Transcript TRAUMA

Tiara Lintoco
Batch 8
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Trauma is a physical injury or wound caused
by external force or violence.
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Trauma to the brain is the most common
cause of motor & sensory symptoms
including brain damage, coma and paralysis.
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Normally, the skull’s thick bones, as well as
the tough membrane of the meninges (dura),
protect the brain, in addition, CSF acts as a
shock absorber.
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However, violent blow to the head can cause
several kinds of seizures and epilepsy later in
life.
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If one of the normal contents of the cranial or
the spinal cavity (brain, tissue or CSF) increased
in size, volume or shape and pressure; this
increase in pressure can cause the delicate
structure to be moved, damaged or destroyed.
There are 2 types of trauma:
1. Craniocerebral Trauma
2.Spinal Cord Trauma
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A broad classification that includes injury to
the scalp, skull, or brain.
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A traumatic insult to the brain capable of
causing physical, intellectual, emotional,
social, and vocational changes.
- Craniocerebral trauma or head injury is the 2nd
most common cause of neurological injuries & the
major cause of death between ages 1 to 35.
- Effects of severe head injury include cerebral
edema, sensory and motor deficits and increased ICP
(intracranial pressure).
- Motor vehicle & motorcycle accidents, falls,
industrial accidents, assaults and sports trauma.
Injuries can be direct or indirect
Direct occurs when the head is directly injured. This
results in an acceleration-deceleration injury, with
rotation of the skull and its content.
Bruising/contusion of the occipital and frontal
lobes, the brain stem and cerebellum may occur.
acceleration-deceleration injury is caused when
the body at motion abruptly comes to a stop
and the body structures are contused from
within. (whiplash or brain contusion, rupture
of the spleen or hepatic capsules)
Indirect is caused by tension strains and
shearing forces transmitted to the head by
stretching of the neck.
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Concussion – a temporary loss of neurologic
function with no apparent structural damage
Contusion – more severe than concussion; brain is
bruised, with possible surface hemorrhage
Diffuse Axonal Injury – widespread damage to
axons in the cerebral hemispheres, corpus
callosum, and brain stem
Intracranial hemorrhage
Brain suffers traumatic injury
Brain swelling or bleeding increases intracranial volume
Rigid cranium allows no room for expansion of contents so ICP increases
Pressure on blood vessels within the brain causes blood flow to the brain to slow
Cerebral hypoxia or ischemia occurs
Intracranial pressure continues to rise. Brain may herniate.
Cerebral blood flow Ceases
1. Concussion – difficulty in awakening or
speaking, confusion, severe headache,
vomiting, weakness on one side of the body,
amnesia, visual disturbances
2. Contusion – altered LOC, nausea, vomiting,
ataxia, speech problems, seizures, cool, pale
skin, shallow respirations, faint pulses. Full
recovery may be delayed for months.
3. Head injuries may be open or closed.
Open injuries may result from a skull fractures or
penetrating wound. The amount of injury from
this type of wound is determined by the velocity,
mass, shape and direction of the impact.
Closed injuries include concussions (a violent
jarring of the brain against the skull), contusions
(brain tissue is bruised) and lacerations (tearing
of the brain tissue).
4.
Skull fractures maybe linear, comminuted,
depressed or compound.
Linear fracture occur when the impact causes
the area of the skull that was stuck to bend
inward, making the area around it buckled
outward.
Depressed fracture is a severe blow to the
head. The fracture breaks the bone and forces
the broken edges to press against the brain,
resulting in significant increase in ICP and
meningitis.
Compound/open fracture expose the brain into
external microorganisms which could lead to
meningitis and encephalitis. Open fractures are
less likely to produce rapid elevations in the ICP
because, the fracture allows the brain to swell.
Comminuted/fragmented fracture is when the
bone is broken or splintered into pieces which
can result in bits of bone being driven into the
brain, lacerating it.
5. Hematoma refers to the blood clot within the skull.
Hemorrhage resulting from craniocerebral trauma may
occur in the following sites: scalp, epidural, subdural,
intracerebral and intraventricular.
Epidural hematomas, resulting from arterial bleeding
forms as blood collects rapidly between dura & the
skull. If lethargy or unconsciousness develops after the
patient develops consciousness, an epidural hematoma
may be suspected and needs immediate treatment.
Subdural Hematomas form as venous blood
collects below dura. Hematoma formation is
slow, because the bleeding is under venous
pressure. The clot will cause pressure on the
brain surface and will displace brain tissue.
Patient who has been conscious for several days
after head injury, loses consciousness or
develops neurological signs and symptoms, a
subdural hematoma should be suspected.
Intracranial Hematoma, which form within the
brain due to hemorrhage & edema. The cause
may be a fracture of a delicate blood vessels due
to HTN or cerebral aneurysm. Rapture blood
vessels are one of the causes of CVAs.
Intraventricular hematoma is a bleeding into the
brain’s ventricular system, cerebrospinal fluid is
produced and circulates through towards the
subarachnoid space.
Subjective:
headache, nausea, vomiting, abnormal
sensations and history of loss of
consciousness and of bleeding from any of
the orifice (ears or nose).
Objective:
status of respiratory system, level of alertness
and consciousness, size and reactivity of the
pupils, orientation, motor status, vital signs,
presence of bleeding or vomiting and abnormal
speech pattern. Presence of “battle’s sign” ( A
small hemorrhage spot behind the ear.) usually is
indicative of a fracture of a bone of the lower
skull.
CT (computed tomography)
CAT (computed axial tomography)
MRI (magnetic resonance imaging)
PET (positron emission tomography)
- Used to assess the location and extent of the
injury.
1. Ensure a patent airway and ensure adequate
oxygenation.
2. Suctioning maybe necessary but, never
through the nose because of the possibility
of skull fracture.
3. Check ABGs
4. Control elevated temperature.
5. Administer medications to reduce cerebral
edema and increased ICP. Medications
include:
- Mannitol & Dexamethasone to treat
cerebral edema
- Codeine or analgesics to manage pain
- Anticonvulsants to prevent/treat siezures
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Prevention of infections
1. Patient’s ears and nose are checked
carefully for signs of blood or serous
drainage.
2. No attempt should be made to clean out
the orifice.
3. If there is evidence of drainage, the patient
should not cough, sneeze or blow the nose.
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Emotional Support
1. Patients need firm but gentle care, with
specific guidelines for what behavior is
allowed.
2. It’s not helpful to argue with patients.
3. Log book or written schedule can be useful
in assisting with orientation.
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Impaired social
interactions related to
cognitive and affective
deficits from
neurophysiological
trauma
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Encourage and support
verbalization of feelings,
medical conditions and current
treatment, listen nonjudgementally.
Build trust through consistency
& keep your promises.
Give attention to patient during
verbal interactions & recognize
qualities to promote selfesteem.
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Patient need to be taught about observations
for complications such as increased
drowsiness, nausea, vomiting, worsening
headache or stiff neck, seizures, blurred
vision, behavioral changes, motor problems,
sensory disturbances or decreased heart rate.
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Outcome is often unpredictable
Extent of damage or recovery is not positively
correlated with the amount of damage seen
in surgery or on CT scan.
Person with head injury is more prone to
injuries and problems related to the brain
damage.
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Injury causes microscopic hemorrhages and
gray matter to fill with blood
Edema causes spinal cord compression, and
blood supply becomes further decreased
Scarring and meningal thickening occurs,
nerves are blocked or tangled, sensory and
motor deficits occur
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Spinal cord injuries (SCI) involve losses of
motor function, sensory function, reflexes
and control elimination.
Accidents is a common and increasing cause
of serious disability and death.
Automobile, motorcycle, diving, surfing and
other athletic accidents and gunshot wounds
are the major causes of spinal cord injury.
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The level of cord involved dictates the
consequences of spinal cord injury.
(C3 to C5 poses a great risk for impaired
spontaneous ventilation because of proximity
of the phrenic nerve.
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SCIs range from contusions to complete
transection of the cord.
- Complete SCI means that there is no function
below the level of the injury (no sensation and no
voluntary movement) and both sides of the body
are equally affected.
- Incomplete SCI means that there is some
functioning below the primary level of the injury.
One limb may be able to be moved more than
the other, the person may be able to feel parts of
the body that cannot be moved and there may be
more functioning on one side of the body than
the other.
Serious Injury
Less Serious Injury
•Diving into shallow water
•Falls
•Gunshot
•Motor vehicle accidents
•Violence-related accidents
•Poor body mechanism
•Minor falls
•Sports
•osteoporosis
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Causes of trauma
 Hyperflexion forward (head-on collision)
 Hyperextention backward (rear-end collision, fall
on chin)
 Axial loading / vertical compression (land on head
or feet)
 Rotation beyond normal range
 Penetrating injury (gunshot, knife wound)
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Spinal shock or areflexia
 The loss of systemic vasomotor tone that may
result in vasodilation, increased venous capacity
and hypotension.
 Spinal shock is temporary, and during this time
the patient may need temporary respiratory
support.
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Autonomic Dysreflexia
 Occurs as a result of abnormal cardiovascular
response to stimulation of the sympathetic
division of the autonomic nervous system as a
result of stimulation of the bladder, large intestine
or other visceral organs.
 Clinical signs include sever bradycardia, HTN,
diaphoresis, “gooseflesh”, flushing (above the
lesion), dilated pupils, blurred vision, nause
restlessness, severe headache and nasal
stuffiness.
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The most common causes of this condition
includes:
▪ Distended bladder
▪ Fecal impaction
▪ Cold stress
▪ Tight clothing
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Emergency care for Autonomic Dysreflexia or
Hyperflexia
 Unless contraindicated, place patient in sitting
position to decrease blood pressure.
 Check patency of catheter for kinking. If catheter
is occluded, insert new catheter immediately.
 Check rectum for impaction.
 If it is necessary to remove impaction, an
anesthetic ointment should be used.
 Administer ganglionic blocking agents such as
hexamethonium or a vasodilator such as
nitroprusside (Nipride) as ordered if conservative
measures are not effective.
 Continue monitoring blood pressure.
 Send urine for culture if no other cause is found.
Urinary infection can lead to symptoms of
autonomic dysreflexia.
Box 54-3
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Sexual Function
 In most cases, men experience impotence,
decreased sensation and difficulties with ejaculation.
 Impairment of fertility is common. The experience of
orgasm is described as different than before the
injury.
 Women with SCI are able to continue to perform
sexually, although perception of sexual pleasure is
usually altered.
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Level of injury and spinal cord damge located
by neurologic assessment
Limited movement and activities cause pain
Surface wounds
Pain location
Loss of sensation below the level of injury
deformity
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Subjective
 Nature of injury
 Presence of dyspnea
 Unusual sensations
 Loss of consciousness
 Absence of sensation on sensory
examination
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Objective
 Level of alertness & consciousness
 Orientation
 Pupil size & reactivity
 Motor strength
 Skin integrity
 Bowel & bladder status
 Fracture bones or head injury
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Spinal X-ray – to detect any cervical
fracture / displacement
Myelography – to detect occlusion
CT Scan & MRI – to rule out spinal cord
injury
 Indicates the location of fracture and the site of
compression. Also used to assess the extent of the
damage & location of blood or bone fragments.
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Immobilization
Skeletal traction
Surgery for spinal decompression
Skeletal traction may include:
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Crutchfield tongs
Halo traction
Stryker or foster frame
Bracing for thoracic or lumbar injuries
**If the patient is seen within 8 hours of injury, high dose
of methylprednisolone is given
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Mobility
 Maintain body alignment
 Monitor skin integrity and provide pin care as
appropriate.
 Maintain ROM to prevent contractures
 Use thromboembolism stockings
 Slowly increase the angle of sitting up.
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Urinary function
 A foley catheter is inserted initially and later bladder
training is started. (Chronic indwelling
catheterization increase the risk of infection.)
 Intermittent catheterization should begin as early as
possible. (Helps maintain bladder tone and decrease
the risk for infection.)
 Fluid intake more than 2000 ml/d is encourage.
 Cranberry juice is encouraged to decrease renal
calculi formation.
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Bowel Function
 Patients are usually started on a bowel program early
in their hospital stay. Patients are given bisacodyl
(Dulcolax) suppositories at regular intervals, usually
every other night.
 Followed by digital stimulation to further stimulate
peristalsis. The goal is to eliminate the use of
suppositories.
 Other aids to bowel programs are the use of
adequate fluids, stool softener and prune juice.
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Autonomic dysreflexia, related to
nuerophysiological trauma to spinal cord above
6th thoracic vertebrae.
Box 54-3
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Impaired urinary elimination, related to sensory
motor impairment.
▪ Check carefully for voiding and for distention of bladder.
▪ Tech patient intermittent self catheterization if indicated.
 Teach patient Crede’s maneuver as indicated.
 Use foley catheter if indicated, administer
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meticulous aseptic technique in changing
catheters.
Teach patient signs of infection.
Encourage patient to have a genetourinary checkup at least once a year.
Maintain fluid intake of 3 to 4 L daily unless
contraindicated.
Use adult perineal protector for incontinency.
Complete SCI
- There is almost no chance of return to any
function.
 Paraplegic or Tetraplegic
- Can live a satisfying life with adaptations and
assistance.
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***The prognosis for life is generally 5 years less
than the people of the same age without SCI.
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Assessment
 Complaints about pain, dizziness or vision difficulties.
 Ability to speak and reason
 Vital signs, data about gait, symmetry of body parts,
evidence of pain, or seizure activity.
 Pupil size, level of alertness, ability to perform motor
tasks, change in level of consciousness, and ability to
speak.
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Nursing Diagnosis
 Autonomic dysreflexia
 Impaired verbal communication
 Compromised family coping
 Risk for disuse syndrome
 Risk for falls
 Grieving
 Risk for infection
 Deficient knowledge
 Impaired memory
 Impaired physical mobility
 Imbalance nutrition, less than body requirement
 Acute pain
 Chronic pain
 Bathing/hygiene self deficit
 Feeding self-care deficit
 Toileting self-care deficit
 Impaired swallowing
 Disturbed thought process
 Ineffective tissue perfusion (cerebral)
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Expected outcome / Planning
 The plan of care should focus on the type of deficit
the patient has as well as the possible
complications.
 Considering the patient’s preferences and mental
status is important.
 The type of care required will determine the
supplies and equipment needed.
 Schedule timely tests and procedures.
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Implementation
 Nursing interventions for the patient with
neurological disorder include those that maintain
cerebral perfusion and other functioning, as well
as those that prevent complications such as
decubitus, falls, or contractures.
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Implementation
Guidelines in providing neurological care
 The neurological system is a complex system that
produces a wide variety of neurological signs and
symptoms
 Identical disorders may result in different sets of
signs & symptoms in different patients.
 The maintenance of cerebral perfusion is of utmost
importance.
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Implementation
Guidelines in providing neurological care
 The patient with neurological illness is very prone
to complications.
 Disorders of the nervous system produce not only
physical problems, but a wide variety of cognitive
difficulties.
Evaluation
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The nurse evaluates the success of planned
interventions during and after care is given.
The nurse must always be ready to revise the
care plan as needed, because patient’s
condition often changes.
The evaluation is specific to measure the
goals identified.
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Foundations and Adult Heath Nursing by
Christensen & Kockrow 5th edition
Textbook of Basic Nursing by Rosdahl and
Kowalski 8th edition
Medical Surgical Nursing by Bruner and
Suddarth 11th edition
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