Student Name:____________Jocelyn Cideos____________
Abdominal & Spinal Trauma Case Study
Directions: Students will work through this case study independently. There are 4 scenes
and 13 questions. This document is to be submitted to canvas by the due date. Late
submissions will not be accepted.
Objectives:
1. Recognize relevant clinical patient data.
2. Recall complications related to a penetrating abdominal trauma.
3. Identify appropriate management strategies associated with a penetrating
abdominal trauma.
Scene 1
Name: CJ
DOB: Unknown (Pt unable to confirm)
MRN: 135798642
Allergies: Unknown (Pt unable to confirm)
CJ is S/P multiple GSWs to the chest & abdomen; found down and brought to Penn
Presbyterian via police drop-off. Once in the trauma bay, a primary survey is conducted;
a chest x-ray & FAST exam are performed. The chest x-ray revealed B/L hemothoracies
and the FAST exam was positive. B/L chest tubes were inserted & CJ is sent for an
abdominal CT scan.
VS: HR 130, BP 100/55, RR 28, Temp 96.4 F, SpO2 93% on 6L NC, Pain 8/10.
Neuro: Eye opening to verbal command, confused verbal responses, follows simple
commands (E3V4M6 = GCS 13). Oriented to person & time only, unable to verbalize
details of incident. Sensation absent below the umbilicus.
CV: Sinus tachycardia, no murmurs, no ectopy. B/L UE pulses 1+, B/L LE pulses 1+.
Cap refill = 3 seconds
Resp: Lung sounds diminished in B/L bases. B/L Chest tubes to -20cm suction, both with
200mL of sanguineous drainage.
GI: Last oral intake unknown. Abd firm, tender, & distended. Hypoactive bowel sounds.
GU: Foley intact, draining minimal amounts of pink tinged urine.
Musculoskeletal: Strength 3/5 in B/L UE and 1/5 in B/L LE.
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Skin: Cool and dry. Multiple GSW entrance wounds on anterior chest & abd. Right AC #
16 & left FA #18
Sodium
137 (135-147)
WBC
8.2 (4.5-10)
Potassium
3.9 (3.5-5.2)
Hgb
6.2 (13.5-16.5)
Chloride
102 (95-107)
Hct
35 (41-50)
Creatinine
1.1 (0.5-1.4)
Plt
250 (100-450)
BUN
20 (7-20)
PT
13 (10-13)
Glucose
100 (70-140)
INR
1.2 (0.9-1.3)
Calcium
9.3 (8.8-10.3)
PTT
35 (22-37)
CO2
32 (20-32)
Magnesium
1.7 (1.6-2.4)
1. What findings are most significant?
Confused, AAOX2, sensation absent below the umbilicus, sinus tachycardia, pulses 1+,
diminished lung sounds in B/L bases, tinged urine, multiple GSW wounds entrance
wounds on anterior chest & abdomen. Right AC # 16 & left FA #18 , lab shows low Hgb,
Hct, temperature is low, positive FAST, sanguineous drainage from tubes, pain 8/10, low
O2 on 6 LT.
2. Based on the information in the scenario, what are potential patient problems?
Patient is experiencing abdominal trauma, his labs indicate he may be losing blood due to
the multiple GSW, and a possibly experiencing a spine injury, hypovolemia, triage of
dead,
3. What interventions are indicated?
Oxygen, Identify bleeding, administer fluids, maintain patient’s airway, and circulation,
BP monitoring, Management of secretions, and damage control surgery, stabilize
temperature, patient needs abdominal decompression, stabilize spine, pain management,
and stabilize airway.
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Scene 2
CJ’s CT scan results reveal a suspected liver laceration, small bowel injury, and spinal
injury. He was transported to the OR for an emergent laparotomy. Damage control
surgery was performed, and CJ was transferred to the surgical trauma ICU with an open
abdomen.
VS: HR 110, BP 115/70, RR 14, Temp 97.8 F, SpO2 98% on 50% FiO2 via ventilator
Neuro: Eye opening – no response, verbal response – no response, motor response – no
response (E1V1M1 = GCS 3T). Pt is intubated & chemically sedated but responds to
painful stimuli. RASS score is -4
CV: Sinus tachycardia, no murmurs, no ectopy. B/L UE pulses 2+, B/L LE pulses 2+.
Cap refill < 2 seconds
Resp: Endotracheal tube in place, pt. breathing comfortably on ventilator. Lung sounds
diminished in B/L bases. B/L Chest tubes to -20cm suction, both with sanguineous
drainage.
GI: Open abd with wound vac in place. Abd distended and firm. Absent bowel sounds.
Nasogastric tube (NGT) intact & on low continuous wall suction (LCWS). Current
bladder pressure is 16 mm Hg. Current wt. is 90 kg.
GU: Foley intact, draining yellow urine. Hourly output has been around 40-45mL.
Skin: Cool and dry. No signs of skin breakdown. Right AC # 16 & left FA #18. Pt
receiving continuous IV Fentanyl and Propofol.
4. Which complications is CJ at risk for?
Severe blood loss, hypothermia, acidosis in blood, coagulopathy, infection,
abdominal compartment syndrome, analgesic opioid overdose, CAUTI, malnutrition,
renal injury, bowel injury, pressure injuries, pneumonia, shock, and anemia.
5. Considering potential problems of this patient, what is the current priority?
Convey that to the healthcare team utilizing SBAR.
S: this is Jocelyn the nursing student calling for CJ patient MRN: 135798642 at room #X
in Presbyterian
B: CJ is a male who was transported to the OR for an emergent laparotomy, and damage
control surgery was performed.
A: patient may be in AKI; spinal cord injury hasn’t been addressed and his abdomen is
still distended.
R: Need to relieve abdominal pressure
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6. Describe the management indicated for CJ’s recovery.
Negative pressure wound therapy, oxygen therapy, nutrition intervention to aid wound
healing, spirometer, and deep breathing techniques, Physical therapy, or occupational
therapy, Caring for ABC’s , good oral care, proper positioning of respiratory tubes,
continue to monitoring CBC lab values, proper NG-tube care, and parenteral nutrition.
Scene 3
It is currently day 6 of CJ’s admission. His abdomen has been surgically closed and he
has been weaned off of the ventilator and extubated.
7. At this juncture, we had competing priorities—all of which nurses are expected to
acknowledge and manage in multifaceted ways. What additional pertinent
assessment data was deemed less of a priority but are still pertinent to CJ’s care
and recovery trajectory? Please highlight below.
Scene 1:
 Resp: b/l hemothoracies, CTs, increased O2 requirements,
diminished breath sounds, tachypnea
 CV: Sinus Tach
 PV: cool & dry, cap refill=3 seconds, diminished pulses
 Integ: GSW
 Labs HgB & Hct
VS: HR 130, BP 100/55, RR 28, Temp 96.4 F, SpO2 93% on 6L NC, Pain
8/10.
Neuro: Eye opening to verbal command, confused verbal responses,
follows simple commands (E3V4M6 = GCS 13). Oriented to person &
time only, unable to verbalize details of incident. Sensation absent below
the umbilicus.
CV: Sinus tachycardia, no murmurs, no ectopy. B/L UE pulses 1+, B/L
LE pulses 1+. Cap refill = 3 seconds
Resp: Lung sounds diminished in B/L bases. B/L Chest tubes to -20cm
suction, both with 200mL of sanguineous drainage.
GI: Last oral intake unknown. Abd firm, tender, & distended. Hypoactive
bowel sounds.
GU: Foley intact, draining minimal amounts of pink tinged urine.
Musculoskeletal: Strength 3/5 in B/L UE and 1/5 in B/L LE.
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Skin: Cool and dry. Multiple GSW entrance wounds on anterior chest &
abd. Right AC # 16 & left FA #18
Scene 2:
CJ’s CT scan results reveal a suspected liver laceration, small bowel
injury, and spinal injury. He was transported to the OR for an emergent
laparotomy. Damage control surgery was performed, and CJ was
transferred to the surgical trauma ICU with an open abdomen.
8. Injury is noted at T10 via CT Scan. How would the neurologist grade the level of
SCI using the ASIA Scoring? Please provide a rationale.
C =Incomplete, some motor function is preserved below the neurological
level, and although there isn’t a muscle grade level based on the information
provided there is only mention of sensation being absent below the umbilicus.
9. What are priority nursing management strategies for CJ with a T10 spinal cord
injury?
Nursing management would include DVT prophylaxis, spine stabilization,
bowel/bladder regime, pain management, telemetry monitoring, psychological
support.
10. What kind of spinal precautions is necessary for this individual?
No bending at the waist, no crossing arms, use both arms to support weight,
stabilizing spine, steroids, PT, rehab or OT, nutrition, bowel regimen, and monitor for
UTI.
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Scene 4
On day 10, CJ is scheduled to be discharged to an inpatient rehabilitation unit.
VS: HR 89, BP 110/60, RR 18, Temp 97.1 F, SpO2 95% on Room Air, Pain 4/10.
Neuro: Eye opening to verbal command, speech clear and appropriate,
follows simple commands (E4V5M6 = GCS 15). Oriented to person,
place, & time. Sensation absent below the umbilicus.
CV: Normal sinus rhythm, no murmurs, no ectopy. B/L UE pulses 1+,
B/L LE pulses 1+. Cap refill< 2 seconds
Resp: Lung sounds diminished in B/L bases. B/L Chest tubes d/c’ed. No
cough. Respirations are even and easy.
GI: Last oral intake unknown. Abd soft, incisional tender, nondistended.
Normoactive bowel sounds. + flatus LBM: last night
GU: Foley d/c’ed last night. Intermittent episodes of incontinence. Texas
condom catheter in place, intact, draining clear yellow, quantity sufficient
urine.
Musculoskeletal: Strength 5/5 in B/L UE and 3/5 in B/L LE. TLSO
present and on when pt. is OOB. Transfers to wheelchair with transfer
board and 1 person assist.
Skin: Warm and dry. Midline abdominal incision with staples CDI &
open to air. Incision is well approximated, no erythema, edema, drainage
present. B/L flank former chest tube sites with occlusive dressing present
CDI. Multiple GSW entrance wounds on anterior chest & abd CDI & open
to air. Left FA #18 IV saline locked.
11. What are pertinent nursing assessment questions to ask to adequately prepare a
discharge plan for CJ? Think about at this current point and beyond rehab.
Consider topics such as understanding of injury & subsequent management,
health literacy, environment, self-management, pharmacy, caregiving/support
person, transportation, etc.)
Transportation, home living situation, emotional support, and patient literacy
about their condition.
12. List 3 nursing goals for CJ at this time (2 short term: for the shift you are
working/for the day & 1 long term: post-discharge).
Nutrition, and bowel/bladder regime, home modifications, mental health support.
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13. Considering this diagnosis, what are pertinent interventions and resources needed
to begin to prepare CJ for rehab and eventually to home?
Assistive devices, and home modifications for patients.
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