Introduction to Emergency Nursing

7/31/2019 Introduction to Emergency Nursing

1/128

Introduction toEmergency Nursing

Concepts


2/128

Prehospital Care and

Transport The time from injury to definitive care is adeterminant of survival, particularly thosewith major internal hemorrhage.

Careful attention must be given to theairway with cervical spine immobilization,breathing and circulation. (ABCs)


3/128

Continued Full spinal mobilization is being challengedand reexamined:

Asking: Is full spinal mobilization

necessary in all trauma patients? How appropriate is the assessment ofprehospital assessment?

Concerns over the high false positive rate

that occurs with prolonged spinalimmobilization.


4/128

Current Guidelines


5/128

Objectives 1. Explain emergency care as acollaborative, holistic approach thatincludes patient, family and significant

others. Discuss priority emergency measures for

any patient with an emergency situation. 3. Discuss pre-hospital, emergency care

and resuscitation of the trauma patient.


6/128

Objectives Discuss disaster triage concepts andcontrast with traditional triage

concepts.


7/128

Trauma The fourth leading cause of death for ALLages.

Nearly of all traumatic incidents involvethe use of alcohol, drugs or othersubstance abuse.

Is predominantly a disease of the youngand carries potential for permanentdisability.


8/128

Systems Approach to

Trauma An organized approach to traumacare that includes:

Prevention, access, acute hospitalcare, rehabilitation, and research.


9/128

Trimodal Distribution of

Death First peak- seconds to minutes from timeof injury to deathsevere injuries:lacerations of the brain, brainstem, high

spinal cord, heart aorta, large bloodvessels. Second peak- minutes to several hours:

subdural, epidurdal hematomas,hemopneumothorax, ruptured spleen,

lacerated liver, pelvic fractures, otherinjuries associated with major blood loss.


10/128

Third peak-occurs several days toweeks after the initial injury: most

often the result of sepsis andmultiple organ failure. At this stage,outcomes are affected by carepreviously provided.


11/128

Levels of Trauma Care American college of SurgeonsCommittee on Trauma

Levels I-IV, Level ones are the mostsophisticated and care for all aspectsfrom prevention to rehabilitation.


12/128

Trauma Triage Minor trauma: single system injurythat does not pose threat to life or

limb and can be appropriately treatedat a basic emergency facility.

Major trauma: serious multi system

injuries that require immediateintervention to prevent disability.


13/128

Mechanism of Injury

Is vital to the initial assessment andmay raise suspicions about the

patients injury pattern. Blunt vs. penetrating injury


14/128

Blunt Trauma Most often results from vehicularaccidents, but may occur in assaults,

falls from heights, and sports relatedinjuries.

May be caused by accelerating,

decelerating, shearing, crushing, andcompressing forces.


15/128

Blunt Trauma, cont. Coup-contra coup injury Body tissues respond differently to

kinetic energylow density poroustissues and structures, such as lungs,often experience little damage

because of their elasticity.


16/128

Blunt Trauma cont. The heart , spleen and liver are lessresilient often rupturing or fragmenting.

Often, overt external signs are notapparentmaking the mechanism of injurymost important to the practitionerperforming the physical examination.


17/128

Penetrating Trauma Results from the impalement of foreignobjects into the body.

More easily diagnosed because of obvious

injury signs. Stab wounds are usually low velocitythedirect path, the depth and widthdetermine injury.

Women tend to have trajectories in adownward motion, men in an upward force.


18/128

Penetrating Trauma cont. Ballistic trauma may be either low orhigh velocity injuries.

Missiles or bullets that come intocontact with internal structures thatproduce a change in in pathway

release more energy and result inmore injury than a direct pathway.


19/128

Penetrating Trauma,

cont. Injuries sustained from penetratingobjects must be assessed for the

potential for infection from thedebris carried by the penetratingobject.


20/128

Disaster / Mass Casualty

Triage Concepts Most severe injuries in mass traumaevents are fractures, burns,

lacerations, and crush injuries. Most common injuries are eye

injuries, sprains, strains, minor

wounds and ear damage. (CDCWebsite)


21/128

Mass Casualty: Who is at

risk? Anyone in surrounding area. Rescue workers and volunteers.


22/128

Bioterrorism

Agents/Diseases, Threats CDC Website ( see handout)


23/128

Disaster Triage www.bt.cdc.gov/masstrauma/index.asp

www.nyerrn.com/simulators
http://www.bt.cdc.gov/masstrauma/index.asphttp://www.bt.cdc.gov/masstrauma/index.asphttp://www.nyerrn.com/simulatorshttp://www.nyerrn.com/simulatorshttp://www.bt.cdc.gov/masstrauma/index.asphttp://www.bt.cdc.gov/masstrauma/index.asp


24/128

Pre-Hospital Care and

Transport The time from injuryto definitive care is adeterminant of

survival. Careful attention is

given to C-spineimmobilization,

breathing andcirculation(ABCs)


25/128

Current Guidelines on

C-Spine Immobilization Although it has been challenged, C-spine immobilization is still the

protocol for trauma patients untildiagnostically cleared (X-Ray)


26/128

Additional Pre-Hospital

Measures Occlusive dressings to open chestwounds

Needle thoracotomy to relievetension pneumothorax

Endotracheal intubation

Cricothyrtomy


27/128

Caveat!!! Research has indicated INCREASEDmortality with IV fluids BEFORE

hemorrhage control. Transport is not delayed to start IVaccess!


28/128

Transport

How is it decided? Travel time Terrain

Availability of air or groundtransport

Capability of personnel

Weather


29/128

Emergency Care Phase

Preparation Trauma team at receiving hospitalresponds before arrival of patient

Report has been transmitted Preparations are initiated based on

report.


30/128

Initial Patient

Assessment Clinical presentation Physical assessment

History of traumatic event Pre-existing illness


31/128

Primary Survey Most crucial assessment tool in traumacare

1-2 minutes MAX!

Designed to identify life threateninginjuries ACCURATELY

Establish priorities

Provide simultaneous therapeuticinterventions.


32/128

Resuscitation Phase Secondary Survey:

Table18:2 page 647/648

32


33/128

EFGHI = E- Expose the patient F- *Full set of vital signs, *five interventions

(cardiac monitor, pulse oximetry, urinary

catheter, NG if not contraindicated, lab studies) G- giving comfort measurespain control,reassurance to patient and family

H- history/ head to toe assessment I- inspect for hidden injuries-log roll patient to

inspect posterior aspect.


34/128

Sequence of Diagnostic

Procedures Influenced by:

Level of consciousness Stability of patients condition

Mechanism of injury

Identified injuries


35/128

Maintain Airway Patency Essential to trauma management EVERY trauma patient has potential for

airway obstruction

Most common obstruction: Tounge

Other common causes: blood or vomitus,secretions, structural impairment,

depressed sensorium, absent gag reflex


36/128

How to open the airway? Jaw thrust or chin lift!!! These maneuvers do not hyperextend

the neck or compromise the integrityof the C-spine


37/128

Maintaining the airway Simple, simple!!

Nasopharyngeal airway

Oropharyngeal airways


38/128

Definitive Nonsurgical

Airway Endotracheal intubation-Complete controlof the airway

Nasotracheal intubationINDICATED forthe spontaneously breathingpatient..CONTRAINDICATED in thepatient with facial, frontal sinus, basilar

skull or cribriform plate fractures.


39/128

Choice of Airway

management Familiarity of procedure Clinical condition of the patient

Degree of hemodynamic stability

A PATENT AIRWAY IS THE

CORNERSTONE OF SUCCESSFULTRAUMA RESUSCITATION


40/128

A LIFE THREATENING

CONDITION EXISTS Altered mental status (agitation) Cyanosis( nail beds and mucous membranes) Asymmetrical chest expansion

Use of accessory muscles/abdominal muscles Sucking chest wounds Paradoxical movements of the chest wall Tracheal shift

Distended neck veins Diminished or absent breath sounds


41/128

Impaired Gas Exchange Follows airway obstruction as the nestmost crucial problem for the traumapatient.

Reasons: decreased inspired air, retainedsecretions, lung collapse or compression,atelectasis, accumulation of blood in the

thoracic space.


42/128

Decreased Cardiac

Output/Hypovolemia Acute Blood lossMOST commoncause in acute trauma

May be external or internal


43/128

Treatment PASG- anti-shock garment (pneumatic anti-shockgarment)

When inflated, PASG compresses the legs andabdomen, resulting in increased venous return and

SVR(systemic vascular resistance) preventingfurther blood loss into the abdomen and legs. Elevates systemic pressure by shunting a small

amount of blood into central circulation. CAN be a detriment, elevates BP, and in the event

of hemorrhage without DEFINITIVE control canbe fatal.


44/128

Additional Causes of

Decreased Cardiac Output (impaired venous return to the heart) Tension Pneumothorax

Pericardial Tamponade (fromdecreased filling and ventricularejection fraction)


45/128

Table 18-4 Pay attention to Class I through IV*EBL (estimated blood loss)

*Changes in pulse, BP, RR, UOP,mental status.

Note the fluid/blood needed to

replace: 3:1 rule


46/128

Priority Interventions Patent airway Maintaining adequate ventilation

Adequate gas exchange Then: Control hemorrhage, replace

circulating volume, restore tissueperfusion


47/128

Control of External

Hemorrhage Direct Pressure Elevation

Compression of pressure points(arteries, veins)

AVOID tourniquetscan compromise

loss of circulation and loss of limb


48/128

Control of Internal

Hemorrhage Identification and correction ofunderlying problem.


49/128

Fluid Resuscitation Venous Access and Volume infused are key. Two large bore IVs 14-16 gauge. (never

less that 18, that is the smallest to give

blood through rapidly and not havehemolysis) Forearm and anti-cubital veins are

preferred Central lines are more beneficial as

resuscitation MONITORING tools


50/128

Fluid Resuscitation Cont A pulmonary artery catheter may beinserted in the critical care unit tomonitor volume.

RULE: Venous access with largest borecatheter possible. Isotonic fluids are used INITIALLY Ringers Lactate is first choice followed by

Normal Saline


51/128

Fluid Resuscitation Cont Large bore catheters, short tubing, rapidinfuser devise that warms fluids and blood.

An initial bolus of 2 liters of fluid is used

unless there is contraindication 3:1 rule= 3mls of crystalloid for each 1mlof blood loss.

INITIAL response to fluid challenge isurine output..should =50 ml in adult, LOC,heart rate, BP and capillary refill.


52/128

Three Response Patterns Rapid Response- respond quickly to fluid challengeand remains stable at completion of bolus.

Transient Response- responds quickly but declineswhen fluids are slowed

(indicates continued blood loss)**Non Response- fail to hemodynamically respond

to crystalloid and bloodrequire immediatesurgical intervention.

See table 18-5 on page 652


53/128

Decision to give Blood Based on patients response to initialfluid.

** if unresponsive to fluid, typespecific blood is given, IF LIFETHREATENINGmay give O positive.

***Crossmatched, type specific

should be given as soon as possible.


54/128

Auto-transfusion Collection of blood from the patientsintra-thoracic injuries is anti-

coagulated and filtered andadministered to the patient.

SAFE, carries no compatibilityproblems, no risk of transmitteddisease.


55/128

During resuscitative

phase Imperative to locate etiology ofhemorrhage:

Chest and pelvis, extremity X-rays

Abdominal ultrasound

Abdominal CT can be used but in the caseof hemodynamic instability Peritoneal

lavage is the quick, invasive test of choice


56/128

Peritoneal Lavage Insertion of lavage catheter directly intothe abdomen

Aspiration of greater than 10 mls blood

and patient goes directly for surgery. If less than 10 mls of blood, 1 liter ofwarmed NS is infused into peritonealcavity, then drained and sent for cellcounts, amylase, bile, food particles,

bacteria, fecal matter.


57/128

Hypothermia Defined as a core temp of 35 degrees Centigrade Can occur year round More susceptible person: older, using alcohol or sedatives,

severe injury, massive transfusions. In presence of cooler atmospheric temps Submersion in water Rapid infusion of room temp. IV fluids Effects the myocardium and the coagulation system. Can result in bradycardia, atrial and ventricular fibrillation.


58/128

Treatment Warm fluids Warming blankets

Overhead warmers

O i i d


59/128

Ongoing Signs and

Symptoms of Shock Decreased H&H Deterioration of PaO2 and pH

Rising base deficits Diminished UOP (less than

>.5ml/kg/hr)

Increasing Lactate levels


60/128

Unreliability of H&H Can take up to 4 HOURS!! To re-equilibrate, therefore cannot gauge

degree of shock.

O i M b li


61/128

On-going Metabolic

acidosis Result of hypovolemia and hypoxia Indicates inadequate tissue perfusion

Indicates anaerobic metabolismvery inefficient cellular metabolism. Must be interrupted or cellular

dysfunction results in cellular

swelling, rupture and death.

M i Fl id


62/128

Massive Fluid

Resuscitation Greater than 10 units of PRBCs over24 hours or the replacement of the

patients total blood volume in lessthan 24 hours.

It is associated with VERY pooroutcomes.


63/128

Continued.. Purpose is to restore oxygentransport to the tissues, stop the

progression of shock, preventcomplications.


64/128

Potential Complications ofMassive Fluid Resuscitation

Acid base imbalances Electrolyte imbalances

Hypothermia Dilutional coagulopathies Volume overload SIRS (systemic inflammatory response syndrome)

ARDS (acute respiratory distress syndrome) MODS (multi-organ dysfunction syndrome)


65/128

Oxygen Debt Result of metabolic acidosisshift

from aerobic to anaerobicmetabolism resulting in accumulationof lactic acidhencelactic acidosis.

MUST REVERSE to prevent cellular

death


66/128

Electrolyte Imbalances Hypocalcemia Hypomagnesemia Hyperkalemia

May lead to changes in myocardialfunction, laryngeal spasm, neuromuscularand central nervous systemhyperirritability


67/128

Third Spacing

Vessels become more permeable tofluids and molecules, leading a changein movement from the intravascularspace to the interstitial space.

Patients become more hypovolemic

requiring more fluid replacement.


68/128

Dilutional Coagulopathy Dilutional thrombocytopenia Reduced fibrinogen Reduced factor V, FactorVIII and other clotting

components

High levels of citrate in blood products reducecalciumleading to an ineffective clotting cascade(calcium is a necessary co-factor for thisprocess).

Platelet dysfunction can occur secondary to

hypothermia or metabolic acidosis

T t t f Dil ti l


69/128

Treatment of DilutionalCoagulopathy

Improve tissue perfusion

Resolve hypothermia

Administer clotting factors (FFP,cryoprecipitate, platelets)

Monitor labs (H&H, PLT count,

fibrinogen, PT, PTT

Ch i th


70/128

Changes in theCoagulation Cascade

Initially helpfulrelease ofinflammatory mediatorsover time

(can be a fairly short time) can resultin SIRS, ARDS, MODS

ssessmen anM f f


71/128

mManagement of specific

Organ Injuries Chest Injuries

Spinal Cord Injuries

Head Injuries Musculoskeletal Injuries

Abdominal Injuries


72/128

Chest Injuries Tension Pneumothorax- is rapidly fatal Easily resolved with early recognition and

intervention Air enters the pleural cavity without a route of

escape, with each inspiration, additional air entersthe pleural space, INCREASING intrathoracicpressure causing collapse of the lung.

The increased pressure causes pressure on the

heart and great vessels compressing themTOWARD the unaffected side.


73/128


74/128

Tension Pneumo cont Diagnosis based on CLINICAL presentation not

Chest x-ray Treatment is never delayed to confirm by X-ray Immediate decompression with a 14 gauge needle

(thoracostomy)..inserted at the 2nd intercostalspace at the midclavicular line on the INJUREDside.

This converts a tension pneumo to a simplepneumo.

Definitive treatment then requires placement of achest tube.


75/128

Hemothorax Collection of blood in the pleural space

From injuries to the heart, great vessels,or pulmonary parenchyma

Signs and symptoms: decreased breathsounds, dullness to percussion on affectedside, hypotension, respiratory distress.

Treatment: Placement of chest tube.


76/128

Open Pneumothorax Results from penetrating trauma that allows air to

pass IN AND OUT of the pleural space. Patient presents with hypoxia and hemodynamic

instability

Management: Three sided occlusivedressingfourth side is LEFT OPEN to allow forexhalation of air from the pleural cavity.

IF the dressing is occluded on all four sides thepatient may develop a tension pneumothorax.

Treatment: Chest tube placement


77/128

Cardiac Tamponade Life threatening condition caused by RAPID accumulation of

fluid (usually blood) in the pericardial sac.

As intra-pericardial pressure increases, cardiac output isimpaired because of decreased venous return.

Classic signs are: BECKs Triad: muffled or distant heartsounds, hypotension, elevated venous pressureand may notpresent until the patient is hypovolemic and hypotensive.

Pulsus paradoxus= a decrease in systolic blood pressureduring spontaneous respiration.


78/128

Cardiac Tamponade Causes: penetrating trauma to chest, blunt

trauma to chest. Diagnosed with FAST ( focused abdominal

sonography or pericardiocentesisdontwith 16 or 18 gauge cath over needle and35 ml syringe and 3 way stopcock)

Aspirated pericardial blood usually will not

clot unless the heart has been penetrated.


79/128


80/128

Pulmonary Contusion Results from blunt or penetrating

trauma to the chest One of the most common causes of

death after trauma Predisposes the patient to pneumonia

and ARDS.

Can be difficult to detect.

P l C t i t


81/128

Pulmonary Contusion cont..

May not be seen on initial X-ray Infiltrates and hypoxemia may not occur

for hours of days.

Clinical presentation includes: chestabrasions, ecchymosis, bloody secretions,PaO2 of 60mmHG or less on room air.

Often associated with flail chest and rib

fractures


82/128


83/128

Rib Fractures Most common injury after chest trauma Rib fractures usually dxd by xray, but can

be clinically dxd

HIGH IMPACT force is needed tofracture the 1st and 2nd ribs. Clinically lookfor major vessel injury..

Injury to the liver spleen and kidneysshould be considered with fracture of ribs10-12


84/128

Rib Fractures cont Treatment: Depends on ribs Fxd and

age of patient. Elderly with multiplerib fx may require hospitalization.

Patient Teaching is very important:

DO NOT restrict chest movement, pain

control, ambulation.


85/128

Flail Chest Usually caused by blunt force trauma, EX: Chest

hits steering wheel. Three or more adjacent ribs are fractured. Flail section floats freely resulting in paradoxical

chest movement. Flail section contracts INWARD with inspirationand expands OUTWARD with expiration.

Treatment: Intubation/mechanical ventilation,frequent pulmonary care, aggressive pain

management.


86/128

Aortic Disruption Produced by blunt trauma to the chest Ex: rapid deceleration from head-on MVA,

ejection, or falls.

Four common sites of dissection: the leftsubclavian artery at the level of theligamentum arteriosum, the ascendingaorta, the lower thoracic aorta above thediaphragm, and avulsion of the innominate

artery at the aortic arch.


87/128

Aortic disruption cont.. Signs: weak femoral pulses, dysphagia,

dyspnea,hoarsness, pain. Chest x-ray shows wide

mediastinum(greater or equal to 8mm),tracheal deviation to the right, depressedmainstem bronchus, first and second ribfractures, left hemothorax.

CONFIRMATION is done with aortogram

Treatment is SURGICAL


88/128

Spinal Cord Injury Mechanism of injury can be:

hyperflexion, hyperextension, axialloading, rotation, penetrating trauma

Initially: ABCs, immobilization

Triage to appropriate facility

Complete sensory &motor neuro exam


89/128

Spinal Cord Injury Lateral C-Spine films, possible Spinal

CT to rule out occult fracture. Dislocations of the spine are reduced

ASAP Postural reduction with tongs, halo

traction or surgical fusion.

IV methylprednisolone within 8 hours


90/128

Spinal Cord Injury Spinal Shock= loss of sympathetic

output=Neurogenic shock results arebradycardia, hypotension.

Need vasopressors to compensatefor loss of sympathetic innervationand resultant vasodilatation.


91/128

Spinal Cord Injury cont. Potential Complications: GI dysfunction,

autonomic dysreflexia, DVT, orthostatichypotension, loss of bowel and bladder

function, immobility, spasticity, andcontractures.

THINK EARLY PREVENTION ANDINTERVENTION!!!!


92/128

Head Injury Can be caused by blunt or

penetrating trauma.

Lacerations to the scalp produceprofuse bleeding.

Fractures of the skull may have

underlying brain injury

Heady Injury cont


93/128

Heady Injury cont

Basilar skull fractures are located atthe base of the cranium andpotentially involve 5 bones that formthe base of the skull.

Are diagnosed based on the presenceof CSF in the nose (rhinorrhea) orears (otorrhea)


94/128

Heady Injury cont.. Basilar Skull Fracture cont Ecchymosis over the mastoid

(Battles sign) Hemotympanium (blood in the middle

ear) Raccoon eyes or periorbital

eccymoses =cribiform plate fracture


95/128

Head Injury cont. Potential complications of Basilar

Skull Fractures: Infection and cranialnerve injury.


96/128

Secondary Head Injury Refers to the systemic (hypotension,

hypoxia, anemia, hypocapnia,hyperthermia) or intracranial (

edema, intracranial hypertension,seizures, vasospasm) changes thatresult in alteration in the nervoussystem..page 657..read this!!! Veryimportant.


97/128

Secondary Head Injury Prehospital MOST important Supplemental oxygen, often intubation Aggressive and careful volume replacement

ICP monitoring/ Goal is 20mm Hg Cerebral Perfusion Pressure=MAP(mean

arterial pressure) Minus Mean ICP andkeep at 70mm Hg to decrease neurologicaldisability.

Secondary Head Injury


98/128

Secondary Head Injurycont..

Osmotic and loop diuretics, CSFdrainage, hyperventilation (results invasoconstriction of cerebral vesselsallowing more space for swelling braintissue), paralysis WITH sedation,pentobarbital induced coma is final

intervention when all else fails.

Nursing Care for


99/128

Nursing Care forTraumatic Head Injury

Airway, adequate ventilation and gas exchange,clearance of pulmonary secretions, proper headalignment, close neurological function monitoring.

Pulmonary complications are common, aggressive

pulmonary hygiene HOB at 30 degrees Assess for intracranial hemodynamics(ICP and

perfusion pressure) and patient tolerance


100/128

Musculoskeletal Injuries See Types of Fractures Table 18-7 on

page 658 Extremity Assessment= the 5 Ps

Pallor pain, pulses, parethesia, paralysis(describes the neurovascular status of theinjured extremity.

When possible the injured extremity if

compared with the non-injured extremity

Musculoskeletal Injury


101/128

Musculoskeletal Injurycont..

Fracture wounds should be debridedand the fracture reduced within 18hours to prevent infection andnonunion.

If hemodynamically unstable, skeletaltraction to realign the extremity maybe used .


102/128

MS Cont.. Unstable Pelvis fractures can be life

threatening secondary to potentialfor severe hemorrhage,exsanguination, damage togenitourinary system and sepsis.


103/128


104/128


105/128

Cont.Can result in life threatening hyperkaemia.

Myoglobin excreted through the urine,combined with hypovolemia, produces ARF

and ATN if not aggressively treated.Treatment= Aggressive saline replacement,

alkalinization of urine, osmotic diuresis.


106/128

Compartment Syndrome Places the patient at risk for limb

loss. More common in the legs and

forearms but can occur other places. The closed muscle compartment

contains neurovascular bundles

tightly covered by fascia.


107/128

Cont An increase in pressure within that compartment produces

the syndrome. Internal sources= hemorrhages, edema, open or closed

fractures, crush injuries External sources=PASGs, casts, skeletal traction, air

splints. The pain is described as throbbing appearingDISPROPORTIONATE TO THE INJURY. Increases withmuscle stretching. The affected area is firm to touch.Paresthesia distal to the compartment, pulselessness, andparalysis are LATE signs.

Treatment s immediate surgical fasciotomy.


108/128

Fat EmbolismUsually associated with long bone, pelvis, and

multiple fractures.Usually develops within 24 to 48 hours after injury.Hallmark clinical signs: low grade fever, new onset

tachycardia, dyspnea, increased resp rate andeffort, abnormal ABGs, thrombocytopenia andpetechiae.

Development of lipuria (fat in the urine) indicates

severe fat embolism syndrome.


109/128

Fat embolism cont.. Prevention is the best treatment. Treatment is directed at preserving

pulmonary function and maintenance

of cardiovascular function. Careful attention to EKG changes. See Box 18-2 on page 660

IMPORTANT!!!


110/128

Abdominal Injuries The Classic sign is PAIN. But may be obscured by AMS, drug

or alcohol intoxication, Spinal cord

Injury with impaired sensation The liver is the most commonly

injured organ from blunt or

penetrating trauma


111/128

Cont Liver injuries are graded I through VI.

Splenic injury most commonly occurs fromblunt trauma but can be caused by

penetrating trauma. Presentation: LUQ tenderness, peritoneal

irritation, referred pain to the left

shoulder (Kerrs sign)


112/128

Cont Graded I to V. Diagnosed with FAST, Abd. CT or

peritoneal lavage. Patients more at risk for

pneumococcal disease and shouldhave immunization with in first few

post op days after splenectomy


113/128


114/128

Cont Diagnostic testing= IVP, CT scan,

angiography, cystoscopy.


115/128

Critical Care Phase ABCc Post OP standard VS= q5min x3,

q15minx3, q30min X2, q1 hour

forward. Shivering is to be avoided=increase in

metabolic rate and increase in oxygen

demands.


116/128

Cont.. Physical Assessment =FULL BODY Level of Consciousness Invasive Line assessment Pain Assessment Ongoing Assessments revolve around the patients

diagnosis and/or surgical procedure. Anticipation and prevention of untoward

complications.

READ PAGES 661-668 CAREFULLY


117/128

Damage Control Surgery = Staged laporaotmy

Trying to avoid hypothermia,

acidosis, coagulopathy Shown to improve outcomes ofcritically ill patients with sever intra-abdominal injuries.


118/128

ARDS Chapter 13 fully covers

May occur 2 to 48 hours after

traumatic injury, however sometimesup to 5 days or more beforeRECOGNIZABLE clinical signs.

There are direct and indirect causes.


119/128

Cont Clinical Manifestations: hypoxemia, rising

CO2 levels, tachypnea, dyspnea, pulmonaryhypertension, decreased lung compliance,new diffuse bilateral lung infiltrates.

Treatment: correction of underlyingcause---maximize O2 to the tissues,decrease pulmonary congestion, preventfurther lung damage, supportcardiovascular system.


120/128

DVT Increased incidence of DVT= patients with

obesity, age, malignancy, pregnancy, heartfailure, SCI, recent surgery, extremity

fractures, pelvic fractures, history ofDVT, prolonged immobilization, resp.failure, # of transfusions,central venouscatheterization, vascular injury.


121/128


122/128

Cont. Pulmonary embolism is an often fatal

complication of DVT Clinical manifestations of PE= sudden

onset dyspnea, sudden onset chest pain,rapid shallow resps, SOB, Auscultation ofbronchial breath sounds, pale, dusky orcyanotic skin, Anxiety, decreased LOC,signs of hypovolemic shock (decreased BP,narrowing pulse pressure, tachycardia)


123/128

Infection Pulmonary

Catheter Sepsis

Sinusitis


124/128

Acute Renal Failure From systemic effects of trauma

OR from actual injury to the renalsystem

There is a reduction in renal bloodflow in the trauma patient associatedwith shock or low cardiac output.


125/128

Altered NutritionNutritional demands are increased in the

trauma patient by alterations inmetabolism

Metabolism is increased by activation of thesympathetic response.

Ebb (1st 24-48 hours after injury) and FlowPhase (peaks 5-10 days after injury)


126/128


127/128

Cont.. Anthropometric measurements

Nutrition replacement in 24 to 48hours.

Route based on individual status ofpatientcan be enteral, or parenteral

Multiple Organ


128/128

Dysfunction Syndrome Immune, inflammatory, and hormonal responses

are underlying causes. Defined as presence of altered organ function in

the acutely ill.

There is incomplete understanding of itspathophysiology.

Management focuses on prevention, earlyidentification, elimination of sources of infection,maint. Of tissue oxygenation and nutritionalsupport.

Date post:	04-Apr-2018
Category:	Documents
Upload:	kristine-joy-revano
View:	236 times
Download:	0 times

Introduction to Emergency Nursing

Documents