CHAPTER III

A. Assessment

1. Patient Identity

Includes patient name, age, address, gender, occupation, education, etc.

2. Identity of Responsible Person

Includes name, age, address, education, relationship with patient.

3. Main Complaint

In abdominal trauma patients found abdominal pain.

4. Primary Assessment

a. Airway

The first action to take is to check the responsiveness of the patient by

inviting the patient to talk to make sure whether or not the airway

obstruction is present. A patient who can speak clearly then the patient's

airway is open (Thygerson, 2011).

Unconscious patients may require airway and ventilation assistance.

The cervical spine should be protected during endotracheal intubation if

suspected head, neck or chest injury is suspected. Airway obstruction is

 most commonly caused by tongue obstruction in unconscious patient

conditions.

With spinal control. Opening the airway using the 'head tilt chin lift'

technique or raising your head and raising your chin, check whether

there is a foreign object that can cause a closed airway. Vomit, food,

blood or other foreign matter.

b. Breathing

Respiratory assessment was conducted to assess respiratory capacity

and respiratory resis- tance in patients. If breathing in the patient is

inadequate, the steps to be considered are: decompression and tension

pneumothorax / haemothorax drainage, closure of open chest injury and

artificial ventilation

With adequate ventilation. Check your breathing by using a 'view-

hear-feel' of no more than 10 seconds to ascertain whether there is a

breath or not. Next check the respiration status of the victim (speed,

rhythm and adequacy of respiration).

c. Circulation

With great bleeding control. If the breathing of the victim is short of

breath and inadequate, then breathing aid can be done. If there are no

signs of circulation, do cardiopulmonary resuscitation immediately. The

 ratio of chest compression and breathing aid in CPR is 30: 2 (30 chest

compressions and 2 breaths).

d. Disability

Review the level of awareness of patients using GCS and pupil checks.

e. Exposure

Uninstall the patient's clothes and check the injury to the patient. If

the patient is suspected of having a neck or spine injury, in-line

immobilization is important to do. Perform a log roll when performing

checks on the patient's back. What needs to be taken into account in

examining the patient is to expose the patient only during external

examination. After all checks have been completed, cover the patient

with a warm blanket and keep the patient privacy, unless re-

examination is required (Thygerson, 2011).

f. Foley catheter

Attach the catheter to determine the urine output and check for the

presence or absence of trauma to the urinary tract

5. Secondary Assessment

a. According to Kartikawati (2013) secondary data SAMPLE mneominic:

1) S: Sign and SymptomsPatients' signs and symptoms.

2) A: Alergies (allergies).Ask about any history of food allergy or

medication in patients.

3) M: MedicationsTreatment includes frequency, dose, and route

4) P: Pertinent medical historyPast medical history such as diabetes and

hypertension

5) L: Last mealLast meal or treatment.

6) E: Events surrounding this incident

The accompanying events.

b. Physical examination

Physical examination by YAGD Team 118 (2010):

1) Head and Neck

Inspect and palpate the entire head and face for pigmentation, lacerations,

mass, contusions, fractures and thermal injuries, rashes, bleeding,

tenderness and headaches.

When examining the neck, check for bone deformities or crepitations,

edema, rashes, lesions, and mass, blunt or sharp injuries, tracheal

 deviation, and additional muscle use. Palpation of pain, deformity,

congestion, subcutaneous emphysema, tracheal deviation, stiffness in the

neck and symmetrical pulsation. Keep inline immobilization and cervical

protection

2) Chest

a) Inspection: Front, side and rear chest wall inspection for blunt / blunt

trauma, cuts, abrasions, bruises, rashes, eczema, scars, frequency and

depth of breathing, symmetry of chest wall expansion, use of additional

breathing muscles and thoracic expansion bilateral, whether installed pace

maker, frequency and heart rate rhythm.

b) Palpation: Whole chest wall for sharp / blunt trauma, subcutaneous

emphysema, tenderness and crepitation.

c) Percussion: to know the possibility of hypersonor and dimming

d) Auscultation: additional breath sounds (whether there are rhonchi,

wheezing, rales) and heart sound (murmur, gallop, friction rub)

3) Abdomen

a) Abdominal inspection for previous injury marks: puncture injuries,

bruises, and bullet exits. Also need to be studied anterior abdomen, back,

pelvis, and rectum. As for knowing the possibility of bleeding, the nurse

must use the cullen's sign guidance that is bleeding on umbilicus in case of

pelvic trauma and Turner's sign is retroperitoneal bleeding in case of

bleeding in the abdominal wall.

 b) Auscultate the presence or absence of bowel sounds and record baseline

data so that changes can be detected. The presence of bowel sounds is an

early sign of intraperitoneal involvement; if there are signs of peritonium

irritation, laparatomy is usually performed (surgical incision into the

abdominal cavity).

c) Percussion using the fingers, when there is an overtone of the tympanic

sound, there is a suspicion of free air accumulation indicating a penetrating

injury. However, if it sounds dim, then the nurse suspects the

accumulation of fluid or blood in the large intestine and stomach.

d) Palpation should be careful and gentle, because in the abdomen area

accumulation of fluid or blood or air, so that the abdomen will be

distended.

e) Pelvis Observation for abrasion, bleeding, hematoma, edema or discharge.

Apply gentle pressure on each iliac crest with small motion movements;

patients pelvic fracture will lose sense (this maneuver will also cause pain

in the patient). As well as observation of bladder distension

5) Extremities

Obseravsi of bleeding, edema, pallor, pain or asymmetry of bone or joint

begins in the proximal segment of each ekstermitas and palpation in the distal.

Observation of movement, ROM and sensation in all ekstermitas and palpation

of the distal pulse and cel capillary refill on the tip of the nail. Assess skin

color on ekstermitas.
6) Back

Checking the back is done by log roll, tilting the patient while maintaining the

body's inheritance). At this time can be done back examination. Check for

bleeding, abrasions, injuries, hematomas, ecchymosis, rashes, lesions, and

edema and pain, as well as on the vertebral column check for deformity.

7) Neurological

The examined neurologic examination included examination of awareness

level, pupil size and reaction, motor and sensory examination. The alteration in

neurological status can be known by the use of GCS. On neurological

examination, inspection of seizures, twitching, parese, hemiplegi or hemiparese

(ganggguan movement), dyslexia (difficulty in coordinating muscles),

meningeal stimuli and also review of vertigo and sensory response

c.Supporting investigation

1) Skelning examination rongten

2) IVP or Uretre Excretory

3) Uretrography

4) Cystography

5) Focused Abdominal Sonography For Trauma (FAST)

6) Peritoneal Lavage Diagnostics (DPL)

7) Photo Toraks

8) CT scan of the abdomen

9) Routine blood examination

10) Routine urine examination

B. Nursing Diagnosis

1. The fluid volume and electrolyte deficits are related to bleeding.

2. Pain is associated with abdominal trauma or abdominal penetration lesion.

3. Anxiety relates to crisis situations and changes in health status

4. Damage to skin integrity associated with puncture injury.

5. Risk of hypovolemic shock

6. The risk of infection is associated with inadequate peripheral defenses,

circulatory changes, high blood sugar levels, invasive procedures and skin

damage. infection does not occur / controlled.