Week Four Flashcards
What are the emergency care ABCDEFGHI?
- Airway
- Breathing
- Circulation
- Disability
- Environment/Exposure
- Full set of vitals/Further investigations/Facilitate family presence
- Give comfort measures
- History/Head to toe
- Inspect posterior surfaces
What is ICP?
- Intracranial pressure
- The pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue
What is the Monro-Kellie Hypothesis?
Increase in volume of one of intracranial component must be compensated by decrease in one or more of other components so that volume remains fixed
What is normal intracranial pressure?
- 5-15 mmHg
- Greater than 20mmHg must be treated
How to measure intracranial pressure?
With a intraventricular catheter
What is cerebral blood flow?
Amount of blood that passes through the brain at any time
How much of the body’s oxygen does the brain use?
20%
How much of the body’s glucose does the brain use?
25%
What is autoregulation?
The automatic alteration in the diameter of the cerebral blood flow to maintain a constant flow of blood to the brain during during systemic arterial pressure
What does auto-regulation equal?
Cerebral perfusion pressure (CPP)
How to find how much cerebral perfusion pressure (CPP) is?
Map minus ICP
What is CPP?
- Cerebral perfusion pressure
- Pressure to ensure blood flow to brain
What is normal CCP?
60-100mmHg
What does CCP of lower than 50mmHg indicate?
Ischaemia and neuronal death
What does CCP of lower than 30mmHg indicate?
Incompatibility with life
What are the implications to nursing assessment of ICP?
- Frequent neurological observations (30 mins-1 hr)
Why must a nurse complete frequent neurological observations for possible increased ICP?
Because a small change in volume can have dramatic effect on ICP
What can increased ICP?
- Anything that increased brain tissue, blood of CSF volume
- Cerebral oedema common factor
What causes cerebral oedema?
- Mass lesion
- Head injuries
- Brain surgery
- cerebral infection
- Vascular insult
- Toxic or metabolic encephalopathic conditions
What are complications of increased ICP?
- Inadequate cerebral perfusion
- Cerebral herniation
What does herniation cause?
1) A potentially reversible process to become irreversible
2) Ischemia and oedema increase
3) Compression of brainstem and cranial nerves
4) Brain death
What is the progression of increased ICP?
- Cranial insult
- Tissue oedema
- Increased ICP
- Compression of blood vessels
- Decreased cerebral blood flow
- Decreased oxygen with death of brain cells
- Oedema around necrotic tissues
- Increased ICP with compression of brainstem and respiratory centre
- Accumulation of carbon dioxide
- Accumulation of carbon dioxide
- Vasodilation - Increased ICP resulting from increased blood volume
- Death
What are clinical manifestation of increased ICP?
- Change in LOC
- Change in vital signs (Cushings triad=high bP with low diastolic, bradycardia, increased temp, erratic/decreased breathing)
- Ocular signs
- Decrease in motor function
- Headache
- Vomiting (projectile without nausea)
What do we assess in a neurological assessment?
- Glasgow coma scale
- Pupillary check for size and response
- Test strength and movement
- Vital signs
Why do we check Glasgow coma scale for a neurological assessment?
Measures consciousness (less than 8/15 = coma)
Why do we check the pupillary check for size and response for a neurological assessment?
Sign CN III, IV, VI nerves are compressed
Why do we check test strength and movement for a neurological assessment?
Testing response in all four limbs for asymmetry in strength and movement fo deficits
Why do we check the vital signs for a neurological assessment?
Checking for signs of Cushing’s triad which indicates severely increased ICP
What is a decorticate response?
Flexion of arms, wrists and fingers with adduction in upper extremities. Extension, internal rotation and plantar flexion in lower extremities
What is a decerebrate response?
All four extremities in rigid extension, with hyperpronation of forearms and plantar flexion of feet
What is opisthotonic posturing?
When the back becomes extremely arched
What are the types of head injuries?
- Scalp laceration
- Skull fractures
- Head trauma: diffuse or focal
What is a diffuse injury?
- Generalised
- Concussion
- Diffuse axonal injury
What is a focal injury?
- Localised
- Contusion
- Hematoma
How do you class head injuries?
- Minor: GCS 13-15
- Moderate: GCS 9-12
- Severe: GCS 3-8
What is a coup-contrecoup injury?
Cerebral contusion on the side of the brain opposite the area that was hit
What is a coup injury?
Cerebral contusion at site of impact with an object
What is a concussion?
- Minor head injury
- Sudden transient mechanical head injury with disruption of neural activity and a change in LOC
What are signs of a concussion?
- Brief LOC
- Amnesia regarding the event
- Headache
- Post concussion syndrome can last 2 weeks to 2 months
What are symptoms of a concussion?
- Persistent headache
- Lethargy
- Personality and behaviour changes
- Short attention span
- Decreased short-term memory
- Changes in intellectual ability
What something to be aware of with scalp laceration?
Profuse bleeding
What are different types of skull fracture?
- Linear
- Depressed
- Simple
- Comminuted
- Compound
Symptoms vary depending on where the fracture is
What to watch for when a patient has a skull fracture?
CSP leaking from nose or ears
What does CSP leaking from nose and ear indicate?
Tear in dura
What are clinical signs of basilar skull fracture?
- Periorbital oedema and bruising
- Bruising behind the ears
- CSF leaking
What is a basilar fracture?
Base of skull fracture
What is contusion?
Bruising
What are complications of head trauma?
- Subdural hematoma
- Intracerebral hematoma
- Epidural hematoma
What is a subdural hematoma?
Bleeding between the dura mater and arachoid layer
What is a intracerebral hematoma?
Bleeding within the brain
What is a epidural hematoma?
Neurological emergency as associated with arterial bleed
What are nursing interventions during the acute phase (head injury/increased ICP)?
- Maintaining respiratory function
- Maintaining fluid and electrolyte balance
- Monitoring ICP
- Body position
- Protection from injury
- Psychological consideration
- Care of the family/ significant other
Why monitor respiratory function in the acute phase?
Injury stops brain regulating breathing
Why monitor fluid and electrolyte balance in the acute phase?
Injury causes excessive loss of fluids in form of urine causing abnormalities
Why monitor ICP in the acute phase?
Monitor through observations to ensure pressure does not increase
Why monitor position in the acute phase?
- Ensure good blood flow to the brain
- Prevent neck injury
Why protect from injury in the acute phase?
- Prevent pressure injury
- Eye care
- Oral care
- Prevent bruising
- Preventing excessive noise and light
What are psychological considerations to have in the acute phase?
To reorientate the patient and keep them calm
What care should you provide to family and significant others in the acute phase?
- To give them a realistic outlook on what could happen
- Keep the patient calm
- Reduce fear
What is brain stem death?
When there is irreversible damage to the brain stem such that it can no longer maintain independent respiratory and cardiovascular function
What are criteria for brain stem death?
- 2 doctors diagnose brain stem death
- Test are performed twice by different doctors
- The test firstly elicit the function of the cranial nerves through stimulation of cortical reflex, gag reflex etc
What results confirm brain stem death?
- No response to pain
- The pupils are fixed and dilated, not responding to sharp changes in the intensity of light
- Oculocephalic reflex (dolls eyes)
- There is no corneal reflex
- There is no vestibulor-ocular reflexes
- There is no motor response
- There is no gag or cough reflex
- There is no respiratory effort, despite allowing the PC02 to rise above the threshold for stimulus of respiration
What does ecchymosis mean?
Bruising
What is diabetes insipidus?
- Large amounts of dilute urine and increased thirst
- When the body can’t regulate how it handles fluids
What is a trauma system and process?
An assembly of health care processes intended to improve survival among injured patients by reducing the time interval between injury and definitive treatment, and by assuring that appropriate resources and personnel are immediately available when a patient presents to a hospital
What are the ATS categories?
- ATS 1
- ATS 2
- ATS 3
- ATS 4
- ATS 5
What is ATS 1?
- Max waiting time: Immediate
- Performance indicator threshold: 100%
What is ATS 2?
- Max waiting time: 10 min
- Performance indicator threshold: 80%
What is ATS 3?
- Max waiting time: 30 min
- Performance indicator threshold: 75%
What is ATS 4?
- Max waiting time: 60 min
- Performance indicator threshold: 70%
What is ATS 5?
- Max waiting time: 120 min
- Performance indicator threshold: 70%
What part of ABCDEFGHI is primary?
ABCDE
What part of ABCDEFGHI is secondary?
FGHI
What do you do for airway?
- Airway with cervical spine immobilisation
- Avoidance of hyperextension of the neck. Cervical spine injury should always be suspected
What are some life threatening airway problems?
- Airway obstruction (complete or partial)
- Inhalation injury
What are signs of airway obstruction?
- Dyspnea, laboured respiration’s
- Decreased or no air movement
- Cyanosis
- Presence of foreign body in airway
- Trauma to face or neck
What are signs of inhalation injury?
- History of enclosed space fire, unconsciousness or exposure to heavy smoke
- Dyspnea
- Wheezing, rhonchi, crackles
- Hoarseness
- Singed facial or nasal hairs
- Carbonaceous sputum
- Burns to face or neck
What do you do for breathing?
Every trauma patient will require supplemental oxygen
What can affect breathing?
Alterations due to fractured ribs, pneumothorax, penetrating injury, allergic reactions, PE, asthma attacks, decreased LOC
What are some life threatening breathing problems?
- Tension pneumothorax, pneumothorax, or hemothorax
- Sucking chest wound
- Failing chest
What to do for circulation?
- Check femoral or carotid pulse
- IV’s are inserted into large veins for aggressive fluid resuscitation
- Direct pressure to obvious bleeding sites
- Blood should be cross-matched
- Blood samples - U&E’s, FBC, Coag, BAL
- Monitoring for arrthymias
What does an effective circulatory system include?
- Heart
- Intact blood vessels
- Adequate blood volume
What are life threatening circulatory problems?
- External hemorrhage
- Obvious bleeding site
- Shock
What are signs of shock?
- Tachycardia
- Weak
- Thready pulses
- Cool pale, clammy skin
- Tachypnea
- Altered mental status
- Delayed capillary refill
- Oliguria or anuria
What to do for disability?
- Brief neurological examination
- AVPU
- GCS
- LOC and pupil size and reactivity to light
What to do for exposure/environmental control?
- All clothing removed
- Limit heat loss/cooling measures
What to do for F?
- Full set of vital signs
- Further investigations
- Facilitate family presence
Also: Cardiac monitor, ECG, CXR, NG tube, laboratory studies
What to do for G?
Give comfort measures:
- Verbal reassurance
- Touch
- Pain management
What to do for H?
- History
- Head to toe assessment
What to do for I?
Inspect the back
What is the history and head to toe assessment?
History:
- Length of time since accident
- Accident type, location and patient position in accident
- Description of accident
- Allergies, Medications, PHx, Last meal, Events leading to accident (AMPLE)
Special cases:
Crime (domestic violence, child abuse, self-harm, attempted murder)
Head to Toe Assessment:
- All areas for cuts, bruises, breaks, internal injuries
What is AMPLE?
- Allergies
- Medications
- PHx
- Last meal
- Events leading to accident
What are mechanisms of injury for chest trauma?
- Blunt
- Penetrating
What are thoracic emergencies for chest trauma?
- Pneumothorax
- Haemothorax
- Tension pneumothorax
- Flail chest
- Cardiac tamponade
What is an open pneumothorax?
Air can enter the pleural space through an opening in the chest wall
What is a flail chest?
Number of ribs break and are not connected to chest cage
What is a tension pneumothorax?
Rapid accumulation of air in the pleural space causing severe inter-pleural pressure, resulting in pressure in the cavity, great pressure on the heart and great vessels, eventually stopping the heart from breathing
What is a hemothorax?
Accumulation of blood within the pleural cavity
What is cardiac tamponade?
Increased pressure on the heart which can prevent it from beating
What are clinical manifestations of pneumothorax?
Small: - Tachycardia - Dyspnoea Large: - Respiratory distress (rapid shallow respirations, dyspnoea, air hunger) - Chest pain - Cough - Minimal or no breath sounds - Hyperresonance - CVS collapse
Why use a chest drain?
- To remove air or fluid
- Allows lung to reexpand
What are three compartments of a chest drain?
- Water seal chamber
- Suction control chamber
- Collection chamber
What should the nurse assess for a chest drain?
- Instruct patient to deep breath and cough
- Change position
- Observe and report unusual respiratory signs
- Observe, S,D,B in tube
- Maintain H20 seal
What should the nurse document for a chest drain?
- Chest tube size and suction pressure
- Character of drainage (amount, colour, consistency)
- Patient tolerance of tube
- Vital signs
How to maintain pressure in chest drain?
- Keep bottles below level of chest
- Maintain suction control
What is S, D, B in a chest drain?
- Swinging (movement of fluid with breathing)
- Draining
- Bubbling (air coming out of tube)
How to manage a patient with chest drain?
- Ongoing assessment (ABCD)
- Pain management
- Education
- Hydration
- Nutrition
- Position/mobilisation
- Multidisciplinary involvement
- Psychological needs
What does the water seal chamber do?
- Acts as a one way valve
- Seals off chest wall preventing air from entering
What does the suction control chamber do?
Controls the amount of suction imposed on the patient
What does the collection chamber do?
Measure drainage from the chest cavity
What is a fracture?
Disruption or break in continuity of the structures of the bone
What can fracture occur from?
- Traumatic injuries
- Secondary to disease process
How is a fracture described?
- Type
- Communication with/without environment
- Location in bone
What are the different types of fractures?
- Simple
- Compound
- Comminuted
- Greenstick
- Oblique
- Spiral
- Impacted
- Transverse
- Compression
- Avulsion
- Depressed
What is a simple fracture?
Fracture straight through bone
What is a compound fracture?
Fracture that communicates with environment
What is a comminuted fracture?
Fracture that has lots of fragments and parts
What is a greenstick fracture?
When a fracture does not break across the whole bone (common in children)
What is an oblique fracture?
Fracture that goes up the bone
What is a spiral fracture?
Fracture that spirals around the bone
What is an impacted fracture?
Fracture from landing on hard surface whereby bone lands on another
What is a transverse fracture?
Fracture that goes straight through bone
What is a compression fracture?
Fracture in the spine
What is an avulsion fracture?
Fracture occurring form pulling of ligament on the bone
What is a depressed fracture?
A depression in the skull
What are clinical manifestations of fractures?
- Oedema and swelling
- Pain and tenderness
- Muscle spasm
- Deformity
- Discolouration of skin from blood in subcutaneous tissue (Ecchymosis)
- Loss of function
- Crepitation (grating or crunching of bony fragments together)
- Shortening of extremity
What is collaborative care for a fracture?
- Anatomical realignment of bone fragments (reduction) (Open or Closed Reduction)
- Immobilisation to maintain realignment (Internal or External fixation)
- Restoration of normal or near normal function
What is open reduction with external fixation?
With external fixation, pins are inserted through the skin into the bone and held in place by an external frame. The usual indications are open fractures such as a tibia fracture which requires dressings or attention to a wound or flap
What is the technique of nailing for tibial fractures?
- Internal fixation
- Open reduction
What is the nursing assessment for fractures?
Subjective data Objective data - General appearance - Integumentary - Cardiovascular - Neurovascular - Musculoskeletal
What is the plan of care of a patient with a fracture?
- Risk for peripheral neurovascular dysfunction
- Acute pain
- Risk for infection
- Risk for impaired skin integrity
- Impaired physical mobility
- Self-care deficit
- Knowledge deficit
- Pre and post operative management
What do to for a neurovascular assessment?
- Looking for nerve or vascular damage
- Causes (original trauma, constrictive cast or dressing, poor positioning and physiologic response to injury)
- Peripheral vascular and neurological assessment
- The 5 P’s
What are the 5 P’s?
- Pain
- Pallor
- Pulse
- Paralysis
- Parasthesia
What are the general principles of traction?
- Maintain the established line of pull
- Prevent friction on the skin
- Maintain countertraction
- Maintain continuous traction unless ordered otherwise
- Maintain correct body alignment
What are complications of fractures?
- Infection
- Compartment syndrome
- Venous thrombosis
- Fat embolism syndrome
