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A stab wound is a penetrating wound made by anything sharp.

This includes knives, ice picks,


screwdrivers, pens, scissors, arrows, or animal horns. Classically, stab wounds are low-velocity
penetrating wounds that damage tissue the offending weapon passes through. Severity depends on the
location of the stab wound, the manner of stabbing, the depth of penetration, and the type of weapon
used. Regardless of the above, the victim almost always experiences pain and bleeding, with some very
rare occasions they are unaware something has penetrated their bodies. The most common site of stab
wounds is the abdominal area, more on the upper left region than right.

Abdominal Stab Wounds


In the 19th century, penetrating abdominal wounds were managed non-operatively. The
associated morbidity and mortality rates were greater than 70%. Experience gained during World War I,
World War II, and the Korean Conflict led to an aggressive approach of operative management for all
penetrating abdominal wounds. This approach resulted in an unacceptably high frequency of laparotomy
with findings negative for trauma. In 1960, Shaftan developed an approach of selective conservatism for
penetrating abdominal injury and revolutionized abdominal stab wound management.

The optimal method to determine the need for laparotomy has yet to be definitively established.
Abdominal stab wound exploration forms part of a strategy developed by surgeons to allow a more
selective approach. In asymptomatic patients with stab wounds to the anterior abdomen, methods are
widely used to help determine the need for laparotomy:
• Abdominal stab wound exploration (Subsequent diagnostic peritoneal lavage [DPL], serial clinical
evaluation, or both are used to further assess patients in whom an exploration cannot definitively
exclude peritoneal penetration.)
• Serial clinical evaluation

The objective is to reduce the number of patients with trivial or no intraperitoneal injury who are
subjected to laparotomy. However, a high degree of diagnostic accuracy must be maintained to limit the
frequency of missed injury. A reduction in unnecessary hospitalization is also targeted.

Abdominal stab wound exploration is a safe, rapid, and cost-effective tool in the management of
asymptomatic patients who present with an anterior abdominal stab wound. This approach has no place
in the treatment of patients who are unstable, who have peritonitis, or who have evisceration. Patients
with peritonitis and those who are hemodynamically unstable should undergo mandatory laparotomy.

More than 25% of anterior abdominal stab wounds do not penetrate the peritoneal cavity. Local
wound exploration allows the safe discharge of these patients from the emergency department. Only half
of the wounds that penetrate the peritoneum cause damage that requires surgical intervention. The
organs most commonly injured with anterior abdominal stab wounds are the small bowel, the liver, and
the colon. Missed hollow viscus injuries are associated with significant morbidity and mortality.

Many modern physicians advocate abdominal stab wound exploration in asymptomatic patients
who present with an anterior abdominal stab wound. An exploration with negative findings is reliable and
highly sensitive. Abdominal stab wound exploration combined with further investigation, such as DPL or
serial evaluation, achieves acceptable specificity rates. Minimizing the time taken to control ongoing
intraperitoneal contamination is critical in penetrating stab wounds, and local exploration is a valuable first
step in speeding up the decision-making process. When combined with DPL, abdominal stab wound
exploration allows significant injuries that are not immediately apparent to be identified early.

Assessment and Diagnostics


In abdominal stab wounds, the liver, stomach, and intestines are commonly affected. Nurses and
doctors in the ER need to thoroughly assess the patient for signs of hemorrhage and hypovolemic shock
(blood may be pooling inside the peritoneum especially when the object used to stab has not been
removed) – a drop in blood pressure, cold, clammy, and paling extremities, diminishing peripheral pulses,
tachycardia, tachypnea, diaphoresis, and confusion – as well as gastric and intestinal leakage into the
peritoneal space. The latter will have to be continually monitored to prevent infection later on. Assess for
liver trauma because bile from the liver can leak into the peritoneal cavity causing bile peritonitis. Some
cases present peritonitis upon abdominal examination secondary to stab wounds. The patient may be
experiencing fever and signs of inflammation, diffuse tenderness, and abdominal pain.

CT-scanning, ultrasonography, abdominal X-ray, peritoneal lavage and DPL can be done to
determine the extent of the injury. Laparotomy is indicated for peritoneal penetration, evisceration, and
massive bleeding. Liver function tests may reveal increased liver enzyme activity, but may also indicate
previously undetected liver disease. Hematology reports may show elevated ESR and WBC count. The
former suggests active inflammation while the latter does a possible ruptured spleen. Increased neutrophil
count means an active infection. Urinalysis may reveal RBC’s from a possible bladder trauma. Arterial
blood gas analysis can reveal abnormalities such as metabolic acidosis. Prothrombin time, international
normalized ratio, and activated partial thromboplastin time screen for coagulopathy. Serum amylase and
lipase levels, when persistently elevated, may indicate injury to the pancreas or bowel.

Nursing Diagnosis
• Acute pain related to abdominal wound
• Deficient fluid volume related to active loss of blood
• Impaired tissue integrity related to penetrating abdominal wound
• Risk for infection related to introduction of a foreign body into the abdomen
Nursing Intervention
• Assist patient onto ER bed.
• Insert two large-bore intravenous (I.V.) lines to infuse 0.9% sodium chloride or lactated Ringer's
solution, according to facility protocol.
• Control the patient's pain without sedating him, so you can continue to assess his injuries and ask
him questions. Generally, I.V. analgesics such as morphine can adequately manage pain without
sedation.

• Insert an indwelling urinary catheter, unless you suspect a urinary tract injury. 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 of hematuria with an indwelling urinary catheter. The initial
urine obtained may have been in the bladder prior to the traumatic event. 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 catheterization through the urethra.
• Draw blood specimens stat for baseline lab values.
• Insert a gastric tube to decompress the patient's stomach, prevent aspiration, and minimize leakage
of gastric contents and contamination of the abdominal cavity. This also gives you access to gastric
contents to test for blood.

• Administer tetanus prophylaxis and antibiotics as ordered.


• Cover open abdominal wounds with a sterile dressing. If evisceration of abdominal contents has
occurred, place a sterile, moist dressing over the injury.
• Stabilize impaled objects

• 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 indicated.

Evaluation and Ongoing Assessment


Refer to Initial Assessment, for a description of the ongoing evaluation of the patient's airway, breathing,
circulation, and disability. Additional evaluations include:
• Monitoring cardiovascular status for changes suggestive of hypovolemic shock
• Reassessing the abdomen frequently and thoroughly to detect subtle changes
• Monitoring urinary elimination for changes suggestive of hypovolemic shock
XAVIER UNIVERSITY – ATENEO DE CAGAYAN
COLLEGE OF NURSING

A Ward Class on Stab Wounds

Submitted by
QUICOY, Horace
RETUYA, James Theodore
TAGARAO, Beardmore
TRIA, Lloyd II
PADUGANAN, Hera Christie Jule
PARAGUYA, Rhea Mae
PASA, Quennie Kaye Lou
PATILANO, Katrina
RIŇON, Kristine Louise
RODULFA, Jasmin
SABERON, Zeleen Anne
SARIPADA, Marjierey
TORRES, Kathreen Mae
VILLONES, Aura Felice

Submitted to
Mrs. Nadine June Rizon, RN
July 13, 2010