DEFINITIONSTrauma is an injury / involuntary or psychological or emotional harm (Dorland,

2002).Trauma is a wound or other physical injury or physiological injury caused severe emotional
disturbance (Brooker, 2001).Trauma is the leading cause of death in children and adults less than 44
years. Alcohol and drug abuse has been a factor in the implications of blunt and penetrating trauma
and trauma intentional or unintentional (Smeltzer, 2001).Abdominal trauma is an injury to the
abdomen, can be blunt and penetrating trauma and trauma intentional or unintentional (Smeltzer,
2001).Abdominal trauma is an injury to the contents of the abdominal cavity can occur with or
without a break of the abdominal wall where the handling / management of emergencies is more to
be done action laparotomy (School of Medicine, 1995).

B. Etiology AND CLASSIFICATION1. Penetrating trauma (trauma abdomen with penetration into the
peritoneum cavity).Caused by: stab wounds, gunshot wounds.2. Blunt trauma (trauma without
penetrating into the abdominal cavity peritoneum).Caused by: blow, collision, explosion, deceleration,
compression or seat belt (set-belt) (School of Medicine, 1995).

C. PathophysiologyJab / shot; blow, collision, explosion, deceleration, compression or seat belt

(set-belt)-Abdominal Trauma-:1. Blunt abdominal trauma blood loss. Bruising / injury to the
abdominal wall. damage organs. Pain irritation intestinal fluid2.Trauma penetrating abdominal
The loss of all or part of the function of organs sympathetic stress response bleeding and blood
clots Bacterial Contamination cell death

1 & 2 causes:

Damage to skin integrity

Shock and hemorrhage

Damage to gas exchange

High risk of infection

Acute pain (Faculty, 1995).

D. SIGNS AND SYMPTOMS1. Penetrating trauma (trauma abdomen with penetration into the
peritoneum cavity): The loss of all or part of the function of organs sympathetic stress response
bleeding and blood clots Bacterial Contamination cell death2. Blunt trauma (trauma without
penetrating into the abdominal cavity peritoneum). blood loss. Bruising / injury to the abdominal
wall. damage organs. tenderness, pain of word, off pain and stiffness (rigidity) abdominal wall.
irritation intestinal fluid (School of Medicine, 1995).

E. COMPLICATIONS Soon: hemorrhage, shock, and injury. Slow: infection (Smeltzer, 2001).

F. DIAGNOSTIC EXAMINATION rectal examination: presence of blood indicates abnormalities in the

large intestine; kuldosentesi, the possibility of the presence of blood in the stomach, and
catheterization, the blood showed a lesion in the urinary tract. Laboratory: hemoglobin, hematocrit,
leukocytes and urine analysis. radiology: when indicated to do a laparotomy. IVP / sistogram: only
when there is suspicion of urinary tract trauma. abdominal paracentesis: This action is done in blunt
abdominal trauma who doubt that defects in the abdominal cavity or abdominal blunt trauma
accompanied with severe head trauma, performed by using needle puncture no 18 or 20 which is
inserted through the abdominal wall or underlined lower quadrant area middle under center with
rubbing jar first. peritoneal Lavase: puncture and aspiration / flushing the abdominal cavity with
saline fluid entering through a cannula inserted into the cavity of the peritoneum (School of Medicine,
1995).
G. MANAGEMENT Emergency Management; ABCDE.Installation NGT for gastric emptying and
prevent aspiration. catheter to empty the bladder mounted and assess the urine comes out
(bleeding). surgery / laparotomy (for penetrating trauma and blunt trauma in case of peritoneal
stimulation: shock; bowel sounds are not audible; prolapsed viscera through a stab wound; blood in
the stomach, bladder, rectum; intraperitoneal free air; lavase positive peritoneal; fluid free in
abdominal cavity) (School of Medicine, 1995).

NURSING MANAGEMENTA. ASSESSMENTAssessment is the first step in the nursing process and basic
overall (Boedihartono, 1994).Assessment of abdominal trauma patients (Smeltzer, 2001) are
included:1. Penetrating Abdominal Trauma Get a history mechanism of injury; strength jab / shot;
blunt force (punches). inspection abdomen for signs of injury before: puncture injuries, bruises, and
a bullet exit.Auscultation presence / absence of bowel sounds and record baseline data so that
changes can be detected. Absence of bowel sounds is an early sign of intraperitoneal involvement: if
there are signs of irritation peritoneum, usually performed laparotomy (surgical incision into the
abdominal cavity). Assess patients for progression of abdominal distension, move to protect,
tenderness, stiffness or aching muscles loose, decreased bowel sounds, hypotension, and shock.
Assess chest injury that often follow an intra-abdominal injury, injury-related observations. Record
all physical signs during patient examinations.

2. Blunt abdominal trauma Get detailed history if possible (often can not be obtained, inaccurate, or
false). get all possible data about the following things:• Method of injury.• Time of onset of
symptoms.• What if the passenger traffic accidents (driver often suffers ruptured spleen or liver).
Safety belt use / not, restrain the type used.• eat or drink last time.• bleeding tendency.• latest
danmedikasi disease.• immunization history, with attention to tetanus.• Allergies. Do a quick check
on the entire body pasienuntuk detect life-threatening problems.

EMERGENCY MANAGEMENT1. Started resuscitation procedures (repair of the airway, breathing,

circulation) as indicated.2. Keep the patient on a gurney or stretcher board; motion can cause
fragmentation clot in the large veins and cause massive hemorrhage.a) Ensure kepatenan airway and
breathing as well as the stability of the nervous system.b) If the patient is comatose, dislocated neck
to neck obtained after x-rays.c) Cut out clothes from the wound.d) Calculate the number of injuries.e)
Determine the location of entrance and exit wounds.3. Assess signs and symptoms of hemorrhage.
Hemorrhage often accompanies abdominal injuries, especially liver and spleen trauma.4. Control
bleeding and blood volume defense until surgery is performed.a) Provide external compression on the
bleeding wound and chest injuries dam.b) Put a large diameter catheter for IV fluid replacement
quickly and improve circulation dynamics.c) Note the initial response syoksetelah incident happened
to transfusion; This is often a sign of internal perdarrahan.d) The doctor may perform paracentesis to
identify the bleeding site.5. Gastric aspiration with a nasogastric tube. This procedure helps detect
ulcers, reducing contamination of the peritoneum cavity and prevent lung complications due to
aspiration.6. Cover the abdominal viscera came out with a bandage sterile, moist saline dressings to
prevent nkekeringan viscera.a) Fleksikan knee patients; protusi prevent further this position.b) Delay
administration of oral fluids to prevent increased peristalsis and vomiting.7. Put settle urethral
catheter to obtain assurance hematuria and monitor urine output.8. Maintain a continuous flow
sheet of vital signs, urine output, central venous pressure readings of patients (if indicated),
hematocrit value, and neurologic status.9. Prepare for paracentesis or peritoneum lavase when there
is uncertainty about intraperitonium bleeding.10. Prepare sinografi to determine whether there is
penetration of the peritoneum in cases of stab wounds.a) Stitches done around the wound.b) a small
catheter is inserted into the wound.c) Agents contrast through a catheter inserted; indicate whether
the x-ray penetration peritoneum has been done.11. Give tetanus prophylaxis according to
regulations.12. Give broad spectrum antibiotics to prevent infection. trauma can lead to infection due
to damage caused by a mechanical barrier, exogenous bacteria from the environment at the time of
injury and diagnostic and therapeutic maneuvers (nosocomial infections).13. Prepare patients for
surgery if there is evidence of shock, blood loss, presence of free air under the diaphragm, eviserasi,
or hematuria.
ADVANCED CARE MANAGEMENT diruangB. Nursing DiagnosisNursing diagnosis is a unification of the
problem of real or potential patients based on the data that has been collected (Boedihartono,
1994).Nursing diagnoses in patients with abdominal trauma (Wilkinson, 2006) are:1. Damage to skin
integrity related to puncture injury.2. High risk of infection associated with impaired skin integrity.3.
Acute pain associated with traumatic / discontinuity network.4. Activity intolerance related to general
weakness.5. Barriers to physical mobility related to pain / discomfort, activity restriction therapy, and
decreased strength / resistance.

C. INTERVENTION AND IMPLEMENTATIONIntervention is planning nursing actions that will be

implemented to address the problem in accordance with the nursing diagnoses (Boedihartono,
1994).Implementation is the realization of management and nursing plans that had been developed
at the planning stage (Effendi, 1995).And implementation of nursing interventions that occur in
patients with abdominal trauma (Wilkinson, 2006) include:1. Damage to skin integrity is the state of
one's skin that changes are not desirable.Goal: Achieve wound healing at the appropriate time.Results
Criteria: - no signs of infection such as pus.- Do not clean the wound moist and not dirty.- Vital signs
are within normal limits or tolerable.Intervention and Implementation:a. Assess skin and wound
identification at this stage of development.R / know the extent of injuries facilitate the development
of appropriate action.b. Assess the location, size, color, odor, and the number and type of wound
fluid.R / identify the severity of the injury will facilitate intervention.c. Monitor the increase in body
temperature.R / increased body temperature can be identified as the process of inflammation.d.
Provide wound care with aseptic technique. Dressing the wound with sterile gauze and a dry, use
paper tape.R / aseptic technique helps accelerate wound healing and prevent infection.e. If recovery
does not occur collaboration further action, such as debridement.R / to be foreign or infected tissue is
not widespread in other areas of normal skin.f. After debridement, dressing bandage as needed.R /
dressing can be substituted one or two times a day depending on the condition of severe / not his
wounds, to prevent infection.g. Collaboration antibiotics as indicated.R / antibiotics to kill pathogenic
microorganisms useful in areas at risk of infection.

2. The risk of infection associated with inadequate peripheral defense, circulation changes, high blood
sugar levels, invasive procedures and skin damage.Objective: infection does not occur /
controlled.Criteria results: - there are no signs of infection such as pus.- Do not clean the wound moist
and not dirty.- Vital signs are within normal limits or tolerable.Intervention and Implementation:a.
Monitor vital signs.R / identify the signs of inflammation, especially when the body temperature
rises.b. Perform wound care with aseptic technique.R / controlling the spread of pathogenic
microorganisms.c. Perform maintenance on invasive procedures such as intravenous fluids, catheters,
wound drainage, etc..R / to reduce the risk of nosocomial infection.d. If signs of infection
collaboration for blood tests, such as hemoglobin and leukocytes.R / Hb decrease and increase in the
number of normal leukocytes may result from the occurrence of the infection process.e.
Collaboration for antibiotics.R / antibiotics to prevent the development of pathogenic
microorganisms.

3. Pain is a sensory and emotional experience that is unpleasant and increased as a result of actual or
potential tissue damage, described in terms of such damage; onset sudden or slowly from heavy to
light intensity samapai can end in anticipation or less predictable and duration of six months.Purpose:
The pain can be reduced or lost.Results Criteria: - Pain is reduced or lost- The client seemed
calm.Intervention and Implementation:a. Approach the client and familyR / client relationship that
makes both cooperative and familyb. Assess the level of intensity and frequency of painR / level of
pain intensity and pain frequency scale showsc. Explain to the client the cause of painR / explanation
would add to the knowledge of the client's paind. Observation of vital signs.R / to find out the client's
developmente. Collaboration with the medical team in the delivery of analgesicsR / is dependent
nursing actions, which serves to block the analgesic pain stimulation.

4. Activity intolerance is a condition is an individual who does not quite have the physiological or
psychological energy to endure or meet the needs or daily activities desired.Purpose: The patient has
enough energy to move.Criteria results: - Behavioral reveals the ability to meet the needs of self.-
Patients expressed able to do some activities without assistance.- Coordination of muscle, bone and
other limbs either.Intervention and Implementation:a. Plan adequate rest periods.R / reducing
activity is not required, and the energy collected can be used for optimal activity secar necessary.b.
Provide training activity gradually.R / stages are given to help the process of the activity slowly with
energy saving but the exact purpose, early mobilization.c. Aids in meeting the needs of patients as
needed.R / reduces energy consumption up to force the patient to recover.d. After reviewing the
exercises and activities of the patient's response.R / keep the possibility of an abnormal response of
the body as a result of the exercise.

5. Barriers to physical mobility is a limitation in self-reliance, beneficial physical movement of the

body or a limb or more.Goal: patient will indicate the optimal level of mobility.Criteria results: -
appearance of a balanced ..- Do the movement and displacement.- Maintaining optimal mobility that
can be tolerated, with the characteristics: 0 = independent full 1 = require aid. 2 = requires
assistance from another person for assistance, supervision, and teaching. 3 = needs help from others
and aid. 4 = dependence; did not participate in the activity.Intervention and Implementation:a.
Assess the need for health care and the need for equipment.R / identify the problem, facilitate
intervention.b. Determine the patient's level of motivation to perform the activity.R / affecting the
assessment of the ability of the activity is due to the inability or unwillingness.c. Teach and monitor
patients in the use of tools.R / judge limits the ability of optimal activity.d. Teach and support patients
in active and passive ROM exercises.R / maintain / increase muscle strength and endurance.e.
Collaboration with a physical or occupational therapist.R / as a source suaatu planning to develop and
maintain / improve patient mobility.

D. EVALUATIONAddalah evaluation stage on the nursing process in which the degree of success in
achieving the goals of nursing assessed and the need to modify or nursing intervention defined
purpose (Brooker, 2001).Evaluation expected in patients with abdominal trauma are:1. Achieve
wound healing at the appropriate time.2. Infection does not occur / controlled.3. Pain can be reduced
or lost.4. Patients have enough energy to move.5. Patients will show optimum level of mobility.

REFERENCESBoedihartono, 1994, Nursing Process in Hospital, Jakarta.Brooker, Christine. , 2001.

Pocket Dictionary of Nursing Ed.31. EGC: Jakarta.Dorland, W. A. Newman. , 2002. Medical Dictionary.
EGC: Jakarta.Faculty of medicine. , 1995. Science Lecture surgical set. Binarupa Literacy: JakartaNasrul
Effendi, 1995, Introduction to Nursing Process, EGC, Jakarta.Smeltzer, Suzanne C. , 2001.
Medical-Surgical Nursing Brunner and Suddarth Ed.8 Vol.3. EGC: Jakarta

Nursing Diagnosis for Cirrhosis :

Risk for Injury related to portal hypertension, changes in clotting mechanisms and disruption in the
process of drug detoxification.

Goal : Reducing the risk of injury.

Nursing Interventions, Rational and Outcome criteria – Risk for Injury related to Cirrhosis:

1. Notice any feces excreted to check the color, consistency and amount.

Rational : Allows detection of bleeding in the gastrointestinal tract.

2. Be aware of the symptoms of anxiety, a feeling of fullness in the epigastrium, weakness and
restlessness.

Rational : Can show early signs of bleeding and shock.

3. Check each stool and vomit to detect occult blood.

Rational : detecting early signs that prove the bleeding.

4. Observe hemorrhagic manifestations: ecchymosis, epistaxis, petechiae and bleeding gums.

Rational : Shows the changes in the blood clotting mechanism.

5. Record vital signs at regular intervals.

Rational : Provide the basis and evidence of hypovolemia and shock.

6. Keep the patient calm and restrict activity.

Rational : Minimizing the risk of bleeding and straining.

7. Observations conducted during blood transfusion.

Rational : Allows detection of transfusion reactions (risk will increase with the implementation of
more than one transfusion is needed to address the active bleeding from esophageal varices).

8. Measure and record the nature, timing and amount of vomit.

Rational : Help evaluate the extent of bleeding and blood loss.

9. Keep the patient in a state of fasting if needed.

Rational : Reduce the risk of aspiration of gastric contents and minimize the risk of further injury to
the esophagus and stomach.

10. Give vitamin K as prescribed.

Rational : Improve freezing by providing fat-soluble vitamins are necessary for blood clotting
mechanism.

11. Accompany patients continuously for bleeding episodes.

Rational : Calming anxious patients and enable monitoring and detection of subsequent patient
needs.

12. Offer a cold drink by mouth when bleeding is resolved (if instructed).

Rational : Reduce the risk of further bleeding by vasoconstriction of blood vessels increases the
esophagus and stomach.

13. Take action to prevent injury:

a. Maintaining a safe environment.

Rational : Reducing the risk of trauma and bleeding to avoid injuries, falls, cuts, etc..

b. Encourage patient to blow his nose slowly.

Rational : Reduce the risk of epistaxis secondary to trauma and decrease blood clotting.

c. Provides a soft toothbrush and avoid using toothpicks.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

d. Encourage consumption of foods with a high vitamin C content.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

e. Perform a cold compress if necessary.

Rational : Reduce bleeding into the tissues by increasing local vasoconstriction.

f. Take note of the location where the bleeding.

Rational : Allows detection of new and bleeding where monitoring of previous bleeding.

g. Using a smaller needle when injecting.

Rational : Minimizing blood loss due to seepage and injecting many times.

14. Give drug with caution; monitor adverse drug delivery.

Rational : Reduce the risk of side effects that occur secondary to the inability of the damaged liver to
detoxify (metabolize) the drug normally.

Outcome criteria :

•Show no significant bleeding from the gastrointestinal tract.

•Show no anxiety, a feeling of fullness in the epigastrium and other indicators that show hemorrhage
and shock.

•Shows the results of the examination were negative for occult gastrointestinal bleeding.

•Free from areas that experienced ecchymosis or hematoma formation.

•Showed vital signs were normal.

•Maintaining a break in a state of calm when there is active bleeding.

•Recognizing the rationale for a blood transfusion and action to overcome the bleeding.

•Take action to prevent the trauma (eg, use a soft toothbrush, blow slowly, avoid knock and drop,
avoid straining during defecation).

•Did not experience the side effects of drug delivery.

•Use all medications as prescribed.

•Recognizing rational to perform maintenance actions using all drugs.

Nursing Diagnosis for Cirrhosis :

Risk for Injury related to portal hypertension, changes in clotting mechanisms and disruption in the
process of drug detoxification.

Goal : Reducing the risk of injury.

Nursing Interventions, Rational and Outcome criteria – Risk for Injury related to Cirrhosis:

1. Notice any feces excreted to check the color, consistency and amount.

Rational : Allows detection of bleeding in the gastrointestinal tract.

2. Be aware of the symptoms of anxiety, a feeling of fullness in the epigastrium, weakness and
restlessness.

Rational : Can show early signs of bleeding and shock.

3. Check each stool and vomit to detect occult blood.

Rational : detecting early signs that prove the bleeding.

4. Observe hemorrhagic manifestations: ecchymosis, epistaxis, petechiae and bleeding gums.

Rational : Shows the changes in the blood clotting mechanism.

5. Record vital signs at regular intervals.

Rational : Provide the basis and evidence of hypovolemia and shock.

6. Keep the patient calm and restrict activity.

Rational : Minimizing the risk of bleeding and straining.

7. Observations conducted during blood transfusion.

Rational : Allows detection of transfusion reactions (risk will increase with the implementation of
more than one transfusion is needed to address the active bleeding from esophageal varices).

8. Measure and record the nature, timing and amount of vomit.

Rational : Help evaluate the extent of bleeding and blood loss.

9. Keep the patient in a state of fasting if needed.

Rational : Reduce the risk of aspiration of gastric contents and minimize the risk of further injury to
the esophagus and stomach.

10. Give vitamin K as prescribed.

Rational : Improve freezing by providing fat-soluble vitamins are necessary for blood clotting
mechanism.

11. Accompany patients continuously for bleeding episodes.

Rational : Calming anxious patients and enable monitoring and detection of subsequent patient
needs.

12. Offer a cold drink by mouth when bleeding is resolved (if instructed).
Rational : Reduce the risk of further bleeding by vasoconstriction of blood vessels increases the
esophagus and stomach.

13. Take action to prevent injury:

a. Maintaining a safe environment.

Rational : Reducing the risk of trauma and bleeding to avoid injuries, falls, cuts, etc..

b. Encourage patient to blow his nose slowly.

Rational : Reduce the risk of epistaxis secondary to trauma and decrease blood clotting.

c. Provides a soft toothbrush and avoid using toothpicks.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

d. Encourage consumption of foods with a high vitamin C content.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

e. Perform a cold compress if necessary.

Rational : Reduce bleeding into the tissues by increasing local vasoconstriction.

f. Take note of the location where the bleeding.

Rational : Allows detection of new and bleeding where monitoring of previous bleeding.

g. Using a smaller needle when injecting.

Rational : Minimizing blood loss due to seepage and injecting many times.
14. Give drug with caution; monitor adverse drug delivery.

Rational : Reduce the risk of side effects that occur secondary to the inability of the damaged liver to
detoxify (metabolize) the drug normally.

Outcome criteria :

•Show no significant bleeding from the gastrointestinal tract.

•Show no anxiety, a feeling of fullness in the epigastrium and other indicators that show hemorrhage
and shock.

•Shows the results of the examination were negative for occult gastrointestinal bleeding.

•Free from areas that experienced ecchymosis or hematoma formation.

•Showed vital signs were normal.

•Maintaining a break in a state of calm when there is active bleeding.

•Recognizing the rationale for a blood transfusion and action to overcome the bleeding.

•Take action to prevent the trauma (eg, use a soft toothbrush, blow slowly, avoid knock and drop,
avoid straining during defecation).

•Did not experience the side effects of drug delivery.

•Use all medications as prescribed.

•Recognizing rational to perform maintenance actions using all drugs.

Hepatitis A is an acute infectious disease of the liver caused by the hepatitis A virus (HAV), an RNA
virus, usually spread by the fecal-oral route; transmitted person-to-person by ingestion of
contaminated food or water or through direct contact with an infectious person. Tens of millions of
individuals worldwide are estimated to become infected with HAV each year. The time between
infection and the appearance of the symptoms (the incubation period) is between two and six weeks
and the average incubation period is 28 days.

Hepatitis B is an infectious inflammatory illness of the liver caused by the hepatitis B virus (HBV) that
affects hominoidea, including humans. Originally known as “serum hepatitis”, the disease has caused
epidemics in parts of Asia and Africa, and it is endemic in China. About a third of the world population
has been infected at one point in their lives, including 350 million who are chronic carriers.
 Hepatitis C is an infectious disease affecting primarily the liver, caused by the hepatitis C virus (HCV).
The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and
ultimately to cirrhosis, which is generally apparent after many years. In some cases, those with
cirrhosis will go on to develop liver failure, liver cancer or life-threatening esophageal and gastric
varices.

Activity Intolerance Definition : Insufficient physiological or psychological energy to endure or

complete required or desired daily activities.

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or
chronic illness and disease. This is especially apparent in elderly patients with a history of orthopedic,
cardiopulmonary, diabetic, or pulmonary- related problems. The aging process itself causes reduction
in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance
may also be related to factors such as obesity, malnourishment, side effects of medications (e.g.,
-blockers), or emotional states such as depression or lack of confidence to exert one’s self. Nursing
goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient
to maintain a satisfactory lifestyle.

Nursing Care Plan for Hepatitis

Nursing Diagnosis : Activity Intolerance related to decreased energy

characterized by:

Subjective data:

•client complained of weakness, can not do the activity of as normal.

Objective data:

•client looks limp.

•client looks assisted families in their daily activities.

Goal:

•Activities are met.

Expected outcomes:

•client can perform the activity even though no oversight from family and caregivers.

Nursing Interventions:

•Assess client activity.

•Assist client activity.

•Increase bed rest / seat.

•Reposition the client every 2 hours once.

•Provide training on passive motion.

Rational:

•Knowing the needs of client activity.

•For the fulfillment of client activity.

•Increase rest and tranquility to provide energy and blood circulation.

•Avoiding the risk of tissue damage

•Prolonged bed rest will reduce the ability.

Stroke is a clinical syndrome that initial sudden onset , rapid progression , a focal neurological deficits
and / or global , which lasted 24 hours or more or the direct cause of death , and solely caused by
circulatory disorders non- traumatic brain . When the brain 's circulatory disorder lasts a while , a few
seconds to several hours ( mostly 10-20 minutes ) , but less than 24 hours , referred to as the face of
brain ischemia attack ( TIA = transient attack ischamia ) .Stroke is one of the causes of death and
major neurological disability in Indonesia. Brain attack is a medical emergency that must be dealt with
quickly, accurately , and thoroughly .Stroke is generally a neurological deficit that has sudden onset
and lasts 24 hours as a result of disruption of the blood vessels of the brain . ( Hudak and Gallo ,
1997)Stroke is used to name or hemiparalisis hemiparese syndrome due to vascular lesions , which
are brain regions suddenly not receiving blood because the arteries are clogged memperdarahi the
area , broken or ruptured .

B. Etiology 1 . Cerebral infarction ( 80 % )a. embolism1 ) cardiogenic embolisma) Atrial fibrillation or

other arrhythmiasb ) left ventrikek mural thrombusc ) mitral or aortic valve diseased ) Endocarditis2 )
paradoxical embolism ( patent foramen ovale )3 . Aortic arch embolismb . Aterotrombotik ( blood
vessel disease medium-high )1 ) Disease ekstrakarniala) the internal carotid arteryb ) the vertebral
artery2 ) Disease intrakarniala) the internal carotid arteryb ) middle cerebral arteryc ) the basilar
arteryd ) Lakuner ( perforans small artery occlusion )2 . Intracerebral hemorrhage ( 15 % )a.
hypertensiveb . Arteriovenous malformationc . amyloid angiopathy3 . Subarachnoid hemorrhage
( 5 % )4 . Other causes ( can lead to infarction or hemorrhage )a. Thrombosis dinus durab . Carotid or
vertebral artery dissectionc . Central nervous system vasculitisd . Moya - moya disease ( occlusion of a
large intracranial arterial progressive )e . migrainef . hypercoagulable conditiong . Misuse of drugs
( cocaine or amphetamines )h . Haematological disorders ( sickle cell anemia , polycythemia , or
leukemia )i . atrial myxoma

C. PathophysiologyThrombosis ( disease trombo - occlusive ) is the most frequent cause of stroke .

Cerebral arteriosclerosis and cerebral circulation slowdown is the main cause of cerebral thrombosis ,
which is a common cause of stroke . Signs of cerebral thrombosis varies . Onset of the headache is not
common . Some patients experience dizziness , seizures , and cognitive changes or some other
common onset . In general, cerebral thrombosis did not occur suddenly , and temporary loss of
speech , hemiplegia or paresthesias in half body weight may precede the onset of paralysis in a few
hours or days .Thrombosis occurs usually has something to do with the local damage blood vessel
walls due atrosklerosis . The process of atherosclerosis is characterized by fatty plaque in the intima
layer of the artery . Sereberi artery intima part becomes thin and stringy , whereas cells - muscle cells
disappeared . Lamina interna elastika torn and frayed , so the vessel lumen partially filled by the
sclerotic material . Plaques tend to form at branching or places - places curved . Thrombi were also
associated with a place - such a special place . Vessels - vascular risk in order to have less and less are
as follows : internal carotid artery , vertebral and basilar part of the bottom . Intima loss will make
connective tissue exposed . Platelets stick to the exposed surface so that the surface of the blood
vessel walls become rough . Platelets will let go of the enzyme , adenosine diphosphate mechanisms
that initiate coagulation . Fibrinotrombosit stopper can be detached and form emboli , or it can
remain in place and eventually all that will be clogged artery perfectly .Embolism : embolism sereberi
including second leading cause of many strokes . Embolism patients are usually younger than patients
with thrombosis . Most sereberi emboli originating from a thrombus in the heart , so the real problem
faced is the embodiment of heart disease . Although less common , embolus may also originate from
atheromatous plaques karotikus sinus or internal carotid artery . Each part of the brain can suffer
embolism , but usually embolus embolus will clog parts - small parts .. the most frequently affected
artery embolus sereberi is sereberi media , especially the top .Cerebral hemorrhage : cerebral
hemorrhage including third leading cause of all cases GPDO ( Brain Blood Vessel Disorders ) and a
tenth of all cases of the disease . Intracranial hemorrhage is usually caused by the rupture of cerebral
arteries . Extravasation of blood occurs in the brain and / or subarachnoid , so the networks are
located nearby will be displaced and depressed . Blood is very irritating to the brain tissue , resulting
in vasospasm in arteries around the bleeding . These spasms can spread throughout the brain and the
circle wilisi hemisper . Blood clot that initially resemble soft red jam will eventually dissolve and
shrink . In the light of histological brain located around the clot can swell and undergo necrosis .
Because the action of the enzyme - enzyme liquefaction process will occur , thus forming a cavity .
After several months of all necrotic tissue will be replaced by astrocytes and capillaries - new
capillaries to form the fabric around the cavity earlier . Finally cavities filled by fibers - fibers that
experienced astroglia proliferation . Subarachnoid hemorrhage is often associated with rupture of an
aneurysm . Most aneurysms of the circle of wilisi . Hypertension or bleeding disorders facilitate the
possibility of rupture . Often there is more than one aneurysm .

D. CLINICAL1 . sudden headache .2 . Paraesthesia , paresis , Plegia part of the way .3 . dysphagia4 .
aphasia5 . Impaired vision6 . Changes in cognitive abilities

E. RISK FACTORSWhich can not be changed : age , male gender , race , family history , history of TIA or
stroke , coronary heart disease , atrial fibrillation , and heterozygous or homozygous for homo
cystinuria .That can be changed : hypertension , diabetes mellitus , smoking , alcohol and drug abuse ,
oral contraceptives , increased hematocrit , asymptomatic carotid bruit , hyperuricemia , and
dispidemia .

F. ACUTE STROKE UNIT IN EMERGENCYTime is brain is an expression that shows the importance of
stroke treatment as early as possible , because the ' therapeutic window ' of a stroke is only 3-6 hours .
Management of rapid , precise , and accurate , emegang dasil major role in determining the end of
treatment . Things that should be done is :1 . Stabilization of patients with ABC action2 . Consider
intubation bil a kesadaranstupor tau respiratory failure or coma3 . Put an intravenous infusion line
with normal saline solution 0.9 % in water and saline 0.45 % , due to brain edema memperhebar4 .
Give oxygen 2-4 liters / minute via nasal cannula5 . Do not give food or drink by mouth6 . Create
recording electrocardiogram (ECG ) and chest X-ray did Rongen photo7 . Take samples for blood tests :
complete examination of peripheral blood with platelets , blood chemistry ( glucose , electrolytes ,
urea and creatinine ) . Asa prothrombin and partial thromboplastin time8 . If there is any indication,
do the following tests : jadar alcohol , liver function , arterial blood gases , and toxicology screening9 .
Enforce diagnosis based on history and physical examination10 . CT scans or magnetic resonance tool
when available . If not, the Siriraj score to determine the type of stroke .G. Nursing care1 .
ASSESSMENT1 . Changes in level of consciousness or responivitas as evidenced by the movement ,
refused to change its position and response to stimulation , oriented towards the time, place and
person2 . Presence or absence of a volunteer or involuntary limb movements , muscle tone , posture
and head position .3 . Flaksiditas stiffness or neck .4 . Eye opening , comparative pupil size , and pupil
reaction to light and ocular position .5 . Color of the face and extremities , skin temperature and
humidity .6 . Quality and frequency of pulse , respiration , arterial blood gases as indicated , body
temperature and arterial pressure .7 . Ability to speak8 . The volume of fluid you drink and urine
volume issued every 24 hours .2 . MANAGEMENTa. Acute phase :

Maintain vital functions : airway, breathing , oxygenation and circulation

Reperfusion with trombolityk or vasodilation : Nimotop

Prevention of increased ICP

Reduce cerebral edema with diureticsb . Post acute phase

 Prevention spatik paralysis with antispasmodics

program Fisiotherapi

Handling psychosocial problemsc . First Aid In Stroke PatientsFirst Aid In Stroke ( By way of bleed on
each end of the leaf tips of fingers and ears ) . There is one best way to provide first aid to people who
had suffered a STROKE . This way can save lives in addition to the patient , also does not cause any
side effects . The first aid is aid EMERGENCY guaranteed to work 100 % .As we know , people who had
suffered a STROKE , whole blood in the body will drain very fast towards the blood vessels in the
brain . If the activities of aid given terlambatsedikit course , the blood vessels in the brain will not
withstand the flow of blood flowing profusely and will soon be broken little by little .In the face of
such circumstances not to panic but to be quiet . Sipenderita should remain its original place where
he fell ( eg in the bathroom , bedroom , or anywhere else ) . DO NOT MOVED ! ! ! because by moving
the patient from the original will hasten rupture small blood vessels in the brain .Patients should be
assisted take a good sitting position in order not to fall again , and at that time extravasation can be
done . It is best to use a syringe , but if not there , then NEEDLE SEWING / pin / pin can be used to
advance first sterilized by burning over the fire . As soon as sterile needles , do the stabbing on 10
END FINGER . Insertion point is approximately 1cm from the tip of the nail . Each finger is quite
stabbed one time only in the hope of every finger dispense 1 drop of blood . Extravasation can also be
assisted by the push of blood if it was not out of his fingertips . In a period of approximately 10
minutes , the patient will regain consciousness soon .When sipenderita looks lopsided mouth / not
normal , then BOTH EARS sipenderita LEAF - DRAWN TO PULL until goldenReddish . After that do 2
TIMES stabbing at each END DOWN LEAF EAR so that 2 drops of blood out of each end of the ear .
Thus in a few minutes form the mouth sipenderita will return to normal .After the state sipenderita
recovered and no significant abnormalities , then take sipenderita carefully to the doctor or the
nearest hospital to get further help .

4 . Nursing Diagnosisa. Damage to physical mobility bd decreased muscle strength , controlb .

Ineffective tissue perfusion related to cerebral hemorrhage . brain edemac . B.d self care less physical
weaknessd . Verbal communication b.d damage brain damagee . Risk of damage to skin integrity bd
mechanical factorsf . Decrease the risk of infection b.d primary defense

5 . INTERVENTIONNo Diagnosis Goals / Interventions Rationale KH1 . Damage to physical mobility bd

penuruna n NOC muscle strength : Ambulation / maintained normal ROM .After the act of nursing
5x24 hoursKH :o The joints are not stiffo No muscle atrophy occurs NIC :1.Terapi exercisejoint
mobilityo Explain to the client & kelg purpose joint movement exercises .o Monitor the location and
discomfort during exerciseo Use loose clothingo Assess client's ability to moveo Encourage active
ROMo Teach ROM active / passive on the client / family .o Change the client's position every 2
hours .o Assess development / progress exercises2 . Self Care Assistanceo Monitor client
independenceo assist the client in terms of self-care : eating , bathing , toileting .o Teach the family in
meeting self-care clients .Movement of active / passive aims to maintain flexibility of jointsPhysical
and psychological disabilities clients can reduce their daily self-care and can be fulfilled with the help
of clients that personal hygiene can be maintained2 . Ineffective cerebral tissue perfusion bd brain
hemorrhage , edema o NOC : cerebral tissue perfusion . After the act of nursing for 5 x 24 hours with
adequate tissue perfusion indicator :o adequate tissue perfusion is based on peripheral pulse
pressure , the warmth of the skin , urine output is adequate and there is no interference with
respiration NIC : Nursing circulationIncrease in brain tissue perfusionactivity :1 . Monitor neurologic
status2 . monitor the status of respitasi3 . monitor heart sounds4 . place the head with a slightly
elevated position and in a neutral position5 . appropriate medication management order6 . Oxygen is
given as indicated 1 . tk identify trends and potential increase ICT awareness and find out the location .
Extensive CNS damage and progress2 . Respiratory irregularity can give you an idea location of
damage / increase in ICT3 . Bradycardia could occur as a result of brain damage .4 . Lowers arterial
pressure by improving drainage and improve circulation5 . Prevention / treatment decreased ICT6 .
lowering hypoxia3 . Decrease the risk of infection bd primary defense NOC : Risk Control After nursing
action for 3 x 24 hours the client does not have an infectionKH :o Clients are free of signs of infectiono
The client is able to explain the signs and symptoms of infection NIC : Prevent infection1 . Observe
and report signs and symptoms of infection , such as redness , warm , discharge and an increase in
body temperature2 . assess client netropeni temperature every 4 hours , reported if the temperature
is more than 380C3 . Using electronic or mercury thermometer to assess temperature4 . Record and
report the value of laboratory5 . Assess skin color , skin moisture , texture and turgor do proper
documentation on any changes6 . Support for the consumption of a balanced diet , the emphasis on
protein for the formation of the immune system1 . Onset of infection with the immune system is
activated and signs of infection appear2 . Clients with netropeni not produce enough heat
inflammatory response because it is usually a sign and often the only sign of3 . Temperature values
have important consequences for the proper treatment4 . Lab values correlated with client history
and physical examination to give him a holistic view5 . Can prevent skin damage , skin intact is the
first defense against microorganisms6 . Immune function is affected by protein intake4 . Self-care
deficit bd physical weakness NOC : Self Care Assistance ( bathing , dressing , eating , toileting .After
the act of nursing for 5 x 24 hour client can meet the needs of self-careKH :- The client is free from
odor , can feed themselves , and dress himself

NIC : Self Care1 . Observation of the client's ability to bathe , dress and eat .2 . Assist the client in
a sitting position , make sure the head and shoulders upright for eating and 1 hour after meals3 .
Avoid exhaustion before eating , bathing and dressing4 . Encourage clients to continue to eat little but
often1 . By using direct intervention to determine appropriate interventions for clients2 . Seated
position helps prevent ingestion and aspiration3 . Improve energy conservation and activity tolerance
improved self-care skills4 . To increase appetite5 . Risk of damage to the skin intagritas bd mechanical
factors NOC : maintain skin integrityAfter a 5 x 24- hour care skin integrity remains adequate
indicators:No significant damage to the skin characterized by redness , sores decubitus NIC : Give
stress management1 . Perform replacement loom every day and place the appropriate mattress2 .
Monitor the skin area kemerahan/pecah23 . monitor the depressed area4 . give masage on back /
depressed area and provide moisturizing pad area pecah25 . monitor nutritional status1 . Improve
comfort and reduce the risk of itchinglajutan damage kulità2 integrity . Indicates the initial
symptoms3 . Depressed area usually less than optimal circulation allows for trigger blisters4 .
facilitate the circulation of. 5. Good nutritional status can help prevent skin integrity keruakan .6 Lack
of knowledge bd less access to health information NOC : Knowledge increased clientKH :- The client
and family understanding of disease Stroke , care and treatment NIC : Health Education1 . Assess the
client's readiness and ability to learn2 . Assess the knowledge and skills of previous clients about the
disease and its effect on the desire to learn3 . Give the most important material on the client4 .
Identify the main source of support and attention to the client's ability to learn and support the
behavior change necessary5 . Assessing the family wishes to support changes in client behavior6 .
Highly priced hasi evaluation pembelajarn through demonstrations and restates the material being
taughtThe learning process depends on the particular situation , the interaction of social , cultural and
environmental valuesNew information is absorbed meallui previous facts and assumptions and biases
affect the process of transformationInformation will be more striking when explained from a simple
concept to complexFamily support is needed to support behavior change.

Definition
Intussusception is the inclusion of part of the intestine into the border or the more distal parts of the
intestine (general, ileal invagination into the descending colon). (Nettina, 2002)

Invagination or intussusception occurs when some gastrointestinal driven such that a portion of it will
cover most of the other to shrink or retracts fully into a segment that is located next to the caudal.
(Nelson, 1999).

An intussusception is a medical condition in which a part of the intestine has invaginated into another
section of intestine, similar to the way in which the parts of a collapsible telescope slide into one
another. This can often result in an obstruction. The part that prolapses into the other is called the
intussusceptum, and the part that receives it is called the intussuscipiens. (wikipedia)

Clinical Manifestations

Early symptoms can include nausea, vomiting (sometimes bile stained (green color)), pulling legs to
the chest area, and intermittent moderate to severe cramping abdominal pain. Pain is intermittent
not because the intussusception temporarily resolves, but because the intussuscepted bowel segment
transiently stops contracting. Later signs include rectal bleeding, often with “red currant jelly” stool
(stool mixed with blood and mucus), and lethargy. Physical examination may reveal a
“sausage-shaped” mass felt upon palpation of the abdomen.

In children or those too young to communicate their symptoms verbally, they may cry, draw their
knees up to their chest or experience dyspnea (difficult or painful breathing) with paroxysms of pain.

Fever is not a symptom of intussusception. However, intussusception can cause a loop of bowel to
become necrotic, secondary to ischemia due to compression to arterial blood supply. This leads to
perforation and sepsis, which causes fever.

Nursing Care Plan for Intussusception

Nursing Assessment – Nursing Care Plan for Intussusception

1. Assessment of general physical

2. Medical history

3. Observation stool patterns and behavior before and after surgery

4. Observations of behavior of children / infants

5. Observation manifestations occur intussusception:

•Paroxysmal abdominal pain.

•Children screamed and fold knees toward your chest.

•Children seem normal and comfortable during the interval between episodes of pain.

•Vomiting.

•Lethargy.

•Currant jelly-like stool containing blood and mucus, hemocculi test positive.

•Feces no increase.

•Abdominal distention and tenderness.

•Palpable mass in the abdomen are like sausages.

•The anus that looks unusual, it can seem like a rectal prolapse.

•Dehydration and fever to rise 41 0C.

•Things like shock with rapid pulse, pale and sweating a lot.

6. Observation of the chronic manifestations of intussusception:

•Diarrhea.

•Anorexia.

•Losing weight.

•Sometimes vomiting.

•Periodic pain.

•Pain without other symptoms.

7. Assess the diagnostic procedures and tests such as plain abdominal examination, barium enema
and ultrasonogram.
Nursing Diagnosis – Nursing Care Plan for Intussusception

1. Acute Pain related to bowel invagination.

2. Ineffective Tissue Perfusion: shock hipolemik related to vomiting, bleeding and accumulation of
fluid and electrolytes in the lumen.

3. Anxiety related to lack of knowledge, foreign environment.

4. Ineffective Thermoregulation related to the process of inflammation, fever.

5. Acute Pain related to surgical incision.

Definition of Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma is a malignant tumor that grows in the nasopharynx with a predilection in
Rossenmuller fossa and roof of the nasopharynx.

Etiology of Nasopharyngeal Carcinoma

High incidence of nasopharyngeal carcinoma is associated with eating behavior, environment and
Epstein-Barr virus. Besides geographic factors, racial, gender, genetics, occupation, habits of life,
culture, socio-economic, bacteria or parasite infections also affect the likelihood of this tumor.
Signs and Symptoms of Nasopharyngeal Carcinoma

Symptoms of nasopharyngeal carcinoma can be divided into 4 sections, which include:

1. Symptoms of nasopharyngeal

Nasopharyngeal Symptoms can be mild epistaxis or nasal obstruction.

2. Disorders of the ear

An early warning because the place of origin of the tumor near the mouth of the Eustachian tube
(Rosenmuller fossa). Disruption resulting from blockage of the Eustachian tube, such as tinnitus,
deafness, ear discomfort until the pain in the ear.

3. Eye and neurological disorders

Because of the proximity to the cranial cavity, then there is spreading through the foramen lacerum,
which will hit the brain to nerves III, IV, VI thus encountered diplopia, squint, exoftalmus, and nerves
to the V form of motor and sensory disturbances.

4. Metastasis to the cervical lymph

Namely in the form of lump medial to the sternocleidomastoid muscular that eventually form large
masses to the skin shiny.

Nursing Assessment – Nursing Care Plan for Nasopharyngeal Carcinoma

1. Hereditary factors or a history of cancer in the family eg mother or grandmother with a history of
breast cancer.
2. Spheres of influence, such as chemical irritants, smoke a certain kind of wood.

3. The habit of cooking with certain ingredients or spices and eating foods that are too hot and
preserved foods (meat and fish).

4. Low socioeconomic classes will also be related to the environment and living habits.

5. Signs and symptoms:

Activity

Weakness or fatigue. Changes in the patterns of rest; presence of factors that affect sleep such as
pain, anxiety.

Circulation

As a result of tumor metastases are palpitations, chest pain, decreased blood pressure, epistaxis /
nose bleeding.

Ego integrity

Stress factors, concerns about appearance changes, deny the diagnosis, feelings of helplessness, loss
of control, depression, withdrawal, anger.

Elimination

Changes in bowel habit constipation or diarrhea, urinary elimination alteration, change of bowel
sounds, abdominal distension.

Food / fluid

Poor dietary habits (low fiber, additives, preservatives), anorexia, nausea / vomiting, mouth dryness,
food intolerance, weight changes, cachexia, changes in humidity / skin turgor.
Neuro-sensory

Headache, tinnitus, deafness, diplopia, squint, eksoftalmus

Pain / comfort

Discomfort in the ear to ear pain (otalgia), stiffness in the neck area due to tissue fibrosis caused by
radiation

Breathing

Smoking (tobacco, marijuana, living with someone who smokes), exposure

Security

Exposure to toxic chemicals, carcinogens, exposure to the sun old / redundant, fever, skin rash.

Sexuality

Sexual problems such as the impact of the relationship, changes in the level of satisfaction.

Social interaction

Inadequate / support system weaknesses

PUD

Assessment for Peptic Ulcer

Patient history acts as an important basis for diagnosis. Patients were asked to describe the pain and
the methods used to eliminate them. Peptic ulcer pain is usually described as a burning or gnawing
and occurs approximately occurs after 2 hours after meals. This pain often awakens the patient hours
of midnight and 3 am. The patient stated that the pain is only removed by antacids, eating or
vomiting.
 Patients were asked when vomiting occurs. If so, how much? Is vomit bright red or coffee color.
Does the patient have a bowel movement with bloody stool? During the history taking, the nurse
asked the patient to write the input of food, usually a period of 72 hours and include all eating habits
(eating speed, regular meals, a fondness for spicy food, use herbs, use of beverages containing
caffeine).

The level of tension and nervousness of patients studied. Does the patient smoke? If yes, how much?
How patients express anger, especially in the context of work and family life? Is there or is there job
stress with family problems? Is there a family history of ulcer disease?

Vital signs assessed for indicators of anemia (tachycardia, hypotension), fecal occult blood checked
against. Physical examination and abdominal palpation performed to localize tenderness.

4 Nursing Diagnosis and Interventions for Peptic Ulcer

1. Acute pain related to irritation of the mucosa and muscle spasms.

Goal: Client expressed pain diminished or disappeared.

Intervention:

1. Give drug therapy according to the program:

2. Instruct to avoid drugs are sold freely, especially those containing salicylates.

R /: Medicines containing salicylates may irritate the gastric mucosa.

3. Encourage clients to avoid foods / drinks that irritate the gastric mucosa: caffeine and
alcohol.

R /: to stimulate the secretion of hydrochloric acid.

4. Encourage clients to use the meals and snacks at regular intervals.

R /: Schedule regular eating helps retain food particles in the stomach that helps neutralize
the acidity of gastric secretions.

5. Instruct patient to stop smoking

R /: Smoking can stimulate ulcer recurrence.

2. Anxiety related to the nature of the disease and long-term management.

Goal: Decrease anxiety.

Intervention:

1. Encourage clients to express their problems and fears and ask questions as needed.

R /: Open communication helps clients develop trusting relationships that help reduce
anxiety and stress.

2. Explain the reasons for the planned treatment schedule obey, such as pharmacotherapy,
dietary restrictions, modification of activity levels, reduce or stop smoking.

R /: Knowledge reduce anxiety appears to be a sense of fear due to ignorance. Knowledge

can have a positive effect on behavior change.
 3. Assist clients to identify situations that cause anxiety.

R /: stressors need to be identified before it can be overcome.

4. Teach stress management strategies: eg drugs, distraction, and imagination.

R /: decrease anxiety decrease the secretion of hydrochloric acid.

3. Imbalanced Nutrition, Less Than Body Requirements related to pain, which is related to food.

Goal: Getting optimal nutrition.

Intervention:

1. Encourage eating foods and drinks that do not irritate.

R /: Food and drinks are not irritating to help reduce epigastric pain.

2. Encourage eating on a regular schedule, avoid snacks before bedtime.

R /: Eating regularly helps neutralize gastric acid secretion; snack before bedtime increases the
secretion of gastric acid.

3. Encourage eating food in a relaxed environment

R /: less relaxed environment cause anxiety. Decreased anxiety helps reduce the secretion of
hydrochloric acid.

4. Knowledge Deficit: the prevention and treatment of symptoms related to the condition of
inadequate information.

Goal: Clients gain knowledge about prevention and management.

Intervention:

1. Assess the level of knowledge and readiness to learn from clients.

R /: Desire to learn depends on the physical condition of the client, the level of anxiety and
mental readiness.

2. Teach the required information: Use words that correspond with the level of knowledge of the
client. Choose a time when most convenient and interested clients. Limit counseling sessions to 30
minutes or less.

R /: Individualization counseling improve learning.

3. Assure the client that the disease can be overcome.

R /: Gives confidence can have a positive influence on behavior change.

A. DEFINITION

A malignant lung tumor in lung tissue (Price, Pathophysiology, 1995).

Lung cancer is an abnormality of cells - cells undergoing proliferation in the lung (Underwood,
Pathology, 2000).

B. Etiology.

Although the exact etiology of lung cancer is not known, but there are several factors that seem to be
responsible for the increased incidence of lung cancer:

Smoking.

Undoubtedly a major factor. A definitive statistical relationship has been established between heavy
smokers (more than twenty cigarettes a day) of lung cancer (bronchogenic carcinoma). Smokers like
this has a tendency to ten times greater than in light smokers. Furthermore the previous heavy
smokers who had quit his habit and will return to the risk of non-smokers in about 10 years.
Carcinogenic hydrocarbons have been found in the tar from tobacco cigarettes which if applied to the
skin of animals, causing tumors.

Irradiation.

A high incidence of lung carcinoma in cobalt miners in Schneeberg and radium miners in Joachimsthal
(more than 50% died of lung cancer) associated with the presence of radioactive material in the form
of radon. This material is thought to be the etiologic agent operative.

Occupational lung cancer.

There is a high incidence of workers exposed to nickel carbonyl (nickel smelters) and arsenic (weed
killers). Workers breaking hematite (lungs - pulmonary hematite) and people - people who work with
asbestos and chromate are also experiencing an increase in incidents.

Air pollution.

Those who live in cities have lung cancer rates are higher than in those who live in the village and
even has been known carcinogens from industrial and diesel vapor in the atmosphere in the city.

(Thomson, Pathology Lecture Notes, 1997).

Genetic.

There is a change / mutation of several genes that play a role in lung cancer, namely:

Proton oncogene.

Tumor suppressor gene.

Gene encoding the enzyme.

Theory of oncogenesis.

The occurrence of lung cancer based on the appearance of a tumor suppresor gene in the genome
(oncogenes). The existence of tumor suppressor genes initiator change by eliminating (deletion / del)
or insertion (insertion / INS) most couples alkaline composition, appearance and or neu/erbB2 erbB1
genes play a role in anti-apoptosis (cell mechanisms to die naturally-programmed cell death) .
Changes in gene display this case led to the target cells in the lung cells turn into cancer cells with
growth autonomic properties. Thus cancer is a genetic disease that is limited to the beginning and
then become aggressive target cells in the surrounding tissue.

Tumor suppressor gene predisposing

Inisitor

Deletions / insertions

Promoter

Tumor / autonomy

Progresor

Expansion / metastasis

Diet.

Reported that low consumption of beta-carotene, vitamin A seleniumdan cause high risk of lung
cancer.

(Medicine, 2001).

C. CLASSIFICATION.

According to the WHO classification for Lung and Pleural Neoplasms - Lung (1977):
 Bronchogenic carcinoma.

Epidermoid carcinoma (squamous).

Cancer is derived from the surface of the bronchial epithelium. Epithelial changes including
metaplasia, or dysplasia caused by long-term smoking, typically precedes the onset of tumors.
Centrally located around the hilum, and large protruding into the bronchi. Tumor diameters rarely
exceed a few centimeters and are likely to spread directly to the hilar lymph nodes, chest wall and
mediastinum.

Small cell carcinoma (oat cell included).

Usually located around the middle of this bronki.Tumor main ramification arising from cells -
Kulchitsky cells, the normal component of the bronchial epithelium. Formed from cells - cells with a
small nucleus and cytoplasm hiperkromatik little soupy. Early metastasis to the mediastinal and hilar
lymph nodes, as well as hematogenous spread to organs - organs distal.

Adenocarcinoma (including alveolar cell carcinoma).

Shows the cellular structure such as bronchial glands and may contain mucus. Most arise in the
peripheral parts of the bronchial segment and sometimes - sometimes can be associated with local
scar tissue in the lungs - pulmonary and chronic interstitial fibrosis. Lesions often spreads through the
blood and lymph vessels in the early stages, and still do not show clinical symptoms - symptoms until
the occurrence of distant metastases.

Large cell carcinoma.

A cell - malignant cells are large and very poorly with large cytoplasm and nucleus size wide - range.
Cells - these cells are likely to arise in the lung tissue - the peripheral lung, grows quickly with
extensive and rapid deployment to places - places far away.

Combined adenocarcinoma and epidermoid.

Other - Other.

1). Carcinoid tumors (adenomas bronchi).

2). Bronchial gland tumors.

3). Papillary tumors of the epithelial surface.

4). Mixed tumors and Karsinosarkoma

5). Sarcoma

6). Not classified.

7). Mesothelioma.

8). Melanoma.

(Price, Pathophysiology, 1995).

 D. Clinical manifestations.

Early symptoms.

Local mild stridor and dyspnea that may be caused by bronchial obstruction.

Common symptoms.

Cough

Probably due to irritation caused by the tumor mass. Cough starts as a dry cough without sputum
formed, but evolved to the point where the molded thick and purulent sputum in responding to
secondary infections.

Hemoptysis

Sputum Sputum faintly through the surface of the blood due to an ulcerated tumor.

Anorexia, fatigue, weight loss.

E. STADIUM.

Table TNM Staging System for Lung Cancer - Lung: 1986 American Joint Committee on Cancer.

Gambarn TNM Definition Primary tumor (T)

T0

Tx

TIS

T1
T2

T3

T4
Regional lymph nodes (N)

N0

N1

N2

N3

Distant metastasis (M)

M0

M1

Group stage

Hidden carcinoma TxN0M0

Stage 0 TISN0M0

T1N0M0 stage I

T2N0M0

Stage II T1N1M0

T2N1M0

Stage IIIA T3N0M0

T3N0M0

Each stage IIIb T N3M0

T4 every NM0

Stage IV Any T, any N, M1

No evidence of primary tumor

Hidden cancers seen in the cytology of bronchial washings but not visible on the radiogram or
bronchoscopy

Carcinoma in situ

Tumors ≤ 3 cm in diameter surrounded by lung - lung or visceral pleura were normal.

Tumor with a diameter of 3 cm or in any measure which has been attacked resulting in atelectasis or
visceral pleura that extends to the hilum; must be within 2 cm distal to the carina.

Tumors in any size with direct extension to the chest wall, diaphragm, pleura mediastinalis, or
pericardium without the heart, great vessels, trachea, esophagus, or vertebral body, or within 2 cm of
the carina but does not involve the carina.

Tumors in any size that has been attacking the mediastinum or the heart, great vessels, trachea,
esophagus, vertebral koepua, or carina, or the existence of a malignant pleural effusion.

Can not be seen in the regional lymph nodes metastasis.

Peribronkial metastasis and / or gland - ipsilateral hilar glands.

Metastasis in the lateral or mediastinal lymph nodes IPSI subkarina.

Or mediastinal nodes metastasis - contralateral hilar lymph nodes; gland - scalenus or supraclavicular
lymph nodes ipsilateral or contralateral.

There are no known distant metastases

Distant metastases present in certain places (like the brain).

Sputum containing cells - malignant cells but not proven the existence of a primary tumor or a
metastasis.

Carcinoma in situ.
Classification of tumors including T1 or T2 without any evidence of metastases in regional lymph
nodes or distant sites.

Classification of tumors including T1 or T2 and there is evidence of lymph node metastasis in

peribronkial or ipsilateral hilar.

Including classification T3 tumors with or without evidence of lymph node metastasis in peribronkial
or ipsilateral hilar, there is no distant metastasis.

Each tumor with hilar lymph node metastasis in contralateral mediastinal tau, or the scalenus or
supraclavicular lymph nodes, or any classification that included T4 tumors with or without regional
lymph node metastasis, there is no distant metastasis.

Any tumor with distant metastsis.

Sources: (Price, Pathophysiology, 1995).

F. Pathophysiology.

Of aetiological attack branching segments / sub bronchus causing lost cilia and desquamation
resulting in the deposition of carcinogens. With the deposition of carcinogens that cause metaplasia,
hyperplasia and dysplasia. When peripheral lesions caused by metaplasia, hyperplasia and dysplasia
penetrate the pleural space, pleural effusion usually arises, and can be followed by direct invasion on
the costal and vertebral bodies.

Centrally located lesions derived from one of the largest branches of the bronchi. This causes lesions
and ulcerations obstuksi bronchus followed by suppuration in the distal part. Symptoms - symptoms
may include cough, hemoptysis, dyspnoea, fever, and unilateral dingin.Wheezing can terdengan on
auscultation.

In later stages, weight loss usually indicate the presence of metastases, particularly in the liver. Lung
cancer can be metastatic to the structure - such as the lymph nodes nearby structures, the
esophageal wall, pericardium, brain, bone frame.

G. DIAGNOSTIC EXAMINATION.

Radiology.

Posterior thorax - anterior (PA) and leteral and chest tomography.

A simple initial examination that can detect lung cancer. Describe the shape, size and location of the
lesion. May declare the air mass at the hilum, pleural effuse, atelectasis erosion ribs or vertebrae.

Bronkhografi.

To look at the branching bronchial tumor.

 Laboratory.

Cytology (sputum, pleural, or lymph nodes).

Conducted to assess the presence / stage carcinoma.

Pulmonary function tests and GDA

Can be done to assess the capacity to meet the ventilation requirements.

Skin test, the absolute number of lymphocytes.

Can be done to evaluate immune competence (common in lung cancer).

Histopathology.

Bronchoscopy.

Allows visualization, parts washing, and cleaning cytological lesions (bronchogenic carcinoma
magnitude can be determined).

Trans thoracic biopsy (TTB).

Biopsy with TTB especially for lesions located peripheral to the size <2 cm, the sensitivity reached
90-95%.

Thoracoscopic.

Pleural biopsy tumor area gave better results with thoracoscopic way.

Mediastinosopi.

Umtuk obtain tumor metastasis or lymph nodes involved.

Thoracotomy.

Totakotomi for lung cancer diagnostic done when wide - range of non-invasive and invasive
procedures previously failed to obtain tumor cells.

Imaging.

CT-Scanning, to evaluate the lung parenchyma and pleural tissue.

MRI, to show the state of the mediastinum.

 H. MANAGEMENT.

Goal of cancer treatment may include:

Curative

Prolong disease-free survival and improve client.

Palliative.

Reducing the impact of cancer, improve the quality of life.

Rawat home (Hospice Care) in terminal cases.

Reduce the physical and psychological impact of cancer on patients and families better.

Supotif.

Supporting curative treatment, palliative and terminal sepertia nutrition, blood transfusion and blood
component, anti-pain medications and anti-infective.

(Medicine, 2001 and Doenges, Nursing care plan, 2000)

Surgery.

Aim at lung cancer surgery as other lung diseases, to pick-up all diseased tissue as possible while
maintaining lung function - which is not affected by lung cancer.

Toraktomi exploration.

To mengkomfirmasi suspected diagnosis of pulmonary disease or carcinoma thoracic particular, to

perform a biopsy.

Pneumonectomy lung removal).

Bronchogenic carcinoma lobectomy does not fit in with all lesions can be removed.
 Lobectomy (removal of the lung lobe).

Bronchogenic carcinoma is confined to one lobe, bronkiaktesis bleb or bulla emfisematosa; lung
abscess; fungal infections; tuberkulois benign tumor.

Segmental recession.

Is pengankatan satau or more lung segments.

Wedge recession.

Benign tumors with well defined, tumor metas picking, or a localized inflammatory diseases. Is the
removal of the surface of the lungs - pulmonary wedge shaped (ice chunks).

Decortication.

An appointment of material - material from pleural fibrin viscelaris)

Radiation

In some cases, radiotherapy is performed as a curative treatment, and can also as adjuvant therapy /
palliation in tumors with complications, such as reducing the effects of obstruction / suppression of
blood vessels / bronchi.

Kemoterafi.

Chemotherapy is used to disrupt the pattern of tumor growth, to treat patients with small cell lung
tumor or the metastasis as well as to complement the extensive surgery or radiation therapy.

I. NURSING CARE OF CLIENTS WITH LUNG CANCER.

1. ASSESSMENT.

Preoperatively (Doenges, Nursing Care Plan, 1999).

1). Activity / rest.

Symptoms: weakness, inability to maintain regular habits,

dyspnea due to inactivity.

Symptoms: Lethargy (usually advanced stage).

2). Circulation.

Symptoms: JVD (vana caval obstruction).

The sound of the heart: pericardial friction (showing effusion).

Tachycardia / dysrhythmias.

Finger clubbing.

3). Ego integrity.

Symptoms: Feelings taku. Fear the results of surgery

Resist the harsh conditions / potential malignancy.

Signs: Anxiety, insomnia, repeated question - again.

4). Elimination.

Symptoms: Diarrhea intermittent (small cell carcinoma).

Increased frequency / amount of urine (hormonal imbalance, epidermoid tumor)

5). Food / liquids.

Symptoms: Weight loss, poor appetite, decreased input

food.

Difficulty swallowing

Thirst / increased fluid intake.

Signs: Petite, or the appearance of less weight (advanced stage)

Edema of the face / neck, chest, back (vena cava obstruction), facial edema / periorbital (hormonal
imbalance, small cell carcinoma)

Glucose in the urine (hormonal imbalance, epidermoid tumor).

6). Pain / comfort.

Symptoms: Chest pain (not normally exist in the early stages and are not always

at an advanced stage) which can / can not be influenced by changes in position.

Shoulder pain / hand (especially on large cell or adenocarcinoma)

Intermittent abdominal pain.

7). Breathing.

Symptoms: Cough cough mild or changing patterns of normal and or

sputum production.
Shortness of breath

Workers exposed to pollutants, dust industry

Hoarse, vocal cord paralysis.

History of smoking

Signs: dyspnea, increased work

Increased tactile fremitus (showing consolidation)

Krekels / wheezing on inspiration or expiration (airflow disruption), krekels / wheezing settled;

pentimpangan trachea (lesion area).

Hemoptysis.

8). Security.

Symptoms: Fever may be a (big or cell carcinoma)

Redness, pale skin (hormonal imbalance, small cell carcinoma)

9). Sexuality.

Signs: Gynecomastia (hormone changes neoplastic cell carcinoma

large)

Amenorrhoea / impotent (hormonal imbalance, small cell carcinoma)

10). Counseling.

Symptoms: family risk factors, cancer (especially lung), tuberculosis

Failure to improve.

Postoperative (Doenges, Nursing Care Plan, 1999).

- Characteristics and depth of breathing and the patient's skin color.

- Frequency and rhythm of the heart.

- Laboratory tests related (GDA. electolyte serum, hemoglobin and hematocrit).

- Monitoring of central venous pressure.

- Nutritional status.

- Status extremity mobilization particularly in the upper extremity on the side of the operation.

- Conditions and characteristics of the water seal drainage.

1). Activity or rest.

Symptoms: Changes in activity, reduced sleep frequency.

2). Circulation.

Signs: rapid pulse, high blood pressure.

3). Elimination.

Symptoms: decreased frequency of elimination CHAPTER

Signs: urinary catheter attached / no, characteristics of urine

Bisng intestine, samara or clear.

4). Food and fluids.

Symptoms: Nausea or vomiting

5). Neurosensori.

Symptoms: Impaired movement and sensation below the level of anesthesia.

6). Pain and discomfort.

Symptoms: Complaints of pain, pain characteristics

Pain, discomfort from a variety of sources such as incision

Or effects - the effects of anesthesia.

2. NURSING NURSING DIAGNOSIS AND PLANS.

Preoperatively (Gale, Oncology Nursing Care Plans, 2000, and Doenges, Nursing Care Plan,
1999).

1). Damage to gas exchange

Can be connected:

Hypoventilation.

Outcomes:

- Demonstrate improved ventilation and adequate oksigenisi with GDA in the normal range and are
free of symptoms of respiratory distress.

- Participated in the treatment program, the ability / situation.

Intervention:

a) Assess the respiratory status with frequent, noted an increase in the frequency or respiratory effort
or change in breathing pattern.

Rationale: Dyspnea is a compensatory mechanism of the airway resistance.

b) Record the presence or absence of additional sound and the sound added, for example krekels,
wheezing.

Rational: decreased breath sounds can be, not the same or does not exist in the area sakit.Krekels is
evidence of increased fluid within the network as a result of increased permeability of the
alveolar-capillary membrane. Wheezing is evidence of resistance or in connection with the narrowing
of the airway mucus / edema and tumor.

c) Assess adanmya cyanosis

Rational: oxygenation significant decline occurred before cyanosis. Central cyanosis of "organ" warm
example, the tongue, lips and ears are the most indicative.

d) Collaboration of moist oxygen as indicated

Rational: Maximizing oxygen preparation for the exchange.

e) Keep an eye or draw the series GDA.

Rationale: Shows ventilation or oxygenation. Used as a basis for evaluation or therapy keefktifan
indicator therapy needs change.

2). Ineffective airway clearance.

Can be connected:

- Loss of airway ciliary function

- Increased number / viscosity of pulmonary secretions.

- Increased airway resistance

Outcomes:

- Declare / show loss of dyspnea.

- Maintain a patent airway with breath sounds clean

- Removing the secretions without any difficulties.

- Demonstrate behaviors to improve / maintain airway bersiahn.

Intervention:
a) Record the change effort and breathing patterns.

Rationale: The use of intercostal muscle / abdominal and nasal dilation showed increased breathing
effort.

b) Observation ekspensi decline and the chest wall.

Rational: Expansion dad limited or no relation to fluid accumulation, edema, and secretions in sexy
lobe.

c) Record the characteristics of cough (eg, settling, effective, not effective), also sputum production
and characteristics.

Rational: Characteristics cough may change depending on the cause / etiology failed perbafasan.
Sputum when there may be many, thick, bloody, adan / or puulen.

d) Maintain the position of the body / head right and use airway device as needed.

Rationale: Allows maintain upper airway patent airway when pasein affected.

e) Collaboration of bronchodilators, aminophylline example, albuterol etc.. Keep an eye for the
adverse effects of drugs, examples of tachycardia, hypertension, tremors, insomnia.

Rationale: Drugs given to relieve bronchial spasms, reduce viscosity of secretions, improve ventilation,
and facilitate disposal of secretions. Require a change in dose / drug choice.

3). Fear / anxiety.

Can be connected:

- Crisis situations

- The threat to / change in health status, fear of death.

- Psychological factors.

Outcomes:

- Declare awareness of anxiety and healthy ways to cope.

- Recognize and discuss fear.

- Looks relaxed and report anxiety levels can be decreased to diatangani.

- Demonstrate problem solving and effective use of resources.

Intervention:

a) Observation of increased anxiety, emotional instability.

Rational: The worsening disease can cause or increase anxiety.

b) Maintain a calm environment with little stimulation.

Rationale: Reduce anxiety by increasing relaxation and energy savings.

c) Show / Aids with relaxation techniques, meditation, imagination guidance.

Rationale: Provide an opportunity for the patient to handle ansietasnya own and feel controlled.

d) Identify the client perspsi against existing threats by the situation.

Rational: Helping the introduction of anxiety / fear and identify actions that can help to individuals.

e) Encourage the patient to recognize and express feelings.

Rationale: The first step in overcoming the feeling is the identification and expression. Encouraging
self-acceptance situation and ability to cope.

4). Lack of knowledge about the condition, action, prognosis.

Can be connected:

- Lack of information.

- Errors of interpretation of information.

- Less remember.

Outcomes:

- Explain the relationship between the disease process and treatment.

- Describing / states diet, medication, and program activities.

- Identify the correct signs and symptoms that require medical attention.

- Make a plan for further treatment.

Intervention:

a) Encourage learning to meet the needs of patients. Rippling information in a clear / concise.

Rational: Recover from failed pulmonary disorders can severely hamper the scope of patient attention,
concentration and energy for receiving information / new task.

b) Provide verbal and written information about the drug

Rationale: The provision of safe medication use instructions memmampukan patients to follow the
proper course of treatment.

c) Assess nutritional counseling on meal plans; needs of high-calorie foods.

Rationale: Patients with severe respiratory problems typically experience weight loss and anorexia
that require enhanced nutrition for healing.

d) Provide guidelines for activity.

Rationale: Patients should avoid too tired and activities counterbalance istirahatdan period to
increase the stretch / stamina and prevent the consumption / excessive oxygen demand.
 Postoperative (Doenges, Nursing Care Plan, 1999).

1). Damage to gas exchange.

Can be connected:

- Appointment of lung tissue

- Impaired oxygen supply

- Decrease in the oxygen-carrying capacity of the blood (blood loss).

Outcomes:

- Demonstrate improved ventilation and adequate tissue oxygenation with GDA in the normal range.

- Free of symptoms of respiratory distress.

Intervention:

a) Record the frequency, depth and ease breathing. Observation of the use of accessory muscles,
breathing lips, skin changes / mucous membranes.

Rationale: Respiratory increased as a result of pain or as an initial compensatory mechanism to the

loss of lung tissue.

b) Auscultation of the lungs for air gerakamn and abnormal breath sounds.

Rational: Consolidation and lack of air movement on the operated side in patients pneumonoktomi
normal. However, patients must demonstrate lubektomi normal airflow in the remaining lobes.

c) Maintain the patient's airway kepatenan to provide position, exploitation, and use of tools

Rationale: Airway obstruction affecting ventilation, interfere with gas exchange.

d) Change position often, place the patient in the supine position until the seat is tilted position.

Rational: Maximizing lung expansion and drainage of secretions.

e) Encourage / assist with breathing in and breathing exercises with proper lip.

Rationale: Increases maximum ventilation and oxygenation and reduce / prevent atelectasis.

2). Ineffective airway clearance

Can be connected:

- Increased number / viscosity of secretions

- Limitations of chest movement / pain.

- Weakness / fatigue.
Outcomes:

Showed patency of the airway, with fluid secretions easily removed, clear breath sounds, and
breathing was noisy.

Intervention:

a) Auscultation of the chest for breath sounds and characteristics of the secretions.

Rationale: Respiratory noise, crackles, and wheezing showed retention of secretions and / or
obstruiksi airway.

b) Assist patients with / instructed to breath deeply and cough effectively with high seating position
and pressing area of the incision.

Rational: The sitting position allows maximal lung expansion and suppression of cough menmguatkan
efforts to mobilize and remove secretions. Emphasis is performed by nurses.

c) Observation of the amount and character of sputum / secretions aspiration.

Rationale: Increased number of colorless discharge / runny initially normal and should decrease
according to the progress of healing.

d) Encourage oral fluid intake (at least 2500 ml / day) in cardiac tolerance.

Rational: to maintain adequate hydration secretions lost / increase in spending.

e) Collaboration of bronchodilators, expectorants, and / or analgesics as indicated.

Rationale: Eliminates spasm of the bronchi to improve air flow, dilute and reduce the viscosity of
secretions.

3). Pain (acute).

Can be connected:

- Surgical incision, tissue trauma, and internal neurological disorders.

- The chest tube.

- The invasion of cancer to the pleura, chest wall

Outcomes:

- Report neyri lost / controlled.

- Looks relax and sleep / rest well.

- Participate in activities desired / needed.

Intervention:

a) Ask the patient about pain. Determine the characteristics of pain. Create a range of intensity on a
scale of 0-10.
Rational: Assist in the evaluation of painful symptoms due to cancer. The use of scales assist patients
in assessing the level of pain and provide a tool for the evaluation of analgesics keefktifan, improve
pain control.

b) Assess the verbal statements and non-verbal pain patients.

Rational: Ketidaklsesuaian between verbal cues / nonverbal clues can provide a degree of pain, the
need / keefketifan intervention.

c) Write down the possible causes of pain patofisologi and psychology.

Rationale: Incision posterolateral more uncomfortable for the patient than the anterolateral incision.
Besides fear, distress, anxiety and loss of appropriate cancer diagnosis can interfere with the ability of
cope.

d) Encourage states tentangnyeri feelings.

Rational: Fear / problems can increase muscle tension and reduce pain perception threshold.

e) Provide comfort measures. Encourage and teach the use of relaxation techniques

Promote relaxation and distraction.

4). Anxiety.

Can be connected:

- Crisis situations

- Threats / health status changes

- The ancman death.

Outcomes:

- Recognize and discuss the fear / problem

- Demonstrate appropriate range of feelings and facial appearance seemed to relax / rest

- Declare an accurate knowledge of the situation.

Intervention:

a) Evaluate the level of understanding of patient / significant other about the diagnosis.

Rationale: The patient and those closest to hear and assimilate new information that includes no
changes in self-image and lifestyle. This involves understanding the perception of individual
arrangement of pressure maintenance and provide the information necessary to select the
appropriate interventions.

b) Acknowledge the fear / problems and encourage patients to express feelings

Rational: Support enables patients began open or accept the reality of cancer and its treatment.

c) Accept the denial of patients but do not be corroborated.

Rationale: When the extreme denial or ansiatas affect the progress of healing, the patient needs to
confront the issue of how to explain and emebuka completion.

d) Provide an opportunity to ask and answer honestly. Ensure that patients and caregivers have the
same understanding.

Rational: Creating trust and reduce misperceptions / incorrect interpretation of information ..

 e) Involve the patient / significant other in treatment planning. Give time to prepare events /
treatment.

Rational: It can help improve some feeling of control / independence in patients who feel powerless
tek in receiving treatment and diagnosis.

f) Provide fiik patient comfort.

Rationale: It is difficult to accept the issue of when the experience of extreme emotions / physical
discomfort settled.

5). Lack of knowledge about the condition, action, prognosis.

Can be connected:

- Less or do not know the information / source

- One interperatasi information.

- Less remember

Outcomes:

- Declare understanding the ins and outs of the diagnosis, the treatment program.

- Perform the necessary procedures correctly and explain the reasons such action.

- Participate in the learning process.

- Change in lifestyle.

Intervention:

a) Discuss the diagnosis, plan / sasat this therapy and the expected results.

Rationale: Provide specific information individuals, making knowledge to learn about management at
home. Radiation and chemotherapy can accompany surgical intervention and important information
to enable the patient / significant other to make informed decisions.

b) Strengthen explanation surgeon about surgical procedures to provide appropriate diagram. Enter
this information in the discussion of short-term expectations / length of healing.

Rationale: The duration of rehabilitation and prognosis depends on the type of surgery, preoperative
conditions, and the length / degree of complication.

c) Discuss the need to evaluate the treatment plan when I go home.

Rationale: Assessment of respiratory status and evaluation of public health imperative to ensure
optimal healing. Also provides an opportunity to refer issues / questions in a bit of stress.…

DM

Definition
Diabetes mellitus is a group of symptoms that occur in a person who is caused by the
presence of elevated levels of blood glucose due to insulin deficiency both in absolute and
relative (Noer, 2003).
 Diabetes mellitus is a disease in which the sufferer can not control the sugar levels in the body.
The body will always lack or excess sugar that interfere with the body's systems work as a
whole (School of Medicine, 2001).
Diabetes mellitus is a common disease resulting from a deficiency of insulin or a decreased
effectiveness of insulin (Brooker, 2001).

B. Classification Types of Diabetes

• Type 1 diabetes mellitus (Type 1 DM)
Incidence of Type 1 diabetes in Western countries + 10% of type 2 DM. In
tropical countries much less again. Clinical picture biasanyatimbul in
childhood and peak during puberty. But there are also arising in adulthood.
• Diabates mellitus type 2 (DM type 2)
Type 2 diabetes is the most common type (over 90%). Arise more often after the age of 40
with a note in the seventh decade of diabetes prevalence reaches 3 to 4 times higher than the
average adult.
• Other Types of Diabetes Mellitus
There are several other types of diabetes such as genetic defects of beta cell function, genetic
defects of insulin action, diseases of the exocrine pancreas, endokrinopati, because of drugs or
chemicals, infections, cause a rare immunological and other genetic syndromes associated
with DM.
• Gestational Diabetes Mellitus
Gestational diabetes mellitus is diabetes that occurs during pregnancy. This type is very
important to know the impact on the fetus are less well when not handled properly.
C. Pathophysiology
In the process of metabolism, insulin holds a very important role
is assigned to the glucose enter the cells. Insulin is a substance secreted by the beta cells
in the pancreas.
1) Pancreatic
The pancreas is a gland located behind the stomach. Inside are a collection of cells
called Langerhans islands that contain beta cells. Mngeluarkan beta cell insulin to
regulate blood glucose levels. In addition there is also the beta cells that produce
glucagon alfa srl that worked contrary to insulin which increases blood glucose levels.
Also there are mngeluarkan somastostatin delta cells.
2) Work Insulin
Insulin is described as the key to unlock the entrance of glucose into the cells, and then
in the cell, it dimetabolismekan glucose into energy.
3) Pathophysiology of Type 1 DM
Why insulin in Type 1 diabetes mellitus is not there? This is caused by this type arise
due to an autoimmune reaction that is caused due to an inflammation in insulitis beta
cells. This led to the emergence of antibodies against beta cells called ICA (Islet Cell
Antibody). Antigen reaction (beta cells) with antibodies (ICA) it creates causes the
destruction of beta cells.
4) Pathophysiology of Type 2 DM
Type 2 diabetes mellitus normal amount of insulin, but instead may be more insulin
receptors located on the cell surface is less. Inulin receptor is described as keyhole
entrance into the cell. At the state had less number of key holes, until despite her key
(insulin) a lot, but because of a lock (receptor) is less, then the glucose enter cells will
be small, so that the cell will lack glucose and glucose in the blood will increase. The
state is the same as in Type 1 DM. The difference is that Type 2 diabetes in addition to
high glucose levels, insulin levels are too high or normal. This condition is called
insulin resistance.
That many factors play a role as a cause of insulin resistance:
1. Especially those that are central obesity (apple shape)
2. Diets high in fat and low in carbohydrates
3. Lack of exercise
4. Hereditary factors (hereditary)

D. Etiology
Viruses and Bacteria
DM is the virus that causes rubella, mumps, and human coxsackievirus B4. Through
the mechanism of infection sitolitik in beta cells, this virus results in the destruction or
disruption of cells. Could also, this virus attacks through autoimmunity reaction leading
to loss of beta cell autoimmunity in. Diabetes mellitus is caused by the bacteria could
still be detected. However, health experts suspect bacterial quite instrumental cause
DM.
Toxic or Toxic Materials
Toxic materials that can directly damage beta cells is alloxan, pyrinuron (rodenticides),
and streptozoctin (products of a type of fungus). Another ingredient is cyanide from
cassava.
Genetic or Heredity Factors
Diabetes mellitus tended to be reduced or diawariskan, not transmitted. Family
members of patients with DM (diabetes) have a greater likelihood of developing the
disease compared with family members who do not have diabetes. Health experts also
said diabetes is a disease which is adrift sex chromosomes or sex. Usually men become
real people, whereas women as party carrying the gene for inherited by his children.

E. Clinical
Symptoms of diabetes
Classic symptoms of diabetes are excessive thirst frequent urination, especially at night,
lots of eating and weight down quickly. In addition, there are complaints sometimes
weak, tingling in fingers and toes, swift hunger, itch, become blurred vision, decreased
sex drive, difficult wounds healed and the mothers often give birth to babies over 4
kg.Kadang- Sometimes there are patients who did not feel any complaints, because
they are aware of any diabetes health check diemukan when blood glucose levels are
high.
F. Investigations
Diagnosis of DM generally will be considered in the presence of typical symptoms of
diabetes such as polyuria, polydipsia, weakness, and weight loss. Other symptoms that
may be raised by the patient is tingling, itching, blurred eyes and impotensia in male
patients, and pruritus vulvae and in female patients. If the complaint and typical
symptoms, the examination found that when blood glucose> 200 mg / dl is sufficient to
establish the diagnosis of DM. Generally, blood glucose test results while the new one
just is not enough to abnormal clinical diagnosis of DM.
If the blood glucose test results dubious, oral glucose tolerance is needed to confirm a
diagnosis of DM. For diagnosis of diabetes mellitus and impaired glucose tolerance
others examined blood glucose 2 hours after a glucose load. Required at least 2 times
the glucose levels had abnormal to confirm the diagnosis of DM, both on 2 different
tests or presence of 2 abnormal results during the same examination.
How to oral glucose tolerance
• Three days earlier meal as usual
• Physical activity enough, not too much
• Fasting overnight, for 10-12 hours
• Fasting blood glucose checked
• Awarded 75 grams of glucose dissolved in 250 ml of water, and drink during / in 5
minutes
• Examined blood glucose 1 (one) hour and 2 (two) hours after glucose load
• During the examination, the patients were examined still a break and not

G. Complication
Complications of diabetes mellitus can occur acutely and chronically, which raised a
few months or a few years after diabetes mellitus.
• Acute Complications of Diabetes Mellitus
Two of the most important acute complication is hypoglycemia and diabetic coma
reaction.
1. Hypoglycemia reactions
Symptomatic hypoglycemia reaction is caused by the body's lack of glucose, with signs
of hunger, trembling, sweating, dizziness, and so on. Hypoglycemic coma patient
should be immediately taken to the hospital because of need to receive injections of
40% glucose and glucose infusion. Diabetes who experienced hypoglycemic reactions
(still conscious), or hypoglycemic coma, usually caused by the anti-diabetic drugs are
taken too high a dose, or people with eating late, or it could be due to excessive physical
exercise.
2. Diabetic coma
Contrary to hypoglycemic coma, diabetic coma was caused by the body's blood levels
are too high, and usually more than 600 mg / dl. Symptoms of diabetic coma that often
arises is:
• Decreased appetite (usually people with diabetes have a big appetite)
• Drink a lot, peeing a lot
• Then followed by nausea, vomiting, breathing became rapid and the patient, as well as
the smell of acetone
• Often accompanied by body heat because there is usually an infection and diabetic
coma patient should be immediately taken to the hospital

• Chronic Complications of Diabetes Mellitus

Chronic complications of diabetes occurs in basically all the blood vessels throughout
the body (diabetic angiopathy). For convenience, divided 2 diabetic angiopathy:
• makroangiopati (macrovascular)
• mikroangiopati (microvascular)
Although it does not mean that each other apart and did not happen all at once
simultaneously.

H. Management
The form:
a. Antidiabetic medication
1) triggers insulin secretion:
 sulfonylureas
 Glinid
2) Incremental sensitivity to insulin:
 biguanid
 Tiazolidindion
 alpha glucosidase inhibitors
b. Insulin
c. Prevention of complications
 Stop Smoking
 Optimizing cholesterol levels
 Maintaining a stable body weight
 Controlling high blood pressure
 Regular exercise can be beneficial:
• Controlling blood glucose levels
• Lose excess weight (preventing obesity)
• Helps reduce stress
• Strengthen muscles and heart
• Increasing levels of 'good' cholesterol (HDL)
• Helps lower blood pressure

NURSING MANAGEMENT

A. ASSESSMENT
Assessment is the first step in the nursing process and basic overall (Boedihartono,
1994: 10).
Assessment of patients with diabetes mellitus (Doenges, 1999) include:
a. Activity / Rest
Symptoms: weakness, fatigue, difficulty moving / walking, muscle cramps, decreased
muscle tone.
Signs: decreased muscle strength.
b. Circulation
Symptoms: foot ulcers, healing time, tingling / numbness in the extremities.
Signs: skin hot, dry and reddish.
c. Ego Integrity
Symptoms: depend on others.
Signs: anxiety, sensitive stimuli.
d. Elimination
Symptoms: changes in the pattern of urination (polyuria), nakturia
Signs: dilute urine, pale dry, poliurine.
e. Food / fluid
Symptoms: loss of appetite, nausea / vomiting, do not follow the diet, weight loss.
Symptoms: dry skin / scaly, ugly turgor.

f. Pain / comfort
Symptoms: pain in the ulcer wound
Signs: face grimacing with palpitations, looks very carefully.
g. Security
Symptoms: dry skin, itching, skin ulcers.
Symptoms: fever, diaphoresis, damaged skin, lesion / ulceration
h. Counseling / learning
Symptoms: family risk factors diabetes, heart disease, stroke, hypertension, healing
Lamba. Obatseperti use steroids, diuretics (thiazides): diantin and phenobarbital (may
increase blood glucose levels).

B. Nursing Diagnosis
Nursing diagnosis is a unification of the problem of real or potential patients based on
the data that has been collected (Boedihartono, 1994).
Nursing diagnoses in patients with diabetes mellitus (Doenges, 1999) are:
1) Lack of fluid volume associated with osmotic diuresis, gastric loss, excessive
diarrhea, nausea, vomiting, limited input, mental mess.
2) Changes in nutrition less than body requirements related to inadequate insulin,
decreased oral input: anorexia, nausea, a full stomach, abdominal pain, change in
consciousness: hipermetabolisme status, the release of stress hormones.
3) High risk of infection related to inadequate peripheral defense, changes in circulation,
high blood sugar levels, invasive procedures and skin damage.
4) Fatigue associated with decreased metabolic energy production, changes in blood
chemistry, insulin insufficiency, increased energy needs, status hipermetabolisme /
infection.
5) Lack of knowledge about the condition, prognosis and treatment needs related to
misinterpretation of information / do not know the source of information.

C. INTERVENTION AND IMPLEMENTATION

Intervention is planning nursing actions that will be implemented to address the
problem in accordance with the nursing diagnoses (Boedihartono, 1994)
Implementation is the realization of management and nursing plans that had been
developed at the planning stage (Effendi, 1995).
And implementation of nursing intervention in patients with diabetes mellitus
(Doenges, 1999) include:
a) Lack of fluid volume associated with osmotic diuresis, gastric loss, excessive
(diarrhea, vomiting) input is limited (nausea, mental chaotic).
Objective: body condition is stable, vital signs, skin turgor, normal.
Results Criteria: - patients showed an improvement in fluid balance, with criteria;
spending adequate urine (normal range), vital signs stable, clear peripheral pulse
pressure, good skin turgor, capillary refill well and mucous membranes moist or wet.
Intervention / Implementation:
1) Monitor vital signs, note the change in blood pressure ortestastik.
R: Hypovolemia can be manifested by hypotension and tachycardia.
2) Assess the pattern of breathing and smelly breath.
R: The lungs secrete carbonic acid is produced through the respiratory compensation
against the state alkosis respiratoris ketoacidosis.

3) Assess temperature, color and moisture.

R: Fever, chills, and diaferesis is common in the infection process. Fever with skin
redness, dry, maybe a picture of dehydration.
4) Assess peripheral pulses, capillary refill, skin turgor and mucous membranes.
R: Is an indicator of the level of dehydration or adequate circulating volume.
5) Monitor intake and output. Record the urine specific gravity.
R: memeberikan estimate the need for fluid replacement, renal function and the
effectiveness of a given therapy.
6) Measure body weight every day.
R: gives the best results of the assessment of the status of ongoing fluid and further in
giving replacement fluids.
7) Collaboration fluid therapy as indicated
R: the type and amount of fluid depends on the degree of dehydration and individual
patient response.

b) Changes in nutrition less than body requirements related to insufficient insulin,

decreased oral input: anorexia, nausea, a full stomach, abdominal pain, change in
consciousness: hipermetabolisme status, the release of stress hormones.
Goals: weight can be increased with normal laboratory values and no signs of
malnutrition.
Results Criteria: - patient is able to express an understanding of substance abuse,
decrease the amount of intake (diet on nutritional status).
- Demonstrate behaviors, lifestyle changes to improve and maintain a proper weight.
Intervention / Implementation:
1) Weigh weight every day as indicated
R: Knowing eating adequate income.
2) Determine the diet and eating patterns of patients compared with foods that can be
spent on the patient.
R: Identify deviations from the requirements.
3) Auscultation of bowel sounds, note the presence of abdominal pain / abdominal
bloating, nausea, vomiting, keep fasting as indicated.
R: influence of intervention options.
4) Observation of signs of hypoglycemia, such as changes in level of consciousness,
cold / humid, rapid pulse, hunger and dizziness.
R: is potentially life threatening, which must be multiplied and handled appropriately.
5) Collaboration in the delivery of insulin, blood sugar tests and diet.
R: It is useful to control blood sugar levels.

c) High risk of infection related to inadequate peripheral defense, changes in circulation,

high blood sugar levels, invasive procedures and skin damage.
Objective: Infection does not occur.
Results Criteria: - identify individual risk factors and potential interventions to reduce
infection.
- Maintain a safe aseptic environment.
Intervention / Implementation
1) Observation for signs of infection and inflammation such as fever, redness, pus in the
wound, purulent sputum, urine color cloudy and foggy.
R: incoming patients with infections that normally might have been able to trigger a
state ketosidosis or nosocomial infections.
2) Increase prevention efforts by performing good hand washing, each contact on all
items related to the patient, including his or her own patients.
R: prevention of nosocomial infections.
3) Maintain aseptic technique in invasive procedures (such as infusion, catheter folley,
etc.).
R: Glucose levels in the blood will be the best medium for the growth of germs.
4) Insert the catheter / perineal care do well.
R: Reduce the risk of urinary tract infection.
5) Provide skin care with regular and earnest. Massage depressed bone area, keep skin
dry, dry linen dantetap toned (not wrinkled).
R: peripheral circulation can be impaired penigkatan that put patients at risk of damage
to the skin / eye irritation and infection.
6) Position the patient in semi-Fowler position.
R: makes it easy for the lung to expand, lowering the risk of hypoventilation.
7) Collaboration antibiotics as indicated.
R: penenganan early can help prevent the onset of sepsis.

d) Fatigue associated with decreased metabolic energy production, changes in blood

chemistry, insulin insufficiency, increased energy needs, status hipermetabolisme /
infection.
Purpose: Fatigue is reduced / decrease fatigue
Results Criteria: - declare mapu to rest and increased power.
- Be able to demonstrate the factors that influence fatigue.
- Shows the increase in capabilities and participate in activities.
Intervention / Implementation:
1) Discuss with the patient the need activity. Create a schedule planning with patients
and identification of activities that cause fatigue.
R: education can provide motivation to improve the activity even though the patient
may be very weak.
2) Provide an alternative activity denagn adequate rest periods / without being
distracted.
R: preventing excessive fatigue.
3) Monitor vital signs before or after the activity.
R: identifying activity level is tolerated physiologically.
4) Discuss how to conserve calories during a shower, change places and so on.
R: with energy saving patients can do more activities.
5) Increase the participation of patients in their daily activities according to ability /
tolerance of the patient.
R: increased confidence / self-esteem is positive according to the activity level of
patients tolerated.

e) Lack of knowledge about the condition, prognosis and treatment needs related to
misinterpretation of information / do not know the source of information.
Purpose: The patient expressed understanding of the conditions, procedures and effects
of the treatment process.
Results Criteria: - perform the necessary procedures and explain the rationale of an
action.
- Initiate the necessary lifestyle changes and participate in treatment regimen.
Intervention / Implementation:
1) Assess the level of knowledge of the client and family about the disease.
R: megetahui how much experience and knowledge of the client and family about the
disease.
2) Provide a description of the client about his illness and his condition now.
R: by knowing the disease and its present state, the client and his family will feel calm
and reduce anxiety.
3) Encourage clients and families to pay attention to her diet.
R: diet and proper diet helps the healing process.
4) Ask the client and reiterated family of materials that have been given.
R: knowing how far the client and family understanding and assessing the success of
the action taken.

D. EVALUATION
Evaluation is the stage at which the level of success of the nursing process in achieving
the goals of nursing assessed and the need to modify or nursing intervention defined
purpose (Brooker, 2001).
Evaluation expected in patients with diabetes mellitus are:
1) the body condition is stable, vital signs, skin turgor, normal.
2) Weight loss may increase with normal laboratory values and no signs of malnutrition.
3) Infection does not occur
4) reduced fatigue / tiredness decrease
5) The patient expressed understanding of the conditions, procedures and effects of the
treatment process.

REFERENCES

Brooker, Christine. , 2001. Pocket Dictionary of Nursing. EGC: Jakarta.Carpenito,

L.J. , 1999. Nursing care plans and documentation of nursing, Nursing Diagnosis and
Collaborative Problems, ed. 2. EGC: Jakarta.
Doenges, Marilynn E. , 1999. Nursing care plan guidelines for planning and
documenting patient, ed.3. EGC: Jakarta.
Effendy, Nasrul. , 1995. Introduction to Nursing Process. EGC: Jakarta.FKUI. ,
2001. Textbook of Medicine Jilid.II ed.3. FKUI: Jakarta.
Haznam. , 1991. Endocrinology. Space Offset: BandungNoer, Sjaifoellah HM, et
al. , 2003. Textbook of Medicine, sixth printing. Hall FKUI Publisher: Jakarta
Soegondo S, et al. 2007. Integrated Management of Diabetes Mellitus, sixth
printing. Hall FKUI Publisher: Jakarta.

Abdominal trauma

INTRODUCTION

EpidemiologyAbdominal injuries are common in patients who sustain major trauma.

Unrecognizedabdominal injuries are frequently the cause of preventable death. Abdominal injuries
rank third as a cause of traumatic death preceded by head and chest injuries. Abdominal
traumaresults in a mortality rate of 13 to 15%. Patients with multiple abdominal organ injuries(with or
without an injury to another body system) have significantly higher mortality ratesthan those with an
isolated abdominal injury. Approximately one-fifth of all traumatized patients requiring operative
intervention have sustained trauma to the abdomen. Thedistribution of patients with abdominal
trauma varies based on triage patterns of traumasystems, geography, and socioeconomic status.

Mechanisms of Injury and Biomechanics

The abdomen is vulnerable to injury since there is minimal bony protection for underlyingorgans.
Because of the retroperitoneal location of certain organs and vascular structures(e.g., vena cava,
aorta, pancreas, and duodenum), these structure are less frequently injured.The physical examination
of the abdomen may not be successful inIdentifying intra-abdominal pathology; therefore, a
description of the mechanism of injuryis importantThe most common mechanism of blunt abdominal
injury is a motor vehicle crash.'Firearms, stabbings, and physical assaults are associated with
penetrating abdominaltrauma. Injuries to the abdomen can result from acceleration, deceleration, or
a combinationof both forces. The abdominal viscera may be compressed or directly impacted.
Crushingforces may compress the duodenum or the pancreas against the vertebral column.
Duringenergy transfer, abdominal structures attached by either ligaments or blood vessels may
bestressed at their attachment points. Forces applied to a solid organ can rupture asurrounding
capsule and injure the parenchyma as well. Safety restraint devices, particularly three-point safety
belts, provide significant protection; however, if they areimproperly positioned, they can cause
deceleration injuries to the lower Lap belt use has been associated with injury to the hollow organs,
particularly the small bowel and colon,lumbar spine, and abdominal wall.' Frontal impact crashes with
a bent steering wheel and broken windshield are associated with spleen and liver injuries as well as
head and chesttrauma. Depending on the side of the impact, side impact crashes can result in injuries
tothe liver and spleen. Rear impact crashes can result in neck or abdominal injuries inunrestrained
drivers who hit the steering column. Ejected motorcyclists may sustain pelvicfractures or
intra-abdominal trauma from collisions with the handlebars or ground.

ypes of Injuries

Blunt and penetrating abdominal injuries may be associated with extensive damage to theviscera
resulting in massive blood loss. Blunt or penetrating abdominal injuries are relatedto the:• Type of
force applied• Tissue density of structure injured (e.g., fluid-filled, gas-filled, solid, or
encapsulated)The liver and spleen are the most commonly injured organs from blunt trauma

The organs of the abdomen are vulnerable to penetrating injury not only through theanterior
abdominal wall, but through the back, flank area and lower chest." Patients with penetrating
abdominal injuries may present with single or multiple wounds. The liver, small bowel and stomach
are the most commonly injured organs from penetrating trauma.

Usual Concurrent Injuries

Because of their anatomical location, fractures of the lower rib cage are often associatedwith spleen
or liver injures. The patient with abdominal trauma, particularly esophageal andgastric injuries, may
have associated chest trauma. Patients with pelvic fractures frequentlyhave associated
intra-abdominal trauma (e.g., bladder laceration). Patients with penetratingwounds at the nipple line
interiorly or at the inferior border of the scapula posterior areconsidered to be at risk for
intra-abdominal injury.

PATHOPHYSIOLOGY AS A BASIS FOR SIGNS AND SYMPTOMS

Patient manifestations of abdominal trauma are frequently subtle. The abdomen maysequester large
amounts of fluid without apparent distention.

Signs and symptoms of blood loss:

Abdominal tenderness

Specific pain patterns

Absent bowel sounds are associated with abdominal injury.

Blood Loss

Injuries to organs or abdominal blood vessels may lead to extensive hemorrhage. Someabdominal
organs are semi-fixed by ligaments, such as the mesenteric attachments of theintestines. When these
organs are stressed at their points of attachment, tears often occur atthe point where the vessels
enter the organ.The spleen and the liver have a rich blood supply and store blood. Rapid loss of large
bloodvolumes from their parenchymal or vascular structures can occur. Because they
areencapsulated, compression of the abdomen may rapidly increase pressure within thecapsule,
resulting in rupture and hemorrhage. In addition, the consistency of the tissuesmakes hemostasis
difficult. Recently, however, there has been a trend toward nonoperativemanagement of patients
with splenic and hepatic injuries if the patient is hemodynamicallystable.Bleeding from organs in the
anterior abdomen is usually confined to that cavity. Bleedingfrom structures in the retroperitoneum
leads to hemorrhage in the retroperitoneum, which ismore difficult to evaluate and diagnose

Pain

Pain, rigidity, guarding, or spasms of the abdominal musculature are classic signs of intra-abdominal
pathology. Sudden movement of irritated peritoneal membranes against theabdominal wall causes
rebound tenderness and guarding of the abdominal muscles.Irritation may be because of the
presence of free blood or gastric contents in the peritonealcavity. Manifestations of pancreatic and
duodenal injury are related to hemorrhage in thearea and the effect of active enzymes on their
surrounding tissues. The resultant "chemical peritonitis" from the enzymes released into the
retroperitoneum and the significant tissueswelling may not appear as signs and symptoms for several
hours after injury.2

The patient with pancreatic and duodenal injury may also complain of diffuse abdominaltenderness
and pain radiating from the epigastric area to the back.

Peristalsis

Following abdominal injury, bowel sounds are frequently hypodynamic. Blood in theabdominal cavity,
direct bowel injury, or any number of conditions including stress maydecrease peristaltic activity;
however, hypoactive or absent bowel sounds combined withtenderness and guarding should be
viewed with a high index of suspicion.

SELECTED ABDOMINAL INJURIES

- Hepatic Injuries

Because of its size and location, the liver is frequently injured when force is applied to theabdomen.
The severity of hepatic injuries ranges from a controlled subcapsular hematomaand lacerations of the
parenchyma to a severe vascular injury of the hepatic veins,retrohepatic cava, and/or hepatic
avulsionThe friability of liver tissue, the extensive blood supply, and the blood storage capacitycause
hepatic injury to result in profuse hemorrhage. These types of injuries requiresurgical control of
bleeding.The success of nonoperative management for hepatic injuries is predicted on adherence
torigid criteria for patient selection. These include hemodynamic stability; the absence of peritoneal
signs: neurologic integrity; precise CT delineation of the injury, degree of freeintraperitoneal blood,
and absence of associated intra-abdominal injuries: need for no morethan two hepatic-related blood
transfusions; and CT scan documented improvement or stabilization with time.

SIGNS AND SYMPTOMS

• Upper right quadrant pain• Abdominal wall muscle rigidity, spasm, or involuntary guarding•
Rebound tenderness• Hypoactive or absent bowel sounds• Signs of hemorrhage and/or hypovolemic
shock

Splenic Injuries

Injury to the spleen is usually associated with blunt trauma, but may also be associated with
penetrating trauma. Fractures of the left 10th to 12th ribs are associated with underlyingdamage to
the spleen. Injuries to the spleen range from laceration of the capsule or anonexpanding hematoma
to ruptured subcapsular hematomas orparenchymal laceration.The most serious splenic injury is a
severely fractured spleen or vascular tear, producingsplenic ischemia and massive blood loss. In cases
of minor, blunt trauma, the treatmentapproach is generally less invasive and dependent on the
patient's age and other clinicalfactors. Nonoperative management of the patient with an isolated
splenic injury mandatesthat the patient be hem dynamically stable This may involve bed rest and
possibly bloodtransfusions (Classes I and II shock only); however, observation or surgical
managementshould be directed at eliminating the need for transfusion.""SIGNS AND SYMPTOMS•
Signs of hemorrhage or hypovolemic shock • Pain in the left shoulder (Kehr's sign)• Tenderness in the
upper left quadrant• Abdominal wall muscle rigidity, spasm, or involuntary guarding

Hollow Organ Injuries

Forces causing trauma to hollow organs may result in either blunt or penetrating injuries.The small
bowel is the hollow organ most frequently injured. Deceleration may lead toshearing, which causes
avulsion or tearing of the small bowel. The areas of the small bowelmost commonly affected are the
areas relatively fixed or looped. Lap seat belts causingcompression have resulted in rupture of the
small bowel or colon.2

SIGNS AND SYMPTOMS

• Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntaryguarding,

rebound tenderness, and/or pain• Evisceration of the small bowel or stomach• Diagnostic Peritoneal
Lavage (DPL) may show presence of bile, feces, or food fibers

Renal Injuries

The most common injury to the kidney is a blunt contusion, Suspect renal injury if there arefractures
of the posterior ribs or lumbar vertebrae. Renal parenchyma can be damaged byshearing and
compression forces causing lacerations or contusion. The deeper the lacerationthe more serious the
bleeding.Rupture of the kidney is not usually associated with hypovolemia unless laceration of arenal
artery has occurred. Deceleration forces may cause vascular damage to the renalartery. Since there is
little collateral circulation in the area of the renal artery, any ischemiais serious and may lead to acute
tubular necrosis

SIGNS AND SYMPTOMS

• Ecchymosis over the flank • Flank or abdominal tenderness elicited during palpation• Gross or
microscopic hematuria—the absence of hematuria does not rule out renal injury

Bladder and Urethral Injuries

The majority of bladder injuries are blunt. Normally, the bladder lies below the level of
thesymphysispubis, but when full, it rises above the pubis into the abdominal cavity. If the bladder is
not full when the rupture occurs, urine may leak into the surrounding pelvictissues, vulva, or scrotum.
If a distended bladder ruptures are perforated, urine is likely toextravasate into the abdomen. Most
ruptures of the bladder occur in association with pelvicfractures.Urethral trauma is more common in
males than females because the male urethra islonger and less protected. The presence of an anterior
pelvic fracture should raise the indexof suspicion for a concomitant urethral injury. Urethral injury in
females is almost alwaysassociated with pelvic fractures. Injury to the penile portion of the urethra in
males is mostcommonly caused by straddle trauma. Prostatic (posterior) urethral injury is usually
caused by pelvic fractures and frequently leads to incontinence and impotence

SIGNS AND SYMPTOMS

• Suprapubic pain• Urge, but inability to urinate• Hematuria (may be microscopic)Blood at the
urethral meatus• Blood in scrotum• Rebound tenderness
bdominal wall muscle rigidity, spasm, or involuntary guarding• Displacement of prostate gland

NURSING CARE OF THE PATIENT WITH ABDOMINAL TRAUMA

AssessmentHISTORYRefer to Initial Assessment, for a description of general information that should

becollected regarding every trauma victim. Only pertinent questions specific to patients
withabdominal injuries are described below.• Was the patient wearing any restraints or protective
devices? Inappropriately positionedlap belts may injure lower abdominal structures. The use of a lap
belt without a shoulder belt is associated with hyperflexion injury to the lumbar spinet• What are
the location, intensity, and quality of pain?• Is nausea or vomiting present?• Does the patient feel an
urge to defecate or urinate?

PHYSICAL ASSESSMENT

Refer to Initial Assessment, for a description of the assessment of the patient's airway, breathing,
circulation, and disability.

Inspection

• Observe the contour of the abdomen (i.e., flat or distended)• Inspect the lower chest, abdomen,
flanks, and back for seat belt abrasions or other softtissue injuries• Ecchymosis over the upper left
quadrant suggests soft tissue trauma or splenic injury• Ecchyrnosis around the umbilicus suggests
intraperitoneal bleeding, and ecchymosis of the flank suggests retroperitoneal bleeding.' Ecchymotic
signs such as these may take hoursor days to develop and may not be noted on initial presentation.•
Inspect gunshot and stab wounds. Wounds should be described by size, appearance,
andlocation.Wounds should NOT be labeled as entrance and exit, but clearly identified and
numbered.• Inspect the pelvic area for soft tissue bruising• Inspect the perineum for hematomas,
bloody drainage from the urethral meatus, andvaginal or rectal bleeding

Auscultation

• Auscultate all four quadrants of the abdomen for bowel sounds. Absence of bowel soundsin
combination with abdominal distention and guarding are highly indicative of visceralinjury.•
Auscultate the chest. If bowel sounds are heard in the chest, it is an indication of diaphragmatic
rupture with heriation of the stomach or small bowel into the thoracic cavity.

Percussion

Percuss the abdomen for hyperresonance or dullness. Hyperresonance indicates air whiledullness
indicates fluid accumulation.

Palpation

• Begin palpating in an area where the patient has not complained of pain. Gently palpateeach of the
four quadrants separately for involuntary guarding, rigidity, spasm, andlocalized pain. Press on the
abdomen and quickly release to determine the presence of rebound tenderness. Any positive findings
of involuntary guarding, rigidity, pain. or spasmduring palpation indicate peritoneal irritation. These
signs may be absent if the patient has

Competing pain from another injury• Retroperitoneal hematoma• Spinal cord injury• Ingested
alcohol or narcotics• Decreased level of consciousness• Palpate the pelvis for bony instability,
asymmetry', or pain, which indicate possibledislocations or fractures• Palpate the. Flanks for
tenderness• Palpate the anal sphincter for presence or absence of tone

DIAGNOSTIC PROCEDURES

Refer to Initial Assessment, for frequently ordered radiographic and laboratory' studies.Additional
studies for patients with abdominal trauma are listed below.Radiographic Studies• Computerized
tomography (CT)An abdominal CT scan may be performed to identify solid organ lacerations,
hematomas,or small amounts of blood or air in the abdominal cavity.Computerized tomography of
the abdomen is most commonly and appropriately used inthe patient who is deemed
hemodynamically stable and does not have other injuriesrequiring immediate diagnostic or
therapeutic intervention that would be delayed by CTexamination of the abdomen.• Intravenous
pyelogram (IVP)Extravasation of the contrast media into surrounding tissues indicates a disruption in
theintegrity of the kidney, ureters, or bladder.• Flat plate, lateral, or upright abdominal radiographic
studiesThese studies are used to:• Visualize foreign bodies and associated visceral damage• Identify
the path of penetrating objects• Visualize free air in the abdomen indicating disruption of the
gastrointestinal tract• Cystogram/urethrogram• Diagnostic ultrasound or sonogram•
Ultrasonography may be used to detect the presence of hemoperitoneum. Indications for this
procedure are the same as for diagnostic peritoneal lavage (DPL).• Angiography, as indicated

Laboratory Studies

• Serum amylase• Liver function studies• Analysis of urine, stool, or gastric contents for blood•
Pregnancy testing for females of childbearing age

Other Studies

Diagnostic peritoneal lavage (DPL)• DPL is one method used to detect intra-abdominal bleeding (see
Fig 21). A diagnostic peritoneal lavage is not useful for identifying retroperitoneal bleeding." After
decompressing the bladder with an indwelling catheter and the stomach with a gastric tubeto avoid
inadvertent puncture, a peritoneal catheter is inserted into the abdomen (usually below the
umbilicus). The catheter is introduced via a puncture or a small incision.Withdrawal of gross blood
from the catheter is considered a positive finding. If gross bloodis not initially aspirated, a liter of
warmed lactated Ringer's solution or normal saline israpidly infused through the catheter. The lavage
fluid is then allowed to drain out via

gravity and analyzed for the presence of red or white blood cells, bile, amylase, food fiber,or feces.
DPL has a 98% accuracy rate in correctly identifying intra-abdominal bleedine.' A positive DPL requires
a surgical consult.• The American College of Surgeons Committee on Trauma recommends that a DPL
be performed early to evaluate the severely injured, hypotensive patient, especially if theabdominal
examination is':• Suggestive of injury• Unreliable (e.g., patient is unresponsive)- Diagnostic peritoneal
lavage may be contraindicated in the following circumstances':• When the decision has already been
made to perform abdominal surgery• When the patient has had previous abdominal surgery
increasing the potential for adhesions• When the patient has known cirrhosis of the liver • When the
patient obese, making technical performance of the procedure difficult• When the patient has a
known medical history of coagulopathyIN

TERVENTIONS

• Cannulate two veins with large-bore, 14- or 16-gauge catheters, and initiate infusions of lactated
Ringer's solution or normal saline• Administer blood, as indicated• Insert an indwelling urinary
catheter An indwelling urinary catheter is inserted to minimize urine leakage into the abdomen or
supporting tissues. If a urethral injury is suspected, consider catheterizing the bladder through a
suprapubic approach.Frequently observe for and quantify the degree o hematuria with an indwelling
urinarycatheter. The initial urine obtained may have been in the bladder prior to the traumaticevent.
If hematuria is noted, this may be because of the placement of the urinary catheter.Measure and
discard the initial urine specimen and test the subsequent urine specimen for the presence of
blood.Suspected injury to the urethra (i.e., gross blood) is a contraindication to
catheterizationthrough the urethra.• Insert gastric tube and aspirate gastric contents, in order to:•
Decompress the stomach and prevent aspiration• Prevent vagal stimulation and resultant
bradycardia• Minimize gastric content leakage and subsequent contamination of the
abdominalcavity• Test the gastric aspirate for the presence of blood• Cover open abdominal wounds
with a sterile dressing. If evisceration of abdominalcontents has occurred, place a sterile, moist
dressing over the injury.• Stabilize impaled objects• Continue or apply a pneumatic antishock
garment (PASG) for patients with severehypotension because of hemorrhage. Although use of the
garment is controversial, if used itmay reduce intra abdominal hemorrhage• Administer antibiotics, as
prescribed. Leakage of gastric and bowel contents will result in peritonitis and possibly sepsis.•
Administer analgesics, as prescribed• Prepare the patient for operative intervention, hospital
admission, or transfer, as indicate

https://www.scribd.com/doc/19056368/Medical-Surgical-Nursing-Orthoped
ic-Nursing

OMPLICATIONS • HAEMORRHAGE • Any pattern stable unstable can cause fatal

haemorrhage. • External rotation or vertical displacements (APC OR VS
TYPE ) of the injured hemipelvis are associated with a greater risk of
hemorrhage than internal rotation displacement. • DVT/PE • When assessed
with magnetic resonance venography, the reported rate of proximal deep
vein thrombosis in patients with pelvic or acetabular fractures is 35% .
• The reported rate of pulmonary embolism after pelvic fracture ranges
from 2% to 12% , and fatal pulmonary embolism ranges from 0.5% to 10% .
• use of low molecular weight heparins has increased in trauma centers.
However, low molecular weight heparins carry a slightly increased risk
of bleeding, and so prophylaxis is normally delayed until 36 hours after
injury (CI in CNS trauma) • combination of elastic stockings, sequential
compression devices, and chemoprophylaxis if hemodynamic status allows.
Repeated Duplex ultrasound examinations ,coagulation profile and D dimer
assays may be necessary. Thrombus formation may necessitate
anticoagulation and/or vena caval filter placement.

54. Complications contd.. • Infection: The incidence is variable, ranging

from 0% to 25%, although the presence of wound infection does not preclude
a successful result. • Malunion: Significant disability may result, with
complications including chronic pain, limb length inequalities, gait
disturbances, sitting difficulties, low back pain, and pelvic outlet
obstruction. • Neurological • Soft tissue complications

55. Rehabilitation/mobilization • Full weight bearing on the uninvolved

lower extremity occurs within several days. • Partial weight bearing on
the involved lower extremity is recommended for at least 6 weeks. • Full
weight bearing on the affected extremity without crutches is indicated
by 12 weeks. • Patients with bilateral unstable pelvic fractures should
be mobilized from bed to chair with aggressive pulmonary toilet until
radiographic evidence of fracture healing is noted. Partial weight
bearing on the less injured side is generally tolerated by 12 weeks.

Etiology • High-energy pelvic fractures result most commonly from: - motor

vehicle accidents, motorcycle accidents, automobile- pedestrian
encounters (60- 84%), - Falls from height (5-12-30%), - Industrial crush
injuries, e.c. Rosen's Emergency Medicine Eighth Edition John A. Marx MD.
Emergency Medicine Second Edition James G. Adams MD.
http://venturegalleries.com/blog/finding-the-truth-in-news-reporting/
http://blog.er24.co.za/wp-content/uploads/2011/12/Motorbike-accident-
Potch-300x222.jpg

6. Tile's Classification of Pelvic Fractures • Type A —Stable • Type B

—Partially stable • Type C —Unstable A C B Pelvis - Orthopaedic Trauma
Association

7. Tile’s- Type A • Stable, posterior arch intact; • A1 Avulsion injury

• A2 Iliac wing or anterior arch fracture caused by a direct blow • A3
Transverse sacrococcygeal fracture A1 A2 A3 Pelvis - Orthopaedic Trauma
Association

8. Tile’s- Type B • Partially Stable (Incomplete Disruption of Posterior

Arch) • Rotationally unstable but vertically stable. • B1 Open book injury
(external rotation) • B2 Lateral compression injury (internal rotation)
- B2-1 Ipsilateral anterior and posterior injuries - B2-2 Contralateral
(bucket-handle) injuries • B3 Bilateral – bilateral open book; B1/B2;
B2/B2. B 1 B 2-1 B 2-2 B 3 Pelvis - Orthopaedic Trauma Association
Clasification of Pelvic Fractures. Zahid Askar. Pelvis - Orthopaedic
Trauma Association

9. Tile’s- Type C • Unstable (Complete Disruption of Posterior Arch) •

C1 Unilateral - C1-1 Iliac fracture - C1-2 Sacroiliac fracture-
dislocation - C1-3 Sacral fracture • C2 Bilateral, with one side type B,
one side type C C1 C2 C3 Pelvis-OrthopaedicTraumaAssociation • C3
Bilateral with both sides type C

10. Young-Burgess Classification of Pelvic Fractures Based on the

direction of forces causing fracture, associated instability of pelivs,
mechanism of injury 1. Lateral compression 2. Anterior–posterior
compression 3. Vertical shear 4. Combined mechanism

11. Y-B: Lateral Compression • I Sacral crush injury on ipsilateral side

• II Sacral crush injury with disruption of posterior SI ligaments; iliac
wing fracture may be present (rotationally unstable) • III LC-I or LC-II
injury on side of impact, contralateral side external rotation (open-book
injury) (rotationally unstable) Browner BD: Skeletal Trauma: Basic
Science, Management, and Reconstruction, 3rd ed.

12. Y-B: Anteroposterior Compression • I Slight widening of pubic

symphisis (<2,5cm) and/or aneterior SI joint; intact posterior SI
ligaments • II Symphysis diastasis >2.5 cm, sacrospinous, sacrotuberous
and anterior SI ligament disruption, intact posterior SI ligaments
(rotational instability) • III Symphysis diastasis >2.5 cm, with complete
disruption of the anterior and posterior SI ligament, (complete
rotational and vertical instability) Browner BD: Skeletal Trauma: Basic
Science, Management, and Reconstruction, 3rd ed.

13. • Y-B: Vertical Shear- symphyseal diastasis or vertical displacement

anteriorly and posteriorly, usually through the SI joint, occasionally
through the iliac wing and/or sacrum • Y-B: Combined mechanism-
combination of other injury patterns. LC/VS most common. Browner BD:
Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed.

14. Judet and Letournel Acetabular Fracture Classification • Type A -

Fractures of one column of the acetabulum (anterior or posterior column).
• Type B - Transverse (T-type) fractures through both anterior and
posterior columns; portion of acetabulum remains attached to proximal
ilium. • Type C - Transverse (T-type) fractures through both anterior and
posterior columns; no portion of acetabulum remains attached to axial
skeleton. Browner BD: Skeletal Trauma: Basic Science, Management, and
Reconstruction, 3rd ed.

15. Presenting Signs and Symptoms • Pelvic pain • Inability to bear weight
• Swelling of the pelvic area • Hematoma in the area of the pelvic bone
• Pelvic deformity • Uneven leg length or asymmetry of the iliac wings
• Numbness or tingling in the perineum or at the top of the thigh • Perineal
ecchymoses, scrotal or labial hematomas • Blood at the urethral meatus

16. Physical Examination 1. Assess for other life-threatening injuries

using Primary Survey (cABCDE). 2. Careful palpation of the posterior
pelvis in awake patients can identify posterior pelvic injuries. 3. Rectal
examination—high-riding prostate may indicate urethral tear. Palpation
of the sacrum for irregularity. 4. Vaginal examination —bleeding or
lacerations indicating open fractures. 5. Perineal skin —lacerations may
indicate open fracture, scrotal, labial hematoma, swelling or ecchymosis,
flank hematoma
17. Imaging • Radiographs 1. Anteroposterior pelvis - part of the initial
trauma series along with a chest and lateral cervical spine X-ray. Can
identify up to 90% of pelvic injuries. 2. Pelvic inlet view - 40° to 45°
caudal tilt. Shows anterior– posterior displacement (rotational
deformity), internal or external rotation of the hemipelvis; widening of
SI joint; sacral ala impaction. 3. Pelvic outlet view - 40° to 45°
cephalad tilt. Shows superior– inferior displacement (vertical
displacement) and visualizes the sacral foramen.

18. A Forty-degree caudal inlet view of pelvis. B Forty-degree cephalad

outlet view of pelvis.
FracturesofAcetabulumandPelvis-Campbell'sOperative
Orthopaedics.Guyton,JamesL.;Perez,EdwardA..PublishedJanuary
2,2013.Pages2777-2828.e5.©2013.

19. • CT • CT is the diagnostic test of choice for detecting pelvic and

intraabdominal injuries. • Better characterization of posterior ring
injuries. • Reveals bleeding in both the peritoneal and retroperitoneal
spaces. • CT with intravenous contrast often can distinguish a stable
hematoma from ongoing bleeding from pelvic arteries. • FAST • Identify
free intraperitoneal fluid in the trauma patient. • FAST is not helpful
for evaluating the retroperitoneal space where pelvic hemorrhage occurs.

20. A Tile type B1 pelvic injury with diastasis of symphysis and anterior
widening of sacroiliac joint. B CT scan shows that posterior sacroiliac
joint ligaments are intact.
FracturesofAcetabulumandPelvis-Campbell'sOperativeOrthopaedics.Guyton
,JamesL.;Perez,Edward
A..PublishedJanuary2,2013.Pages2777-2828.e5.©2013.

21. Initial Treatment

22. HD unstable patients: Hemorrhage • Occurs in up to 75% of pelvic

fractures. • Leading cause of death in patients with pelvic fractures.
• Three sources of bleeding—osseous, vascular, and visceral. • Posterior
pelvic venous plexus accounts for more than 80% of hemorrhages. •
Intra-abdominal source of bleeding is present in up to 40% of cases. •
Arterial source of bleeding is present in only 10- 15% of cases. •
Retroperitoneal space can hold up to 4 L of blood.
http://benthamopen.com/contents/figures/TOORTHJ/TO ORTHJ-9-283_F6.jpg

23. HD unstable patients • Damage Control Orthopedics 1. Temporary

stabilisation of the pelvis 2. Resuscitation of Patients in Hypovolemic
Shock (i/v fluids) 3. External Fixation- AEF, Pelvic C-Clamp • Open
reduction and internal fixation when the patient's state of health has
stabilized: - ≥5 days - Acetabular fractures 5-10 days

24. Stabilization • Pelvic Binder ˗ Commercial device that can be used

for prehospital and emergent stabilization of pelvic fractures. ˗ In APC
(“open-book”) fractures, use of a pelvic binder will close the ring and
tamponade venous bleeding. ˗ An improvised binder can be made using a sheet
to provide circumferential compression around the pelvis. • Skeletal
Traction —May be used to correct vertical displacement of the hemipelvis.
Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics.
Guyton, James L.; Perez, Edward A.. Published January 2, 2013. Pages
2777-2828.e5. © 2013.

25. Fractures of Acetabulum and Pelvis- Campbell's Operative Orthopaedics.

Guyton, James L.; Perez, Edward A.. Published January 2, 2013. Pages 2777-
2828.e5. © 2013. A Initial anteroposterior radiograph of open-book pelvic
fracture. B After application of pelvic binder (C) .

26. Pelvic Fractures- Emergency Medicine Second Edition. James G. Adams

MD. Copyright © 2013, 2008 by Saunders, an imprint of Elsevier Inc.

27. Resuscitation of Patients in Hypovolemic Shock • Two large bore

intravenous lines (16G or larger) in the upper extremities. • Administer
crystalloid, coloid solution and determine response. • If only a transient
improvement or no response then begin EM administration. • Platelets and
fresh frozen plasma will be required with massive transfusions to correct
dilutional coagulopathy. • Avoid or correct hypothermia. Warm fluids,
increase ambient temperature, and avoid heat loss. Hypothermia can lead
to coagulation problems, ventricular fibrillation and acid– base
disturbances.

28. External Fixation: Anterior external fixator • Anterior superior

iliac spine (ASIS) pin and the anterior inferior iliac spine (AIIS) pin.
• Two 5-mm pins are placed in between the iliac cortical tables and
placement is confirmed on fluoroscopy. • Emergently placed in
hemodynamically unstable patient who does not respond to initial fluid
resuscitation. • Anterior external fixation alone does not provide
adequate posterior stabilization if the posterior ring is disrupted. •
Indications - pelvic ring injuries with an external rotation component
(APC, VS) - unstable ring injury with ongoing blood loss •
Contraindications - ilium fracture that does not allow safe application
PokaA,LibbyEP:Indicationsandtechniquesforexternalfixationofthepelvis,
Clin OrthopRelatRes329:54,1996.
29. External Fixation: Pelvic Clamps • Pelvic clamps have been developed
to help control the posterior pelvis in the resuscitation phase: the Ganz
C-clamp. • These devices use large, percutaneously placed pins over the
region of the sacroiliac joint posteriorly. • Pelvic C-Clamps—in
original design, points of clamp applied to posterior ilium in line with
the sacrum. • Requires fluoroscopy and technical expertise. • Higher risk
of iatrogenic injury than standard anterior external fixator. Fractures
of Acetabulum and Pelvis- Campbell's Operative Orthopaedics. Guyton,
James L.; Perez, Edward A.. Published January 2, 2013. Pages 2777- 2828.e5.
© 2013.

30.
FracturesofAcetabulumandPelvis-Campbell'sOperativeOrthopaedics.Guyton
,JamesL.;Perez,
EdwardA..PublishedJanuary2,2013.Pages2777-2828.e5.©2013.

31. http://www.hwbf.org/ota/s2k/images/pohlcs.jpg Pelvic Packing •

Patients who hemorrhage from both the pelvis and the abdomen have
mortality rates above 40%. • Packing may aid in tamponading bleeding from
the posterior venous plexus. • Pelvis should be stabilized before packing
to provide solid structural support against which packing may be performed.
• Packs can be placed in the pre- peritoneal and retro-peritoneal spaces.

32. Angiography / embolization • Contrast material injected through the

femoral artery on the less-injured side or via the upper extremity. •
Transcatheter embolization with thrombogenic coils, foam, or spherules
• Indicated for patients who remain HD unstable following resuscitation,
application of external fixator, and after other sources of bleeding
(abdomen, chest) are ruled out. • Arterial source of bleeding is present
in only 10% to 15% of patients. http:// www.wheelessonline.com/images/

33. HD stable patient • Stable pelvic fracture- nonoperative treatment

• Unstable pelvic fracture - External fixation- anterior external
fixator/ Pelvic-clamps - Open Reduction and Internal Fixation

34. Nonoperative Treatment • Stable nondisplaced or minimally displaced

fractures may be treated nonoperatively (isolated pubic ramus fractures,
B1-1). • Bed rest 2-3 weeks • Lateral compresion fractures- weight bearing
only on the unaffected side. • Vertically unstable fractures in which
there is a contraindication to operative treatment may be treated with
skeletal traction.

35. Internal Fixation • Indications: - symphysis diastasis > 2.5 cm - SI

joint displacement > 1 cm - sacral fracture with displacement >1 cm - pubic
rami fractures >2 cm displacement - displacement or rotation of hemipelvis
- open fracture - rotationally unstable pelvic injuries with significant
limb-length discrepancy >1.5 cm or unacceptable pelvic rotational
deformity Fractures of Acetabulum and Pelvis- Campbell's Operative
Orthopaedics. Guyton, James L.; Perez, Edward A.. Published January 2,
2013. Pages 2777- 2828.e5. © 2013.

36. • Tile type C pelvic injuries require anterior and posterior fixation
to regain rotational and vertical stability. • Anterior ring
stabilization - single superior plate • Posterior ring stabilization -
anterior SI plating - iliosacral screws - posterior SI "tension" plating

37. A and B Anterior plating of sacroiliac joint. Fractures of Acetabulum

and Pelvis- Campbell's

38. Associated Injuries 1. Hemorrhage 75% 2. Chest injury 63% 3. Long bone
fractures 50% 4. Head and abdominal injury 40% 5. Spine fractures 25% 6.
Urogenital injuries (posterior urethral tear, bladder rupture) 12-20% 7.
Lumbosacral plexus injuries 8%
http://www.orthobullets.com/trauma/1030/pelvic-ring-fractures