Page 664 - ACCCN's Critical Care Nursing

Trauma Management 641

2. The catheter is clamped and 25 mL (use consistent Where the patient has undergone a trauma laparotomy,
amount for all measurements) of room-temperature postoperative care is standard as for any patient who has
0.9% saline is infused into an empty bladder via undergone an abdominal surgical procedure. The specific
the indwelling urinary catheter. This will create the nursing care elements will depend on what organ has
static column of fluid for pressure measurement. been injured and the surgical procedure that has been
Higher infused volumes may create a falsely ele- undertaken to repair the injury. Careful attention must
vated intraabdominal pressure. be paid to those general nursing care elements that all
3. After 30–60 seconds of dwell time, the pressure is patients require (see Chapter 6).
measured via the transducer or manometer. Postoperative feeding and bowel care should be discussed
4. The catheter is unclamped to allow fluid to drain with the healthcare team and plans made early to avoid
out. It must be remembered to deduct the fluid delays and adverse events such as constipation (see
installation amount from any future urine output Chapter 19 for principles of feeding). A paralytic ileus is
measurements.
a common manifestation of the critically-ill abdominal
There is some evidence that accurate IAP measurements trauma patient. Ensuring that the gut is decompressed,
can be obtained on a continuous basis using a three-way with a functional enterogastric tube that is correctly posi-
catheter. The benefits of this method include the provi- tioned, is essential. Because constipation is a common
67
sion of a continuous measurement as well as the absence problem, early intervention and implementation of a
of instillation of additional fluid into the bladder. The bowel-care protocol for trauma should be considered (see
primary disadvantage is the potential for inaccuracy, Chapter 6).
depending on the volume of urine in the bladder.
Collaborative practice
Nursing Practice Collaborative practice for the care of patients after
Recent trends have seen an increasing use of nonoperative abdominal trauma includes effective diagnosis, surgical
care of patients with abdominal injury. In these patients, or radiological interventions, and associated care.
monitoring for deterioration is essential, as is the ability Damage-control surgery is now a mainstay in
to activate surgery and care for patients accordingly. management.
Diagnosis in the trauma setting consists of a thorough
Independent practice clinical assessment, the potential use of FAST, diagnostic
With the high use of nonoperative management tech- peritoneal lavage (DPL), abdominal computed tomogra-
niques for solid organ injury, the role of monitoring of phy (CT) and laparotomy or laparoscopy. Clinical assess-
patients with abdominal trauma is pivotal. Nurses must ment has the potential to reveal such clinical signs as skin
be cognisant of the clinical signs of abdominal injury, bruising, lacerations, signs of abdominal rigidity and
especially haemorrhage, and act on these immediately guarding. The various locations of clinical signs are clues
(see Table 23.8). Specific aspects of nursing care for to potential abdominal injury. The results of this phase
patients after abdominal trauma include pain manage- of the investigation will determine what additional diag-
ment, monitoring and postoperative care. Abdominal nostic tests are undertaken. FAST is rapidly becoming an
trauma patients will often experience severe pain, as a extension of the clinical assessment in abdominal trauma
result of both the primary trauma and any surgical inter- patients.
vention for repair (see Chapter 7).
Collaborative practice: diagnostic
Vital sign monitoring is a mainstay of nursing manage-
ment in patients with abdominal trauma, and all patients peritoneal lavage
should have appropriate monitoring (as outlined in The diagnostic peritoneal lavage (DPL) is a diagnostic
trauma reception). It is also essential that all patients procedure that can be undertaken rapidly to assess for
receive a urinalysis after incurring abdominal trauma in intraabdominal bleeding. It can identify the presence of
order to identify trauma to the urinary system. haemorrhage but gives no indication of its source. DPL

TABLE 23.8 Common signs of abdominal injury 83

Sign Description Suspected injury
Grey Turner’s sign Blueish discolouration of the lower abdomen and flanks Retroperitoneal haemorrhage
6–24 hours after onset of bleeding
Kehr’s sign Left shoulder tip pain caused by diaphragmatic irritation Splenic injury, although can be associated with any
intra-abdominal bleeding
Cullen’s sign Bluish discolouration around the umbilicus Pancreatic injury, although can be associated with any
peritoneal bleeding
Coopernail’s sign Ecchymosis of scrotum or labia Pelvic fracture or pelvic organ injury