Transcript Trauma File
Nursing 202 Janie McCloskey, R.N., M.S.N. Injury to human tissue and organs resulting from the transfer of energy from the environment Gender ◦ 2:1 ratio for men Violence ◦ 19,000-23,000 per year deaths ◦ Firearm death rate for teenagers (15-19 yrs) up 77% ◦ 1.8 million women per year are assaulted by their partners Amount of Risk Occupations Cultural factors Race ◦ Whites 54 per 100,000 ◦ Blacks 84.9 per 100,000 ◦ Other 73.4 per 100,000 ETOH ◦ 36% of fatal MVA had intoxicated drivers 3rd leading cause of death for all ages 1st leading cause of death for 1-44 yr of age Injuries most commonly seen ages 25-34 but greater than 85 yr greater likelihood to die 146,000 deaths from trauma per year MVA 28% Suicide 21% Homicides 17.5% Other 33.5% Severe ◦ accounts for 5% of total injuries ◦ Life-threatening Urgent ◦ 10 - 15% of all injuries ◦ may progress to life-threatening Non-urgent ◦ 80% of injuries Blunt trauma ◦ Common causes - MVA, pedestrian collisions, falls, assaults & contact sports Penetrating injury ◦ Common causes - GSW, stabbings, & impalements High Priority ◦ ◦ ◦ ◦ ◦ Airway/breathing C- Spine Shock External hemorrhage Impending cerebral herniation Lower priority Evaluations ◦ ◦ ◦ ◦ ◦ Neurologic Abdominal Cardiac Musculoskeletal Soft Tissue A systematic process for the initial assess of the trauma patient ◦ recognizing life threatening situations ◦ Identifying injuries ◦ Determining priorities of care based on findings Airway Breathing Circulation Disability Exposure/Environmental Control Airway obstruction is a rapidly fatal problem if not corrected ◦ ◦ ◦ ◦ ◦ Positioning Remove obstructions Secure the airway Suctioning Intubation Injuries that impair ventilation include pneumothorax, tension pneumothorax open chest wounds and flail chest Assessment should include: ◦ ◦ ◦ ◦ ◦ ◦ spontaneous respirations rate & depth of respirations length of inspiratory/expiratory cycle symmetry of chest movement splinting JVD & trach position Assess circulatory status ◦ ◦ ◦ ◦ IV access Fluid resuscitation Three-for- one replacement rule PRBCs Disability ◦ mental status-AVPU or Glasgow Coma Score ◦ Pupils Expose/Environmental Control Secondary survey consists of a more thorough examination in order to identify all injuries. It is assumed that an injury is present until ruled out. F- Full Set of VS/ Five interventions/Facilitate Family Presence (EKG, SaO2, Foley, OG, Labs) G-Give Comfort Measures H- History- AMPLE H-Head to Toe I- Inspect back Diagnosed by ◦ ◦ ◦ ◦ ◦ Pain Rigidity Guarding Rebound tenderness Referred pain May result in massive hemorrhage Spleen is the most commonly injured abdominal organ Liver and pancreas injuries are also frequent “Hollow” organ may rupture if intra-abdominal pressures are high. Blood in NG aspirate may indicate injury to the stomach or swallowed blood. Injury to the small bowel may cause necrosis & perforation Injury to the large bowel carry a high rate of morbidity & mortality. Peritonitis & sepsis may occur. Fluid Volume Deficit related to hemorrhage secondary to disruption of visceral organs GOAL The client will have an effective circulating blood volume as evidenced by: *Stable VS appropriate for developmental age *Urine output of 1 ml/kg/hr *Strong, palpable pedal pulses *Improved level of consciousness *Skin Normal color, warm and dry *Maintains HCT=30ml/dl or Hgb= 12-14g/dl *CVP reading between 5-10 cm H20 pressure *External hemorrhage controlled VS q 5-15 minutes I&O q 1 hr Assess pedal pulses q 1 hr Glasgow coma score q 15 min Assess skin temp and cap refill q 15 min Assess HCT & Hgb levels for variations CVP readings q 1 hr Assess wounds for any evidence of bleeding NS/LR as prescribed Assist with peritoneal lavage ◦ stomach and bladder decompression Peritoneal lavage is an important diagnostic procedure in patients with blunt trauma ◦ Immediate blood return of 10 mL or greater=to OR ◦ Lavage drainage that unable to see through=to OR ◦ Elevated established lab values in drainage=to OR The client will experience a decrease in pain ◦ ◦ ◦ ◦ NO pain medicine until diagnosis is made Rate pain using a 1-10 scale splint or place in position of comfort when able Decompress stomach and bladder 7% of pregnant women will be injured during pregnancy MVA leading cause of death during childbearing years Falls is the 2nd most common injury Head Injury/trauma Pelvic fracture with hemorrhage Diaphragmatic Tears Bladder Injury Uterine injury Fetal Injury during 3rd trimester Same as any trauma patient PLUS History- pregnancy related questions ◦ ◦ ◦ ◦ EDC Fetal activity Prenatal problems Uterine contractions Inspection ◦ Perineum Auscultation ◦ FHT Palpation ◦ Fundal height Positioning Preterm Labor ◦ ◦ ◦ ◦ Most common Contractions >6/min. Clear or bloody Vag Discharge Cervical dilation Abruptio Placentae ◦ ◦ ◦ ◦ ◦ ◦ Vaginal bleeding Premature labor Pain Fetal distress Maternal hemorrhage Increasing fundal height Meconium or blood in urine Pain Difficulty palpating uterine wall Fetal part outside of uterus Change in fetal movement Fetal tachycardia or bradycardia Maternal CPR Impaired Gas Exchange ◦ Position as soon as possible Risk for Aspiration ◦ Positioning ◦ Decompress stomach Fluid Volume Deficit ◦ Isotonic Solutions Anxiety ◦ 2 family members involved ◦ decisional conflict REMEMBER!! The #1 cause of fetal death due to trauma is maternal death. Treat the mother and then the fetus! Of Traumas that result in Death in the United States, Seventy-Five percent Involve Chest Trauma Penetrating ◦ Gun Shot Wounds ◦ Stab Wounds ◦ Foreign Bodies Blunt Trauma ◦ Motor Vehicle Accidents ◦ Assaults All Chest Trauma is Serious Respiratory System Major Blood Vessels Heart Most Common Chest Injury Complications ◦ Hemothorax ◦ Pneumothorax ◦ Lacerated Liver, Spleen or Lung Pain ◦ Increased with Cough ◦ Increased with Movement Point Tenderness Diagnosed by Chest Xray Pain related to Movement of the Chest ◦ Medicate as Prescribed ◦ Splinting (NO Wrapping) Risk for Ineffective Breathing Pattern related to Chest Wall Movement ◦ Cough and Deep Breath Two or More Fractures in Two or More Adjacent Ribs resulting in a Floating Segment Paradoxical Chest Movement Ribs move Inward on Inspirations Ribs Move Outward on Expiration Decreased Chest Expansion Change in Pressure Gradient Resulting in Decreased Air Movement Ineffective Cough resulting in Increased Secretions Paradoxical Movement Respiratory Distress with Hypoxemia Asymmetric Chest Tachypnea Restlessness Cyanosis Diagnosis by Chest Xray and Mechanism of Injury Ineffective Breathing Pattern related to Change in Thoracic Pressure Secondary to Flail Chest ◦ ◦ ◦ ◦ ◦ Oxygen Therapy Analgesics Stabilization Surgical Repair Mechanical Ventilation with Elective Paralysis Risk for Ineffective Airway Clearance related to Ineffective Cough and Pain ◦ Turn, Cough and Deep Breath ◦ Suction ◦ Keep Hydrated Pneumothorax- Air in the Pleural Space Hemothorax- Blood in the Pleural Space Hemopneumothorax- Blood and Air in the Pleural Space Open- Hole in the Chest Wall that allows atmospheric Air into the Pleural Space ◦ Penetrating Injury ◦ Surgical Procedure Closed- Air Enters the Pleural Space Through the Lung ◦ Bleb Rupture ◦ MVA ◦ Emphysema Open Sucking, Gurgling sound on Inspiration Respiratory Distress Asymmetrical Chest Closed Shortness of breath Chest Pain Tachypnea Cyanosis Decreased Breath Sounds Subcutaneous Emphysema Bleeding into the Pleural Space 300-1500ccs Penetrating or Blunt Air Leaks into the Pleural Space During Inspiration but Doesn’t Leak Out. The Amount of Air Increases with Each Inspiration. The Lung Collapses and Due to A Pressure Buildup the Mediastinum Shifts to the Opposite Side. This is A medical Emergency!! It Puts a Large Amount of Pressure on the Heart and Decreases Blood Return Severe Dyspnea- Progressive Distant Breath Sounds Deviated Trachea Jugular Vein Distention Cyanosis Cardiogenic Shock Impaired gas Exchange related to Collapsed Area of the Lung ◦ ◦ ◦ ◦ ◦ ◦ Semi Fowlers Cough and Deep Breath Monitor ABGs, Electrolytes and Blood Counts Administer Oxygen Pain medications as Ordered Chest Tube Anxiety related to Dyspnea And or Treatment ◦ Explain Procedures ◦ Be Calm and Reassuring Lungs are Surrounded by Pleura. Usually Negative Pressure Exists that keeps the Pleura Adhered to the Chest wall and Causes Inspiration. If Pleura in Interrupted, Air enters The Pleural Space and Negative Pressure is Lost and the Lung Collapses. To Remove Air or Fluid a Chest Tube is Inserted to Remove Air &/or fluid to Restore negative Pressure and Reexpand the Lung. All Are systems in which a 34 or 36 French Chest Tube are attached to an Underwater System. This allows the escape of air with exhalation but will not allow air to be inspired through the tube. ( Not enough negative Pressure to Override the Water pressure) Works Like a Three Bottle System ◦ Underwater seal ◦ Suction chamber ◦ Drainage Collection Chamber May use Valves instead of Underwater Seal Assess Respiratory Status Q2 Hr VS Q4 Note Quality of Respirations ◦ Labored ◦ Shallow ◦ Cyanosis Check Chest Drainage System Q1 Hr ◦ ◦ ◦ ◦ ◦ ◦ ◦ Keep Below Chest level No Kinks or Dependent Tubes Assure that Connections are secure Note Type and Amount of Drainage Check Fluctuation Check Bubbling Check Anxiety Level Ineffective Breathing Pattern related to Deceased Lung Expansion ◦ ◦ ◦ ◦ ◦ ◦ ◦ Maintain Functioning Chest Drainage System Keep Petroleum Gauze Around Tube Keep Tubing Free of Kinks and Loops Cough and Deep Breath frequently Change Position Frequently Clear Tubing of drainage Maintain Water Seal Anxiety related to Perceived Risk of Chest Tube Dislodgment , System Disruption and Inability to Breath ◦ ◦ ◦ ◦ ◦ Provide Information regarding Chest tube Sutured In Place Avoid Kinks and Loops Expect Bright Red Blood for 72 Hrs System is Checked Frequently Reexpansion Confirmed by Chest Xray Premedicate 30 minutes before Removal Valsalva and Remove Airtight Dressing Monitor for Respiratory Distress and Drainage Crushing or Bruising of the Lung due to a Severe Blow to the Chest. This Results in Alveolar Damage leading to Atelectasis. The airway Becomes Plugged With Blood and Edema. This Impairs Ventilation Mild- No Symptoms Extensive ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Deceased Lung Compliance Hypoxemia Dyspnea Cough Hemoptysis Tachypnea Chest Pain Restlessness Dependent upon extent of the Injury Mild ◦ Oxygen ◦ Observation Extensive ◦ ◦ ◦ ◦ ◦ ◦ Restrict Fluids Antibiotics High fowlers Suction Pain Medication Deep Breathing Exercises NUR 202 Janie McCloskey, RN, MSN Inadequate tissue perfusion Hemorrhagic Hypovolemic Anaphylactic Septic Cardiogenic Neurogenic Oxygen Delivery ◦ Arterial oxygen saturation ◦ Hemoglobin ◦ Cardiac output Oxygen Consumption ◦ Tissue needs ◦ Shunting 1. Compensatory mechanisms 1. Neural (pressoreceptors-SNS) 2. Endocrine/hormonal (SNS) 1. Renal flow-aldosterone/ADH 2. Anterior pituitary-glucocorticoids 3. Adrenal Medulla-epinephrine/norepinephrine 3. Chemical (chemoreceptors-paO2) 2. Intermediate and progressive ◦ ◦ ◦ ◦ ◦ ◦ Compensation continues with deterioration Prolonged vasoconstriction of extremities Anaerobic metabolism Cellular NA/K pump failure-Edema Microcirculation dilates-DIC Histamine release-capillary permeability Stagnant blood in the microcirculation ◦ Lactic acid buildup-metabolic acidosis ◦ Pyruvic waste products ◦ Increased concentration of clotting factors Depletes clotting factors Bleeding Client will be free of signs and symptoms of bleeding ◦ ◦ ◦ ◦ Assessment Minimal invasive sticks Soft tooth brushes Protect from trauma ◦ Treat the underlying cause ◦ Obtain and monitor labs PT/PTT Platelets Fibrinogen *D-dimer Fibrin split products (FSP) ◦ Heparin drip ◦ FFP (clotting factors) ◦ Cryoprecipitate (factor VIII) 3. Refractory or irreversible ◦ Prolonged inadequate tissue perfusion that is unresponsive to therapy Absolute hypovolemia ◦ External Loss Blood Plasma Body fluids Relative hypovolemia ◦ Internal loss Third spacing Internal hemorrhage Based upon: Age General health Extent of injury Loss of 15% or 750 ml can compensate Loss between 15-30% (750-1500ml) SNS stimulation Loss of 30-40% requires aggressive replacement ◦ IVF and or Blood Loss of >40% -Ineffective autoregulation and irreversible tissue destruction Client will have adequate circulating fluid volume as evidenced by: (see multiple trauma) A B C ◦ Transfusion of blood products Whole Blood PRBC FFP Platelets Treat underlying cause Requires MD order ◦ Verify and compare with clinical status and Lab values Explain procedure to client (RN or MD) ◦ Obtain consent One consent per product category OR consent includes blood transfusion and 2 hours post op Assure size and patency of line-flush with 10 ml of NS Use 2 identifiers to establish client’s identity Copy the blood bank number # (BB# C) on the “Results form Blood Bank” If no armband on the client then a new Type and cross must occur Transport can pick up the blood but only for one client Do not remove the armband until 72 hours after blood is administered Obtain VS 15 minutes before beginning administration Check order for transfusion, type and rate Two licensed personnel must go to the clients room. Establish identity with 2 identifiers Each nurse reads aloud to the other the client’s name, history number, blood bank number (C) from the arm band and the requisition that is attached to the bag. Leave the requisition attached. If scanner used, Info is still verified. Compare the donor number on the unit and the requisition Compare the ABO grouping, Rh, and expiration date Both personnel must sign the requisition Spike unit with tubing provided by the blood bank. Squeeze drip chamber until blood level is above the filter Licensed personnel must stay with the client during the first 15 minutes of the transfusion. Assess for signs of reaction Take complete VS at the end of 15 minutes Take VS at the end of 1 hr (45 minutes later) and then hourly until blood completed. VS at the completion of transfusion and 30 minutes post transfusion Start blood as soon as obtained Cannot return blood if out for >20 min Do not put in unit refrigerator If need to infuse for >4 hours-ask blood bank to split unit Discard unit after use unless RXN Compatible only with NS Change filter every 4 hours or after 4 units Acute Hemolytic-ABO incompatibility ◦ Chills, fever, LBP, flushed skin, VS changes, hemoglobinuria, bleeding, ARF, shock Febrile Reaction-leukocyte incompatibility ◦ Chills, fever of 1 degree increase, HA, flushing, anxiety, muscle spasm Delayed ◦ Hemolytic, hepatitis B, hepatitis C, HIV Stop infusion NS to IV site Notify MD and Blood bank Recheck tag and numbers Monitor UOP and VS Treat symptoms per MD order Send blood and tubing to lab Complete transfusion reaction report Collect blood and urine samples as ordered Document 2 or more of the following: ◦ ◦ ◦ ◦ Temp > 100.4 or <97 HR >90 PCO2<32 WBC >12000 or <4000 or with 10% bands Gram negative/gram positive Invading bacteria multiply faster than body can kill them-endotoxins ◦ Damages cells and alters metabolism ◦ Releases histamine Massive vasodilatation, increased capillary permeability, maldistribution of blood Hyperdynamic - Warm Shock Hypodynamic- Cold shock Multi system Organ Failure (MODS) ◦ Dysfunction of 3 or more organs Impaired Gas exchange Altered tissue perfusion Altered thermoregulation Altered thought processes Anxiety/fear Anticipatory grieving Prevention ◦ ◦ ◦ ◦ ◦ ◦ Know the population at risk Thorough history Sterile technique Early nutrition Standard precautions Continual assessment Provide oxygenation and ventilation Monitor hemodynamic values Administer and monitor IV fluids Monitor EKG Daily weights Monitor lab values C&S of specimens Timely antibiotic therapy Pharmacological interventions Nutritional support Calm, quiet environment Reduce myocardial O2 demand Thorough assessment Emotional support for client and family Prevent complications ◦ Skin breakdown ◦ Contractures ◦ Foot drop