I.

INTRODUCTION

Blunt abdominal trauma is a leading cause of morbidity and mortality among all age groups.
Identification of serious intra-abdominal pathology is often challenging. Many injuries may not
manifest during the initial assessment and treatment period. Mechanisms of injury often result in
other associated injuries that may divert the physician's attention from potentially life-threatening
intra-abdominal pathology. The most common causes of blunt abdominal trauma are from motor
vehicle accidents and automobile-pedestrian accidents.
In a large review of operating room deaths in which blunt trauma accounted for 61% of all
injuries, abdominal trauma was the primary identified cause of death in 53.4% of cases. Most
studies indicate that peak incidence occurs in persons aged 14-30 years. A review of 19,261
patients with blunt abdominal trauma revealed equal incidence of hollow viscus injuries in both
children and adults.

RATIONALE
LEARNING OBJECTIVES
a. Cognitive

To acquire knowledge about abdominal blunt injury

To identify the risk factors that have been linked to this health problem, the signs
and symptoms, and its clinical manifestations

To determine the previous and present clinical history of the patient and its
relation to present illness.

b. Psychomotor

To practice the chosen profession by means of knowing the patients condition

To provide proper nursing management and reinforcement with regards this

condition

To use the appropriate nursing process for effectiveness and achievement of

nursing care

c. Behavioral

To acquire positive attitude about abdominal blunt injury, its effect to every
individual, its manifestations, necessary treatment, and appropriate nursing
actions and interventions

To be able to interact to the patient with rapport and therapeutic communication

II. CLINICAL SUMMARY

a. GENERAL DATA
Name:

B.S.M.

Hospital number:

81233

Age:

22 y/o

Gender:

Male

Address:

Lumangbayan, San Teodoro (8), Oriental Mindoro

B-day:

September 2, 1987

B-place:

Lumangbayan, San Teodoro

Civil status:

Single

Nationality:

Filipino

Religion:

Catholic

Date of admission:

August 12, 2010

Time of admission:

1:40 PM

Admission Diagnosis: R/O Blunt Abdominal Injury

Principal Diagnosis:

Gastric Perforation R to Blunt Abdominal Injury

Principal Operation Procedure: Exploratory Laparotomy, Gastrorrhaphy

Admitting Physician: Dr. Ariel Tria, M.D.
b. CHIEF COMPLAINT
His chief complaint is abdominal pain.

d. HISTORY OF PRESENT ILLNESS

Prior to confinement the patient was riding on his motorcycle when stumbled
hitting a wall in Lumangbayan, San Teodoro at 11:10 am on August 12, 2010.
Admission vital signs at OMPH were as follows: T: C; PR bpm; RR: cpm; and
BP: mmHg.
e. PAST MEDICAL HISTORY
According to the patient, he was admitted when he was 15 years of age at
Oriental Mindoro Provincial Hospital with a health problem of pneumonia.
f. FAMILY HISTORY
g. GENERAL APPEARANCE
The patient was conscious. Lying on bed wearing maroon shorts and maroon
jersey with IVF of D5LR 1L at 250cc level regulated at 24gtts/min inserted at left
metacarpal vein with Jackson Pratz drain inserted to right connected to one way bottle.
III. PHYSICAL ASSESSMENT
A. HEAD-TO-TOE ASSESSMENT
DATE:
BP: mmHg
PR: bpm
RR: cpm
T:
AREAS
ASSESS

C
TECHNIQUE
USED

NORMAL
FINDINGS

SIGNIFICANT
FINDINGS

ANALYSIS AND
INTERPRETATION

SKIN

Inspection,
Palpation

Intact.
Skin color varies
depending on
race, sun
exposure,
nutrition, and
Pigmentation of
the skin.

Moist, smooth

HEAD

NAILS

Inspection

Inspection
Blanch test

SKULL AND
FACE

EYE
STRUCTURE
AND VISUAL
CAPACITY

Inspection,
palpation

Inspection

Can accommodate
facial expression
with no lesion.
Head should be
free from scalp
flaking, should
have proper
distribution of hair
with healthy hair.
Nails are smooth.
Capillary Refill 2
seconds
Symmetrical in
size and shape.
Face is soft, no
nodules should not
be palpated
Eyebrows hair are
evenly distributed
and aligned.
Eyelashes are
evenly distributed
and direction of
curl is upwards
Has the ability to
blink,
Corneas are
brownish. Corneal

Pale complexion of
skin

Due to decrease
oxygenation

Dry skin

Poor hygiene

Dry, roughed, and

Crackled. Skin return
To shape when
pinched.

Drying, roughing and

crackling of skin

Normal cephalic

Facial grimacing is a sign of

physiological response.

Capillary refill 3
seconds.

Poor arterial circulation

Pale conjunctiva

Significant sign of low blood

that affects tissue
perfusions

EARS AND
HEARING

Inspection,
Decibels test,
Palpation

NOSE AND
SINUSES

Inspection

MOUTH

Inspection,
Palpation

TEETH AND
GUMS
TONGUE/FL
OOR OF THE
MOUTH

NECK

sensitivity has a
good reflex.
Pupils equally
round reactive to
light and
accommodation.
Ears are
symmetrical size
and position.
No signs of
tenderness
Ears are not
obstructed and
glossy
Can perceive high
pitch and low pitch
sounds
No tenderness on
the outer ear
No septal
deviation, in
midline, patent
nostril, can
identify different
smell or odor.
Inner lips and
buccal mucosa are
pinkish and moist.
No lesions.

Inspection

Teeth and gums

are complete and
aligned well.
Tongue is pinkish
and has a
maximum range of
movement.
No signs of
redness or
swelling

Inspection,

No palpable mass
or nodules, with
maximum head
movement and

palpation

Both ears have no

inflammation,
tenderness. Ears can
perceive high pitch
and low pitch sounds.

No tenderness
palpated.

Buccal mucosa is pale

Teeth are not properly

aligned.

Indication of poor oral

hygiene.

LYMPHNODE
S

Inspection

good muscle
strength. No
palpable lymph
nodes. Thyroid
glands are
symmetrical and
no enlargement,
masses or
nodules.
Not palpable

TRACHEA

Inspection

At midline

At midline

Normal

CRICOTHYR
OID
CARTILLAG
E

Inspection

Centrally located,
smooth, painless

Centrally located and

rise freely with
swallowing

Normal

THORAX

Inspection
Palpation

Chest symmetric
Skin intact, full and
symmetric chest
expansion
Normal breath
sounds

Symmetrical
No chest pain

A. POSTERIOR
THORAX

Auscultation
B. ANTERIOR
THORAX

Inspection
Palpation
Auscultation

HEART

BREAST
AND
AXILLAE

Auscultation

Inspection,
Palpation

Quiet, rhythmic
and effortless
respiration
Full symmetric
excursion
Normal breath
sounds

Not palpable

Normal

Symmetric
Apical pulse present
with a rate of 89 bpm

Lubb dub sound

was auscultated

Lubbdubb sound was

auscultated

Normal

Heart rate must be

60-100.

Heart rate is 83 bpm.

No murmurs and
abnormal sounds.

Normal

Symmetric and
equal in size and
shape
No palpable

Normal

tenderness
masses or nodules
ABDOMEN
UPPER AND
LOWER
EXTREMITIE
S

Inspection,
Palpation
Inspection,
Palpation

Flat, soft, nontender, globular

No lesion,
swelling,
inflammations.
Limbs are
complete. Good
peripheral pulses

Normal
Have good reflex,
complete. No lesion,
inflammation and
swelling. Good
peripheral pulses are
palpated.

Normal

B. REVIEW OF SYSTEMS

LEVEL
INTEGUMENTARY SYSTEM

RESPIRATORY SYSTEM

CARDIOVASCULAR SYSTEM

GASTROINTESTINAL/DIGESTIVE
SYSTEM

FINDINGS
His skin was dry, rough and crackled. He
has a pale complexion of skin. His body
temperature is 37.5 C.
Respiratory rate was 15 cpm. Chest wall
symmetrical in expansion.
Apical pulse - 83 bpm.
BP 90/60 mmHg.
Capillary refill - 3 seconds.
Radial pulse - 62 bpm.
He has a normal bowel sounds with
irregular gargling noises with a rate of
10/secs.

GENITOREPRODUCTIVE SYSTEM
MUSCULOSKELETAL SYSTEM

NEUROLOGIC SYSTEM

He is sexually active. He masturbates once

a day and three times a week. No reports
of pain in his sexual organ.
The client was thin, he complains of body
weakness. All joints function.
The patient was conscious, coherent and
well oriented to time and place. He can
answer questions related to her condition
and can recall other matters regarding him.

IV. FUNCTIONAL ASSESSMENT

DATE: July 16, 2010
Health perception/
Health management

Nutrition/metabolism

Prior to hospitalization
The patient perceived that he is
healthy when he is not ill.
Whenever he feels pain or slight
weakness he endures it and
consults a doctor if its too much
body weakness with dizziness.

He was able to eat 3 times a

day. His usual breakfast is
bread and milk. While his meal
for lunch and dinner is always
rice, meat, inihaw and street
foods. He doesnt eat
vegetables. His appetizer was
banana cue. He loves soda,
salty foods and junk foods. He

During hospitalization
The patient stated that for
him, health is when a
person has no any kind of
illness and he can do his
daily activities well. He
stated that he would
cooperate and pursue just
to get well. He would also
pray and pray until he gets
well.
He has loss of appetite but
eats of the foods serve
by the dietary service which
is usually rice, fish and
vegetables.

Elimination

Activity and Exercise

Cognitive/ Perceptual

Sleep/Rest pattern

Role/relationship
pattern

Sexuality/
reproductive
Coping/Stress
Tolerance

drinks 5-7 glasses of water a

day.
He has a normal pattern of
defecation. It has a noxious
odor and black color.
He has a good pattern of
urination. He voids daily 5-6
times at an estimated amount of
half glass per voiding.
As a teenager his daily
activities are playing basketball
1 to 2 hours per day with his
friends. He also considers this
as an exercise pattern.
He watches television during
vacant hours. He was a
cigarette smoker two years ago
with an estimated 2 packs per
week. He was also an alcoholic
drinker approximately 1 bottle of
gin occasionally.
His mental ability is in good
condition. His answers were
direct to the point. He didnt
experience any kind of mental
illness. He has no memory gap
or no memory loss.
Hes oriented with the time, date
and place.
He spent 8-10 hours of sleep;
He usually sleeps at 10 or 11 o
clock in the evening and wakes
up at 8 or 9 o clock in the
morning. He naps at day time
for an hour.
He is the only child of his
parents. He is responsible by
helping his parents in doing
household chores like cleaning
surroundings, washing the
dishes and cooking.
He was circumcised when he
was in the 4th grade. He is
sexually active. He masturbates
twice a week.
Whenever he experiences
emotional problems he chooses
to keep quiet instead of sharing

He defecates once a day.

The black stool turns into
yellowish one and with
normal odor.
He has a good pattern of
urination. He voids 5-6
times at an estimated
amount of half of an 8 oz.
glass per voiding.
He wasnt able to do his
usual activities. He usually
lies and sits on his bed. He
takes a little walk whenever
he feels boredom.

Still, He hasnt experience

any kind of mental illness.
He has no memory gap or
memory loss. He was still
oriented with time, date and
place.
He sleeps at 7 in the
evening and wakes up at
seven in the morning. He
has more time of sleep
during hospitalization than
the ordinary days.
He thinks that he is a
burden to his family.

He never experienced
coitus.
His illness makes him sad
because he and his family
had to sacrifice lots of

Values and Beliefs

it with somebody because it

makes him feel more
comfortable.
He goes to church occasionally
with his family.

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things just to make him

well.
The patient prays for his
early recovery.