NR341- Week 5 content

thermal burns

Caused by flame, flash, scald, or contact with hot objects most common burn injury is from house fires Severity of injury depends on o Temperature of burning agent o Duration of contact time Treat by removing victim from source, cool burn with water, check for bleeding and shock, seek medical attention

Acute (wound healing) phase: infection complications

Watch for signs & symptoms: - Hypothermia or hyperthermia -Increased HR & RR - Decreased BP - Decreased urine output

Emergent Phase: respiratory complications

o Upper airway burns -Edema formation -Mechanical airway obstruction and asphyxia o Lower airway injury Pneumonia Pulmonary edema

Exposure nursing interventions

o Warm up room o Remove clothing for other injuries o Put on warm blankets o Stabilize impaled objects if not already done o Maintain privacy

Risk factor of burns: Pre-existing condition

o cardiovascular, respiratory, and renal diseases contribute to poorer prognosis o Diabetes mellitus and peripheral vascular disease contribute to poor healing and gangrene o Especially with foot and leg burns-- high risk for delayed healing

flash injury (thermal)

o generates light & heat § Caused by heat generated to exposed areas OR by flames from ignition of clothing.

Clinical manifestations of pneumothorax

o mild tachycardia o dyspnea o respiratory distress o chest pain o "no" breath sounds in affected lung area o SOB o cough o hypoxia

conductive injuries

o occur when the current overcomes the skins resistance and travels through body o Current passing through vital organs produces more life-threatening injuries than current that passes through other tissue. o Electric current immediately contracts muscles causing possible skeletal/joint injuries o Direct current (DC): travels in ONE direction -- explosion o Alternating current (AC): passes BACK & FORTH from point of contact o Compartment syndrome is common -- due to edema from injured tissues compounded by large fluid volume o Invasive decompressive therapies include: o Fasciotomies o Nerve releases o Ocular releases o Laparotomies

Acute (wound healing) phase: musculoskeletal complications

decreased ROM & contractures

Disability nursing interventions

o GCS score o Sternal rub for eye responsiveness o Assess LOC o Check for PERRLA

Chemical burns- contact

** Result of contact with acids, alkalis, & organic compounds o Acid chemicals: toilet bowl cleaners, bathroom tile cleaners o Hydrofluoric acid: refrigerants, herbicides, and fluorescent light bulbs o Organic compounds: phenols (disinfectants) & petroleum products (gasoline) o Alkalis: cement, oven cleaners, drain cleaners -- Alkali burns are hard to manage because they adhere to skin tissue (up to 72 hours) and cause protein hydrolysis and liquefaction*** .

Emergent Phase: nursing managment of wound care

***Should be delayed until patent airway, adequate circulation, adequate fluid replacement established!!!!! o Debridement o Infection most serious threat to further tissue injury -- source is pt own flora ; need to do reverse isolation o open method= burn is covered with topical antibiotic with no dressing over wound o Multiple dressing changes or closed method o When open burns wounds are exposed, staff should wear - Disposable hats Masks Gowns Gloves o Allograft or homograft skin-- Usually from cadavers; typically used with newer biosynthetic options

Blunt abdominal trauma

- most frequently caused by MOTOR VEHICLE ACCIDENTS - MOST COMMON SOLID ORGANS INJURED - LIVER + SPLEEN **** - presentation - hypotension, tachycardia, chest + abd wall tenderness + ecchymoses after motor vehicle accident - ANYTIME YOU SEE THIS SX AFTER MOTOR VEHICLE ACCIDENT (BAT) OR SEE FREE INTRAPERITONEAL FLUID AFTER BAT, THINK SPLEEN OR LIVER INJURY Compression injuries (direct blow to abdomen) shearing injuries (rapid deceleration in MVC some tissue to moves forward while other tissues stay stationary)

Iatrogenic pneumothorax

-Collection of air in the pleural cavity -caused by medical procedures EX: thoracentesis, pleural biopsy, central line placement, high positive pressure ventilation setting

collaborative care for pneumothorax

- If minimal no treatment may be necessary. -Thoracentesis: aspirate with large-bore needle - Heimlich valve may also be used - Chest tube insertion with chest drainage system - If keeps happening = treated surgically by a partial pleurectomy, stapling, -pleurodesis to promote adherence of the pleurae to one another o Urgent needle decompression for tension pneumothorax -- followed by chest tube insertion to water-seal drainage.

Traumatic blunt (closed) pneumothorax

- Lung laceration - Alveolar rupture (COPD patients, doing CPR to a frail copd patient can cause a pneumothorax)

Acute abdominal pain- clinical manifestations

- Pain is most common symptom - Nausea, vomiting, diarrhea, constipation - Flatulence - Fatigue - Fever - Rebound tenderness - Bloating

Depth of Burn Injury

-Superficial - damage to epidermis -Superficial partial thickness (1st degree) - damage to the entire epidermis and some parts of the dermis - Sunburn; NO blisters -Deep partial thickness (2nd degree) - damage to entire epidermis and deep into the dermis - Blisters; shiny, red, wet -Full thickness (3rd degree) - damage to the entire epidermis and dermis, and may extend into the subcutaneous tissue. Nerve damage also occurs. -Deep full thickness (4th degree) - damage to all layers of skin and extends to muscle, tendons and bones

American Burn Association Referral criteria

1) parital or full thickness burn greater than 10% TBSA 2)burns that involve the face, hands, feet, genitalia, perineum, and major joints. 3) full-thickness (3rd degree) burns in any age group 4) electrical burns, including lightening injury 5) chemical burns 6) inhalation burns 7) burn injury with a preexisting medical disorder that could complicate management, prolong recovery, or affect mortality 8) burns accompanied by trauma (ex: fractures) in which the burn injury poses the greatest risk for morbidity and mortality 9) burned children in hospitals without qualified personnels or equipment for the care of children 10) burn injury for those who will require social, emotional, or rehabilitative intervention. ALL burns should be treated w/ concern

Chest Trauma Emergency Management -initial interventions

1. ABC's - findings will guide management 2. Ensure patent airway. 3. Assess for signs of respiratory distress 4. *Keep pulse oximetry > 90%* 5. Prepare for Chest tube insertion 6. Maintain hemodynamic stability 7. Establish IV access 8. Begin fluid resuscitation as appropriate 9. *Fluid bolus (500 mL-1 L) to expand blood volume in patient with blood loss; done PRIOR to type and cross* 10. Manage pain 11. Remove clothing 12. Cover sucking chest wound 13. Stabilize impaled objects. 14. Assess for other significant injuries and treat appropriately. 15. Stabilize flail rib segment. 16. *Place patient in a semi-Fowler's position or position of comfort.* 17. *Prophylactic antibiotics may be prescribed for penetrating trauma* 18. Analgesics 19. prepare for needle decompression

Breathing

1. Assess presence & effectiveness 2. Observe expansion & effort (rate & depth) 3. Tracheal position & jugular distension

acute abdominal pain- initial interventions

1. Ensure patent airway. 2. Apply O2 via NC or nonrebreather mask 3. Establish IV access with large-bore IV & infuse warm normal saline or LR. Insert another large-bore IV if shock present. 4. Obtain blood for CBC & electrolyte levels 5. Obtain blood for amylase level, pregnancy tests, clotting studies, and type & crossmatch as appropriate. 6. Insert indwelling urinary catheter. 7. Obtain urinalysis. 8. Insert NG tube as needed.

chest tube insertion steps

1. Insertion of a chest tube can take place in the emergency department (ED), at the patient's bedside, or in the operating room. 2. The patient is positioned with the arm raised above the head on the affected side to expose the midaxillary area, the standard site for insertion. Elevate the patient's head 30 to 60 degrees, when possible, to lower the diaphragm and reduce the risk of injury. 3. A chest x-ray is used to confirm the affected side. 4. The area is cleansed with an antiseptic solution. The chest wall is prepared with a local anesthetic, and a small incision is made over a rib. 5. The area is first probed digitally to avoid injury with a sharp instrument. 6. A clamp is used to hold the chest tube and guide it into place. The tube is advanced up and over the top of the rib to avoid the intercostal nerves and blood vessels that are behind the rib inferiorly. 7. Once inserted, the tube is connected to a pleural drainage system (will discuss in next few slides). Two tubes may be connected to the same drainage unit with a Y-connector. 8. The incision is closed with sutures, and the chest tube is secured. The wound is covered with an occlusive dressing. Some clinicians prefer to seal the wound around the chest tube with petroleum gauze. 9. Proper tube placement is confirmed by chest x-ray. 10. The insertion of a chest tube and its presence in the pleural space is painful. Monitor the patient's comfort at frequent intervals and use the appropriate pain-relieving interventions.

Airway / cervical spine

1. Most important step in the primary survey 2. If clients are awake and responsive, airway is open 3. Head tilt chin lift maneuver is most effective technique; DO NOT perform if clients have a potential cervical spine injury 4. If trauma suspected c-collar should be applied

Circulation

1. check HR, BP, pulses, & capillary refill 2. Assess for bleeding 3. Obtain large bore IV's & fluids 4. Shock can develop, inadequate tissue perfusion & oxygenation

Disability

1. determine LOC-AVPU 2. determine Glascow Coma Scale

Prehospital care for large thermal burns (>10% TBSA, electrical/inhalation burn, pt UNRESPONSIVE)

1st focus is CAB!!! Circulation: o check for pulse o elevate burned limb(s) above heart to decrease pain/swelling Airway: o check patency o soot around nares on tongue o singed nasal hair o dark oral/nasal membranes Breathing: o Check for adequacy of ventilation

flail chest

A condition in which two or more ribs are fractured in two or more places or in association with a fracture of the sternum so that a segment of the chest wall is effectively detached from the rest of the thoracic cage. o fracture of several consecutive ribs, in two or more separate places, causing an unstable segment

spontaneous pneumothorax

A pneumothorax that occurs when a weak area on the lung ruptures in the absence of major injury, allowing air to leak into the pleural space. -- usually in patients with asthma, COPD, cystic fibrosis, or pneumonia risk factor: smoking

What is LOC-AVPU

A: is the patient awake? V: does the patient respond to verbal stimulation? P: does the patient respond to painful stimuli? U: is the patient completely unresponsive?

Auto transfusion

Also called blood salvaging. A method of retrieving blood lost at the operative site, reprocessing it, and infusing it back to the patient.

Emergent Phase: nursing managment of drug therapy

Analgesics/Sedations: - morphine -haloperidol -lorazepam (Ativan) -midazolam (versed) Tetanus immunization Antimicrobial agents (topical): - silver sulfadiazine (silvadene) - mafenide acetate (sulfamylon) VTE prophylaxis: - heparin or enoxaparin (lovenox) -compression stockings; SCDs

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration D. Exposed sutures without dressing E. Drainage system upright at chest level

B, C Gentle bubbling in the suction control chamber is an expected finding as air is being removed A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicate that the drainage system is functioning properly

Acute (wound healing) phase: Duration & healing factors

Beginning of diuresis to near completion of wound closure o Healing begins as WBCs surround burn wound & phagocytosis occurs o Necrotic tissue sloughs off & granulation tissue forms---Done by debridement o Partial-thickness burn wounds heal from edges and from dermal bed, eschar is removed, skin can grow back o Full-thickness burns must have eschar removed (debrided) & skin grafts applied

Diagnostic test of flail chest

CXR ABG

metabolic asphyxiation

Carbon monoxide (CO) poisoning: CO is produced by the incomplete combustion of burning materials *Inhaled CO displaces oxygen causing: -Hypoxia -Carboxyhemoglobinemia (hemoglobin combined with CO) ---- administer 100% O2!!!!!! -Death (CO level >20%)

hemothorax

Collection of blood in the pleural cavity. This condition often results from chest trauma, such as a stab wound, or it can be caused by disease or surgery

Acute (wound healing) nursing management of pain

Continuous background pain: - IV infusion of an opioid - slow-release, twice-a-day oral opioid Analgesic and anxiolytic nonpharm methods: guided imagery, hypnosis, aromatherapy, music therapy

Prehospital care for small burns (<10% TBSA)

Cover with clean, cool, tap water—dampened towel NO ICE ; slows down circulation

Prehospital care for prevention of hypothermia in large thermal burns:

Do not immerse in cool water or pack with ice cause extensive heat loss Remove burned clothing to prevent further tissue damage Wrap in clean, dry sheet or blanket

Chest tube nursing management-- dressing care

Dressing care •Sterile occlusive dressing

Emergent (resuscitative) : Duration & Primary Concerns

Duration: onset of injury to completion of fluid resuscitation · Usually last up to 72 hours Main concerns: hypovolemic shock & edema

Emergent (resuscitative) : Patho

Fluid & electrolyte massive shift = increased capillary permeability due to fluid out of blood vessels This leads to edema! Pt is severely HYPOVOLEMIC

Rehabilitation (restorative) Phase: Duration & healing factors

From major wound closure to return to individual optimal level of physical & psychosocial adjustment (self-care) Burn wound heals either by spontaneous re-epithelialization or by skin grafting

Acute abdominal pain

General symptom that can be life-threatening; requires immediate attention

Rule of Nines (adult)

Head 9% Back 18% Chest 9% Abdomen 9% Arms 9% each Groin 1% Upper Leg 9% each Lower Leg 9% each. remember to split anterior vs posterior

Chest tube nursing management-- observe fluid levels in water-seal chamber

High fluid levels in the water-seal indicate residual negative pressure.

Chest tube nursing management-- how to observe tidaling

If no tidaling is observed; the drainage system is blocked, the lungs are reexpanded, or the system is attached to suction. If the chest tube is connected to suction, disconnect from wall suction to check for tidaling.

upper airway injury- above glottis

Injury to mouth, oropharynx, and/or larynx Thermally produced Hot air, steam, or smoke *Swelling may be massive and onset rapid* -Eschar and edema may compromise breathing -Swelling from scald burns can be lethal

lower airway injury

Injury to trachea, bronchioles, and alveoli Injury is related to length of exposure to smoke or toxic fumes--- incomplete combustion or nocxious gases Pulmonary edema may not appear until 12 to 24 hours after burn ---Later manifests as acute respiratory distress syndrome (ARDS)

Chemical Burn: Nursing Interventions

Interventions: REMOVE CLOTHING AND RINSE SKIN Chemical & clothing should be quickly removed from skin Tissue destruction may continue up to 72 hours after chemical injury

location of burn

Location of the burn is related to the severity of the injury: Face, neck, chest, -respiratory obstruction secondary to edema/eschar Hand, feet, joints, eyes- self- care Ears, nose- infection Circumferential burns of the extremities can cause circulatory compromise -Patients may also develop compartment syndrome

Lund-Browder Chart

Most accurate method for estimating burn extent, & must be used in the evaluation of all pediatric patients

Acute (wound healing): lab values

Na+ : 135-145 -- hyponatremia o Excessive GI suction o Diarrhea o Water intoxication o Give juices, nutritional supplements K+ : 3.5-5 -- hyperkalemia o Renal failure/ AKI o Massive deep muscle injury o Muscle broken down Hyperkalemia can cause o Dysrhythmias & ventricular failure o Muscle weakness

Emergent (resuscitative) : Net result of fluid & electrolyte shift

Net result fluid shift is intravascular volume depletion: o Edema o ↓ Blood pressure o ↑ Pulse o RBCs hemolyzed by circulating factor released at time of burn=Thrombosis. o ↑ hematocrit Immune system challenged: o Skin barrier destroyed o Bone marrow depressed o immune globulins are decreased o WBCs develop defects

Glascow Coma Scale (GCS)

Neurologic assessment of a patient's best verbal response, eye opening, and motor function. (review chart)

Prehospital care for inhalation injury:

Observe for signs of respiratory distress Treat quickly and efficiently 100% humidified oxygen if CO poisoning is suspected or may need to intubate

Lightning injury: risk for

Patients are at risk for: dysrhythmias cardiac arrest severe metabolic acidosis myoglobinuria (muscle damage--lead to kidney failure if not tx) Myoglobin & Hgb from damaged RBCs travel to kidneys: o Acute tubular necrosis (ATN) o Eventual acute kidney injury

Removal of chest tube steps?

Premedicate patient prior to removal (30-60mins) Valsalva maneuver (hold breath or bear down) apply occlusive dressing monitor for respiratory distress

Chest tube nursing management-- how to prepare drainage

Prepare drainage unit by adding water to water-seal chamber and suction control chamber as indicated.

prehospital care for chemical injury:

Remove chemical particles or powder from skin Remove contaminated clothing Flush affected area for 20min-2hrs

Exposure

Remove clothing to assess completely.

Risk factors of burns: physical debilitation

Renders patient less able to recover (generalized weakness): o Alcoholism o Drug abuse o Malnutrition o Concurrent fractures, head injuries, or other trauma leads to more difficult time recovering

classification of burn injury

Severity of injury is determined by -Depth of burn -Extent of burn- amount of body surface -location of burn -Patient risk factors

Abdominal Compartment Syndrome (ACS)

Sustained IAP of >20 mmHg with or without an APP of 60 mmHg o high pressure in abdomen o restricts ventilation leading to ARF o can decreases cardiac output, venous return, & perfusion of organs and decreased perfusion to kidneys can lead to renal failure

Hemopneumothorax

The accumulation of blood and air in the pleural space of the chest.

Types of Burn Injury

Thermal burns- most common Chemical burns Smoke inhalation injury Electrical burns Cold thermal injury- not as common

Chest tube nursing management-- prepare CDU

Wet suction: add sterile water to 2-cm mark in water-seal chamber and to 20-cm mark (or as ordered) in suction control chamber. Dry suction: add sterile water to the fill line of the air leak meter. Attach suction tubing and increase suction until the bellows-like float moves across the display window.

Chylothorax

a condition marked by lymphatic fluid in the pleural space caused by a leak in the thoracic duct. -- Normal lymphatic flow through the thoracic duct is 1500 to 2500 mL/day. This amount can be increased up to tenfold after ingestion of fats.

Secondary Survey

a head-to-toe physical assessment; an additional assessment of a patient to determine the existence of any injuries other than those found in the primary survey

pleurodesis

artificial production of adhesions between the parietal and visceral pleura for treatment of persistent pneumothorax and severe pleural effusion o usually done with a chemical sclerosing agent, such as talc or doxycycline.

pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall - positive pressure causes lungs to collapse

Primary Survey

an examination of the patient to determine the presence of any life-threatening emergencies; the initial assessment of airway, breathing, and circulation on a patient

chest tube sizes

approx 20 in long and vary from 12F to 40F large tubes (36-40) -drain blood medium tubes (24-36)- drain fluid small tubes (10-14) - drain air

electrical burn: tissue densities

bone, muscle, and fat offer the most resistance. Nerves and blood vessels offer the least resistance.

Prehospital care for large thermal burns (>10% TBSA, pt RESPONSIVE)

follow ABC

Hemothorax Treatment/Management

immediate insertion of a chest tube for evacuation of the blood

Octreotide (Sandostatin)

it acts directly on vascular somatostatin receptors to minimize lymphatic fluid excretion decreases chyle production includes reducing the intestinal absorption of fats, mainly triglycerides, and increasing fecal fat excretion.

flail chest treatment

o Adequate airway & ventilation (may be intubated) o Oxygen therapy &IV Fluids o Pain control o Surgical fixation

lower airway injury : clinical manifestations

o Altered mental status o Carbonaceous sputum -- CARDINAL SIGN OF INJURY o Dyspnea o Facial burns/singed nasal or facial hair o Hoarseness; wheezing

upper airway injury: clinical manifestations

o Blisters, edema o Copious secretions o Difficulty swallowing o Hoarseness; Stridor o Substernal/intercostal secretions o Total airways obstruction

circulation nursing interventions

o Check BP & HR o Give fluid bolus or blood products o Check carotid or femoral pulse o Check capillary refill o Start 2 large IV bore o Start CPR if absent pulse o Assess skin color, temp & moisture

Acute (wound healing) nursing management of wound care:

o Cleansing, Debridement & Dressing reapplication Enzymatic debridement: speeds up removal of dead tissue from healthy wound bed Appropriate coverage of the graft: - Gauze next to graft followed by middle and outer dressings - Unmeshed sheet grafts used for facial grafts-- Grafts are left open Complication: Blebs (prevent graft from attaching to wound bed)

acute abdominal pain-- caused by

o Damage to organs in the abdomen and pelvis, which leads to inflammation, infection, obstruction, bleeding, & perforation o Perforation results in peritonitis o Hypovolemic shock from bleeding or obstruction & peritonitis causes fluid to move from the vascular space into the abdomen

Chest Trauma Emergency Management -assess for signs of respiratory distress

o Dyspnea o Cough may have hemoptysis o Cyanosis o Tracheal deviation o Decreased breath sounds o O2 sats o Frothy secretions

Emergent Phase: Cardiovascular Complications

o Dysrhythmias & hypovolemic shock; can progress to irreversible shock o Impaired circulation to extremities ---Escharotomy is done to restore circulation or improve chest expansion o VTE= start anticoagulants o Tissue ischemia o Paresthesia o Necrosis o Impaired microcirculation &↑ viscosity→sludging (corrected with fluid replacement)

Emergent Phase: nursing managment of airway

o Early endotracheal intubation o Escharotomies of chest wall - may be needed to relieve resp. distress 2nd to circumferential, full-thickness burns of neck, trunk o Fiberoptic bronchoscopy o Humidified air & 100% O2

Rehabilitation (restorative) Phase nursing management

o Encourage pt & caregiver to participate in care: skills for dressing changes & wound care o Use water-based creams o Reconstructive surgery often needed following major burns o Role of exercise cannot be overemphasized o Constant encouragement & reassurance o Discoloration of scar fades with time o Pressure dressings can help keep scar flat o Healed areas must be protected from direct sunlight for 3 months: newly healed areas can be hyper or hypersensitive to cold, heat, & touch

Acute (wound healing) nursing management of excision & grafting

o Eschar removed down to subcutaneous tissue or fascia o Graft placed on clean, viable tissue o Wound covered with autograft from donor skin taken with dermatome Grafts attached with: - Fibrin sealant - Sutures or staples Cultured epithelial autographs (CEAs) - Grown from biopsies of patient's own skin; skin placed on petry dish and grown - Used in pts with large TBSA or those with limited skin for harvesting

Emergent Phase: nursing managment of facial care (open method)

o Eye care for corneal burns: Antibiotic ointment used Periorbital edema o no pillows o indwelling catheter

Emergent Phase: nursing managment of nutritional therapy

o Fluid replacement takes priority over nutritional needs Hypermetabolic state o Resting metabolic needs may be increased 50%- 100% above normal o Core temperature elevated o Caloric needs about 5000 kcal/day o Early, continuous enteral feeding promotes wound healing o Supplemental vitamins and iron may be given

smoke inhalation injury

o From inhalation of hot air or noxious chemicals causing damage to respiratory tract o Mainly caused by house fires -- inhalation of CO2 or hydrogen cyanide from the use of: § Use of gas products § Gas stove § Gas heater § Fireplace

Secondary Survey nursing interventions

o Get equipment for MD to do FAST exam o Splint injured extremity o Insert NG tube o Pain assessment & management o Suture lacerations o Obtain 12-lead ECG & chest x-ray o Insert foley cath o CT scan for internal bleeding o Do SAMPLE assessment o Symptoms o Allergies o Medication hx o Past health hx o Last oral intake o Events/environment leading to injury Lab testtype & crossmatch

Acute (wound healing) nursing management of physical & occupational therapy

o Good time for exercise during wound cleaning o Passive and active ROM o Splints should be custom-fitted

Acute (wound healing) nursing management of nutritional therapy

o High-protein, high-carbohydrate foods o Favorite foods from home o Patients should be weighed regularly

Chest tube nursing management-- observe for air leak ( bubbling in water-seal chamber)

o If leak persists, briefly clamp the chest tube at the patient's chest. If the leak stops, then the air is coming from the patient. o If the air leak persists, briefly and methodically move the clamps down the tubing away from the patient until the air leak stops. The leak will then be present between the last two clamp points. If the air leak persists all the way to the drainage unit, replace the unit.

Abdominal trauma emergency management &

o If unresponsive, assess C-A-B o If responsive, monitor A-B-C 1. Apply appropriate O2 therapy 2. Control external bleeding with direct pressure or pressure dressing 3. Establish 2 lg Ivs & infuse NS or LR 4. Obtain blood for type and crossmatch and CBC 5. Remove clothing 6. Stabilize impaled objects with bulky dressing—do not remove 7. Cover protruding organs or tissue with sterile saline dressing 8. Insert Foley if no blood at meatus, pelvic fracture, or boggy prostate 9. Obtain urine for urinalysis 10. Insert NG tube if no evidence of facial trauma 11. Anticipate diagnostic peritoneal lavage

Airway / cervical spine nursing interventions

o Immobilize cervical spine o Put on C-collar o Remove/suction foreign bodies in mouth o Check for loose teeth & bleeding o Determine airway patency Open airway using jaw-thrust maneuver

Rehabilitation (restorative) Phase: Patho changes

o Layers of keratinocytes begin to rebuild tissue structure o Collagen fibers add strength to weakened areas o In approximately 4 to 6 weeks, area becomes raised and reddened o Mature healing reached about 12 months o Skin never completely regains its original color

Rib Fractures

o Most common type of chest injury due to blunt trauma o Ribs 5 through 9 - most common (least protected by chest muscle) o Can damage pleura and lungs if fractured rib is splintered or displaced

Clinical Manifestations of flail chest

o Movement of chest is asymmetric & uncoordinated. o Rapid, shallow respirations; Dyspnea o tachycardia o Pain on inspiration

Rib fracture treatment

o NO strapping or binding chest o NSAIDs, opioids, nerve blocks o Patient teaching: -Deep breathing and coughing -Incentive spirometry -Appropriate use of analgesics

Breathing nursing interventions

o Needle decompression o Chest tube insertion o Ventilate w/ BVM with 100% O2 o Assess for JVD & tracheal position o Give o2 via nasal cannula or mask o Prepare intubate for severe respiratory distress o Look for paradoxical movement of the chest o Look for signs if respiratory distress: § Tachypnea § Use of accessory muscle use § Color of mucous membranes

Acute (wound healing) phase: neurological complications

o No physical symptoms unless severe hypoxia o Disoriented, combative, hallucinations, delirium & transient state

Burns

o Occur when injury to tissues of body caused by heat, chemicals, electrical current, or radiation o Special attention needs to be given for infection & preventing malnutrition.

Acute (wound healing) phase: GI complications

o Paralytic ileus o Diarrhea/Constipation o Curling's ulcer; can happen w/ intubation

upper airway injury - indicators

o Presence of facial burns o Singed nasal hair o Hoarseness, painful swallowing o Darkened oral & nasal membranes o Carbonaceous sputum o History of being burned in enclosed space o Clothing burns around chest & neck

Emergent (resuscitative) : Burn Shock

o RBCs & WBCs do not leak; blood becomes thick o increased viscosity causes peripheral resistance

Chest Trauma Emergency Management -assess for signs of cardiovascular compromise

o Rapid, thready pulse o Decreased BP with narrowed pulse pressure (the systolic and diastolic pressures are closer in measurement, like 100/80) o Distended neck veins o Muffled heart sounds o Pale/coolness o Chest pain o Dysrhythmias

Electrical Burns

o Result from coagulation necrosis caused by intense heat generated from an electric current o May result from direct damage to nerves and vessels, causing tissue anoxia and death o Severity of injury depends on § Amount of voltage § Tissue resistance § Current pathways § Surface area § Duration of the flow

Emergent (resuscitative) : Clinical Mainfestations

o Shock from hypovolemia o Blisters - common in partial-thickness burns o Paralytic ileus - if not fed within 24 hours of burn o Shivering: result of chilling caused by heat loss, anxiety, or pain o Altered mental status: Not result of burn, but hypoxia associated with smoke inhalation

chemical burn injuries to:

o Skin o Eyes o Respiratory system o Liver and kidney

chest tube and pleural drainage

o To remove air or fluid from pleural and/or mediastinal space (pressure becomes positive instead of negative - lungs collapse) o Chest tubes inserted to drain the pleural space and reestablishes negative pressure, allowing for lung to re-expand o They may also be inserted in the mediastinal space to drain air and fluid postoperatively.

Emergent Phase: nursing managment of fluid therapy

o Two lg-bore IV lines for >15% TBSA o Arterial line if frequent ABGs / invasive BP monitoring needed o Parkland Baxter Formula : 4ml x TBSA x kg --- 50% given 1st 8hrs; 50% given 2nd 16 hrs

Clinical Manifestations of Rib Fractures

o pain (esp. during inspiration & cough) o splinting (shallow breathing to decrease pain) o shallow respirations o atelectasis & pneumonia (due to decreased ventilation and retained secretions)

Lightning injury

o result from direct strike, high voltage DC injury o Side flash: occurs when lightning strikes a taller object near the victim and a portion of the current jumps from taller object to the victim o Results in immediate depolarization of entire myocardium w/ possible cardiac arrest

Emergent Phase: urinary complications

o ↓ Blood flow to kidneys causes renal ischemia o Acute tubular necrosis (ATN) ; breakdown of protein

Penetrating abdominal trauma

occur when a gunshot or stabbing produces an obvious, open wound into the abdomen - Solid organs (liver, spleen) when injured can bleed profusely, causing hypovolemic shock. - If contents from hollow organs (e.g., bladder, stomach, intestines) spill into peritoneal cavity, risk for peritonitis Indications for immediate exploratory laparotomy (Q) in patient with penetrating abdominal trauma (any of following) 1. Hemodynamic instability (SBP < 90) 2. Peritonitis (Q) (rigidity, rebound tenderness) 3. Evisceration (ie, externally exposed intestines)

Acute (wound healing) phase: cardiovascular/respiratory complications

same as emergent phase

acute abdominal pain- diagnostic tests

§ CBC & urinalysis § Abdominal x-ray § ECG § Ultrasound or CT scan

abdominal trauma diagnostic test

§ CBC and urinalysis § ABGs § PT § Electrolytes, BUN & creatinine § Type & crossmatch (if transfusions needed) § Abd. CT scan & US

abdominal trauma ongoing monitoring

§ Monitor vital signs, level of consciousness, O2 sats & urine output § Maintain warmth w/blankets, warm IV flds, or warm humidified O2

Gerontological considerations

§ Unsteady gait § Limited eyesight § Diminished hearing wounds take longer to heal

abdominal trauma clinical manifestations

§ guarding & splinting of the abdominal wall (indicating peritonitis) § hard, distended abdomen (occurs with intraabdominal bleeding) § decreased or absent bowel sounds § abrasions or bruising over the abdomen § abdominal pain § hematemesis or hematuria § signs of hypovolemic shock § ecchymosis around the umbilicus (Cullen's sign) or flanks (Grey Turner's sign) may mean retroperitoneal hemorrhage

Acute (wound healing) phase: endocrine complications

↑ Blood glucose levels ↑Insulin production

Chest tube nursing management-- Monitor integrity of chest tube system

•If the following occur within the first hour, notify HCP at once: •Drainage > 200 mL •Subcutaneous emphysema •Respiratory distress •Monitor color and amount of drainage Do not elevate system above chest. Change when full. Measure fluid level. Report > 100mL/hr. If unit overturned, have patient exhale and cough Do NOT clamp If break in system, place distal end in sterile water to maintain water seal

Chest tube nursing management-- how to maintain patency in drainage system

•Keep tubing loosely coiled. •Tubing should drop straight from bed or chair to drainage unit. Do not let it be compressed. •Tape connections.

Chest tube nursing management-- milking or stripping chest tube

•Not recommended •Can increase intrapleural pressures and damage lungs. If health care provider orders - do so GENTLY Milking: alternately folding or squeezing and then releasing drainage tubing. Milk only if drainage and evidence of clots / obstruction. Take 15-cm strips of the chest tube and squeeze and release starting close to the chest and repeating down the tube distally. Stripping: squeeze drainage tube with thumb and forefinger and use gentle pulling motion down tube with other hand, then release the tubing.

traumatic penetrating (open) pneumothorax

•Penetrating trauma allows air to enter the pleural space through an opening in the chest wall. - Can cause a sucking chest wound (breathing - sounds like they are sucking air in) - Apply vent dressing. (tape 3 sides) - Do not remove impaled object.

Chest tube nursing management-- monitor for complications

•Reexpansion pulmonary edema •Vasovagal response •Subcutaneous emphysema

Chest tube nursing management-- assess pt clinical status

•Vital signs, lung sounds, pain •Drainage amount •Drainage site infection •Subcutaneous emphysema Encourage deep breathing, range-of-motion exercises, incentive spirometry.