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I. Introduction

The skin is the body's outer covering. It protects us against heat and light,

injury, and infection. In fact, the skin is an essential part of our body's defense

against infection from microbes in our environment. The skin also regulates bodytemperature and stores water, fat, and vitamin D. weighing about 6 pounds, the

skin is the body's largest organ. It is made up of two main layers the outer

epidermis and the inner dermis.

!tab wounds are wounds where the depth of injury is greater than the

length. They penetrate more deeply than the slash wounds and tend to come into

contact with vital organs in the chest and abdomen. !tabbing is the most

common mode of homicide in the "#, due to the strict control of gums. !tab

wounds are caused most obviously by knives, but are also caused by bayonets

and swords, as well as scissors and even blunter instruments such as

screwdrivers. !tab wounds are usually slit$like, but when the object is removed

the skin contracts slightly, leaving a wound that is slightly shorter than the blade

width. The center of the wound often widens. %ost operative wound infection

delays recovery and often increases length of slay and produce lasting scars and

re&uire e tra resources for investigations, management and nursing care.

Therefore, its prevention or reduction is relevant to &uality patient care.!tudies support the concept that reduction in post operative wound

infection is directly relate influenced to increased education and awareness of its

causes its prevention is greatly aided by critically evaluated infection control

practice. !urveillance for wound infection is a useful tool to demonstrate the

magnitude of the problem. (ombined with a regular feedback to the surgeon it

has been shown to decrease the infection rate. It is important to reali)e that

surveillance alone cannot act as a substitute for action and prevention.

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II. SIGNIFICANCE OF THE STUDY

*iven the tremendous increase in the crime rate in the %hilippines, it is

very important for health care providers to learn the basic concept of initial

assessment and stabili)ation of severely injured patients. Trauma is one of the

major leading causes of death for +ilipinos under forty and the initial assessment

and stabili)ation of the patient strongly influences the ultimate outcome for the

severely traumati)ed patient. ost jurisdictions re&uire that injuries arising from

acts of violence such as gunshot wounds, stab wounds be reported to the local

police. - fundamental point to remember regarding blunt and penetrating trauma

is that a patient who has been stabbed may also have been beaten and kicked

and subse&uently has sustained both blunt and penetrating injury to the body.

This could be a tool so that we can be a help for those patient s in need of

care like patients who are in pain from having stab wounds. -nd be able to

understanding those parts of the body affected from the wound.

III. OBJECTIVES OF THE SUDY

This study provides information for the patient s condition and gives

understanding in providing comfort of the patient while he is in pain and having

some discomfort in his recovery from the stab wounds and surgical wounds. This

could student nurses to be more caring and to manage a patient who have the

same condition like r. /amerel +ajanilag.

-ll the given care to the patient while he is admmited in the male surgical

ward is reflected in this study in the two day of the duty. This could be a help for

further study about the patient s condition and be able to upgrade skills in

handling patient having the incident of multiple stab wounds in patient s

abdomen.

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IV. PATIENT PROFILE

/amerel +ajanilag, a 01 year old male, single, 2oman (atholic, living in 3aloy,

Tablon, admitted for the first time at 4orthern indanao edical (enter 54 (with an initial diagnosis of acute abdomen secondary to stab wounds. 7e had no

known allergy. "pon admission, he had a blood pressure of 189:;9 mm7g, heart

rate of 191 bpm, respiratory rate of 86 cpm, and a temperature of 8<.=> (.

V. HISTORY OF PRESENT ILLNESS

- case of /amerel +ajanilag admitted at 4orthern indanao edical

(enter with multiple stab wounds at lower abdomen and left upper &uadrant with

the use of kitchen knife done by his companions in Tablon due to

misunderstanding and in layman s term ?bikil@. The patient was stabbed

unconscious because he being hit in the head by a paddle from his back. Then at

that time he didn t know what happened ne t, all he knew he felt someone

stabbed him.

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VII. ANATOMY AND PHYSIOLOGY

An!to"# o$ t%& '(in

S(in Structur&

The skin is the largest human organ. It covers between 1.= and 0 m 0, comprising

about one si th of total body weight.

Function o$ S(in

The skin performs a comple role in human physiologyE

• serves as a barrier to the environment, and some glands 5 sebaceous mayhave weak anti$infective properties.

• acts as a channel for communication to the outside world.

• protects us from water loss, friction wounds , and impact wounds.

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• uses speciali)ed pigment cells to protect us from ultraviolet rays of the

sun .• produces vitamin D in the epidermal layer, when it is e posed to the sun's

rays.• helps regulate body temperature through sweat glands .

• helps regulate metabolism.

• has esthetic and beauty &ualities.

The skin consists of three functional layersE

E)id&r"i'

D&r"i' or corium

Su*cuti' 5hypodermis

T%& E)id&r"i'

-s the outermost skin layer, the epidermis forms the actual protective

covering against environmental influences. Its thickness averages 9.1 mm. An

the face it is only 9.90 mm, while on the soles of the feet between 1 and = mm.

Though paper thin, the epidermis is composed of many layers of cells. In

the basal layer 5the living epidermis , new cells are constantly being reproduced,

pushing older cells to the surface. -s skin cells move farther away from their

source of nourishment, they flatten and shrink. They lose their nuclei, move out

of the basal layer to the horny layer 5the dead epidermis , and turn into a lifeless

protein called keratin. -fter serving a brief protective function, the keratinocytes

are imperceptibly sloughed off. This process of a living cell's evolution, called

keratini)ation, takes about F weeks.

The epidermis consists of up to ;9 percent keratinocytes, the actual

epidermal cells or dead skin cells, that are held together by what are called

desmosomes. #eratinocytes function as a barrier, keeping harmful substances

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out and preventing water and other essential substances from escaping the body.

The other 19 percent of epidermal cells are melanocytes, which manufacture and

distribute melanin, the protein that adds pigment to skin and protects the body

from ultraviolet rays. !kin color is determined by the amount of protein produced

by these cells, not by the number of melanocytes, which is fairly constant in all

races.

7air and nails are speciali)ed keratin structures and are considered part of

the epidermis. Bhile animals use fur and claws for protection and defense, these

corresponding structures are largely cosmetic in humans. The skin, however, is

uni&uely human, since it can betray emotion by blushing 5embarrassment ,

turning red 5anger , blanching 5fear , sweating 5tension , and forming goosebumps 5terror .

An the skin surface are the sweat gland pores 5199$099:cm 0 and the

openings of the sebaceous glands 5=9$199:cm 0 . Their secretions ensure skin

moisture and oiliness, and thus maintain the hydro lipid film. The epidermis itself

has no blood vessels, so the nutrients are supplied through the fine blood

vessels in the dermal papillae.

The epidermis is differentiated into five layersE

7orny layer 5stratum corneum

(lear layer 5stratum lucidum

*ranular layer 5stratum granulosum

%rickle$cell layer 5stratum spinosum

3asal layer 5stratum basale

T%& D&r"i'

The dermis forms a well$defined border with the epidermis 5scarf skin and

a more fluid border with the subcutis 5subcutaneous fatty tissue .

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The dermis, or the Gtrue skin,G is composed of gel$like and elastic

materials, water, and, primarily, collagen. Cmbedded in this layer are systems

and structures common to other organs such as lymph channels, blood vessels,

nerve fibers, and muscle cells, but uni&ue to the dermis are hair follicles,

sebaceous glands, and sweat glands.

Str!tu" )!)i++!r& !nd 'tr!tu" r&ticu+!r&

The stratum reticulare 5reticular H net$like: at. makes up the lower part of

the dermis and shows a continuous transition to subcutis. The stratum papillare

5papillae H protuberance: at. is the upper layer which is clearly demarcated from

the epidermis by an undulated border. The wave$like structure increases the

contact area with the epidermis, thus ensuring optimal nourishment of the

deepest layer of the epidermis $ the basal cells $ by way of the blood vessels

running through the papillae.

T%& conn&cti,& ti''u& o$ t%& d&r"i'

The main constituent of the dermis is the proteinous connective tissue

made up of arc$shaped, elastic fibres and undulated, nearly inelastic collagen

fibres. These are responsible for the high elasticity and tensile strength of the

dermis.

oung collagen fibre $ glycosaminoglycan $ can bind large amounts of water and

so determine the high intrinsic tension of young skin. -s the skin ages, the

interweaving of the collagen fibres increases and the water$binding capacity

diminishes. The skin tends to wrinkle. 54oteE *lycosaminoglycans

5mucopolysaccharides bind with the proteinous connective tissue matri to form

proteoglycans. These form a gel$like mass that can absorb and e pel water like asponge.

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Conn&cti,& ti''u&- +#co'!"ino +#c!n& !nd /!t&r0*indin c!)!cit#

The space within the dermal meshwork contains a sort of GfillingG made of

long chains of sugar molecules 5polysaccharides poly H many, sacchar H

sugar:*k. . These are known as glycosaminoglycans 5also

mucopolysaccharides . Bith the help of fibronectins a type of GglueG, they bind to

the proteinous connective tissue matri to form proteoglycans, which can bind

water molecules. This gel$like mass functions like a sponge. "nder pressure it

can e pel the bound water and in a reverse process take it up again. This

process is the probable route of nourishment for the dermis. 7yaluronic acid

5hyalo H glass:*k. belongs to the group of glycosaminoglycans and so

contributes to the water$binding whole. *lycosaminoglycans are subject to acontinuous wa ing and waning. In contrast, the collagen fibres are only renewed

when necessary, such as when injury is sustained.

Ather constituents of the dermis are various types of cells such as

fibroblasts, mast cells and other tissue cells, as well as a multitude of blood and

lymph vessels, nerve endings, hot and cold receptors as well as tactile sensory

organs.

ike the epidermis, the hair follicle manufactures a keratin structure, hair.

These follicles are found everywhere on the body e cept for the palms and soles,

though most of the hairs produced are fine, light hairs that, &uite unlike the hair of

the scalp, are scarcely visible to the naked eye. The sebaceous glands are

attached to the hair follicles and through the follicles e crete an oily substance

called sebum, which both lubricates and protects the skin. An most of the skin

surface sebum appears constantly and imperceptibly, but in areas with a higher

concentration of sebaceous glands, such as the face and back, there are wide

variations in the amount of sebum produced.

There are two distinctive sweat$producing glands, the apocrine and the

eccrine. The apocrine gland is best known for producing body odor but otherwise

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has no known physiological function and is apparently a holdover from times

past. In the ear it forms a portion of what we see as earwa . It is also present

under the arms, around the nipples and navel, and in the anal$genital area.

The eccrine glands are an advanced and e tensive system of temperature

control. !everal million of these glands are distributed over the entire body, with

the highest concentration in the palms, soles, forehead, and underarms.

!weat, a dilute salt solution, evaporates from the skin's surface to cool the

body. C cessive sweating without replacement of lost water can cause heat

stroke. Cccrine glands sweat in response to physical activity and hot

environments, but emotional stress and eating spicy foods can also cause

perspiring.

The dermis also regulates heat through a network of tiny blood vessels. In

hot weather these vessels dilate to give off heat, causing the skin to flush. In cold

weather, they constrict, conserving heat, causing pallor. The blood in these

vessels nourishes the skin and provides protection for the cellular and fluid

systems. ike the eccrine glands, blood vessels in the dermis are responsive to

emotional stress, causing the color changes mentioned previously.

4erve endings in the dermis are the source of the body's sense of touch.

They sense heat, cold, and pressure, providing both pain and pleasure.

T%& Su*cuti' 1H#)od&r"i'2

The subcutis 5sub H under cutis H skin: at. refers to the fat tissue below

the skin. It consists of spongy connective tissue interspersed with energy$storing

adipocytes 5fat cells .

F!t c&++ c+u't&r'

+at cells are grouped together in large cushion$like clusters held in place

by collagen fibres called connective tissue septa or sheaths.

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Nouri'%"&nt- in'u+!tion !nd )!ddin

The subcutis is heavily interlaced with blood vessels, ensuring a &uick

delivery of stored nutrients as needed. The functions carried out by the

subcutaneous fatty tissue, beside the storage of nutrients in the form of li&uid

fats, include the insulation of the body from cold and shock absorption. An the

palms of the hand, the soles of the feet and the buttocks, fat padding serves

almost e clusively for shock absorption. 54oteE +ats, also triglycerides or

acylglycerins, are the most plentiful and simplest fatty acid$containing lipids. They

are esters of the triol alcohol, glycerine with three saturated and:or unsaturated

fatty acids. +ats make up the main component of the fat depots.

F!t di'tri*ution in "&n !nd /o"&n

The fat content of the subcutis is not the same in all body regions. -lso

men and women differ in the distribution of subcutaneous fat. -n e ample is

cellulite $ it is characteri)ed by a special arrangement of the subcutaneous fat

tissue septa and predisposes to fat deposition on the hips, thighs and buttocks $

which occurs mostly in women. en on the other hand tend to store fat on the

torso.

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T%& 'tructur& o$ %u"!n !*do"&n

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The human abdomen 5from the atin word meaning GbellyG is the part of

the body between the pelvis and the thora . -natomically, the abdomen stretches

from the thora at the thoracic diaphragm to the pelvis at the pelvic brim . The

pelvic brim stretches from the lumbosacral angle 5the intervertebral disk between

= and !1 to the pubic symphysis and is the edge of the pelvic inlet . The space

above this inlet and under the thoracic diaphragm is termed the abdominal cavity .

The boundary of the abdominal cavity is the abdominal wall in the front and the

peritoneal surface at the rear.

+unctionally, the human abdomen is where most of the alimentary tract is

placed and so most of the absorption and digestion of food occurs here. The

alimentary tract in the abdomen consists of the lower esophagus , the stomach ,the duodenum , the jejunum , ileum , the cecum and the appendi , the ascending ,

transverse and descending colons , the sigmoid colon and the rectum . Ather vital

organs inside the abdomen include the liver , the kidneys , the pancreas and the

spleen .

A*do"in!+ or !n'

The abdomen contains most of the tubelike organs of the digestive tract,

as well as several solid organs. 7ollow abdominal organs include the stomach ,

the small intestine , and the colon with its attached appendi . Argans such as the

liver , its attached gallbladder , and the pancreas function in close association with

the digestive tract and communicate with it via ducts. The spleen , kidneys , and

adrenal glands also lie within the abdomen, along with many blood vessels

including the aorta and inferior vena cava . -natomists may consider the urinary

bladder , uterus , fallopian tubes , and ovaries as either abdominal organs or as

pelvic organs. +inally, the abdomen contains an e tensive membrane called theperitoneum . - fold of peritoneum may completely cover certain organs, whereas

it may cover only one side of organs that usually lie closer to the abdominal wall.

-natomists call the latter type of organs retroperitoneal.

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VIII. P!t%o)%#'io+o #

%erforation of a bowel segment. Cvisceration of bowel content through a penetrating injury. Injury to

the kidneys and ureters. %ancreatic injury, %elvicorgan injury

- stab wound to the abdomen fre&uently leads tohemorrhage from the penetration of major vessels or

solid organs, such as the liver or spleen.

The signs and symptoms depend upon which part of the body is involved

The victim usually presents with aktered mentalstatus, hypo ia, paralysis, une&ual pupils, shock, or

major bleeding

Injury results in a hemorrhage from the penetration toa major vessel or solid organ

%enetrating injury to the body

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P&n&tr!tin in3ur# to t%& !*do"&n

- stab wound to the abdomen fre&uently leads to hemorrhage from the

penetration of major vessels or solid organs, such as the liver or spleen.

%erforation of a bowel segment.

Cvisceration of bowel content through a penetrating injury.

Injury to the kidneys and ureters.

%ancreatic injury.

%elvic organ injury.

I4. MEDICAL MANAGEMENT

Doctor5' Ord&r

1:J:9<

ay have soft diet this am D-T this pm

IK+ to follow D= 2 1 L09 gtts:min

%lease regulate %4!! IK+ for volume: volume replacement

Terminate all IK medicines

(hange dressing

-mbulate

1:<:9<

D-T

D:( IK+

*7

+ollow up with surgery A%D 1:1=:9<, Dr. 2ocha

7ome meds

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o (efuro ime =99 mg 1 cap TID

o etronida)ole =99 mg 1 tab TID

o Cteroco ib 1 cap AD

o KM +e a cap AD

L!*or!tor# t&'t

1:1:9<

7ematology

2esults are within normal

1:0:9<

3lood (hemistry

(reatinine 8.J; mg:d ref. value 59.69$1.09

1:F:9<

7ematology

7emoglobin 19.= g:d ref. value 510.9$16.9

7amatocrit 81.6 N ref. value 58J.9$FJ.9

3lood (hemistry(reatinine 0.9F ref. value 59.69$1.09

4. NURSING MANAGEMENT

Id&!+ nur'in "!n! &"&nt

%ost op care includesE

• Immediate rapid assessment, then review all systems

• K! and assessments every 1= minutes F, &89m F, &1hr F, &Fh until 0F

hrs has elapsed.

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7Init akong paminaw na ug hawoy kayo akong lawas@, as verbali)ed by

the patient.

• O*3&cti,&

TemperatureE 8<.0>(, warm skin, moist skin, tachypnea

Di! no'i'

7yperthermia related to dehydration as evidence by flushed skin and

warm to touch

O*3&cti,&'

-t the end of 89 minutes, the patient will be able toE

1. maintain core temperature within normal range

0. demonstrate behaviors to monitor and promote normothermia

Int&r,&ntion'

Independent

• promote surface cooling by means of tepid sponge bath

• maintain bed rest

• increase fluid intake 5%A

(ollaborative

• administer antipyretic 5paracetamol as ordered

E,!+u!tion

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-t the end of 89 minutes, patient s temperature was rechecked and it

lowered down from 8<.0>( to 8J.6>(. Tepid sponge bath was successful in

lowering the patient s fever.

8. Cu&'

• Su*3&cti,&

73asa lage kayo akong tae bai, kapila nko nalibang karon nga buntag na@,

as verbali)ed by the patient.

• O*3&cti,&

oose bowel movement, F defecated with loose watery stool

Di! no'i'

7igh risk for fluid volume deficit related to e cessive losses through

normal routes 5diarrhea

O*3&cti,&'

-t the end of < hours, the patient will be able toE

1. control diarrhea

0. have replacement for fluid loss

Int&r,&ntion'

Independent

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• encourage oral intake

• provide supplement fluid, volume: volume replacement

• monitor Intake and Autput

•

asses skin turgor

(ollaborative

• -dminister medication as indicated 5anti$diarrheals

E,!+u!tion

-t the end of the shift, patient was asked If how was his feeling, and he

said ?murag paminaw nku nag arang$arang bya@, as verbali)ed by the patient.

The manifested some degree of progress in the span of care during the shift.

9. Cu&'

• Su*3&cti,&

7Daghan lage kayo ni akoa samad bai na, puro ni dunggab, way kaluoy

ang nag$buhat@, as verbali)ed by the patient.

• O*3&cti,&

Damage or destroyed tissue at lower and left upper &uadrant, presence of

wound dressings

Di! no'i'

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researchers with the essential information on disease and infection prevention,

health promotion and health maintenance.

4III. BIBLIOGRAPHY

o httpE::en.wikipedia.org

o www. kidshealth.org

o 4urse s pocket guide F th edition

3y arilynn C. Doenges and ary +rances oorhouse

o www.udmercy.edu