trauma Flashcards
Nursing assessments for a pts with traumatic injuries post resuscitation and/or critical care?
HEAT TO TOE FRONT TO BACK observe/look! -are they breathing? -any bleeding? -is there guarding, rigidy? auscultation -bs in all 4 quads? hypo or hyper active? -resp and cardiac sound like they should? percussion -hyper resonance--> air -dullness--> fluid palpation -all 4 quads -pelvis for stability -anal sphincter for tone--> nerve damage, damage to lower GI tracht!!
diagnostics for pts with traumatic injuries?
- x-ray–> some injuries may not be picked up the first time!!
- labs- cbc, preg, coagulation, lactate, urinalysis, R&M, stool for occult blood
- CT
- FAST exam
- angiography
- urinalysis=myoglobin in the urine= rhabdo
- cystogram= damage to heart or urinary system
- STOOL for occult blood!!
- ->if there throwing up fresh blood (upper GI)
- -> stool, fresh blood–> lower GI!!, coffee grounds either direction=lower GI
what is FAST?
focused assessment for trauma, ultrasound in ER. 80-90% effective for picking up bleedings
nursing interventions for traumatic injury pt?
- maintain pt airway
- serial vital signs
- IV input and blood volume
- insert 2 large bore IVs (OR) one for fluid one for blood products… not just RBC, clotting factors, albumin etc.
- I&o–> output can be one of the biggest factors for hemostability for trauma pt!
- pain management–> addressing the cause of the pain!!!
- foley catheter
- antibiotics
- psychosocial support
- prepare for OR
- NG as indicated
- cover wounds
ibuprofen impact with trauma?
antiplatet effect!!! keep an eye on platelet count and clotting factors if administering this anti-inflammatory…
collaborative management for trauma?
- PREVENTION!! we want to prevent them in the first place
- IV therapy, critical care nurses, PT/RT, emerg doctors
- rehab STARTS on admission
- WHOLE focus of care= maximize patient function down the road… preventing complications
- surgery
- pharmacotherapy
- -> abx
- ->opiate analgesia
- -> tetanus prophylaxis
- -> gastric protection
- -> anticoagulation
- rehabilitation
- psycho/social support
when do fatty embolisms occur?
12-72 hours!! usually.. could very well happen on your unit after transfer from emerg
neurological trauma=
direct injury to skull, brain, or spinal cord
- -> brain= concussion/contusion/bleeds
- SUBTLE CHANGES OVER TIME!!
- we need a good solid baseline.. might be impacted by patients state
- glascow goma scale-LOC!!
- could be language barriers, hearing impairments, or cultural differences!! could impact ability to communicate
example of focal head injury
hit head–> subdural hematoma
example of diffuse head injury
concussion
assessing head trauma
- changes in respiration–> RAPID look at what is happening!!
- cervical integrity checked in ER
- decreased LOC
- GCS
- papillary response
- assessing cranial nerves
- decreased pulse
- increased systolic BP
- widening PP
- observe, palpate
- changes in temperature
- history of loss of consciousness or amenia
GCS less than 8?
major head injury!! comatose, likely need ventilation
when is mannitol administered?
if increased ICP but NOT if bleed suspected!!!
any injuries to mouth or head bleed….
PROFUSELY!!
why do we see increased systolic BP with head injuries?
increased ICP, body trys to maintain cerebral perfusion
-maintaining systolic over 100 is important for patient outcome!!
are blood products usually given to head trauma pts?
not usually!! risk of reaction to blood transfusion is greater than benefit
–> if they are also bleeding out somewhere as well you will see blood products being given!
body goes into hypermetabolic state after injury, why do we monitor glucose after injury
make sure brain is getting glucose it needs
with severe ICU patients injured we see which positions?
GCS 3 —> decorticate posturing, decerebrate posturing GCS 2!!
- in the process of dying
primary brain injury usually results from?
mechanical damage caused by traumatic forces being applied. concussion.. laceration.. hemorrhage due to tearing of vessels.. burising, deforming of tissues…..
secondary brain injury results from?
changes within the brain as a result of initial injury…
- brain swells & increases intracranial volume
- rigid cranium allows no room for expansion of contents so intracranial pressure increases
- pressure on BV within the brain causes blood flow to the brain to slow
- cerebral hypoxia and ischemia occur!!
- intracranial pressure continues to rise… brain may herniate!!
- cerebral bf ceases
our huuuuge focus with primary brain injuries??
controlling intracranial pressure to avoid secondary injuries!!!
what is shaken baby syndrome?
-very hard to deal with a child that wont stop screaming but education is sooo important!!
-infants have fontaneles that allow for swelling
–> posterior closes at 2-3 months, anterior closes between 12 and 18 months of age
-bulging fontanelle–> increased intracranial pressure–> HIGH PITCH SCREAM!!
ACT QUICKLY!!!
over time in elderly, brain starts..
shrinking…. sometimes we think we are seeing depression or delirium but it is actually brain damage!!
any time you have elderly pt with fractured anything and you see a cut or bruise on face or neck, and then you see increased confusion or changed in LOC.. think UNDIAGNOSED CRANIAL BLEED!!
elderly risk with cranial bleeds?
often on anticoagulants, heparin, warfarin!! really stop and think… do we have a brain injury with elderly pts and confusioN!!
3 primary types of brain injuries?
intracranial lesions, contusions, lacerations
non-displaced linear fractures?
cracked skull, may have negligible neurological deficits
basilar skull fractures?
substantial force to skull, significant impact, not always detected on x-rays or CT scans. often looking at clinical findings for skull fractures
base of skull fracture signs?
- raccoon eyes
- CSF rhinorrhea
- CSF otorrhea
- battle sign
- haemotympanum
- bump
acute spinal cord injury?
- can result from concussion, contusion, laceration, hemorrhage, or impaired blood supply to the cord
- -> fracture of vertebral body
- -> spinal shock
- -> neurogenic shock
- -> autonomic dysreflexia
- -> cord syndromes (central, lateral, homers, anterior)
stabilizers for spinal fractures?
- jewett hyperextension brace
- aspen collar
- halo brace
thoracic trauma?
- 25% of MVC deaths are related to thoracic trauma
- second only to brain and spinal cord injuries as the l
