NURB 4120 Nursing Care for Trauma Pts

NURB 4120 Nursing Care for Trauma Pts Types of Injuries - - Blunt force—fall 15-20 ft, contact sports, MVC, crush injury - Penetrating What is the golden hour? - First hour after an injury - Critical in determining survival chances Rapid Primary Hx - - SAMPLE—s/sx, allergies, meds, PMH, last meal, event/environment of injury - Head/neck/face - Chest/abd/flanks—log roll to inspect all surfaces - Pelvis/perineum - ETOH/drug use Primary Survery - *ABCDE* A—Airway patent—may require cricothyroidectomy if airway obstructed B—Breathing and ventilation C—Circulation—hypovolemic shock D—Disability—neuro status; rapid LOC assessment (AVPU); GCS; PQRST for pain E—Exposure & Environmental Control—remove clothing, inspect body, prevent hypothermia S/SX of Hypovolemic Shock - - MAP 60 w/ evidence of decreased perfusion - Cold, pale - Slow cap refill - Cyanotic—late sign How do you determine SBP using pulses? - - If carotid pulse is present SBP is at least 60 - If femoral pulse is present SBP is at least 70 - If radial pulse is present SBP is at least 80 Fluid Resuscitation - Immediate crystalloids/colloids/volume expanders used for fluid volume loss *- RL—3-6 L (wide open line)* - NS—large vol may worsen acidosis d/t Cl- displacing HCO3 - Albumin 5% - Blood products—PRBCs, FFP; use rapid transfuser and blood warmer to prevent DIC *Large vol resuscitation w/ blood increases risk for DIC* Secondary Survey - *FGH* F: - Full VS - Focused Assessments—foley (UO/hr), further lab - Family presence - For prevention, tetanus G: - Give comfort - Get pain meds - Get info H: - Hx - Head to toe What complications can occur d/t SIRS? - - ARDS - DIC What are the functions of the kidneys? - *FEARS* - *F*luids - *E*lectrolytes - *A*cid-base balance - *R*ids waste - *S*ecretes renin and erythropoietin Traumatic Brain Injury - A penetrating or blunt force injury to the head, damaging the brain - Forces—acceleration/deceleration (Coux-Contracoux), shearing (Diffuse Axonal) - Primary vs Secondary injury - Diagnostics—ABGs, ETOH/drug screen, CBC, CT, MRI TBI Severity - MILD: - GCS 13-15 - Loss of consciousness for 15 min MODERATE: - GCS 9-12 - HRF deterioration SEVERE: - GCS 8 - Vent support/ICP/HD monitoring TBI Classifications - - Skull fractures—risk of hematoma and infection (Meningitis) - Concussion—brief loss of neuro function - Contusion - Cerebral hematomas—epidural, subdural, intracranial, subarachnoid hemorrhage Monroe-Kellie Doctrine - Hypothesis stating when the volume of one of the components determining ICP increases, there must be a compensatory decrease in others - Components—brain tissue, blood, CSF EXAMPLE: - TBI causes cerebral edema - Vasoconstriction occurs to lower volume of blood in the brain in an attempt to decrease pressure - If cerebral edema worsens, compensatory mechanism fails - ICP increases, lowered blood flow to brain Diabetes Insipdus vs SIADH - "DI is not enough letters, too much pee. SI is too many letters, not enough pee." - Diabetes Insipidus—low ADH increases UO, causing dehydration - SIADH—excess ADH decreases UO, causing fluid retention *Hypo/hypernatremia cause cerebral edema* TBI Mgmt - - HOB 15-30 degrees - Minimal stimulation, sedation - Mannitol—reduces cerebral edema, ICP; IVP; *must be used w/ filter d/t crystallization* - CPP 60 - Hemi-craniectomy—alert staff of bone flap - ICP monitoring—EVD (internal), Bolt (external); zero and line EVD to tragus *MAP - ICP = CPP* Normal ICP and CPP - - ICP 5 - 15 mmHg - CPP 70-100 mmHg Can you drain CSF with a Bolt? - No, only with an EVD - Bolt's also have a decreased risk of infection d/t external placement ICP Mgmt - - CSF drainage - Hyperventilation—decreasing CO2, decreasing fluid - Maintain body in midline, neutral position MEDS: - Fentanyl, versed, propofol - Precedex - Morphine, Ativan - Mannitol/0.7% NS How can you determine the difference between CSF and other fluids? - - Halo sign—clear fluid (CSF) develops a ring around blood Complications of Head Injuries - - Neurogenic shock - Seizures—give Keppra, Dilantin - Infections - Immobility Syndrome—stasis pneumonia, stasis/stress ulcers, venostasis, bone demineralization What is Cushing's Triad? - A set of signs indicating increased ICP - Elevated SBP (widened pulse pressure) - Bradycardia - Irregular respirations