Question

The nurse is caring for a client in the emergency room who is admitted after an MVA. Which assessment finding best indicates a possible spleen rupture? A. Diminished bowel sounds B. BP \(120 / 70\), pulse rate 100 , respiration 18 C. Ballance's sign D. Wheezing on chest auscultation

Short answer

Answer: Ballance's sign

Step-by-step solution

Define spleen rupture and its symptoms

A spleen rupture is a medical condition where the spleen (an organ involved in producing and clearing blood cells, and forming part of the immune system) is damaged and starts to bleed. Symptoms can include abdominal pain, tenderness, and swelling, left shoulder pain, rapid heart rate, dizziness, and low blood pressure.

Evaluate Option A

Diminished bowel sounds might indicate a gastrointestinal issue, but it does not directly indicate a spleen rupture. Although abdominal pain could be present in both cases, diminished bowel sounds are not specific to a spleen rupture.

Evaluate Option B

Blood pressure 120/70, pulse rate 100, and respiration 18 are relatively normal vital signs on its own and do not necessarily suggest a spleen rupture. However, it is worth noting that an increased heart rate may be present in cases with spleen rupture due to bleeding.

Evaluate Option C

Ballance's sign is a medical sign found in patients with a ruptured spleen. It is characterized by dullness to percussion (tapping) of the left upper abdomen, along with shifting dullness to the right side when the patient is lying on their left side. This sign is indicative of internal bleeding, which is a feature of a ruptured spleen.

Evaluate Option D

Wheezing on chest auscultation is generally associated with respiratory issues and is not directly indicative of a spleen rupture.

Choose the best option

Of the four assessment findings, option C, Ballance's sign, is the most indicative of a spleen rupture. This is because it is directly related to internal bleeding and is a well-known sign typically associated with ruptured spleens.

Key concepts

Spleen Rupture Diagnosis

Spleen rupture is a serious condition where the spleen, an important organ in our immune system, is damaged and starts to bleed internally. This can happen due to trauma, such as a motor vehicle accident, making prompt diagnosis crucial. Common symptoms of a spleen rupture include severe abdominal pain, particularly in the left upper side, and signs of internal bleeding. Patients might also experience referred pain in the left shoulder, known as Kehr's sign.
Other symptoms may include rapid heart rate, dizziness, and low blood pressure, as the body responds to the internal blood loss. Recognizing these symptoms promptly is critical to providing appropriate medical care because a ruptured spleen can lead to life-threatening complications if not addressed quickly.

Emergency Nursing Assessment

In an emergency room setting, nurses play a vital role in the initial assessment of patients who have experienced trauma, such as in a motor vehicle accident. Their swift identification of critical signs and symptoms can make a significant difference in patient outcomes.
Important assessment steps include:

• Evaluating vital signs for abnormalities. While a pulse rate of 100 might be slightly elevated, it may still be considered normal in anxious or stressed patients post-trauma. However, a rapid heart rate in combination with other symptoms could indicate internal bleeding.
• Performing a physical examination for any signs of trauma or internal damage. This includes checking for abdominal tenderness and referred pain.
• Observing for specific signs, such as Ballance's sign, that suggest internal organ complications.

These assessments help prioritize care and ensure timely interventions for life-threatening conditions.

Ballance's Sign

Ballance's sign is a specific clinical sign that can indicate a ruptured spleen. It is detected through a physical examination where the healthcare provider taps on the abdomen.
In patients with a ruptured spleen, there is dullness to percussion on the left upper quadrant of the abdomen. This dullness may appear as "fixed" on the left side but is "shifting" when the patient changes position.
The presence of Ballance's sign is strongly associated with internal bleeding due to spleen rupture. It helps medical professionals differentiate spleen-related issues from other gastrointestinal problems that might cause similar symptoms but are unrelated to spleen damage.

Medical Symptoms Evaluation

Evaluation of medical symptoms is a critical skill in identifying potential health issues quickly. When assessing symptoms like those seen in spleen rupture cases, healthcare providers focus on the most relevant indicators to make accurate decisions.
The following elements are considered:

• History of recent trauma or injury, as spleen ruptures most often occur following an impact.
• Specific symptom patterns such as abdominal pain, low blood pressure, or rapid heart rate.
• Referred symptoms like left shoulder pain, highlighting the interconnectivity of bodily systems.
• Objective signs from examination tools such as percussion, vital statistics, and response to changes in position.

These evaluations allow for holistic assessments, pinpointing critical health conditions swiftly, giving patients the best chance at successful treatment. Simplifying these concepts and focusing on the most telling symptoms can empower students and healthcare professionals alike in their learning and practice.