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Nursing 202
Janie McCloskey,
R.N., M.S.N.
Injury to human tissue and organs resulting from
the transfer of energy from the environment
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Gender
◦ 2:1 ratio for men
Violence
◦ 19,000-23,000 per year
deaths
◦ Firearm death rate for
teenagers (15-19 yrs) up
77%
◦ 1.8 million women per
year are assaulted by
their partners
 Amount of Risk
 Occupations
 Cultural factors
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Race
◦ Whites 54 per 100,000
◦ Blacks 84.9 per 100,000
◦ Other 73.4 per 100,000
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ETOH
◦ 36% of fatal MVA had
intoxicated drivers
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3rd leading cause of
death for all ages
1st leading cause of
death for 1-44 yr of
age
Injuries most
commonly seen ages
25-34 but greater than
85 yr greater likelihood
to die
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146,000 deaths from
trauma per year
MVA 28%
Suicide 21%
Homicides 17.5%
Other 33.5%
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Severe
◦ accounts for 5% of total injuries
◦ Life-threatening
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Urgent
◦ 10 - 15% of all injuries
◦ may progress to life-threatening
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Non-urgent
◦ 80% of injuries
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Blunt trauma
◦ Common causes - MVA, pedestrian collisions, falls,
assaults & contact sports
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Penetrating injury
◦ Common causes - GSW, stabbings, & impalements
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High Priority
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Airway/breathing
C- Spine
Shock
External hemorrhage
Impending cerebral
herniation
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Lower priority
Evaluations
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Neurologic
Abdominal
Cardiac
Musculoskeletal
Soft Tissue
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A systematic process for the initial assess of the
trauma patient
◦ recognizing life threatening situations
◦ Identifying injuries
◦ Determining priorities of care based on findings
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Airway
Breathing
Circulation
Disability
Exposure/Environmental Control
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Airway obstruction is a rapidly fatal problem if not
corrected
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Positioning
Remove obstructions
Secure the airway
Suctioning
Intubation
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Injuries that impair ventilation include
pneumothorax, tension pneumothorax open chest
wounds and flail chest
Assessment should include:
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spontaneous respirations
rate & depth of respirations
length of inspiratory/expiratory cycle
symmetry of chest movement
splinting
JVD & trach position
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Assess circulatory status
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IV access
Fluid resuscitation
Three-for- one replacement rule
PRBCs
Disability
◦ mental status-AVPU or Glasgow Coma Score
◦ Pupils
Expose/Environmental Control
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Secondary survey consists of a more thorough
examination in order to identify all injuries.
It is assumed that an injury is present until ruled
out.
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F- Full Set of VS/ Five interventions/Facilitate Family
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Presence (EKG, SaO2, Foley, OG, Labs)
G-Give Comfort Measures
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H- History- AMPLE
H-Head to Toe
I- Inspect back
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Diagnosed by
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Pain
Rigidity
Guarding
Rebound tenderness
Referred pain
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May result in massive hemorrhage
Spleen is the most commonly injured abdominal
organ
Liver and pancreas injuries are also frequent
“Hollow” organ may rupture if intra-abdominal
pressures are high.
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Blood in NG aspirate may indicate injury to the
stomach or swallowed blood.
Injury to the small bowel may cause necrosis &
perforation
Injury to the large bowel carry a high rate of
morbidity & mortality. Peritonitis & sepsis may
occur.
Fluid Volume Deficit related to hemorrhage
secondary to disruption of visceral organs
GOAL
The client will have an effective circulating blood
volume as evidenced by:
*Stable VS appropriate for developmental age
*Urine output of 1 ml/kg/hr
*Strong, palpable pedal pulses
*Improved level of consciousness
*Skin Normal color, warm and dry
*Maintains HCT=30ml/dl or Hgb= 12-14g/dl
*CVP reading between 5-10 cm H20 pressure
*External hemorrhage controlled
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VS q 5-15 minutes
I&O q 1 hr
Assess pedal pulses q 1 hr
Glasgow coma score q 15 min
Assess skin temp and cap refill q 15 min
Assess HCT & Hgb levels for variations
CVP readings q 1 hr
Assess wounds for any evidence of bleeding
NS/LR as prescribed
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Assist with peritoneal lavage
◦ stomach and bladder decompression
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Peritoneal lavage is an important diagnostic
procedure in patients with blunt trauma
◦ Immediate blood return of 10 mL or greater=to OR
◦ Lavage drainage that unable to see through=to OR
◦ Elevated established lab values in drainage=to OR
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The client will experience a decrease in pain
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NO pain medicine until diagnosis is made
Rate pain using a 1-10 scale
splint or place in position of comfort when able
Decompress stomach and bladder
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7% of pregnant women will be injured during
pregnancy
MVA leading cause of death during childbearing
years
Falls is the 2nd most common injury
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Head Injury/trauma
Pelvic fracture with hemorrhage
Diaphragmatic Tears
Bladder Injury
Uterine injury
Fetal Injury during 3rd trimester
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Same as any trauma
patient PLUS
History- pregnancy
related questions
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EDC
Fetal activity
Prenatal problems
Uterine contractions
Inspection
◦ Perineum
Auscultation
◦ FHT
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Palpation
◦ Fundal height
Positioning
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Preterm Labor
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Most common
Contractions >6/min.
Clear or bloody Vag Discharge
Cervical dilation
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Abruptio Placentae
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Vaginal bleeding
Premature labor
Pain
Fetal distress
Maternal hemorrhage
Increasing fundal height
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Meconium or blood in urine
Pain
Difficulty palpating uterine wall
Fetal part outside of uterus
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Change in fetal movement
Fetal tachycardia or bradycardia
Maternal CPR
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Impaired Gas Exchange
◦ Position as soon as possible
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Risk for Aspiration
◦ Positioning
◦ Decompress stomach
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Fluid Volume Deficit
◦ Isotonic Solutions
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Anxiety
◦ 2 family members involved
◦ decisional conflict
REMEMBER!! The #1 cause of fetal death due to
trauma is maternal death. Treat the mother and
then the fetus!
Of Traumas that result in Death in the United States,
Seventy-Five percent Involve Chest Trauma
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Penetrating
◦ Gun Shot Wounds
◦ Stab Wounds
◦ Foreign Bodies
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Blunt Trauma
◦ Motor Vehicle Accidents
◦ Assaults
All Chest Trauma is Serious
 Respiratory System
 Major Blood Vessels
 Heart
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Most Common Chest Injury
Complications
◦ Hemothorax
◦ Pneumothorax
◦ Lacerated Liver, Spleen or Lung
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Pain
◦ Increased with Cough
◦ Increased with Movement
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Point Tenderness
Diagnosed by Chest Xray
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Pain related to Movement of the Chest
◦ Medicate as Prescribed
◦ Splinting (NO Wrapping)
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Risk for Ineffective Breathing Pattern related to
Chest Wall Movement
◦ Cough and Deep Breath
Two or More Fractures in Two or More Adjacent
Ribs resulting in a Floating Segment
Paradoxical Chest Movement
Ribs move Inward on Inspirations
Ribs Move Outward on Expiration
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Decreased Chest Expansion
Change in Pressure Gradient Resulting in
Decreased Air Movement
Ineffective Cough resulting in Increased
Secretions
Paradoxical Movement
 Respiratory Distress with Hypoxemia
 Asymmetric Chest
 Tachypnea
 Restlessness
 Cyanosis
Diagnosis by Chest Xray and Mechanism of Injury
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Ineffective Breathing Pattern related to Change in
Thoracic Pressure Secondary to Flail Chest
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Oxygen Therapy
Analgesics
Stabilization
Surgical Repair
Mechanical Ventilation with Elective Paralysis
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Risk for Ineffective Airway Clearance related to
Ineffective Cough and Pain
◦ Turn, Cough and Deep Breath
◦ Suction
◦ Keep Hydrated
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Pneumothorax- Air in the Pleural Space
Hemothorax- Blood in the Pleural Space
Hemopneumothorax- Blood and Air in the Pleural
Space
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Open- Hole in the
Chest Wall that
allows atmospheric
Air into the Pleural
Space
◦ Penetrating Injury
◦ Surgical Procedure
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Closed- Air Enters the
Pleural Space
Through the Lung
◦ Bleb Rupture
◦ MVA
◦ Emphysema
Open
 Sucking, Gurgling
sound on Inspiration
 Respiratory Distress
 Asymmetrical Chest
Closed
 Shortness of breath
 Chest Pain
 Tachypnea
 Cyanosis
 Decreased Breath
Sounds
 Subcutaneous
Emphysema
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Bleeding into the Pleural Space
300-1500ccs
Penetrating or Blunt
Air Leaks into the Pleural Space During
Inspiration but Doesn’t Leak Out. The
Amount of Air Increases with Each
Inspiration. The Lung Collapses and
Due to A Pressure Buildup the
Mediastinum Shifts to the Opposite
Side. This is A medical Emergency!! It
Puts a Large Amount of Pressure on
the Heart and Decreases Blood Return
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Severe Dyspnea- Progressive
Distant Breath Sounds
Deviated Trachea
Jugular Vein Distention
Cyanosis
Cardiogenic Shock
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Impaired gas Exchange related to Collapsed Area
of the Lung
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Semi Fowlers
Cough and Deep Breath
Monitor ABGs, Electrolytes and Blood Counts
Administer Oxygen
Pain medications as Ordered
Chest Tube
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Anxiety related to Dyspnea And or Treatment
◦ Explain Procedures
◦ Be Calm and Reassuring
Lungs are Surrounded
by Pleura. Usually
Negative Pressure
Exists that keeps the
Pleura Adhered to the
Chest wall and
Causes Inspiration.
If Pleura in Interrupted,
Air enters The Pleural
Space and Negative
Pressure is
Lost and the Lung
Collapses.
To Remove Air or Fluid a
Chest Tube is Inserted
to Remove Air &/or fluid
to Restore negative
Pressure and
Reexpand the Lung.
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All Are systems in which a 34 or 36 French Chest
Tube are attached to an Underwater System. This
allows the escape of air with exhalation but will not
allow air to be inspired through the tube. ( Not
enough negative Pressure to Override the Water
pressure)
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Works Like a Three Bottle System
◦ Underwater seal
◦ Suction chamber
◦ Drainage Collection Chamber
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May use Valves instead of Underwater Seal
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Assess Respiratory Status Q2 Hr
VS Q4
Note Quality of Respirations
◦ Labored
◦ Shallow
◦ Cyanosis
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Check Chest Drainage System Q1 Hr
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Keep Below Chest level
No Kinks or Dependent Tubes
Assure that Connections are secure
Note Type and Amount of Drainage
Check Fluctuation
Check Bubbling
Check Anxiety Level
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Ineffective Breathing Pattern related to
Deceased Lung Expansion
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Maintain Functioning Chest Drainage System
Keep Petroleum Gauze Around Tube
Keep Tubing Free of Kinks and Loops
Cough and Deep Breath frequently
Change Position Frequently
Clear Tubing of drainage
Maintain Water Seal
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Anxiety related to Perceived Risk of Chest Tube
Dislodgment , System Disruption and Inability to
Breath
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Provide Information regarding Chest tube
Sutured In Place
Avoid Kinks and Loops
Expect Bright Red Blood for 72 Hrs
System is Checked Frequently
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Reexpansion Confirmed by Chest Xray
Premedicate 30 minutes before Removal
Valsalva and Remove
Airtight Dressing
Monitor for Respiratory Distress and Drainage
Crushing or Bruising of the Lung due to a
Severe Blow to the Chest. This Results in
Alveolar Damage leading to Atelectasis. The
airway Becomes Plugged With Blood and
Edema. This Impairs Ventilation
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Mild- No Symptoms
Extensive
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Deceased Lung Compliance
Hypoxemia
Dyspnea
Cough
Hemoptysis
Tachypnea
Chest Pain
Restlessness
Dependent upon extent of the Injury
 Mild
◦ Oxygen
◦ Observation
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Extensive
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Restrict Fluids
Antibiotics
High fowlers
Suction
Pain Medication
Deep Breathing Exercises
NUR 202
Janie McCloskey, RN, MSN
Inadequate tissue perfusion
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Hemorrhagic
Hypovolemic
Anaphylactic
Septic
Cardiogenic
Neurogenic
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Oxygen Delivery
◦ Arterial oxygen saturation
◦ Hemoglobin
◦ Cardiac output
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Oxygen Consumption
◦ Tissue needs
◦ Shunting
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Compensatory mechanisms
1. Neural (pressoreceptors-SNS)
2. Endocrine/hormonal (SNS)
1. Renal flow-aldosterone/ADH
2. Anterior pituitary-glucocorticoids
3. Adrenal Medulla-epinephrine/norepinephrine
3. Chemical (chemoreceptors-paO2)
2. Intermediate and progressive
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Compensation continues with deterioration
Prolonged vasoconstriction of extremities
Anaerobic metabolism
Cellular NA/K pump failure-Edema
Microcirculation dilates-DIC
Histamine release-capillary permeability
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Stagnant blood in the microcirculation
◦ Lactic acid buildup-metabolic acidosis
◦ Pyruvic waste products
◦ Increased concentration of clotting factors
 Depletes clotting factors
 Bleeding
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Client will be free of signs and symptoms of
bleeding
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Assessment
Minimal invasive sticks
Soft tooth brushes
Protect from trauma
◦ Treat the underlying cause
◦ Obtain and monitor labs
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PT/PTT
Platelets
Fibrinogen
*D-dimer
Fibrin split products (FSP)
◦ Heparin drip
◦ FFP (clotting factors)
◦ Cryoprecipitate (factor VIII)
3. Refractory or irreversible
◦ Prolonged inadequate tissue perfusion that is
unresponsive to therapy
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Absolute hypovolemia
◦ External Loss
 Blood
 Plasma
 Body fluids
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Relative hypovolemia
◦ Internal loss
 Third spacing
 Internal hemorrhage
Based upon:
 Age
 General health
 Extent of injury
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Loss of 15% or 750 ml can compensate
Loss between 15-30% (750-1500ml) SNS
stimulation
Loss of 30-40% requires aggressive replacement
◦ IVF and or Blood
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Loss of >40% -Ineffective autoregulation and
irreversible tissue destruction
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Client will have adequate circulating fluid volume
as evidenced by: (see multiple trauma)
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A
B
C
◦ Transfusion of blood products
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Whole Blood
PRBC
FFP
Platelets
Treat underlying cause
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Requires MD order
◦ Verify and compare with clinical status and Lab values
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Explain procedure to client (RN or MD)
◦ Obtain consent
 One consent per product category
 OR consent includes blood transfusion and 2 hours post op
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Assure size and patency of line-flush with 10 ml of
NS
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Use 2 identifiers to establish client’s identity
Copy the blood bank number # (BB# C) on the
“Results form Blood Bank”
If no armband on the client then a new Type
and cross must occur
Transport can pick up the blood but only for
one client
Do not remove the armband until 72 hours after
blood is administered
Obtain VS 15 minutes before beginning
administration
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Check order for transfusion, type and rate
Two licensed personnel must go to the clients
room. Establish identity with 2 identifiers
Each nurse reads aloud to the other the client’s
name, history number, blood bank number (C)
from the arm band and the requisition that is
attached to the bag. Leave the requisition
attached. If scanner used, Info is still verified.
Compare the donor number on the unit and the
requisition
Compare the ABO grouping, Rh, and expiration
date
Both personnel must sign the requisition
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Spike unit with tubing provided by the blood
bank. Squeeze drip chamber until blood level is
above the filter
Licensed personnel must stay with the client
during the first 15 minutes of the transfusion.
Assess for signs of reaction
Take complete VS at the end of 15 minutes
Take VS at the end of 1 hr (45 minutes later)
and then hourly until blood completed.
VS at the completion of transfusion and 30
minutes post transfusion
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Start blood as soon as obtained
Cannot return blood if out for >20 min
Do not put in unit refrigerator
If need to infuse for >4 hours-ask blood bank to
split unit
Discard unit after use unless RXN
Compatible only with NS
Change filter every 4 hours or after 4 units
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Acute Hemolytic-ABO incompatibility
◦ Chills, fever, LBP, flushed skin, VS changes,
hemoglobinuria, bleeding, ARF, shock
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Febrile Reaction-leukocyte incompatibility
◦ Chills, fever of 1 degree increase, HA, flushing, anxiety,
muscle spasm
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Delayed
◦ Hemolytic, hepatitis B, hepatitis C, HIV
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Stop infusion
NS to IV site
Notify MD and Blood bank
Recheck tag and numbers
Monitor UOP and VS
Treat symptoms per MD order
Send blood and tubing to lab
Complete transfusion reaction report
Collect blood and urine samples as ordered
Document
2 or more of the following:
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Temp > 100.4 or <97
HR >90
PCO2<32
WBC >12000 or <4000 or with 10% bands
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Gram negative/gram positive
Invading bacteria multiply faster than body can kill
them-endotoxins
◦ Damages cells and alters metabolism
◦ Releases histamine
 Massive vasodilatation, increased capillary permeability,
maldistribution of blood
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Hyperdynamic - Warm Shock
Hypodynamic- Cold shock
Multi system Organ Failure (MODS)
◦ Dysfunction of 3 or more organs
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Impaired Gas exchange
Altered tissue perfusion
Altered thermoregulation
Altered thought processes
Anxiety/fear
Anticipatory grieving
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Prevention
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Know the population at risk
Thorough history
Sterile technique
Early nutrition
Standard precautions
Continual assessment
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Provide oxygenation and ventilation
Monitor hemodynamic values
Administer and monitor IV fluids
Monitor EKG
Daily weights
Monitor lab values
C&S of specimens
Timely antibiotic therapy
Pharmacological interventions
Nutritional support
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Calm, quiet environment
Reduce myocardial O2 demand
Thorough assessment
Emotional support for client and family
Prevent complications
◦ Skin breakdown
◦ Contractures
◦ Foot drop