Page 319 - Critical Care Nursing Demystified

304 CRITICAL CARE NURSING DeMYSTIFIED

Interpreting Test Results

Chest x-ray showing elevated hemidiaphragm on affected side and tip of
nasogastric tube (NGT) above the diaphragm.

Focused assessment with sonography for trauma (FAST), which is a nonin-
vasive test that examines the abdominal quadrants before a diagnostic peri-
toneal lavage (DPL).
DPL.

NGT shows blood if abdominal injury.
UA shows blood if kidney injury.

NURSING ALERT

A DPL that is positive for frank blood or lavage fluid of greater than 100,000/mL indi-

cates the presence of intraperitoneal hemorrhage.

Hallmark Signs and Symptoms
Signs of respiratory distress if ruptured diaphragm. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Signs of hemorrhagic shock if spleen and liver are damaged.

Auscultation of bowel sounds in the chest if ruptured diaphragm.
Diminished breath sounds on affected side.
Diminished or absent bowel sounds if injury to small, large bowel.
Shoulder pain and SOB if ruptured diaphragm.

Elevated temperature and abdominal tenderness if peritonitis.
Blood at the tip of the urethra can indicate urethral trauma.

Nursing Diagnoses Expected Outcomes
See nursing diagnoses for shock and ABCs

Nursing Interventions

Assess the ABCs to treat life-threatening emergencies on first priority basis.
Hemodynamic monitoring with a central line if shock is suspected.
Observe for signs/symptoms of peritonitis including abdominal guarding,
pain, tenderness, rigidity, discoloration around the umbilicus (Cullen’s sign),
decreased bowel sounds, tachycardia, and fever.
Assist with FAST and possible DPL to determine if blood has entered the
peritoneum due to trauma.