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Trauma Nursing

Trauma Nursing. By: Diana Blum RN MSN Metropolitan Community College. Priority Emergency Measures for All Patients. Make safety the first priority Preplan to ensure security and a safe environment

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Trauma Nursing

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  1. Trauma Nursing By: Diana Blum RN MSN Metropolitan Community College

  2. Priority Emergency Measures for All Patients Make safety the first priority Preplan to ensure security and a safe environment Closely observe patient and family members in the event that they respond to stress with physical violence Assess the patient and family for psychological function

  3. Patient and family-focused interventions • Relieve anxiety and provide a sense of security • Allow family to stay with patient, if possible, to alleviate anxiety • Provide explanations and information • Provide additional interventions depending upon the stage of crisis

  4. Common Trauma Heat Bites Cold Electrical Altitude Near drowning Spinal Head Musculoskeletal Stab/gunshot wounds rape

  5. Requirements to work in ER • Graduated RN program • Med/Surg and or ICU experience • BLS • ACLS • PALS • Some facilities require ER certification

  6. Triage is from a French word meaning to sort. Emergency services regularly face patient loads that overwhelm resources. To better serve patients and make sure the worst patients get treatment as quickly as possible, emergency medical providers use a method of prioritizing patients by medical severity

  7. Triage Nurse has 2-3 minutes to decide how long each patient should wait for medical care and assign a corresponding Triage Category

  8. The nurse will use their expertise to process data obtained from the presenting problem, physiological observations, general appearance and all important gut feelings

  9. urgency based on vital signs, complaints, appearance, and history • Coming by ambulance think of the following • Code 1 did not need ambulance • Code 2 minor injuries • Code 3 serious injury • Code blue =coding

  10. A client arrives in the emergency room with multiple crushing wounds of the chest, abdomen, and legs. The assessments that assume the greatest priority are: select all that apply: • A. Level of consciousness and pupil size • B. Abdominal contusions and other wounds • C. Pain, respiratory rate, and blood pressure • D. Quality of respirations and presence of pulses

  11. The charge nurse is overseeing care of 10 clients on a general obstetrical floor. Concerning which of the following patient-care situations should the nurse notify the physician FIRST?a. Prenatal client at 7 weeks gestation with nausea and vomiting and a whitish vaginal discharge.b. A gravida 2 para 1 client at 28 weeks gestation with brownish facial blotches and +1 glucose and trace protein in a random urinalysis.c. Seventeen-year-old client at 15 weeks gestation with missed abortion and bleeding from IV site.d. Rh-negative client at 38 weeks gestation with blood pressure of 150/105, brisk reflexes, and generalized edema in hands and ankles.

  12. You are asked what the correct steps in CPR are. Number them in the correct order. • ___ initiate breathing • ___ Open the client airway • ___ Determine breathlessness • ___ Perform chest compressions • ___ determine unconsciousness by shaking the client and asking “ Are you Okay?”

  13. You are preparing to suction a client with a trach. List the order of priority for the actions to take during this procedure. • ____ hyperoxygenate the client • ____ Place the client in a semi fowler position • ____ turn the suction on and set regulator to 80 mmHG • ____ Apply gloves and attach the suction tubing to the suction catheter • ____ Insert the Catheter into the trach until resistance is met and pull back 1 cm • ____ Apply intermittent suction and slowly withdraw while rotating it back and forth

  14. You are the triage nurse coming on duty. The following patients come in to be seen. This is all the info you have. How would you triage them and why? • 54/m c/o chest pain 2/10 had a CABG 6 months ago. Hr 92 BP 140/90 RR32 SAO2 95% on 4 liters • 7 /F mom states has been vomiting and diarrhea x 2 days. She has not voided for 12 hours and can not keep fluids down. HR 112 RR24 lips and mouth dry, skin cool • 70/m with general weakness and unable to due ADL. He is SOB and c/o abd pain. Bibasilar crackles, HR 123 irregular BP 150/72 sat 88% RA

  15. Hyperthermia • Acute Medical Emergency • Failure of heat regulating mechanisms • Elderly and young at risk • Exceptional heat exhaustion • Stems from heavy perspiration • Need to stay hydrated! • Causes thermal injury at cellular level

  16. Treatment • Lower temp as quickly as possible(102 and lower) How can this be done? • ABC’s • Give 02, Start large bore IV • Insert foley • Labs: • Lytes, CBC, myoglobin. Cardiac enzymes

  17. Assessment • Mental status…Seizure may occur • Monitor vitals frequently • Renal status • Monitor temp continuously • EKG, Neuro status • Hypermetabolism due to increased body temp • Increases 02 demand • Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

  18. Heat Exhaustion Stroke

  19. Heat Exhaustion • Caused by dehydration • Stems from heavy perspiration • Poor electrolyte consumption • Signs/Symptoms • Normal mental status • Flu like • Headache • Weakness • N/V • Orthostatic hypotension • Tachycardia

  20. Heat Exhaustion • Treatment • Outside hospital • Stop activity • Move to cool place • Cold packs • Remove constrictive clothing • Re-hydrate (water, sports drinks) • If remains call 911 • In hospital • IV 0.9% saline • Frequent vitals • Draw serum electrolyte level

  21. Heat Stroke • Assessment • Monitor mental status • Monitor vitals • Monitor renal status • Treatment • At site • ensure patent airway • Move to cool environment • Pour water on scalp and body • Fan the client • Ice the client • Call 911 • At hospital • O2 • Start IV • Administer normal saline • Use cooling blanket • DO NOT give ASA • Monitor rectal temp q15 minutes • Insert foley to monitor I/Os closely and measure specific gravity of urine • Check CBC, Cardiac enzymes, serum electrolytes, liver enzymes ASAP • Assess ABGs • Monitor vitals q 15 minutes • Administer muscle relaxants if the client shivers • Slow interventions when core temp is 102 degrees or less

  22. Management of Patients With Heat Stroke • Remember ABCs (decrease temp to 39° C as quickly as possible • Cooling methods • Cooling blankets, cool sheets, towels, or sponging with cool water • Apply ice to neck, groin, chest, and axillae • Iced lavage of the stomach or colon • Immersion in cold water bath • Monitor temp, VS, ECG, CVP, LOC, urine output • Use IVs to replace fluid losses • Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

  23. Patient teaching • Ensure adequate fluid and foods intake • Prevent overexposure to sun • Use sunscreen with at least SPF 30 • Rest frequently when in hot environment • Gradually expose self to heat • Wear light weight, light colored, loose clothing • Pay attention to personal limitations: modify accordingly

  24. Cold Injuries • Most common • Hypothermia • Frostbite • Synthetic clothing is best because it wicks away moisture and dries fast • “cotton kills” it holds moisture and promotes frostbite • A hat is essential to prevent heat loss though head • Keep water, extra clothing, and food in car in case of break down

  25. Hypothermia Internal core temperate is 35° C or less Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk Alcohol ingestion increases susceptibility Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence Physiologic changes in all organ systems Monitor continuously

  26. Assessment • Apathy, drowsiness, pulmonary edema, coagulopathies • Weak HR and BP • Hypoxemia • Continuous temperature and EKG • Watch for dysrhythmias

  27. Inadequate insulation is the culprit 3 stages Superficial (frost nip) Mild Severe Frostnip produces mild pain, numbness, pallor of affected skin Frost Bite

  28. NOW for the Bugs and Creatures

  29. Snake Bites • Most species non venomous and harmless • Poisonous snakes found in each state except Maine, Alaska, and Hawaii • Fatalities are few • Children 1-9 yrs old victims during daylight hours • AWARENESS is KEY • Most bites between April and October • Peak in July and August • 2 main types in North America are • pit vipers (look for warm blooded prey) • Water moccasins, copperheads, rattlesnakes • Most of bites • Coral snakes • From North Carolina to Florida and in the Gulf states, Arizona, and Texas

  30. Pit Vipers • Depression between eye and nostril • Triangular head indicative of venom • Venom function is to immbolize, kill and aid in digestion of prey (systemic effects happen with in 8 hours of puncture) • impairs blood clotting • Breaks down tissue protein • Alters membrane integrity • Necrosis of tissues • Swelling • Hypovolemic shock • Pulmonary edema, renal failure • DIC • 2 retractable curved fangs with canals • Rattlers have horny rings in tail that vibrates as a warning

  31. Treatment • At site • Move person to safe area • Encourage rest to decrease venom circulation • Remove jewelry and restrictive clothing • Splint limb below level of heart • Be calm and reassuring • No alcohol or caffeine 2nd to speed of venom absorption • At hospital • Constrict extremity but not to tight • Do NOT incise or suck wound • Do NOT apply ice • Use Sawyer extractor if available if used within 3 minutes of bite and leave for 30 minutes in place • At hospital continued • O2 • 2 large bore IV sites • Crystalloid fluids (NS or LR) • Continuous tele and bp monitoring • Opiod pain management • Tetanus shot • Broad spectrum antibx • Lab draw (coagulation studies, CBC, creatinine kinase, T and C, UA) • ECG • Obtain history of wound and pre-hospital tx • measure circumference of bite every 15-30 minutes • Possibly give antivenom if ordered (see page 177) • Monitor for anaphylaxis • Notify poison control

  32. Coral Snakes • Corals burrow in the ground • Bands of black, red, yellow • “red on yellow can kill a fellow” • “red on black venom lack” • Are generally non aggressive • Ability to inject venom is less efficient • Maxillary fangs are small and fixed • Use chewing motion to inject • Venom is neurotoxic and myotoxic • Enough in adult coral to kill human

  33. Action of venom • Blocks binding of acetylcholine at post synaptic junction • S/S • pain mild and transient • Fang marks may be hard to see • Effects may be delayed 12 hours but then act rapidly after • N/V • Headache • Pallor, abd pain • Late stage: parathesias, numbness, mental status change, crainal and peripheral nerve deficit , flaccid, difficulty speaking, swallowing, breathing • elevated creatinine kinase

  34. Coral Treatment • At site • Try to ID snake • Same as pit viper without concern of necrosis • At Hospital • Continuous tele • Continuous bp and pulse ox • Provide airway management (possible ET tube) • Provide antivenom treatment as ordered • Monitor for anaphylaxis from antivenom • Notify poison control

  35. Patient teaching • Avoid venomous snakes as pets • Be cautious in areas that harbour snakes like tall grass, rock piles, ledges, crevices, caaves, swamps • Don protective attire like boots, heavy pants and leather gloves. Use a walking stick • Inspect areas before placing hands or feet in them • Do not harass snakes….striking distance is the length of the snake • Snakes can bite even 20—60 minutes after death due to bite reflex • Use caution when transporting snake with victim to hospital…make sure it is in a sealed container.

  36. Arthropod Bites and Stings • Spiders: carnivorous • Almost all are venomous • Most not harmful to humans • Brown recluse, black widow, and tarantula are dangerous for example • Scorpions: not in Midwest or New England • Sting with tail • Bark scorpion is most dangerous • Bees and Wasps • Wide range of reactions • African or killer bees are very aggressive found in southwest states http://www.videojug.com/film/how-to-treat-an-insect-bite

  37. Brown recluse spider Bites result in ulcerative lesions Cytotoxic effect to tissue Medium in size Light brown color with dark brown fiddle shaped mark from eyes Shy in nature..hide in boxes, closets, basements, sheds, garages, luggage, shoes, clothing, bedsheets, clothes

  38. Over 1-3 days lesion becomes dark and necrotic…eschar even forms, and sloughs • Surgery is often needed • Skin grafting • Rare: Malaise, Joint pain, Petechaie, N/V Fever, Chills • Pruritis • Erythema • Extreme: hemolytic, renal failure, death

  39. Treatment • At site • Cold compress initially and intermittently over 4 days (may limit necrosis) • Rest • Elevation of extremity • NEVER use heat • At hospital • Topical antiseptic • Sterile dressing changes • Antibx • Dapsone: polymorphonuclear leukocyte inhibitor: 50mg twice/day • Monitor lab work closely • Surgery consult • Debridment and skin grafting

  40. Black Widow Found in every state but Alaska Prefers cool, damp, environment Black in color with red hourglass pattern on abd Male are smaller and lighter color that females Carry neurotoxic venom Bites to humans are defensive in nature Main prey other bugs, snakes, and lizards Bite is can be painful, local reactions Systemic reactions can happen in 1 hour and involve the neuromuscular system

  41. Causes lactrodectism • Venom causes neurotransmitters to release from nerve terminals • s/s • Abd pain • Peritonitis like symptoms • N/V • Hypertension • Muscle rigidity • Muscle spasms • Facial edema • Pytosis • Diaphoresis • Weakness • Increased salavation • Priapism • Respiratory difficulty • Faciculations • parathesias

  42. At site • Apply an ice pack • Monitor for systemic involvement • ABCs • At hospital • Monitor vitals • Pain meds • Muscle relaxants • Tentanus • Monitor for seizures • Antihypertensives • Anti venom if needed • Call poison control

  43. Tarantulas Largest spider Found mostly in tropical and subtropical parts of USA Some are in dry arid states like New Mexico and Arizona Can live 25 years Venom paralyzes prey and causes muscle necrosis Most human bites have local effects Have urticating hairs in dorsal abd area that can be launched for a defensive technique landing in skin and causing an inflammatory response

  44. USA trantulas don’t produce systemic reactions • Worldly ones do • S/S • Pain at site • Swelling • Redness • Numbness • Lymphangitis • Intense pruritis • Severe ophthalmic reactions if hairs come in contact with eyes

  45. Treatment • Pain meds • Immobolize extremity • Elevate site • Remove hairs with sticky tape followed by irrigation • For eyes: irrigation with saline • Antihistamines and steroids for pruritis

  46. Scorpions • Found in many states • Not usual in midwest or new england unless pet, or transported in baggage • Venom in stinger located on the tail • s/s • Localized pain • Inflammation • Mild symptoms • Treatment: pain meds, wound care, supportive management

  47. Bark scorpion Deadly Has a fatal sting Found in tress, wood piles, and around debris Humans stung when it gets in clothing, shoes, blankets, and items left on ground Solid yellow, brown, or tan in color Have thin pinchers, thin tail, and a tubercle Found in Arizona, New Mexico, Texas, Nevada, and California Has neurotoxic venom

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