Download Nr341 study guide wk and more Study notes Nursing in PDF only on Docsity!
NR341 WEEK 5
INTRODUCTION TO NURSING CARE: TRAUMA AND EMERGENCY
EMERGENCY SEVERITY INDEX
ESI-
- unstable client who requires immediate life-saving intervention
- high resource utilization For Example: cardiac arrest, severe respiratory distress, excessive bleeding ESI-
- client in high-risk situation with likely life-threatening injury who must be seen within 10 minutes
- high resource utilization For Example: cardiac ischemia, unresponsive with multiple trauma ESI-
- stable client with unlikely but possible life-threatening injury who should be seen within one hour
- medium to high resource utilization For Example: abdominal pain, hip fracture ESI-
- stable client without life-threatening injuries whose care can be delayed
- low resource utilization For Example: closed extremity trauma, laceration, cystitis
- stable client without life-threatening injuries whose care can be delayed
- low resource utilization PRIMARY AND SECONDARY SURVEY Primary Alertness and airway Breathing Circulation Disability Exposure and environmental control Facilitate adjuncts and family Get resuscitation adjuncts (LMNOP) Secondary History and heat to toe Head, neck and face Chest Abdomen and flanks Pelvis and perineum Extremities Inspect posterior surfaces It is essential to begin adjunct measures for monitoring the client’s condition. Use the mnemonic “LMNOP” to remember key resuscitation aids needed.
- L = laboratory testing
- M = monitor electrocardiogram (ECG) for heart rate and rhythm (initiate continuous cardiac monitoring)
- N = nasogastric tube to decompress and empty the stomach, reducing the risk for aspiration
- O = oxygenation and ventilation (continuous pulse oximetry [SaO 2 ] monitoring)
- P = pain assessment and management The family should be allowed to be present during resuscitative and invasive procedures. It reduces client anxiety and increases comfort as well as allows the client advocate to be present. Care should not be transferred from the emergency department until the client has been stabilized.
Ongoing Evaluation Airway patency and effectiveness of breathing are the highest priorities. Closely monitor level of consciousness, vital signs, peripheral pulses, and skin temperature/color for information about circulation and perfusion. TARGETED TEMPERATURE MANAGEMENT Clients with non-traumatic, prehospital cardiac arrest may benefit from therapeutic hypothermia. Therapeutic hypothermia, most often referred to as targeted temperature management (TTM), may be used for at least 24 hours after the return of spontaneous circulation. It can decrease mortality rates and improve neurologic outcomes. The TTM induction phase begins in the emergency department. The goal is a core temperature of 89.6º–96.8ºF (32º–36ºC). Various methods are used to cool the client, including intravenous cold saline infusions and surface cooling devices. TTM requires intubation, mechanical ventilation, invasive monitoring, and continuous assessment. HEAT-RELATED EMERGENCIES Heat Cramps (FATIGUE BY OVERUSE) Heat cramps are severe cramps in muscle groups fatigued by overuse. They are usually brief, intense, and occur after exercise or hard labor. Cramping is accompanied by nausea, tachycardia, pallor, weakness, and profuse sweating. Heat cramps usually resolve with rest and hydration (sodium and water). Elevate the extremity and administer analgesia to assist with pain. Heat Exhaustion (PROLONGED EXPOSURE) Heat exhaustion occurs after prolonged exposure (several hours to days) to heat. Symptoms include fatigue, nausea, vomiting, extreme thirst, anxiety, hypotension, tachycardia, elevated temperature, dilated pupils, confusion, and profuse sweating. Heat exhaustion usually occurs during strenuous activity in hot, humid weather. Fluid replacement is needed (oral or parenteral). Temperature reduction can be accomplished with a moist sheet over the patient (evaporative heat loss). Heatstroke(MEDICAL EMERGENCY)
Heatstroke is the most serious form of heat stress and is a medical emergency. It results from hypothalamic thermoregulatory failure. Diaphoresis, vasodilation, and tachypnea deplete fluid and electrolytes, especially sodium. Eventually, sweat glands stop functioning. Core temperature increases rapidly (within 10–15 minutes). Cerebral edema and hemorrhage occur from thermal injury to the brain and decreased cerebral blood flow. Death is directly related to the amount of time the client is hyperthermic. Thermal Burns (SKIN CONTACT WITH HOT SURFACES) Thermal burns are a common occurrence in hot environments, particularly when outside temperatures rise above 95 degrees. Exposure of the skin to objects in direct sunlight can result in deep tissue burns within seconds, often as secondary injuries. For instance, an elderly client walking outside on a day with a temperature of 105 degrees could fall on the pavement, leading to a secondary burn injury. Essential measures to prevent burn complications include the use of towels and/or oven mitts and immediate removal from hot areas or objects. Other preventative actions include walking in shaded areas, conducting "touch tests" on equipment before allowing children to play with it, requiring clients with neuropathy in the feet to wear shoes with adequate soles, and never leaving children, pets, or older adults in unairconditioned cars. These precautions can help prevent significant injuries.
- Tissue that has sustained superficial frostbite is easily damaged. Avoid squeezing, massaging, or scrubbing the injured area. Swelling will occur with thawing, so remove clothing and jewelry to avoid constriction.
- Immerse affected extremity in circulating water that is 98.6ºF–104ºF (37ºC – 40ºC). Use warm soaks for the face. Blisters will form within a few hours of thawing and must be debrided and covered with a sterile dressing.
- Rewarming is extremely painful, so analgesia is essential. Tetanus prophylaxis may be necessary as well. Deep Frostbite
- Deep frostbite involves muscle, bone, and tendon. The tissue will appear white, then mottled, and progress to gangrene if not treated. The skin is not sensitive to touch.
- Immerse the affected extremity in circulating water at 98.6ºF–104ºF (37ºC – 40ºC) until skin flushing occurs distal to the injured area. After rewarming, elevate the extremity to reduce edema, which begins within 3 hours. Blisters will form within hours to days.
- Rewarming is painful. Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain management and to reduce swelling. Tetanus prophylaxis is necessary as well as evaluation for systemic hypothermia. HYPOTHERMIA Mild Hypothermia (SHIVERING, LETHARGY) Mild hypothermia is a core body temperature between 93º–95ºF (33.9º– 35ºC). Symptoms include shivering, lethargy, confusion, and minor heart rate changes. Moderate Hypothermia (RIGIDITY, BRADYCARDIA, LOW BP) Moderate hypothermia is a core body temperature between 86º–93ºF (30º– 33.9ºC). Symptoms include rigidity, bradycardia, bradypnea, severe hypotension, metabolic and respiratory acidosis, and hypovolemia. Atrial and ventricular dysrhythmias may develop. Blood flow to the kidneys is decreased, which impairs water reabsorption and leads to dehydration. Hematocrit increases as intravascular volume decreases. As cold blood becomes thicker, the client is at risk for thrombus formation.
Severe Hypothermia (SHIVERING STOP, LIFE THREATENING) Severe hypothermia is a core body temperature below 86ºF (30ºC). Shivering stops and results in a potentially life-threatening situation. Metabolic rate, heart rate, and respirations slow dramatically. Reflexes are absent. Pupils are fixed and dilated. Ventricular fibrillation or pulseless electrical activity may be present. Attempt to warm the client to at least 86ºF (30ºC) before pronouncing death. Rewarming during hypothermia involves passive, active external, and active internal rewarming. Passive Rewarming
- Remove wet clothing. Apply dry clothing, warm blankets. Use radiant lights. Keep the head covered to limit heat loss. Active External Rewarming
- Apply heating devices (warming blankets). Use warm water submersion. Active Internal Rewarming
- Administer warmed (intravenous) IV fluids and heated, humidified oxygen. Peritoneal or rectal lavage with warmed fluids. Extracorporeal circulation (hemodialysis, rapid fluid infuser, cardiopulmonary bypass) may be used. Important! Warm the trunk first in patients with severe hypothermia to limit the development of shock. ADEQUATE RESUSCIATION Hemodynamic/renal parameters within normal limits Normal core body temperature Lactate less than 2 mmol/L Normal pH Hemoglobin above 9g/dL Normal calcium levels Normal potassium levels Pain managed INTRODUCTION TO NURSING CARE: TRAUMA BY SYSTEM Traumatic Brain Injury
A subdural hematoma occurs from bleeding between the dura mater and the arachnoid layer of the meninges and is typically venous in origin. An acute hemorrhage develops within 24–48 hours. Signs are those of increased intracranial pressure. Rapid surgical intervention to evacuate the hematoma and prevent cerebral herniation is necessary. NURSING PRIORITIES DURING TBI Airway, stabilization of the spine, IV access & neuro status CLINICAL MANIFESTATIONS OF TBI Clinical manifestations of head injury are categorized as surface findings, central nervous system findings, and respiratory findings. Surface Findings
- bruises and contusions on the face
- Battle’s sign (bruising behind the ears)
- skull fracture
- raccoon eyes (periorbital edema and bruising)
- scalp lacerations Central Nervous System Findings
- confusion
- cerebrospinal fluid (CSF) leaking from the nose or ears
- decerebrate or decorticate posturing
- decreased level of consciousness
- dilated or unequal pupils
- Glasgow coma scale (GCS) less than 12
- seizures
- depressed or hyperactive reflexes Respiratory Findings
- Cheyne-Stokes respirations
- decreased oxygen saturation
- pulmonary edema ACUTE SPINAL CORD INJURY Spinal cord injury (SCI) is caused by trauma to the spinal cord and results in temporary or permanent alteration in function. Clinical manifestations are a result of cord compression, ischemia, and edema. Symptoms are related to the level (cervical, thoracic, lumbar, sacral) and degree of injury (complete or incomplete cord transection) and may include:
- respiratory distress
- muscle weakness, paralysis, flaccidity
- changes in sensation
- numbness, paresthesia
- pain, muscle spasms
- bowel and bladder incontinence
- priapism (persistent, painful erection of the penis) Select each tab to learn about spinal shock and neurogenic shock, which are serious complications of acute spinal cord injury. MEDICAL MANAGEMENT OF ACUTE SPINAL CORD INJURY
- Airway
- Immobilize
- Bleeding
- Temperature
- Pain
- Heart
- Urine
- Loc
- Function AUTONOMIC DYSREFLEXIA Medical management of acute spinal cord injury depends on the level and degree of the injury and can be complex. Nursing priorities include:
- Ensure a patent airway and adequate breathing.
Ribs 5 to 9 are most often fractured as they are the least protected by chest muscles. A splintered or displaced rib can puncture the lungs, heart, or other internal organs. When three or more consecutive ribs are fractured in two or more separate places, or the sternum is fractured, a flail chest (instability of the chest wall) results. This instability causes paradoxical movement of the chest wall during breathing. During inspiration, the affected part of the chest wall is sucked in and, during expiration, it bulges out, preventing adequate ventilation and increasing the work of breathing, leading to hypoxia. Vital sign changes include rapid, shallow respiration and tachycardia. Crepitus can be palpated near the rib fractures. Chest movement is uncoordinated and movement of the thorax is asymmetric. A chest x-ray confirms the diagnosis. The goal of treatment is to support lung expansion and ensure adequate ventilation using supplemental oxygen. Ventilation may be needed depending on the extent of the injury. Monitor the client for atelectasis and pneumonia, which may develop due to decreased chest wall expansion and retained secretions. Analgesia (non-steroidal anti-inflammatory drugs, opioids, thoracic nerve blocks) helps promote ease of breathing. Sometimes, surgical repair of the flail segment may be needed. The nurse should encourage coughing and deep breathing, early ambulation, and the regular use of an incentive spirometer. Pneumothorax When air enters the pleural cavity, normal negative pressure changes to positive pressure, causing a partial or complete lung collapse. Pneumothorax can be open or closed (no external wound). Penetrating chest injury (sucking chest wound) causes air to enter the pleural space during inspiration. Pneumothorax should always be suspected following any chest trauma. Clinical manifestations include tachycardia, dyspnea, tachypnea with shallow respiration, and oxygen desaturation. Breath sounds will be absent on the affected side. Tension pneumothorax , a medical emergency, is when trapped air cannot escape, putting pressure on the heart and great vessels, pushing them away from the affected side and compressing the “good” lung. Cardiac output decreases. Clinical manifestations include severe respiratory distress,
tracheal deviation, neck vein distention, cyanosis, and profuse diaphoresis. The client may die from inadequate cardiac output or severe hypoxemia. Treatment for pneumothorax is chest tube insertion connected to water-seal drainage. Tension pneumothorax may require emergent needle decompression followed by chest tube insertion. Similar injuries include hemothorax and chylothorax.
- Hemothorax is the accumulation of blood in the pleural space from a chest wall injury. Blood must be removed from the cavity with the urgent insertion of a chest tube. Recovered blood can be reinfused (autotransfusion) shortly after the injury. A hemothorax can occur with a pneumothorax, which is called a hemopneumothorax.
- Chylothorax is the accumulation of lymphatic tissue (milky white fluid) in the pleural space. The thoracic duct is disrupted, which allows lymphatic fluid to enter the pleural space. Cardiac Tamponade Cardiac tamponade, a medical emergency, occurs when blood rapidly collects in the pericardial sac, compresses the myocardium, and prevents the ventricles from filling. Clinical manifestations include muffled, distant heart sounds, hypotension, neck vein distention, and increased central venous pressure. Treatment requires an emergent pericardiocentesis with surgical repair as appropriate. ABDOMINAL TRAUMA Damage
- Fracture
- Spinal cord injuries
- Thoracic injuries
- Internal bleeding
- Internal organs Both blunt and penetrating injuries are common in the abdominal area and can result in a lacerated liver, ruptured spleen, tear in the mesenteric artery, renal or pancreas injury, or rupture of the diaphragm, urinary bladder, stomach, or intestines.
- pain
- hematuria/hematemesis
- cullen’s sign
- grey-turner sign Abdominal Compartment Syndrome Abdominal compartment syndrome (or abdominal hypertension) is excessively high pressure in the abdomen caused by increased volume in the cavity (edema, hemorrhage). The high pressure restricts ventilation, leading to respiratory failure, and decreases cardiac output, venous return, and arterial perfusion of organs, leading to renal failure. NURSING MANAGEMENT OF ABDOMINAL TRAUMA
- Airway
- Oxygen
- Bleeding
- IV access
- Temperature
- Maybe NG tube
- Maybe Urinary catheter Medical management of abdominal trauma depends on the type and severity of the injury and can be complex. Nursing priorities include:
- Ensure a patent airway and adequate breathing.
- Administer supplemental oxygen to maintain normal oxygen saturation.
- Control external bleeding.
- Establish IV access and administer isotonic solution.
- Stabilize any impaled objects with a bulky dressing. Do not remove impaled objects!
- Cover protruding organs or tissues with a sterile dressing soaked in sterile saline.
- Maintain normal temperature using blankets and warmed IV fluids.
- Facilitate diagnostic testing to determine the extent of the injury. If there is no blood at the urinary meatus or suspicion of pelvic fracture, insert an indwelling urinary catheter. If there is no evidence of facial trauma,
insert a nasogastric tube to decompress the stomach and prevent aspiration. The nurse should closely monitor vital signs, oxygen saturation, level of consciousness, and urinary output while preparing the client for surgery. ORTHOPEDIC TRAUMA
Traumatic fractures are described as open (skin is broken and bone exposed)
or closed (skin is intact over the injury). They are also described as complete (break through the bone) or incomplete (break partly across the bone shaft). Fractures are identified according to the direction of the fracture line:
- Linear: Break is parallel to the bone’s long axis
- Transverse: Break extends across the bone shaft
- Oblique: break has a curved or sloped pattern
- Spiral: One part of the bone has been twisted at the breakpoint
Medical management of acute orthopedic injury depends on the location and severity of the injury and can be complex. Nursing priorities include:
- Control external bleeding with direct pressure and elevation of the extremity.
- Immobilize suspected fracture sites.
- Perform neurovascular assessment on the extremity distal to the injury to ensure adequate perfusion.
- Apply ice packs to prevent swelling and promote numbness for pain control.
- Facilitate diagnostic testing to determine the location and severity of the injury.
- Administer a tetanus vaccination if there is a break in skin integrity. Repair of orthopedic trauma can involve either open-reduction or closed- reduction techniques. Select each tab to learn about both types of repair. Traction is the application of a pulling force to an injured part of the extremity. It is used to reduce pain, immobilize the body, or reduce the fracture. Skin Traction
Skin traction is used temporarily until skeletal traction or surgery is possible. Boots or splints are applied to the skin to decrease muscle spasms. Traction weights are used as the pulling force. This had SKINS TRACTION pic Skeletal Traction Skeletal traction provides long-term alignment and fracture reduction by inserting pins or wires into the bone. Weights may be attached to assist with alignment and immobilize the injured body part. Infection is a major complication. COMPLICATIONS OF ORTHOPEDIC INJURIES
- Orthopedic injuries can lead to life-threatening complications such as compartment syndrome and fat embolism syndrome. Select each tab to learn more.
- Compartment Syndrome – left pic Compartment syndrome is an emergent condition in which swelling causes increased pressure in a limited space (muscle compartment). Continued pressure compromises the function of the blood vessels and nerves in the compartment, leading to diminished perfusion. Ongoing neurovascular assessment to monitor for compartment syndrome is essential. Signs include pulselessness distal to the injury, excessive pain, pallor, paresthesia, paralysis, and poikilothermia. Do not elevate the extremity above the level of the heart. Do not apply cold compresses that cause vasoconstriction and worsen the problem. Surgical decompression (fasciotomy) is needed to decompress the tissue. The site is left open for several days and infection is a main concern. In severe cases, amputation may be necessary Fat Embolism Syndrome – right pic Fat embolism syndrome is characterized by fat globules entering the circulatory system from fractures of the long bones, ribs, tibia, and pelvis. Early recognition is critical to prevent death. Clinical manifestations typically occur within 24–48 hours of injury and include severe respiratory distress, chest pain, apprehension, anxiety, tachycardia, and petechiae of the neck, chest wall, axilla, mucous membranes, and conjunctiva.
