ENA: EMERGENCY NURSING ORIENTATION

444 Pages·2012·3.9 MB·English

by  Marti Majino

ENA: EMERGENCY NURSING ORIENTATION
Comprehensive Lesson Notebook

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.
ENA: EMERGENCY NURSING ORIENTATION
Lesson Notebook: Abdominal and Genitourinary Trauma

Lesson Outline
Key Resources
Preceptor Exercises

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.
LESSON OUTLINE
Anatomy and Physiology Review
The abdominal cavity extends from the diaphragm to the pelvic brim. The abdomen is divided into
three sections: anterior, flanks, and posterior.
The peritoneum is a smooth, serous membrane that covers abdominal structures and lets the viscera
move within the abdomen without friction.
o Intraperitoneal solid organs include the liver, spleen, and gallbladder.
o Retroperitoneal solid organs include the kidneys and pancreas.
o Hollow abdominal organs include the stomach and the small and large intestines.
o Hollow genitourinary structures include the bladder and ureters.
o Vascular structures include the abdominal aorta, iliac arteries, renal arteries, and inferior
vena cava.
Assessment
Clues to a potential abdominal injury may come from the patient’s report of symptoms, history,
mechanism of injury, and assessment findings.
o Abdominal pain, rigidity, guarding, or spasms are classic symptoms of abdominal injury. Pain
may also be referred to the shoulder.
o The mechanism of injury, such as blunt or penetrating trauma, a motor vehicle crash, or a
fall, can suggest abdominal injury.
In abdominal injury, inspection may reveal asymmetric chest wall movement, abdominal distention
or other abnormal contour, and abdominal bruises, abrasions, or lacerations.
Auscultation may detect absent bowel sounds, bowel sounds in the thoracic cavity, or an abdominal
bruit.
Palpation may uncover pain, rigidity, tenderness, rebound tenderness, guarding, fullness or a doughy
consistency, crepitus, or pelvic instability.
Initial Stabilization and Emergency Department Interventions
For a patient with abdominal or genitourinary trauma, first secure the airway, breathing, and
circulation. Start two large-bore intravenous catheters and administer fluids, blood products,
analgesics, and antibiotics, as ordered. Obtain specimens for baseline laboratory tests.
Perform additional interventions in the emergency department:
o Unless the patient has signs of urethral damage, insert a urinary catheter to monitor urine
output.
o Insert a gastric tube to decompress the stomach.
o Admit the patient for surgery or observation or provide discharge instructions.
If the patient’s condition permits, prepare for diagnostic evaluation, as ordered.
o Common tests include radiography, computed tomography, focused assessment sonography
in trauma (FAST), diagnostic peritoneal lavage, and exploratory laparoscopy.
o Other imaging studies include magnetic resonance imaging, retrograde urethrography,
cystography, arteriography, and intravenous pyelography.
o If the patient is too unstable for imaging studies, prepare for exploratory surgery and
hemorrhage control.
o Obtain specimens for additional laboratory tests, as indicated.
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LESSON OUTLINE
Specific Abdominal Injuries
Splenic injury commonly results from blunt trauma, as in falls and motor vehicle crashes. It causes
left upper quadrant pain, Kehr sign, and significant hemodynamic instability. Splenic injuries are
graded by severity. Stable patients are managed nonoperatively. Surgery is reserved for unstable
patients.
Liver injury may result from blunt or penetrating trauma and causes right upper quadrant pain and
bruising and referred pain in the right shoulder. Major hepatic damage almost always causes
hemodynamic instability. Hepatic injuries are graded by severity, which helps determine the need for
surgery. More than 50 percent of adults with liver injury receive nonoperative treatment.
Stomach injury usually occurs with penetrating trauma and multiorgan, multisystem injuries. It
causes left upper quadrant pain, abdominal muscle rigidity, gross blood in gastric aspirate, and free
air on abdominal radiography.
Intestinal injury can result from blunt or penetrating trauma, which can lead to intestinal rupture and
peritoneal contamination. It causes abdominal tenderness and rigidity, crepitus, and signs of
peritoneal contamination. Surgery is required.
Pancreatic injury is likely to result from penetrating retroperitoneal trauma. It causes epigastric or
back pain, Cullen sign, and an altered lipase level. When surgery is needed, the pancreas is preserved
as much as possible.
Diaphragmatic rupture may stem from blunt or penetrating trauma. It causes respiratory
compromise, bowel sounds in the chest, cardiac compression, and radiography that shows abdominal
contents in the chest. Immediate surgery is required.
Vascular injury can result from blunt or penetrating trauma. Hemorrhage can lead to metabolic
acidosis, coagulopathy, and hypothermia. Without surgical repair, severe hemorrhage and death can
occur.
o Foreign bodies in the stomach or rectum result from ingestion and other causes. In body
packing, a condom or other drug wrapper can rupture, causing toxic effects. Depending on
the foreign body’s size, shape, and location, removal may occur in the emergency
department or surgical suite.
Specific Genitourinary Injuries
Most genitourinary injuries result from blunt force and are not immediately life threatening.
Renal injury causes flank or abdominal tenderness, Grey Turner sign, a mass or hematoma over the
flank, and hematuria. Renal injuries of grade I to III do not usually require surgery. Higher grades may
require nephrectomy.
Ureteral injury rarely occurs but may result from penetrating trauma. Consider this injury in any
trauma patient with worsening abdominal pain, fever, leukocytosis, or an unexplained fluid
collection. Surgical repair is needed.
Bladder injury typically is associated with pelvic injuries from motor vehicle crashes, falls, and
physical assaults. It may cause hematuria, suprapubic pain, an inability to urinate, localized bruising,
abdominal distention, guarding, and rebound tenderness. Intraperitoneal bladder rupture requires
exploratory laparotomy and repair. Extraperitoneal injury needs bladder drainage only.

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LESSON OUTLINE
Urethral injury mainly affects men. Posterior-segment injuries are related to pelvic ring fractures.
Anterior-segment injuries result from external blunt or straddle mechanisms. Manifestations include
blood at the meatus; localized pain, swelling, and bruising; a high-riding prostate gland; and
hematuria. Most injuries require cystostomy and injury repair.
Urethral foreign bodies usually result from self-insertion. Common complaints include dysuria, pain,
discharge, hematuria, swelling, or abscess formation. Management calls for removing the foreign
body and treating complications.
Penile injury commonly takes the form of a fracture. Manifestations include a popping sound
followed by pain, swelling, and rapid detumescence. Surgery is essential to prevent deformity,
impotence, and other complications.
Testicular injuries include contusion, hematocele, rupture, dislocation, and torsion. Findings may
include severe scrotal pain, swelling, and bruising. Apply ice and provide analgesics while the patient
awaits urologic consultation.
Straddle injury occurs when a patient falls and takes the brunt of the fall on the perineum. Treatment
calls for laceration repair and hematoma evacuation and drainage.

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KEY RESOURCES
Grading of Splenic Injuries
Category Description
Grade
Hematoma Subcapsular hematoma involves less than 10% of
I
the surface area and does not expand.
Laceration Nonbleeding capsular tear is less than 1 cm deep.
Hematoma Subcapsular hematoma covers 10% to 50% of the
II
surface area and does not expand.
Intraparenchymal hematoma is less than 2 cm
wide.
Laceration Capsular tear is accompanied by active bleeding.
Intraparenchymal injury is 1 to 3 cm deep.
Hematoma Subscapular hematoma involves more than 50%
III
of the surface area or is expanding.
Intraparenchymal hematoma is 5 cm or larger or
expanding. Ruptured subscapular hematoma is
accompanied by active bleeding.
Laceration Laceration is more than 3 cm deep or involves
intracellular vessels.
Hematoma Ruptured intraparenchymal hematoma is
IV
accompanied by active bleeding.
Laceration Laceration is segmental or involves hilar vessels
and devascularization of more than 25% of the
spleen.
Hematoma Spleen is shattered.
V
Laceration Laceration causes hilar vascular injury. Spleen is
devascularized.
Source: Pearl, W.S., & Todd, K.H. (1996). Ultrasonography for the initial evaluation of blunt
abdominal trauma: A review in prospective trials. Annals of Emergency Medicine, 27, 353–361.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.
KEY RESOURCES
Grading of Hepatic Injuries
Category Description
Grade
Hematoma Nonexpanding subcapsular hematoma involves less than 10% of the liver’s surface.
I

Laceration Nonbleeding capsular tear is less than 1 cm deep.
Hematoma Nonexpanding subcapsular hematoma covers 10% to 50% of the surface area and is less
II
than 2 cm deep.

Laceration Laceration penetrates less than 3 cm into the parenchyma and is less than 10 cm long.
Hematoma Subcapsular hematoma covers more than 50% of the surface area or is expanding.
III
Ruptured subcapsular hematoma causes active bleeding. Intraparenchymal hematoma is

more than 2 cm wide.
Laceration Laceration is more than 3 cm deep.
Hematoma Central hematoma ruptures.
IV

Laceration From 15% to 25% of the hepatic lobe is destroyed.
Laceration More than 75% of the hepatic lobe is destroyed.
V

Vascular Major hepatic veins are injured.
Vascular The liver is avulsed.
VI
Source: Pearl, W.S., & Todd, K.H. (1996). Ultrasonography for the initial evaluation of blunt abdominal
trauma: A review in prospective trials. Annals of Emergency Medicine, 27, 353–361.

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.
KEY RESOURCES
Grading of Renal Injuries

Injury Description
Grade
Contusion with microscopic or gross hematuria and normal urologic studies
I
Subscapular hematoma, nonexpanding and with no laceration
Laceration of renal parenchyma less than 1 cm with no extravasation
II
Perinephric hematoma, nonexpanding
Laceration of renal parenchyma greater than 1 cm
III
No urinary extravasation and no collecting system involvement
Laceration involving the collecting system
IV
Perinephric and paranephric extravasation
Thrombosis of segmental renal artery
Main renal artery or vein injury with controlled hemorrhage
Fractured kidney
V
Thrombosis of the main renal artery
Avulsion of the main renal artery or vein
Grades I and II are minor. Grades III, IV, and V are major.
Source: Dixon, M.D., & McAninch, J.W. (1991). Traumatic renal injuries. Part I: Patient assessment and
management. AUA Update Series, vol. 10, lesson 36. Houston: American Urological Association.*

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PRECEPTOR EXERCISES
Discuss the following questions or statements with your preceptor:

Abdominal Trauma Protocol
1. Does our emergency department have an abdominal trauma protocol?

2. What is our facility’s protocol for the emergency release of O-negative blood?

3. Does our facility have a massive transfusion protocol?

4. Which equipment is used in our department for rapid fluid administration? Demonstrate how to use
this equipment.

5. What strategies are used in our department to prevent hypothermia in a trauma patient?

6. Does our facility have the ability to take a patient to a surgical suite for stabilization, or does the
patient need to be transferred?

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.
PRECEPTOR EXERCISES
Diagnostic Peritoneal Lavage
1. Which equipment do we use to assist with diagnostic peritoneal lavage?

2. What procedure do we follow when assisting with diagnostic peritoneal lavage?

3. How do we label samples obtained via diagnostic peritoneal lavage? How do we send them to our
laboratory for analysis?

Diagnostic Testing
1. Which diagnostic tests are most commonly used in our emergency department to evaluate
abdominal and genitourinary injury?

2. If invasive diagnostic tests are required, what, if any, is my role in caring for the patient while in the
radiology department? Do I stay with the patient, or is care transferred to the radiology staff?

Elsevier items and derived items ©2012 Emergency Nurses Association. Published by MC Strategies, Inc., a subsidiary of Elsevier Inc. All rights reserved.