Emergency

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ARCHDIOCESE OF TUGUEGARAO LYCEUM OF APARRI APARRI, CAGAYAN

COLLEGE OF HEALTH

Submitted to: Mrs. Maurene T. Conde, RN, MSN, RPT (Clinical Instructor) Submitted by: CORTIÑAS, James Laurence DELA ROSA, Jhon Roy GUIANG, Nieva Joy MANUEL, April Grace TABULOG, Nadyne (BSN IV- GROUP C)

I. INTRODUCTION II. APPENDICITIS III. BURNS IV. EPISTAXIS V. FRACTURES VI. HEMORRHAGE VII. TRAUMA AND INJURIES VIII. WOUNDS

INTRODUCTION
EMERGENCY NURSING Care given to patients with urgent and critical needs Also for non-urgent cases or whatever the patient or family considers an emergency Serious life-threatening cardiac conditions (Myocardial infarction, Acute heart failure, Pulmonary edema Cardiac dysrhythmias) The Emergency Nurse Applies the ADPIE on the human responses of individuals in all age groups whose care is made difficult by the limited access to past medical history and the episodic nature of their health care Triage and prioritization. Emergency operations preparedness. Stabilization and resuscitation. Crisis intervention for unique patient populations, such as sexual assault survivors. Provision of care in uncontrolled and unpredictable environments. Consistency as much as possible across the continuum of care The Nursing Process Provides logical framework for problem solving in this environment Nursing assessment must be continuous, and nursing diagnoses change with the patient’s condition Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones Both independent and interdependent nursing interventions are required Emergency Nursing in Disasters The emergency nurse must expand his or her knowledge base to encompass recognizing & treating patients exposed to biologic and other terror weapons The emergency nurse must anticipate nursing care in the event of a mass casualty incident.

Documentation of Consent Consent to examine and treat the patient is part of the ER record. The patient must consent to invasive procedures unless he or she is unconscious or in critical condition and unable to make decisions. If the patient is unconscious and brought to the ER without family or friends, this fact should be documented After treatment, a notation is made on the record about the patient’s condition on discharge or transfer and about instructions given to the patient and family for follow-up care. Exposure to Health Risks All emergency health care providers should adhere strictly to standard precautions for minimizing exposure. Early identification and adherence to transmission-based precautions for patients who are potentially infectious is crucial. ER nurses are usually fitted with a personal high-efficiency particulate air (HEPA)-filter mask apparatus to use when treating patients with airborne diseases. Providing Holistic Care Sudden illness or trauma is a stress to physiologic and psychosocial homeostasis that requires physiologic & psychological healing. When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis beginning with anxiety, and progress through denial, remorse & guilt, anger, grief & reconciliation. The initial goal for the patient and family is anxiety reduction, a prerequisite to recovering the ability to cope. Assessment of the patient and family’s psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning. Nursing Diagnoses Possible nursing diagnoses include: Anxiety related to uncertain potential outcomes of the illness or trauma and ineffective individual coping related to acute situational crises Possible diagnoses for the family include: Anticipatory grieving and alterations in family processes related to acute situational crises Patient-Focused Interventions Those caring for the patient should act confidently and competently to relieve anxiety.

Reacting and responding to the patient in a warm manner promotes a sense of security. Explanations should be given on a level that the patient can understand, because an informed patient is better able to cope positively with stress. Human contact & reassuring words reduce the panic of the severely injured person and aid in dispelling the fear of the unknown. The unconscious patient should be treated as if conscious (i.e. touching, calling by name, explaining procedures) As the patient regains consciousness, the nurse should orient the patient by stating his or her name, the date, and the location. Family-Focused Interventions The family is kept informed about where the patient is, how he or she is doing, and the care that is being given. Allowing the family to stay with the patient, when possible, also helps allay their anxieties. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing. Helping Them Cope With Sudden Death Take the family to a private place. Talk to the family together, so they can mourn together. Reassure the family that everything possible was done; inform them of the treatment rendered. Show the family that you care by touching, offering coffee, and offering the services of the chaplain. Helping Them Cope With Sudden Death Encourage family members to support each other & to express emotions freely. Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. Encourage the family to view the body if they wish; this action helps integrate the loss. Spend time with the family, listening to them and identifying any needs that they may have. Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss. Avoid volunteering unnecessary information. Discharge Planning Instructions for continuing care are given to the patient and the family or significant others.

All instructions should be given not only verbally but also in writing, so that the patient can refer to them later. Instructions should include information about prescribed medications, treatments, diet, activity, and contact info as well as follow-up appointments. Principles of Emergency Room Care Triage: comes from the French word trier, which means "to sort;” A method to quickly evaluate and categorize the patients requiring the most emergent medical attention. ER Triage Emergent (immediate): patients have the highest priority; must be seen immediately Urgent (delayed or minor): patients have serious health problems, but not immediately life-threatening ones; seen w/in 1 hour Non-urgent (minor or support): patients have episodic illnesses addressed within 24 hours. Determination of Priority in ER Triage: Classified based on principle to benefit the largest number of people Determination of Priority in Field Triage Critical clients are given lowest priority Victims who require minimal care and can be of help to others are treated first. 1. Red – Emergent (immediate) 2. Yellow – Immediate (delayed) 3. Green – Urgent (minor) 4. Blue – Fast track or psychological support needed 5. Black – Patient is dead or progressing rapidly towards death Triage Tags should be used on all calls involving 3 or more patients. The general placement location should be on one of the patient’s arms. When a triage tag has been utilized, remember to document the tag number in the history portion of your run report. “E”– Cart Located in designated areas where medical emergencies and resuscitation is needed Purpose: to maximize the efficiency in locating medications/supplies needed for emergency situations. Drawer 5: Contains respiratory supplies such as oxygen tubing, a flow meter, a face shield, and a bag-valve-mask device for delivering artificial respirations

Drawer 4: Contains suction supplies & gloves Drawer 3: Contains intravenous fluids Drawer 2: Contains equipment for establishing IV access, tubes for laboratory tests, and syringes to flush medication lines. Drawer 1: Contains medications needed during a code such as epinephrine, atropine, lidocaine, CaCl 2 and NaHCO 3 The back of the cart usually houses the cardiac board. Assessment and Intervention in the ER The Primary Survey: Focuses on stabilizing life-threatening conditions; employs the ABCD Method The ABCD Method Airway - Establish the airway Breathing - Provide adequate ventilation Circulation - Evaluate & restore cardiac output by controlling hemorrhage, preventing & treating shock, and maintaining or restoring effective circulation Disability - Determine neurologic disability by assessing neuro function using the Glasgow Coma Scale Eye opening response Spontaneous To voice To pain None Oriented Confused Inappropriate words Incomprehensible sounds None Obeys command Localizes pain Withdraws Flexion Extension 4 3 2 1 5 4 3 2 1 6 5 4 3 2

Verbal response

Motor response

None

1

Assess and Intervene: The Secondary Survey includes: A complete health history & head-to-toe assessment Diagnostic & laboratory testing Application of monitoring devices Splinting of suspected fractures Cleaning & dressing of wounds Performance of other necessary interventions based on the patient’s condition.

APPENDICITIS
The appendix is a small fingerlike appendage about 10 cm (4 in) long, attached to the cecum just below the ileocecal valve. No definite functions can be assigned to it in humans. The appendix fills with food and empties as regularly as does the cecum, of which it is small, so that it is prone to become obstructed and is particularly vulnerable to infection (appendicitis). Appendicitis is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity. About 7% of the population will have appendicitis at some time in their lives, males are affected more than females, and teenagers more than adults. It occurs most frequently between the age of 10 and 30. The disease is more prevalent in countries in which people consume a diet low in fiber and high in refined carbohydrates. The lower quadrant pain is usually accompanied by a low-grade fever, nausea, and often vomiting. Loss of appetite is common. In up to 50% of presenting cases, local tenderness is elicited at Mc Burney’s point applied located at halfway between the umbilicus and the anterior spine of the Ilium. Rebound tenderness (ex. Production or intensification of pain when pressure is released) may be present. The extent of tenderness and muscle spasm and the existence of the constipation or diarrhea depend not so much on the severity of the appendiceal infection as on the location of the appendix.

If the appendix curls around behind the cecum, pain and tenderness may be felt in the lumbar region. Rovsing’s sign maybe elicited by palpating the left lower quadrant. If the appendix has ruptured, the pain become more diffuse, abdominal distention develops as a result of paralytic ileus, and the patient condition become worsens.

Constipation can also occur with an acute process such as appendicitis. Laxative administered in the instance may result in perforation of the in flared appendix. In general a laxative should never be given when a person’s has fever, nausea or pain. Nursing Interventions 1. Monitor frequently for signs and symptoms of worsening condition, indicating perforation, abscess, or peritonitis (increasing severity of pain, tenderness, rigidity, distention, absent bowel sounds, fever, malaise, and tachycardia). 2. Notify health care provider immediately if pain suddenly ceases, this indicates perforation, which is a medical emergency. 3. Assist patient to position of comfort such as semi-fowlers with knees are flexed. 4. Restrict activity that may aggravate pain, such as coughing and ambulation. 5. Apply ice bag to abdomen for comfort. 6. Avoid indiscriminate palpation of the abdomen to avoid increasing the patients discomfort. 7. Promptly prepare patient for surgery once diagnosis is established. 8. Explain signs and symptoms of postoperative complications to report-elevated temperature, nausea and vomiting, or abdominal distention; these may indicate infection. 9. Instruct patient on turning, coughing, or deep breathing, use of incentive spirometer, and ambulation. Discuss purpose and continued importance of these maneuvers during recovery period. 10. Teach incisional care and avoidance of heavy lifting or driving until advised by the surgeon. 11. Advise avoidance of enemas or harsh laxatives; increased fluids and stool softeners may be used for postoperative constipation. Discharge Planning M Antibiotics for infection Analgesic agent (morphine) can be given for pain after the surgery

E

Within 12 hrs of surgery you may get up and move around. You can usually return to normal activities in 2-3 weeks after laparoscopic surgery. Pretreatment of foods with lactase preparations (e.g. lactacid drops) before ingestion can reduce symptoms. Ingestion of lactase enzyme tablets with the first bite of food can reduce symptoms.

T

H To care wound perform dressing changes and irrigations as prescribe avoid taking laxative or applying heat to abdomen when abdominal pain of unknown cause is experienced. Reinforce need for follow-up appointment with the surgeon Call your physician for increased pain at the incision site O Document bowel sounds and the passing of flatus or bowel movements (these are signs of the return of peristalsis) Watch for surgical complications such as continuing pain or fever, which indicate an abscess or wound dehiscence Stitches removed between fifth and seventh day (usually in physicians office) Liquid or soft diet until the infection subsides Soft diet is low in fiber and easily breaks down in the gastrointestinal tract

D

BURNS
Alteration in skin and underlying tissues as a result of: Too much exposure to sun and UV Direct contact with heat and burning object Hot water and liquids Chemicals Factors considered when assessing the severity of a burn: depth of the burn and size the part of the body burned the age of the client, and the client's previous and past medical history “Rule of Nines” Chart

Assessment of Damage Lund & Browder Method: Assigns percentage of BSA for various anatomic parts; more precise method of estimating the extent of burn Palm Method: The size of the palm (approximately 1% of BSA) can be used to assess the extent of burn injury in patients with scattered burn. Factors considered when assessing the severity of a burn: depth of the burn and size the part of the body burned the age of the client, and the client's previous and past medical history Depth of Burns: Superficial burn The epidermal layer is damaged and hurt Wound is quite painful. Skin is characteristically red and dry. Redness generally subsides within 24 to 48 hours Scarring does not occur Depth of Burns: Deep partial thickness Burns affect the dermal layer of the skin. The injured skin is red or mottled, possibly weepy with vesicles or blisters and considerable swelling. When healing is complete, the skin is usually somewhat discolored Tightening and contracture may develop. Depth of Burns: Full thickness burn the injury extends all the way through the subcutaneous tissue sometimes to muscle and bone no regeneration can occur skin is leathery and charred. The surface is dry and edema is present.

Part of the Body Burned Special attention to the hands, head, neck, chest, ears, face, perineum and feet Prevention of contractures in these areas is crucial to good healing. Any time there is soot around the nose or mouth, burned nasal hairs, stridor, hoarseness, decreased breath sounds, upper airway damage should be suspected.

Management of Burn Injury The phases in the management of a burn injury are the following:


Emergent phase

This phase begins immediately at the time of injury and ends with the restoration of capillary permeability. The main goal of this phase is to prevent hypovolemic shock and preserve vital organ functioning. Methods used during this time are prehospital care and emergency room care.


Resuscitative Phase

The management involving resuscitation begins when the fluid replacement are initiated or started and ends when the capillary integrity returns to the near normal levels and when the large fluid shifts have decreased. The amount of fluid administered to the patient is based on the client’s weight and extent of injury. Usually, fluid replacement formulas are calculated from the time of injury not on the arrival on the hospital. The main goal of the resuscitative phase is to prevent shock through the initiation of fluids to maintain adequate circulating blood volume and maintain vital organ perfusion.


Acute Phase

When the client is hemodynamically stable, has restored capillary permeability and has been showing signs of dieresis, acute phase took place. During this time, the emphasis is palced on restoration of the patient’s capillary permeability and the phase continues until the wound is totally closed. Main goal of the acute phase is focused on prevention of infection, wound care, optimum nutrition and physical therapy.


Rehabilitative Phase

Rehabilitative phase is the final phase of managing a burn injury. Most frequently, it overlaps the acute phase and it goes on after hospitalization. Main goals during this phase are helping the client gain independence and achieve maximal function.

Epistaxis (Nosebleed)
Epistaxis, also known as nosebleed, is a hemorrhage from the nose caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Usually, the site is the anterior septum, where the three major blood vessels enter the nasal cavity: (1) the anterior ethmoidal artery on the forward part of the roof, (2) the sphenopalatine artery in the posterosuperior region and (3) the internal maxillary branches (the plexus of veins located at the back of the lateral wall under the inferior turbinate); rarely does epistaxis originate in the densely vascular tissue over the turbinates. Causes of epistaxis may include infection, trauma, nose picking, cardiovascular diseases, vigorous nose blowing, nasal tumors, low humidity, inhalation of illicit drugs, blood dyscrasias, a foreign body in the nose, and deviated nasal septum. Management Management of epistaxis usually depends on the location of the bleeding site.


     

Application of direct pressure: the patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 to 10 minutes continuously Monitor the vital signs closely Assist the patient in the control of bleeding Provide tissues or towels and an emesis basin to facilitate expectoration of any excess blood Assure the patient that bleeding can be controlled Teach ways to prevent epistaxis (straining, high altitudes avoiding forceful nose blowing, and nasal trauma) Instruct patient to apply direct pressure to the nose with the thumb and index finger for 15 minutes in the case of recurrence; if cannot be stopped, additional medical attention should be sought, call the doctor on duty and refer the situation

In anterior nosebleeds
 

Apply silver nitrate applicator or Gelfoam as ordered Electrocautery can be indicated.



Topical vasoconstriction (adrenaline, cocaine and phenylephrine)

In posterior nosebleeds


Cotton pledgets soaked in a vasoconstricting solution may be inserted into the nose to reduce blood flow and improve the examiner’s view of the bleeding site o Cotton tampon may be used to stop the bleeding o Suction may be used to remove excess blood and clots from the field of inspection

When origin of bleeding is not identified
  

A topical anesthetic spray and decongestant agent may be used prior to inserting a gauze packing, or a balloon inflated catheter may be used Nose may be packed with gauze covered with petrolatum jelly or antibiotic ointment for 48 hours or up to 5 or 6 days if necessary Antibiotics for risks of iatrogenic sinusitis and toxic shock syndrome are given as ordered.

There are two types: anterior (the most common), and posterior (less common, more likely to require medical attention). Sometimes in more severe cases, the blood can come up the nasolacrimal duct and out from the eye. Fresh blood and clotted blood can also flow down into the stomach and cause nausea and vomiting. It is rarely fatal, accounting for only 4 of the 2.4 million deaths in the U.S. in 1999 Seek immediate medical attention if: 1. 2. 3. 4. 5. 6. 7. 8. Blood flows from both nostrils and doesn’t stop for 20 minutes The nosebleed has occurred after a head injury The bleeding lasts for longer than half an hour despite applications of cold and pressure The bleeding resulted from a severe blow that also caused dizziness and nausea The nose looks crooked or displaced in any way The individual is elderly The individual has high blood pressure The individual is using blood-thinning drugs

First Aid for Nosebleeds While you wait for medical attention: 1. Sit down and lean forward. Have the individual lower her head and leave her mouth open. Try to stop the bleeding by pinching the soft part of the nostril closed by pressing with the thumb and index finger, below the cartilage, for at least ten minutes. Release the pressure slowly. 2. Loosen any clothing around the neck. 3. Apply a cold water compress to the base of the skull and top of the nose to help constrict blood vessels. After ten minutes gradually release the nostrils, but still sit quietly and avoid blowing the nose for at least three hours. Most nosebleeds don’t last longer than 15 minutes. Take it easy and rest for at least half an hour afterward. Avoid vigorous exercise for a day or two so that the nose doesn’t start bleeding again. Avoid tobacco smoke since it can dry out the nasal passages and make them prone to bleed. If you frequently get nosebleeds, check with your doctor. You may also consider taking a supplement of vitamin C with bioflavonoids.

FRACTURES
When a client is being examined for a fracture, the body part is handled gently & as little as possible. Clothing is cut off to visualize the body & assessment is done for pain over or near a bone, swelling, & circulatory disturbance, ecchymosis, tenderness & crepitation. Management of Fractures ABCD Method & evaluation for abdominal injuries is performed BEFORE an extremity is treated unless a pulseless extremity is seen. If the extremity is pulseless, repositioning of the extremity to proper alignment is required. Pulseless Extremities

If the pulseless extremity involves a fractured hip or femur, a Hare traction may be applied to assist w/ alignment. If repositioning is ineffective in restoring the pulse, a rapid total body assessment is completed, followed by a transfer to the operating room for arteriography and possible arterial repair. Management of Fractures After the 1° survey, the 2° survey is done using a head-to-toe approach. Observe for lacerations, swelling & deformities including angulation, shortening, rotation, & symmetry. Palpate all peripheral pulses. Assess extremity for coolness, blanching, decreased sensation & motor function. Splinting of Extremities Before moving the patient, a splint is applied to immobilize the joint above & below the fracture Relieves pain, restores circulation, prevents further tissue injury Procedure: 1. One hand is placed distal to the fracture & some traction is applied while the other hand is placed beneath the fracture for support. 2. The splint should extend beyond the joints adjacent to the fracture. 3. Upper extremities must be splinted in a functional position. 4. If a fracture is open, moist, sterile dressing is applied. 5. Check the vascular status by assessing color, temperature, pulse, and blanching of the nail bed. 6. If there is neurovascular compromise, the splint is removed and reapplied. Investigate complaints of pain or pressure.

Acetabular Fractures
   

Usually caused by force applied to the femur which is translated to the acetabulum. In young adults, acetabular fractures are due to high energy injuries, primarily motor vehicle accidents. The majority of patients are evaluated for and have associated injuries that require initial evaluation of the multiple trauma patient. There are also minority of patients, which are elderly, and suffer relatively minor trauma causing acetabular fractures.

Pathophysiology
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Fractures maybe caused by direct trauma to the bone. Disruption of blood vessel in cortex periostrum. Soft tissue bleeding from damage end of bone. Hematoma formation Bone tissue death Necrosis Stimulation of inflammatory response vasodilation Exudation of plasma Increase leukocytes and infiltration of wbc

Signs and Symptoms
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Crepitus Deformity Pain Tenderness at the site Swelling Loss of function Discoloration Dislocation of bone Bleeding from an open wound with protrusion of bone ends. Fever Dysfunction Hematoma on the site Abnormal or decrease sensation of the affected extremity Change in size Moderate or severe edema joint point Dyspnea Rapid weal pulse Mental confusion apprehension due to hypoxia Mental aberration before signs of infection



Metabolic disturbance

Assessment 1. 2. 3. 4. 5. 6. 7. 8. 9. Remove clothing so that entire extremity may be visualized. Cut clothing along seems when necessary. Assess for neurovascular changes distal to fracture. Assess for change in length, shape or alignment. Support joint extremity at all times; including joints above and below the suspected injury. If fracture is impacted the patient may be able to bear weight and walk for a short period of time after the initial injury. History of simple fall. Decrease range of motion. Affected limb shortened abducted and externally rotated. Greater thochanter may be displaced into the buttock.

Complications 1. Pulmonary embolism 2. Fat embolism 3. Gas gangrene 4. Tetanus 5. Loss of bone substance 6. Soft tissue interposed between bone ends. 7. Infection 8. Loss of circulation 9. Interrupted or improper immobilization 10. Inadequate fixation 11. Necrosis due to fixation devices 12. Metabolic disturbance Nursing Diagnoses 1. Altered health maintenance 2. Risk for infection

3. Risk for injury 4. Impaired skin integrity 5. Impaired tissue integrity 6. Self-care deficit 7. Impaired physical mobility 8. Activity intolerance 9. Anxiety 10. Pain 11. Fear 12. Disturbed body image Nursing Interventions 1. 2. 3. 4. 5. 6. 7. 8. 9. Assist the patient or significant others to identify self-care deficits. Develop plan with patient for self-care, adapting, and organizing care as necessary. Assist the patient to maintain and manage usual health practices during period of wellness or when progressive illness. Provide for communication and coordination between the healthcare facility team. Monitor lesion or wound daily for changes. Promote good nutrition with increase protein intake to facilitate healing. Encourage adequate period of rest and sleep. Provide devices that aid in comfort or healing. Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts and changes. 10. Identify required changes in lifestyle. 11. Encourage verbalization of feeling about pain. 12. Provide comfort measure like backrubbing. 13. Encourage patient to do deep breathing exercises during pain.

Fracture Of The Hips
Etiology And Pathophysiology 1. Fractures of the head or neck of the femur (intracapsular fracture) or trochanteric area (extracapsular fracture).

2. Incidence highest in elderly females because of osteoporosis and degenerative joint disease. Signs and Symptoms
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Pain Changes in sensation Affected leg appears shorter External rotation of the affected limb

Diagnostic Procedure


X-ray examination reveals lack of continuity of the bone.

Therapeutic Interventions 1. Buck’s extension or Russell traction as a temporary measure to relieve the pain of muscle spasm or if surgery is contraindicated. 2. Closed reduction with a hip spica cast in fractures of the intertrochanteric region. 3. Open reduction and internal fixation. o Austism Moore prosthesis o Thompson prosthesis o Smith-Petersen nail o Jewert nail o Zickel nail 4. Total hip replacement when joint degeneration will not permit an internal fixation. Assessment 1. 2. 3. 4. 5. Shortening and external rotation of leg. Degree and nature of pain. Baseline vital signs Neurovascular status of involved extremity. Other health problems that may affect recovery.

Nursing Diagnosis
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Constipation Fear Risk for injury Pain Impaired physical mobility Altered role performance Self-care deficit Situation low self-esteem Risk for impaired skin integrity

Nursing Interventions 1. 2. 3. 4. 5. 6. 7. 8. Assess for complications of immobility. Encourage the use of a trapeze or side rails to facilitate movement. Use the fracture pan for elimination. Inspect dressing and linen for bleeding. Use a trochanter roll to prevent external rotation of legs. Do not turn client on the affected side unless specifically ordered. Place pillow between legs when turning on the unaffected side. Use pillows or abductor pillow to maintain the legs in slight abduction; after hip replacement it prevents dislodging of the prosthesis. 9. Encourage quadriceps setting exercises. 10. Assist the client to ambulate by using a walker and eventually progressing to a cane; follow orders for extent of weight bearing permitted on affected extremity because this will depend on the type of surgery performed and the type of device inserted. 11. Support on unaffected side. 12. Avoid flexing the hips of a client with a total hip replacement, assist to a lounge chair position when permitted to sit. 13. Prevent complication of thromboembolism: o Administer prescribed anticoagulants, observe for bleeding. o Apply antiembolism stockings. o Encourage dorsiflexion of feet.

14. Prevent pulmonary complication. o Encourage coughing and deep breathing exercises. o Explain use of incentive spirometry. o Assist with frequent position changes.

Hemorrhage
Bleeding that may be external, internal or both External: Laceration, avulsion, GSW, stab wound Internal: Bleeding in body cavities and internal organs Assessment Results in reduction of circulating blood vol., w/c is the principal cause of shock Signs and symptoms of shock: 1. Cool, moist skin 2. Hypotension 3. Tachycardia 4. Delayed capillary refill 5. Oliguria Management Fluid Replacement Two large-bore intravenous cannulae are inserted to provide a means for fluid and blood replacement, and blood samples are obtained for analysis, typing, & cross-matching. Replacement fluids may include isotonic solutions (LRS, NSS), colloid, and blood component therapy. • Packed RBCs are infused when there is massive hemorrhage • In emergencies, O(-) blood is used for women of child-bearing age. • O(+) blood is used for men and postmenopausal women. • Additional platelets and clotting factors are give when large amounts of blood is needed. Control of External Hemorrhage Physical assessment is done to identify area of the hemorrhage. Direct, firm pressure is applied over the bleeding area or the involved artery.

A firm pressure dressing is applied, and the injured part is elevated to stop venous & capillary bleeding if possible. If the injured area is an extremity, it is immobilized to control blood loss. Control of Bleeding: Tourniquets Applied only as a last resort just proximal to the wound and tied tightly enough to control arterial blood flow; tag the client with a “T” stating the location and the time applied Loosened periodically to prevent irreparable vascular on neuro damage If still with arterial bleeding, remove tourniquet and apply pressure dressing If traumatically amputated, the tourniquet remains in place until the OR. Control of Internal Bleeding Watch out for tachycardia, hypotension, thirst, apprehension, cool and moist skin, or delayed capillary refill. Packed RBC are administered at a rapid rate, and the patient is prepped for OR. Arterial blood is obtained to evaluate pulmonary perfusion & to establish baseline hemodynamic parameters Patient is maintained in a supine position and closely monitored.

Trauma
The unintentional or intentional wound or injury inflicted on the body from a mechanism against w/c the body cannot protect itself Leading cause of death in children and in adults younger than 44 y/o Alcohol & drug abuse are implicated in both blunt & penetrating trauma Collection of Forensic Evidence: Included in documentation are the ff: 1. Descriptions of all wounds 2. Mechanism of injury 3. Time of events 4. Collection of evidence 5. Statements made by the patient If suicide or homicide is suspected in a deceased patient, the medical examiner will examine the body on site or have it moved to the medico-legal office for autopsy.

All tubes & lines are left in place. Patient’s hands are covered with paper bags to protect evidence. Injury Prevention Components 1. Education: Provide information and materials to help prevent violence, and to maintain safety at home and in vehicles. 2. Legislation: Provide universal safety measures without infringing on rights (Seatbelt Law). 3. Automatic Protection: Provide safety without requiring personal intervention (Airbags, seatbelts). High incidence of injury to hollow organs, particularly the small intestines The liver is the most frequently injured solid organ. High velocity missiles create extensive tissue damage. Intra-abdominal Injuries: Blunt (MVA, falls, blows) Associated with extra-abdominal injuries to chest, head, extremity Incidence of delayed & trauma-related complications is higher Leads to massive blood loss into the peritoneal cavity Trauma: Assessment 1. Inspection of abdomen for signs of injury (bruises, abrasions) 2. Auscultation of bowel sounds 3. Watch out for signs of peritoneal irritation like distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness together with absent BS. Trauma: Diagnostic Findings 1. Urinalysis to detect hematuria 2. Serial hematocrit to detect presence or absence of bleeding 3. WBC count to detect elevation associated with trauma 4. Serum amylase to detect pancreatic or GIT injury PE for Internal Bleeding Inspect body for bluish discoloration, asymmetry, abrasion, & contusion FAST (Focused Assessment for Sonographic Examination of the Trauma Patient) exam through CT scan to assess hemodynamically unstable patients and detect intraperitoneal bleeding Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen. Pain in the right shoulder can result from a laceration of the liver.

Administration of opioids is avoided during the observation period. Trauma: Genitourinary Injury A rectal or vaginal exam is done to determine any injury to the pelvis, bladder, and intestinal wall. To decompress the bladder & monitor urine output, a Foley catheter is inserted AFTER DRE. A high-riding prostate gland indicates a potential urethral injury. Trauma: Management of Intra-abdominal Injuries 1. A patent airway is maintained. 2. Bleeding is controlled by applying direct pressure to any external bleeding wounds & by occlusion of any chest wounds. 3. Circulating blood vol. is maintained with intravenous fluid replacement including blood component therapy. 4. In blunt trauma, cervical spine immobilization is maintained until cervical x-rays have been obtained & injury is ruled out. 5. All wounds are located, counted & documented. 6. If abdominal viscera protrude, the area is covered with sterile, moist saline dressing to prevent drying. 7. Oral fluids are withheld and stomach contents are aspirated with an NGT in anticipation of surgery. Tetanus and broad-spectrum antibiotics are given as prescribed. 8. If still with evidence of shock, blood loss, free air under the diaphragm, evisceration, hematuria or suspected abdominal injury, transport to OR. Trauma: Crushing Injuries Occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery Watch out for hypovolemic shock from extravasation of blood & plasma into injured tissues after compression has been released. Crushing Injuries: Assessment Watch out for paralysis of a body part, erythema & blistering of skin, damaged part appearing swollen, tense & hard. Renal dysfunction is secondary to prolonged hypotension. Myoglobinuria is secondary to muscle damage causing ARF. In conjunction with ABC’s, the patient is observed for acute renal insufficiency

Major soft tissue injuries are splinted early to control bleeding and pain. If an extremity is involved, it is elevated to relieve swelling & pressure. A fasciotomy is done to restore neurovascular function. Medications for pain & anxiety are given as prescribed, and the patient is transported to the OR for debridement & fracture repair Trauma: Multiple Injuries Requires a team approach with one person responsible for coordinating the treatment Immediately after injury, the body is hypermetabolic, hypercoagulable, and severely stressed. Mortality is related to the severity & the number of systems involved. Multiple Injuries: Nursing Responsibilities 1. Assessing & monitoring the patient 2. Ensuring venous access 3. Administering prescribed meds 4. Collecting laboratory specimens 5. Documenting activities and the patient’s response 6. Gross evidence may be slight or absent; the injury regarded as the least significant may be the most lethal. 7. Determine the extent of injuries & establish priorities of treatment (ABC’s) 8. Establish airway & ventilation. 9. Control hemorrhage. 10. Prevent & treat hypovolemic shock & monitor intake & output. 11. Assess for head & neck injuries. 12. Evaluate for other injuries – reassess head & neck, chest; assess abdomen, back & extremities. 13. Splint fractures. Carry out a more thorough and ongoing examination & assessment.

HEAD INJURIES NURSING INTERVENTIONS: 1. Maintain a patent airway. Assist with endotracheal intubation or tracheotomy as necessary. 2. Administer medications as ordered. 3. Protect the patient for further injury by using side rails. 4. Assist the unsteady patient with walking. 5. Insert an indwelling urinary catheter if ordered. 6. If the patient is unconscious, insert a nasogastric tube to prevent aspiration. 7. Monitor the patient’s intake and output as needed to help maintain a normovolemic state. 8. Monitor vital signs continuously and check for additional injuries. 9. Observe the patient for headache, dizziness, irritability, and anxiety. 10. Monitor fluid and electrolyte levels and replace them as necessary. 11. Carefully observe the patient for CSF leakage. 12. Tell the patient to return to the hospital immediately if he experiences a persistent worsening headache, forceful or constant vomiting, blurred vision, any change in personality, abnormal eye movements, and twitching.

SPINAL INJURIES INTERVENTIONS: 1. During the initial assessment and X-rays, immobilize the patient on a firm surface, with sandbags on both sides of his head. 2. Instruct the patient not to move. If possible, avoid moving the patient because hyperflexion can damage the cord. 3. Offer comfort and reassurance to the patient, talking to him quietly and calmly. 4. If the injury necessitates surgery, administer prophylactic antibiotics as ordered. 5. Catheterize the patient as ordered to avoid urine retention, and monitor defecation patterns to avoid impaction. 6. If the patient has a halo or skull tong traction device, clean the pin sites daily, trim his hair short, and provide analgesics for headaches. 7. During traction, turn the patient often to prevent pneumonia, embolism, and skin breakdown. 8. Perform passive-range-of-motion exercises to maintain muscle tone.

9. To prevent aspiration, turn the patient on his side during feedings. Create a relaxed atmosphere at mealtimes. 10. If necessary, insert a nasogastric tube to prevent gastric retention. 11. Suggest appropriate diversionary activities to fill the hours of immobility. 12. Help the patient walk as soon as the doctor allows the patient. 13. Explain the traction methods to the patient and his family.

Wounds
A type of physical trauma wherein the skin is torn, cut or punctured (open wound), or where blunt force trauma causes a contusion (closed wound). Specifically refers to a sharp injury which damages the dermis of the skin. Types of Wounds 1. Open (Incised wound, Laceration, Abrasion, Puncture wound, Gunshot wound) 2. Closed (Contusion, Hematoma, Crushing injury) Incised Wound A clean cut by a sharp edged object such as glass or metal. As the blood vessels at the wound edges are cut straight across, there may be profuse bleeding Laceration Ripping forces or rough brushing against a surface which can cause rough tears in the skin or lacerations. Laceration wounds are usually bigger and can cause more tissue damage due to the size of the wound. Abrasion Superficial wounds that occur at the surface of the skin. Friction burns and slides can cause abrasion Characteristic in the way that only the top most layer of the skin is scrapped off. Bleeding is not profuse though wounds Puncture Wound Small entry site Though not large in surface area, wounds are deep and can cause great internal damage.

Closed Wounds
External forces, such as falls and motor vehicle accidents, cause most closed wounds. May closed wounds are relatively small and involve soft tissues; the black eye is an example: Others, however, involve fractures of the limbs, spine, or skill and damage to vital organs within the skull, chest, or abdomen. Massive injury to soft tissues – such as muscles, blood vessels, and nerves – can be very serious and can result in lasting disabilities. Signs and Symptoms Pain and tenderness are most common. Usual signs are swelling and discoloration of soft tissues and deformity of limbs caused by fractures or discolorations, Suspect a closed wound with internal bleeding and possible rupture of a body organ whenever powerful force exerted on the body has produced severe shock or unconsciousness. Even of signs of injury are obvious, internal injury is probable when any of the following general symptoms are present:
   

Cold, clammy pale skin, very rapid but weak pulse, rapid breathing and dizziness. Pain and tenderness in a part of the body in which injury is suspected, especially if deep pain continues but seems out of proportion to the outward signs of injury. Uncontrolled restlessness and excessive thirst. Vomiting or coughing up of blood or passage of blood in the urine or feces.

To stop severe bleeding: 1. Have the injured person lie down. If possible, position the person’s head slightly lower than the trunk or elevate the legs. This position reduces the risk of fainting by increasing blood flow to the brain. If also possible, elevate the site of bleeding. 2. Remove any obvious dirt or debris from the wound. Don’t remove any large or more deeply embedded objects. Don’t probe the wound or attempt to clean it at this point. Your principal concern is to stop the bleeding. 3. Apply pressure directly on the wound. Use a sterile bandage, clean cloth or even a piece of clothing. If nothing else is available, use your hand. 4. Maintain pressure until the bleeding stops. When it does, bind the wound tightly with a bandage (or even a piece of clean clothing) and adhesive tape.

5. Don’t reposition displaced organs. If the wound is abdominal and organs have been displaced, don’t try to reposition them. Cover the wound with a dressing.

Contusion a.k.a. bruise: Caused by blunt force trauma that damages tissue under the skin
Hematoma: Also called a blood tumor Caused by damage to a blood vessel that in turn causes blood to collect under the skin Caused by a great or extreme amount of force applied over a long period of time Patterned Wound: Wound representing the outline of the object (e.g. steering wheel) causing the wound Management: Wound Cleansing 1 . Hair around wound may be shaved. 2 . NSS is used to irrigate the wound. 3 . Betadine & hydrogen peroxide are only used for initial cleaning & aren’t allowed to get deep into the wound without thorough rinsing. 4 . Use local or regional block anesthetics if indicated. Wound Management 1 . Use of antibiotics depends on how the injury occurred, the age of the wound, & the risk for contamination 2 . Site is immobilized & elevated to limit accumulation of fluid 3 . Tetanus prophylaxis is administered based on the condition of the wound and the immunization status Wound Healing: By First Intention Occurs when tissue is cleanly incised and re-approximated and healing occurs without complications. The incisional defect re-epithelizes rapidly and matrix deposition seals the defect. Wound Healing: By Second Intention Healing occurs in open wounds. When the wound edges are not approximated and it heals with formation of granulation tissue, contraction and eventual spontaneous migration of epithelial cells. Wound Healing: By Third Intention

Occurs when a wound is allowed to heal open for a few days and then closed as if primarily. Such wounds are left open initially because of gross contamination

GUNSHOT WOUNDS
Caused by firing bullets or any other small arms. Have a clean entry site but a large and ragged exit site. IMMEDIATE MANAGEMENT OF GUNSHOT WOUNDS treatment of gunshot wounds depends on the area(s) struck. generally should be covered by a dry dressing or a clear transparent dressing if available Manual pressure should be applied if the wound is bleeding. Once in a hospital, clean the wound, possible debride some edges, and change the dressings daily A gunshot is never sutured closed as the infection rate is very high. Bullets drag clothing into the wound and along the bullet track. Since clothing is of course not sterile, the wound is prone to infection if closed. Open wounds almost never get infected. GSW to HEAD typically fatal if the bullet crosses both of the brain hemispheres or hit the brain stem which is responsible for control of basic vitals Head elevation or seated positioning and rapid transport to a trauma center with neurosurgical capabilities is key. GSW to FACE & NECK often troublesome since your face and neck have excellent circulation; bleeding is often heavy airway can become obstructed by blood, teeth, and swelling. Manual pressure should be applied to a bleeding wound and leave the victim in the upright position. ‐‐ Direct pressure should be strong enough to stop the bleeding. ‐Avoid pressing over a large area as you can compromise blood flow to the brain or shift the trachea causing an airway obstruction. GSW to CHEST & BACK may affect lungs, heart, and major blood vessels collapsed lung or pneumothorax will manifest with difficulty breathing. ‐hemothorax is

blood in the chest cavity Upon arrival to a trauma center, the trauma team will place a chest tube to relieve these conditions and drain blood Sucking chest wounds occur when air is seen traveling in and out of a wound with each breath. Never completely occlude these sucking chest wounds as you can cause a build up of pressure within the chest and cause a life‐threatening tension pneumothorax. ‐ A three‐sided tape technique with an occlusive dressing is indicated to manage these wounds. ‐ Direct pressure should be applied to a bleeding wound but it is often hard to compress chest bleeding as the structures that are bleeding are protected by the bony rib cage. If you are trained, needle decompression should be used if you suspect a tension pneumothorax. GSW to ABDOMEN ‐ can cause bowel damage as well as significant bleeding ‐ internal hemorrhage difficult to manage ‐ transport to a trauma center ASAP GSW to the extremities ‐ Direct manual pressure is indicated to initially control bleeding. ‐ An injured blood vessel can either bleed externally or sometimes clot and block blood flow to the remainder of the extremity. ‐ press hard enough to stop the bleeding. Tourniquets may be used ‐ Large skin defects, from for example shotgun wounds, may require topical clotting agents to help control bleeding. Typically, direct pressure is almost always enough.

Wound Cleaning and Dressing
A wound is defined as any disruption along the skin. As skin is the largest protection of the body from the environment, the skin is prone in various physical and chemical irritants. A break in the skin may predispose an individual to tetanus as well as other complications such as nerve damage. A normal wound healing process can take place through three stages: 1. Reaction Phase – Upon the occurrence of injury, constriction of blood vessels occur in order to control the entrance of foreign bodies into the wound. Some tissues become edematous as a form of combating the injury to the skin. The neutrophils

then surround the wound to eat the loosened tissues and fight the infection. Once the neutrophils have served its purpose they will die forming pus. 2. Regrowth Phase – After the debris has been taken out, a thin covering or film of tissue is outline on the wound. Collagen for instance gives strength to the scar. For pressure ulcers, granulation tissue covered the hollow area during this stage. The reaction phase and the regrowth phase may actually overlap. 3. Remodeling Phase – The new scar formation is strengthened through time. The average maturation of the scar may range from 6 months to 12 months depending on the intensity of the wounds and its damaged area. Wound Cleaning & Dressing Procedure: 1. 2. 3. 4. 5. 6. 7. 8. Observe the whole body of the patient, survey the extent of injury. Prioritize the type of wounds to be cleaned from the worst to the minimal open wound. Check for nerve damage. Explain to the patient that you will start cleaning the wounds. Expose the needed area of the body to be cleaned. Preserve privacy as much as possible. Cleanse the wounds with normal saline solution or a combination of betadine solution. Drape the wound. Please observe sterility of the environment. Anesthetize the surrounding wound area with local anaesthetics such as Lidocaine or Benzocaine. Some of the local anaesthetics might be skin tested before induction. 9. Provide a direct pressure using sterile gauze on the wound area afterwards to stop bleeding or minimal bleeding must be obtained. For wounds on the limb, elevate the area above the level of the heart in order to slow the bleeding process. 10. Paint the wound area with betadine solution. 11. Use surgical forceps for picking up debris on the wound if there are any. 12. Irrigate the wound with normal saline from time to time. 13. Once the bleeding has stopped as well as no debris or foreign materials are found in the wound. Close the wound using sterile gauze. 14. Lacerations, abrasions and avulsions can be closed with butterfly tape to hold the wound areas. 15. Instruct the patient about proper wound care as well as follow-up if there are stitches along the wound. Encourage them to eat foods rich in Vitamin C in order to promote a faster wound healing.

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