NR 341 Week 5 Nursing Care: Trauma and Emergency

NR 341 Week 5 Nursing Care: Trauma and Emergency

Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

Nursing Care for Trauma: Key Considerations

The nursing care for a homeless client presenting to the emergency department with hypothermia, indicated by a core body temperature of 87ºF (30.5ºC), requires thorough assessment and understanding of potential findings. Nurses should anticipate various assessment outcomes, including bradypnea, lethargy, absent patellar reflex, dilated pupils, shivering, hypertension, elevated hematocrit levels at 55%, Kussmaul respirations, and tachycardia.

Submersion injuries are critical considerations, especially as they primarily affect children. These injuries occur when an individual becomes hypoxic due to immersion in liquid, leading to fluid imbalances as water is aspirated. In cases of hypotonic freshwater exposure, absorption through alveoli causes pulmonary edema, while hypertonic saltwater can draw fluid from the circulatory system, impairing gas exchange and resulting in hypoxia. Compensatory mechanisms divert blood to the lungs, depriving other organs of oxygen and potentially resulting in cerebral injury and edema. Treatment focuses on correcting hypoxia and fluid imbalances while supporting physiological function, with rewarming procedures necessary if hypothermia is present.

Trauma Types and Management

Penetrating trauma occurs when an object pierces the skin, leading to open wounds. Common examples include gunshot and stab wounds, with penetrating head trauma often resulting in high mortality rates and permanent neurological deficits. Neck injuries pose risks for hemorrhage and spinal cord damage, while abdominal trauma severity is determined by the involved organs. Extremity trauma may cause lasting disabilities due to hemorrhage, and angulated fractures can lead to penetrating injuries.

Adequate resuscitation indicators include stable hemodynamic and renal parameters, normalized core body temperature, serum lactate levels below 2 mmol/L, and no base deficit. Arterial pH should range from 7.35 to 7.45, with hemoglobin above 9 g/dL, and normal serum calcium and potassium levels. Coagulation profiles should also be within normal limits, ensuring pain is managed effectively.

Emergency Preparedness and Triage

Emergencies can arise from internal threats, such as power loss and facility damage from natural disasters, or external threats, including biological, chemical, hazardous, radiologic, or explosive events. In a mass casualty incident, the priority is to assess and categorize injuries as life-threatening, urgent but not life-threatening, minor, or extensive/deceased. Life-threatening injuries demand immediate intervention, whereas urgent cases require assessment but are not immediately life-threatening. Minor injuries can withstand delayed treatment, while extensive injuries indicate a low likelihood of survival.

Using the START (Simple Triage and Rapid Treatment) method, triage color tags are assigned based on the severity of injuries. For example, a victim who is not breathing and has no radial pulse should receive a black tag, indicating deceased status. In contrast, a victim with weak and thready pulse and shallow respirations should be tagged red, signifying a need for immediate attention.

The client admitted on a backboard, with cervical immobilization and significant leg deformities, should have vital signs monitored closely, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Essential nursing interventions include removing wet clothing to minimize heat loss, facilitating lab tests, and initiating ECG monitoring.

Table of Nursing Care Considerations

Traction and Its Types

Traction is a therapeutic method used primarily to alleviate pain, immobilize the body, or aid in the reduction of fractures. There are two main types of traction utilized in medical practice: skin traction and skeletal traction.

Skin Traction is typically used as a temporary measure until skeletal traction or surgery becomes feasible. This method involves applying boots or splints directly to the skin, which helps decrease muscle spasms. Traction weights serve as the pulling force to maintain the necessary alignment.

Skeletal Traction, on the other hand, offers a long-term solution by inserting pins or wires into the bone. Weights are then attached to these devices to ensure proper alignment and immobilization of the injured body part. However, one significant complication associated with skeletal traction is the risk of infection.

Compartment Syndrome

Compartment syndrome is an urgent medical condition characterized by swelling that leads to increased pressure within a confined anatomical space, known as a muscle compartment. This elevated pressure compromises the function of blood vessels and nerves within the compartment, resulting in diminished perfusion. Continuous neurovascular assessment is crucial in monitoring for signs of compartment syndrome. Symptoms may include pulselessness distal to the injury, severe pain, pallor, paresthesia, paralysis, and poikilothermia.

It is important to avoid elevating the affected extremity above heart level or applying cold compresses, as these actions can exacerbate the condition through vasoconstriction. Surgical intervention, such as fasciotomy, is often required to relieve the pressure, with the surgical site typically left open for several days to monitor for infection. In severe cases, amputation may become necessary.

Fat Embolism Syndrome

Fat embolism syndrome occurs when fat globules enter the bloodstream, often following fractures of long bones, ribs, tibia, or pelvis. Early recognition is vital to prevent potentially fatal outcomes. Symptoms generally manifest within 24 to 48 hours and can include severe respiratory distress, chest pain, tachypnea, cyanosis, dyspnea, apprehension, anxiety, tachycardia, hypoxemia, and petechiae on the neck, chest wall, axilla, mucous membranes, and conjunctiva.

Treatment focuses on preventing hypovolemic shock, providing respiratory support, correcting acidosis, and administering blood transfusions. Vasopressors may also be used for hemodynamic stability. Moreover, it is critical to prevent secondary injuries by ensuring careful immobilization and handling of long bone fractures and minimizing movement before stabilization.

Rhabdomyolysis

Rhabdomyolysis is a syndrome that arises from the breakdown of damaged skeletal muscle cells, resulting in the release of myoglobin into the bloodstream. This myoglobin can precipitate and obstruct renal tubules, leading to acute kidney injury (AKI). Common signs of rhabdomyolysis include dark reddish-brown urine, alongside other symptoms indicative of AKI.

Types of Burns

Burn injuries can be categorized into different types, each with unique characteristics and management requirements.

Thermal Burns are caused by exposure to flames, flashes, scalds, or contact with hot objects. The severity of thermal burns depends on the burning agent’s temperature and the duration of contact. Scald injuries frequently occur in bathrooms and kitchens, while flash and contact burns can arise during cooking or burning debris.

Chemical Burns result from contact with acids, alkalis, and organic compounds. Common acids include hydrochloric, oxalic, and hydrofluoric acid; while alkalis can include cement, oven cleaners, and industrial cleaners. Organic compounds such as chemical disinfectants and petroleum products also pose a risk.

Smoke and Inhalation Burns occur when noxious chemicals or hot air are inhaled, leading to damage to the respiratory tract. These types of burns can quickly lead to airway compromise and pulmonary edema, making smoke inhalation a significant predictor of mortality in burn patients.

Electrical Burns result from the intense heat generated by electric currents, with severity depending on voltage, tissue resistance, current pathways, and duration of current flow. Bone and fat tissues are generally more resistant to damage, whereas nerves and blood vessels are the least resistant.

Cold Thermal Injuries are caused by frostbite, which affects tissues due to exposure to cold temperatures.

Depth and Location of Burns

The depth of burns is classified as follows:

• Superficial Partial Thickness (1st degree): Involves only the epidermis, with intact tactile and pain sensations.
• Deep Partial Thickness (2nd degree): Involves both the epidermis and dermis, allowing for potential epithelial regeneration.
• Full Thickness (3rd and 4th degree): Involves destruction of all skin elements and local nerve endings, necessitating surgical intervention for healing.

Assessing the exact extent and depth of a burn injury can be challenging during the emergent phase due to edema and inflammation obscuring injury demarcation. The location of the burn also plays a critical role in determining severity. Burns on the face, neck, or circumferential areas of the chest can compromise breathing, while burns to the hands, feet, and eyes can hinder self-care. Burns on thin-skinned areas like the ears and nose are at a higher risk for infection, as are those in the buttocks or perineum due to potential contamination.

Rule of Nines and Risk Factors

The Rule of Nines and the Lund-Browder chart are tools used for the initial assessment of burn patients to estimate the percentage of total body surface area (TBSA) affected. For instance, using the Lund-Browder Chart:

• 3½% (face) + 1% (anterior neck) + 6½% (right anterior trunk) + 2% + 1½% (anterior right arm) + 3½% (anterior right lower leg) = 18% TBSA.

Using the Rule of Nines might yield:

• 4½% (face) + 9% (anterior upper chest & neck) + 4½% (anterior right arm) + 4½% (anterior right lower leg) = 22½% TBSA.

Risk factors for poor burn recovery include preexisting conditions such as heart, lung, or kidney diseases, which can complicate recovery due to increased bodily demands. Diabetes and peripheral vascular disease can delay healing, particularly for leg or foot burns. Malnutrition significantly hinders recovery from burn injuries, and the presence of additional trauma such as fractures or head injuries complicates the recovery process further.

Priorities in Burn Management

The priority in managing burn injuries is to remove the source of the burn and halt the burning process. Cooling the affected area within one minute is critical to minimize injury depth. Immediate removal of chemicals from the skin is essential, and in cases of significant burns (greater than 10% TBSA) or suspected inhalation burns, healthcare providers should focus on the ABCs of assessment:

• Airway: Assess patency, check for soot around the nostrils, singed nasal hair, and observe for darkened mucous membranes.
• Breathing: Evaluate ventilation adequacy.
• Circulation: Check pulses and elevate burned limbs above heart level to reduce pain and swelling.

Continuous monitoring for lung-related injuries is vital, noting any excessive secretions, difficulty swallowing, hoarseness, stridor, chest wall retractions, altered mental status, dyspnea, or wheezing. Avoid cooling large burns for more than 10 minutes to prevent hypothermia, and do not submerge burned areas in cold water or use ice, as this can cause vasoconstriction and decrease perfusion.

Phases of Burn Management

Phase 1: Emergent (Resuscitative)

This phase addresses immediate life-threatening issues resulting from burn injuries and typically lasts up to 72 hours. The primary concerns include hypovolemic shock and edema, necessitating fluid mobilization and diuresis. Preventative measures against infection, hypothermia, and emotional support are also essential. Increased capillary permeability causes significant fluid shifts from the intravascular to the interstitial space, leading to fluid loss that can result in hypovolemic shock. Fluid replacement, particularly with Lactated Ringer’s solution, is necessary to restore vascular space fluid levels.

Phase 2: Acute (Wound Healing)

The acute phase begins with the mobilization of extracellular fluid and diuresis, concluding when partial-thickness wounds heal or full-thickness burns are covered with skin grafts. This phase can last from weeks to months. As fluid returns to the intravascular space and diuresis begins, edema subsides, and bowel sounds return. Partial-thickness burns can heal if kept free from infection and dryness, while full-thickness burns require surgical intervention for healing.

Phase 3: Rehabilitation (Restorative)

This phase begins when the patient’s wounds have nearly healed, allowing them to engage in self-care activities. This stage can last for years, focusing on reestablishing a functional role in society and addressing any necessary cosmetic reconstructive surgery. Priorities include psychosocial well-being and prevention of scarring and contractures. Continuous physical and occupational therapy is crucial for maintaining muscle strength and optimal joint function. Common complications during this phase include skin and joint contractures and hypertrophic scarring.

Fluid Replacement and Nutritional Support

The Parkland Formula is utilized to determine the appropriate amount of fluid replacement within the first 24 hours post-burn:

1. Calculate TBSA % and multiply by 4 ml and the patient’s body weight in kilograms.
2. Administer half of the calculated fluid over the first 8 hours.
3. Administer the remaining half over the subsequent 16 hours.

For example, a patient weighing 19 kg with burns covering 38% of their body would require 2,888 ml total fluid

replacement over the first 24 hours.

Nutritional support is essential in promoting healing and maintaining lean body mass, often requiring higher caloric intake to sustain metabolic demands.

Skin Graft Types and Complications

There are several types of skin grafts:

1. Autografts: Skin taken from the same patient.
2. Allografts: Skin taken from another person.
3. Xenografts: Skin taken from another species (often porcine).
4. Synthetic grafts: Materials used to promote healing.

Complications can arise from the grafting process, such as hematoma, seroma, and infection. Additionally, surgical debridement may be necessary for nonviable tissue.

Conclusion

The comprehensive management of trauma involves recognizing and addressing the potential for various complications that can arise from burn injuries. Early assessment, timely interventions, and coordinated care are essential in ensuring optimal outcomes for affected individuals.

References

American Heart Association. (2022). Advanced cardiovascular life support (ACLS) provider manual.

Chamberlain, R. S., & Sarin, E. (2023). Principles of trauma management.

Harris, J. D., & Miller, D. J. (2021). Management of traumatic brain injury. Journal of Neurotrauma, 38(7), 1012-1024.

NR 341 Week 5 Nursing Care: Trauma and Emergency

National Institute of Health. (2024). Trauma care: A multidisciplinary approach.

World Health Organization. (2023). Emergency preparedness and response.