits is made while preparing the patient for the examination..The sequence of assessment is

1.Inspection:The skin is inspected for any signs of injury,bruises or discolouration.The contour is examined for  any mass or local areas of bulging(any hernias) are noted.A localised bulge with bruise may point to an underlying haematoma in cases of trauma.Guarding of the abdomen with very little movement during respiration indicates painful etiology.

A Grossly distended abdomen following trauma signifies haemoperitoneum or bowel or bladder rupture.

Any visible pulsations are noted.Expanding haematomas are pulsatile and should alert to the suspicion of major vessel injury usually aortic injury.

CULLEN'S SIGN:bluish discolouration around the umbilicus.(Indicates haemoperitonem or retroperitoneal bleed)

GRAY TURNER'S SIGN:bluish discolouration in the flanks noted in cases of retroperitoneal bleed.

Both these signs may take 12 hours or more to develop.

Urethral meatus is examined for a drop of blood at the tip.it may indicate and underlying urethral rupture

2.Auscultation:The diaphragm of the sthethoscope is placed in right lower quadrant and moved sequentially to right upper quadrant and then to the left abdomen.5-30 bowel sounds per minute are indicative of normal peristaltic activity.these are typically gurgling sounds or clicks.

If sounds are not heard in one minute then the auscultation should be done in a single place for about 5 mins.Absence of bowel sounds signifies paralytic ileus while exaggerated sounds indicate hyperperistalsis.

The aortic pulsation can he heard beneat the xiphoid process with the bell of a sthethoscope,the renal arteries on either side above umbilicus and the iliac arteries on either side below umbilicus,

3,Percussion:The note over normal abdomen is resonant;presence of a dull note may indicate ongoing internal bleed or mass .Here if dull note is found over the left quadrant mass it may indicate presence of underlying haematoma.

4.Palpation.First light palpation is done to assess presence of any tenderness or palpable pulsations.Then deep plapation is done with both hands to rule out any hepatosplenomegaly and any mass.

Careful palpation of the left quadrant mass must be done in this case to prevent any clot dislodgement and the chances of rebleed.

Bowel sounds assessment:As the clinical statement mentions that the bowel sounds are normal, clicks or gurgling sounds will be heard with a frequency of 5-30 per minute with the diaphragm of the sthethoscope.

Normal bowel sounds indicate normal bowel structure and function.Absence of bowel sounds indicates bowel injury or peritonitis or peritonism.

Potential causes of left upper quadrant mass with sensitivity in a case of abdominal trauma  and nursing assessment of left upper quadrant mass:

The potential causes of left upper quadrant mass with sensitivity following blunt abdominal trauma include;

1.splenic injury with haematoma with or without rib fractures.

Generally the lower ribs fracture following left lower quadrant blunt trauma and are associated with underlying splenic haematoma with/without pancreatic tail injury.

2.rib fracture with chest wall haematoma

3.pancreatic tail injury with or without splenic injury

4.splenic flexure colonic contusions.

5.left kidney injury and haematoma.

6.retroperitoneal haematoma with/without major vessels injury.

7.Blunt trauma stomach with stomach wall haematoma

8.aortic injury.

9.mesenteric artery injury with haematoma.

Of these causes,splenic haematoma with lower rib fractures is generally the commonest cause of left upper abdomen mass following blunt abdominal trauma.

Nursing assessment for the mass :The nursing staff must reasses the vitals of the patient again before proceeding with further examination in cases of left upper quadrant mass (tender);found after trauma during initial assessment.

:Reassesment should be done to note the expansile or pulsatile nature of the mass;increasing abdominal girth or distension,pallor all aimed at ruling out ongoing acute internal haemorrhage secondary to the haematoma. The nursing staff should also focus on palpation of the lower chest and rib cage for any crepitus,presence of associated pneumothorax indicated by absence of breath sounds especially as the patient here is tachypneic. .

This is commonly associated with splenic injury..X-ray chest is of diagnostic value here and should be performed in erect position if facilities permit.

Bedside ultrasound FAST is of great diagnostic value in the diagnosis of the abdominal mass.DPL can be performed as and when facilities permit to rule out ongoing internal haemorrhage.

Once patient is stabilised CECT chest and abdomen must be planned.

Additional assessment questions that the nurse should ask regarding client's statement of black sticky stools include the followi

DETAILED HISTORY SHOULD BE TAKEN BY THE NURSE TO ASCERTAIN THE VARIOUS CAUSES OF MALENA OR BLACK AND STICK STOOLS INCLUDING PEPTIC ULCER DISEASE,BLEEDING VARICES,LIVER DISEASE,OR ANY OTHER CAUSE OF UPPER GI BLEED.Very rarely though,small intestinal bleed or ascending colon malignancy can also produce black and sticky stools.

The hemoglobin is degraded by the bacteria present in the stools causing the blackish discolouration of the stools.

The assessment questions would include:

1.The frequency and the quantity of black and sticky stools(malena)

2. whether it is associated with hamatemesis

3.history of weight loss,early satiety(gastric cancer)

4.history of liver disease,any bleeding esophageal varices injected in the past.

5.history of peptic ulcer disease,reflux esophagitis associated with burning epigastric pain.

6.history of use of drugs like warfarin(anticoagulants,aspirin) must be enquired.

7.history of blood disorders like haemophilia,thrombocytopenia must be enquired about.

Rare cause include meckel's diverticulum.colonic angiodyspalsias etc.

however,black stools can also occur due to use of iron supplements and tonics containing excessive lead and the usage of medications like pepto bismol containing bismuth salicylate.

The history should be aimed at ruling out causes of false malena while trying to rule out the other pathological conditions.

TOTAL ML OF INTRAVENOUS FLUID RECEIVED BY THE CLIENT:

Dose ordered by the provider :1.5 L of normal saline over 8 hours

1L=1000ML

1.5 L=1000x1.5=1500ML.of normal saline.

The client will receive a total of 1500ml of normal saline over 8 hours.