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1 Chapter 6 Lecture Outline Trauma I. Analysis of Trauma A. Definition and Impact 1.

. Definition: sudden accidents or purposeful acts leading to injury, disability or death 2. Impact: initial physical injuries and long term effects; rehabilitation and psychosocial effects on clients and family members B. Components of Traumas 1. Host: person or group at risk of injury 2. Mechanism: source of energy that causes trauma Most common: mechanical energy from motor vehicles in accidents 3. Intention: deliberate or unintentional 4. Environment: location and under what circumstances C. Types of trauma 1. Blunt: no communication between damaged tissue and outside environment; injuries are internal and can be minor to lethal 2. Penetrating: actual tissue damage to body structures, obvious from outside 3. Often combination of blunt and penetrating II. Prehospital Care A. Injury identification 1. Rapid comprehensive trauma assessment 2. Determine need for trauma center and rapid transport 3. Airway, Breathing, Circulation 4. Level of consciousness/possible spinal cord injuries 5. Any obvious injuries B. Critical interventions 1. Life support 2. Immobilize cervical spine 3. Airway management (intubation) 4. Treat hemorrhage and shock 5. Apply direct pressure over wounds C. Rapid Transport III. Hospital Care: Emergency Department Care A. Support above critical interventions B. Determine extent of injuries/plan of treatment through common diagnostic tests 1. Blood type and crossmatch: determine clients blood type; ready donor blood for transfusion 2. Blood Alcohol level: alters level of consciousness and pain response 3. Urine Drug screen: alters level of consciousness and pain response 4. Pregnancy test for women of child-bearing age: treatment concerns 5. Diagnostic Peritoneal Lavage: test for presence of blood in peritoneal cavity; determine hemorrhaging internally (Catheter placed in lower abdomen and aspiration for free blood; infuse warm isotonic solution rapidly and drain by gravity; check for presence of blood)
Avelino Grospe Jr. RN, RM 8/8/2011

2 6. Computerized Tomography (CT Scan) special xray of body area in layers with computerized views; brain, chest, abdomen Medications 1. May have been initiated at scene 2. Intravenous access and fluids, blood components 3. Cardiovascular support with inotropic agents, vasopressors 4. Pain control 5. Tetanus immunization, if indicated Blood Transfusions Emergency surgery Organ Donation 1. Client will not recover; client meets brain death criteria 2. Uniform Anatomical Gift Act (1968, 1987): client be informed about options for organ donation; address option with next of kin 3. Care given to maintain circulation and perfuse organs, if organs will be harvested 4. Supportive care to family member; assist with grief Forensic Considerations 1. Trauma may have occurred in illegal activity 2. Determine if client is under influence of alcohol, illegal drugs 3. Maintain chain of custody, i.e. preserve, label, document, dispose evidence

C.

D. E. F.

G.

IV. Prevention of Trauma Educate the public about trauma prevention and safety e.g. seatbelts, bicycle helmets V. Common Nursing Diagnoses for Trauma Clients A. Ineffective Airway Clearance B. Risk for Infection C. Impaired Physical Mobility D. Spiritual Distress: Client and Family E. Risk for Post-Trauma Syndrome 1. Intense emotional response to disastrous event 2. Impaired coping mechanisms 3. Nurses assist client and family to express feelings 4. Referrals for counseling, support groups

Avelino Grospe Jr. RN, RM 8/8/2011

3 Shock I. Definition and Pathophysiology A. Definition 1. Clinical syndrome, systemic imbalance between oxygen supply and demand 2. Inadequate blood flow to body organs and tissue causing lifethreatening cellular dysfunction B. Pathophysiology 1. Stimulus leads to alteration in hemodynamics within the body 2. Body responds by maintaining perfusion to vital organs, heart and brain 3. Results in inadequate tissue and cellular perfusion; if not reversed, body develops acidosis and if untreated, progresses to organ hypoxia, ischemia and death 4. Alteration in hemodynamics results in a drop in arterial blood pressure by one of these mechanisms a. Decrease in cardiac output (ability of heart to supply adequate circulation) b. Decrease in circulating blood volume c. Increase in size of vascular bed II. Hemodynamic terms A. Stroke Volume (SV): amount of blood pumped into aorta by contraction of left ventricle B. Cardiac Output (CO): amount of blood pumped into aorta by contraction of left ventricle in one minute C. Mean arterial pressure (MAP): product of cardiac output and systemic vascular resistance III. Stages of Shock A. Early reversible and compensatory shock 1. Mean arterial pressure drops 10 -15 mm Hg 2. Decrease in circulating blood volume (25-35%) 1000ml 3. Sympathetic nervous system stimulated; release of catecholamine 4. To maintain blood pressure: increase in heart rate and contractility; increase in peripheral vasoconstriction 5. Circulation maintained, but can only be sustained short time without harm to tissues 6. Underlying cause of shock must be addressed and corrected or will progress to next stage B. Intermediate or progressive shock 1. Further drop in MAP (20%) 2. Increase in fluid loss (1800 25400 ml) 3. Vasoconstriction continues and leads to oxygen deficiency 4. Body switches to anaerobic metabolism forming lactic acid as a waste product. 5. Body increases heart rate and vasoconstriction.
Avelino Grospe Jr. RN, RM 8/8/2011

4 6. Heart and brain become hypoxic 7. More severe effects on other tissues which become: ischemic and anoxic 8. State of acidosis with hyperkalemia develops 9. Needs rapid treatment C. Refractory or irreversible shock 1. Tissues are anoxic, cellular death widespread 2. Even with restoration of blood pressure and fluid volume there is too much damage to restore homeostasis of tissues 3. Cellular death leads to tissue death; vital organs fail and death occurs IV. Effects of Shock on Body Systems A. Cardiovascular 1. Initially: slight tachycardia, normal blood pressure 2. Progresses to weak, rapid pulse with dysrhythmias 3. Progressive decrease in systolic and diastolic blood pressures with narrowing of pulse pressure; blood pressure becomes inaudible B. Respiratory 1. Initially: Increased respiratory rate, but gas exchange is impaired; leads to anaerobic metabolism and development of acidosis 2. Acute Respiratory Distress Syndrome (ARDS): complication of decreased lung perfusion C. Gastrointestinal and Hepatic 1. GI organs become ischemic, with blood circulation shunted to heart and brain 2. Complications a. Stress Ulcers: GI mucosa becomes ischemic, prone to rapid ulceration b. Paralytic Ileus: decreased gastrointestinal motility with decreased blood flow 3. Altered liver metabolism: initially glucose made available, then hypoglycemia, fat breakdown leads to ketones and metabolic acidosis D. Neurologic 1. Develops cerebral hypoxia 2. Restlessness initially, then altered level of consciousness, lethargy, coma E. Renal: Decreased kidney perfusion leads to oliguria (urine output < 20 ml/o) F. Skin, temperature, thirst 1. Skin: cool, pale, hypothermic 2. Thirsty from dehydration V. Types of Shock (categorized according to underlying causes) A. Hypovolemic 1. Decrease in intravascular volume > 15% 2. Most common: occurs with other types of shock
Avelino Grospe Jr. RN, RM 8/8/2011

5 3. Common stimuli: hemorrhage, burns, severe dehydration, third spacing 4. Progresses through stages of shock without restoration of fluid volume B. Cardiogenic 1. Pumping ability of heart compromised to a degree that cannot maintain cardiac output and adequate tissue perfusion 2. Common stimuli: myocardial infarction, cardiac arrest 3. Develops left and right sided heart failure 4. Cyanosis occurs with this type of shock C. Obstructive 1. Heart or great vessels obstructed; venous return or cardiac pumping action impeded 2. Common stimuli: pulmonary embolism, pneumothorax D. Distributive (Vasogenic) 1. Widespread vasodilatation 2. Decreased peripheral resistance E. Septic Shock 1. Leading cause of death in intensive care units 2. Common stimuli: Gram negative bacterial infections (pseudomonas, E coli); Gram positive bacterial infections (staphylococcus and streptococcus) 3. Increased risk: clients with chronic illness, poor nutritional status, invasive procedure or tubes, such as foley catheters 4. Course a. Septicemia develops (pathogens and their toxins in the blood) b. Endotoxins disrupt circulation c. Normal coagulation mechanisms d. Inflammatory response triggered 5. Phases of Septic Shock a. Warm Phase (early): skin flushed, warm due to vasodilatation b. Cold Phase (late): skin cool due to fluid deficit with shock F. Neurogenic Shock 1. Imbalance between parasympathetic and sympathetic nervous stimulation of vascular smooth muscle, resulting in sustained vasodilatation 2. Common stimuli: head injury, spinal cord trauma, insulin reactions, anesthesia G. Anaphylactic Shock 1. Result of widespread hypersensitivity (anaphylaxis) 2. Vasodilatation occurs leading to hypovolemia and altered cellular metabolism 3. Sensitized in past, re-contact with the allergen (medication, bee sting, food allergen) 4. Allergic reaction with large amounts of histamine released
Avelino Grospe Jr. RN, RM 8/8/2011

6 5. Histamine leads to increased permeability and massive vasodilatation, 6. Develops respiratory distress with bronchospasm and laryngospasm VI. Collaborative Care A. Focus on treating underlying cause to stop progress through stages of shock B. Rapid shock identification; rapid diagnosis of cause; rapid aggressive treatment: better outcome for client C. Goal: improving arterial oxygenation and tissue perfusion D. Determine type of shock E. Diagnostic tests and purpose used with clients in shock 1. Blood hemoglobin and hematocrit: hypovolemic shock 2. Arterial Blood Gases: identify body compensatory mechanisms, such as acidosis 3. Electrolytes 4. BUN and creatitine, osmolality: renal function 5. Blood cultures: identify causative organism in septic shock; treatment 6. White blood count and differential: septic shock 7. Cardiac enzymes: diagnosis of cardiogenic shock (Cardiac enzymes are: lactate dehydrogenase (LDH); Creatine phosphokinase (CPK); serum glutamic-oxaloacetic transaminase (SGOT): 8. Other tests may be ordered F. Medications 1. Inotropic agents: improve cardiac contractility 2. Vasoactive agents: drugs causing vasoconstriction or vasodilatation according to client symptoms 3. Other meds according to cause such as antibiotics, steroids G. Oxygen Therapy 1. Patent airway and adequate oxygenation critical interventions 2. Monitor with ABG, pulse goniometry (more accurate in early stage) 3. Mechanical ventilation assistance may be needed H. Fluid Replacement 1. Essential for hypovolemic shock; also with other types as symptoms indicate 2. Types of Intravenous Fluids a. Crystalloid solutions 1. Dextrose or electrolyte solutions 2. Increase intravascular and interstitial fluid volume 3. Examples: Isotonic (0.9% NaCl, lactated Ringers) Hypotonic (5% dextrose in water, .45% NaCl) b. Colloids 1. Do not diffuse easily through capillary walls 2. Fluids stay in vascular compartment; increase osmotic pressure
Avelino Grospe Jr. RN, RM 8/8/2011

7 3. Examples: albumin, hetastarch, plasma protein fraction, dextran. c. Blood and Blood Products 1. Treatment of hemorrhage 2. Restore coagulation properties VII. Blood Transfusion A. Background 1. Four blood types; categorized according to antigens on red blood cells a. Type A: A antigens b. Type B: B antigens c. Type O: no antigens (universal donor) d. Type AB: A and B antigens (universal recipient) 2. D antigen, third antigen; may be present on the red blood cells a. Rh factor positive: D antigen is present b. Rh factor negative: D antigen is not present B. Type and Crossmatch 1. Performed on blood to be transfused 2. Donated blood is matched to the recipients blood according to type and Rh factor status. C. Blood transfusion reactions 1. Occur when there is some degree of incompatibility between the donor and recipient blood 2. Nurses administering blood need to aware and observant for signs of transfusion reactions 3. Types of blood transfusion reactions a. Febrile 1. Recipients antibodies are directed against donors white blood cells, causing fever and chills 2. Occurrence: within first 15 minutes of transfusion b. Hypersensitivity 1. Recipients antibodies react against proteins in donors blood causing urticaria (hives) and itching 2. Occurrence: during or after transfusion c. Hemolytic 1. Most dangerous; ABO incompatibility causing red blood cells to clump and block capillaries decreasing blood flow to vital organs; hemoglobin is released which blocks renal tubules and can cause renal failure. 2. Signs and symptoms: lumbar, abdominal and/or chest pain, fever, chills, urticaria, nausea and vomiting 3. Occurrence: after 100 200 ml of incompatible blood infused 4. Nursing interventions with transfusions and reactions: a. Follow policy of institution for blood transfusion which includes
Avelino Grospe Jr. RN, RM 8/8/2011

8 1. Procedure to establish client and unit of blood are correctly matched (verification by 2 nurses) 2. Assessment of vital signs prior to transfusion 3. Direct observation of client during first 15 minutes of infusion 4. Take vital signs according to protocol b. Established procedure if transfusion reaction is suspected 1. Stop transfusion immediately and do not transfuse the blood in the tubing 2. Continue IV infusion with fluid 3. Notify physician of clients signs and symptoms 4. Provide care for client as indicated 5. Complete reaction form according to institution protocol. 6. Obtain urine specimen from client and send for free hemoglobin. VIII. Nursing Process with Clients in Shock: A. Nurse assesses and analyzes client situation and any change in condition B. Notification of physician: early treatment before shock is advanced and less responsive to treatment C. Care of client in shock: constant assessment with modification of treatment D. Transferred to intensive care unit for hemodynamic monitoring and respiratory support E. Complexities of changing status of fluid, acid-base, cardiovascular function F. Support of client and family IX. Common Nursing Diagnoses 1. Decreased Cardiac Output 2. Altered Tissue Perfusion 3. Anxiety

Avelino Grospe Jr. RN, RM 8/8/2011

Nursing Care Plan Present the following client situation for discussion: A 56-year-old man was admitted to the hospital three days ago, after being injured in an industrial accident in which his right leg was crushed. Upon admission to the emergency department, he was hypovolemic and was treated with intravenous fluids and blood transfusions. He underwent surgery the day of the accident and has been recovering on a surgical unit in the hospital. He has been stable since surgery and has had good pain control. At 2 AM he puts on his call light and summons the nurse. The client tells the nurse that he feels nervous inside and unsettled. What should the nurse include in the assessment? The nurse finds that the clients vital signs are essentially unchanged. His BP is 112/70 (LAR) P: 104 R: 22 T: 37.2o C. His right leg dressing is dry with no new drainage. His skin is warm and dry. The nurse questions the client and he has no other complaints. The nurse informs the client that he will continue to check on him frequently. At 2:30 a.m. the nurse returns to assess the client. His skin is cool to touch. The client states he is nauseous. Vital signs are now B/P: 100/62 P: 112 R: 24 T: 37.0o C. The client begins to vomit. There is 300 mL of dark coffee groundscolored emesis. The client states he feels slightly dizzy. What are the collaborative interventions needed to stop the progression of shock. What type of shock is being described? What are the early signs of shock described in the first scenario? The nurse notifies the physician of the change in the clients condition and orders are received. What orders would you expect from the physician? What diagnostic studies would you expect to be ordered?

Avelino Grospe Jr. RN, RM 8/8/2011

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