NUR 408: Exam 4

Nursing Safety Priority 9

Convulsive status epilepticus must be treated promptly and aggressively! Establish an airway and notify the primary health care provider or Rapid Response Team immediately if this problem occurs! Establishing an airway is the priority for this patient's care. Intubation by an anesthesia provider or respiratory therapist may be necessary. Administer oxygen as indicated by the patient's condition. If not already in place, establish IV access with a large-bore catheter and start 0.9% sodium chloride. The patient is usually placed in the intensive care unit for continuous monitoring and management.

ED: Patient and Family Education

Most discharge instructions are either preprinted or computer generated and can be customized to address the patient's needs. Consider reading level, primary language, and visual acuity. For those with visual deficits, large-print materials may be helpful. Educational materials and instructions should be available at no higher than the sixth-grade reading level. For patients who do not speak English or who speak English as a second language, many hospitals have educational materials available in Spanish and other regional languages. Interpreters may be necessary to help the interprofessional health care team customize the information appropriately.

Management of Neurogenic Bladder

1. Reflex (spastic) -Upper motor neuron spinal cord injury above T12 -Urinary frequency, incontinence but may not empty completely -Interventions: .Triggering or facilitating techniques .Drug therapy, as appropriate .Bedside bladder ultrasound .Intermittent catheterization .Consistent toileting schedule .Indwelling urinary catheter (as last resort) .Increased fluids 2. Flaccid -Lower motor neuron spinal cord injury below T12 (affects S2-4 reflex arc) -Urinary retention, overflow -Interventions: .Valsalva and Credé maneuvers .Increased fluids .Intermittent or indwelling urinary catheterization

trauma center

Trauma centers have their roots in military medicine. Injured soldiers who received rapid transport from the battlefield and treatment from skilled health care personnel had a survival advantage in the mobile army surgical hospital (MASH) units first deployed in the Korean and Vietnam wars. Consequently the MASH unit became the original model for the development of civilian trauma centers. In modern society the trauma center in the United States is a specialty care facility that provides competent and timely trauma services to patients, depending on its designated level of capability.

Status Epilepticus Management

Status epilepticus is a medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes. It is a potential complication of all types of seizures. Seizures lasting longer than 10 minutes can cause death! Common causes of status epilepticus include: • Sudden withdrawal from antiepileptic drugs • Infection • Acute alcohol or drug withdrawal • Head trauma • Cerebral edema • Metabolic disturbances The drugs of choice for treating status epilepticus are IV-push lorazepam or diazepam. Diazepam rectal gel may be used instead. Lorazepam is usually given as 4 mg over a 2-minute period. This procedure may be repeated, if necessary, until a total of 8 mg is reached.

Yellow-tagged patients

Yellow-tagged patients have major injuries such as open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours.

What Patients Need to Know About Aging With Spinal Cord Injury

-Follow guidelines for adult vaccination, particularly influenza and pneumococcus vaccination recommendations. Respiratory complications are the most common cause of death after spinal cord injury (SCI). -For women, have Papanicolaou (Pap) smears and mammograms as recommended by the American Cancer Society or your primary health care provider. Limitations in movement may make breast self-awareness difficult. -Take measures to prevent osteoporosis, such as increasing calcium and vitamin D intake, avoiding caffeine, and not smoking. Exercise against resistance can maintain muscle strength and slow bone loss. Women older than 50 years often lose bone density, which can result in fractures. Men can also have osteoporotic fractures as a result of immobility. -Practice meticulous skin care, including frequent repositioning, using pressure-reduction surfaces in bed and chairs/wheelchairs, and applying skin protective products. As a person ages, skin becomes dry and less elastic, predisposing the patient to pressure injuries. -Take measures to prevent constipation, such as drinking adequate fluids, eating a high-fiber diet, adding a stool softener or bowel stimulant daily, and establishing a regular time for bowel elimination. Constipation is a problem for most patients with SCI, and bowel motility can slow, contributing to constipation later in life. -Modify activities if joint pain occurs; use a powered rather than a manual wheelchair. Ask the primary health care provider about treatment options. Arthritis occurs in more than half of people older than 65 years. Patients with SCI are more likely to develop arthritis as a result of added stress on the upper extremities when using a wheelchair.

The Primary Survey and Resuscitation Interventions

1. A: Airway/cervical spine -Establish a patent airway by positioning, suctioning, and administering oxygen as needed. -Protect the cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. -If the Glasgow Coma Scale (GCS) score is 8 or lower or the patient is at risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation. 2. B: Breathing -Assess breath sounds and respiratory effort. -Observe for chest wall trauma or other physical abnormality. -Prepare for chest decompression if needed. -Prepare to assist ventilations if needed. 3. C: Circulation -Monitor vital signs, especially blood pressure and pulse. -Maintain vascular access with a large-bore catheter. -Use direct pressure for external bleeding; anticipate need for a tourniquet for severe, uncontrollable extremity hemorrhage, wound packing, and/or use of a hemostatic dressing. 4. D: Disability -Evaluate the patient's level of consciousness (LOC) using the GCS. -Re-evaluate the patient's LOC frequently. 5. E: Exposure -Remove all clothing for a complete physical assessment. -Prevent hypothermia (e.g., cover the patient with blankets, use heating devices, infuse warm solutions).

emergency preparedness

1. Common to all mass casualty events, the goal of emergency preparedness is to effectively meet the extraordinary need for resources such as hospital beds, staff, drugs, PPE, supplies, and medical devices. Emergency management includes actions or steps taken to decrease the potential loss during a disaster, and it involves mitigation, preparedness, response, and recovery. Mitigation involves preplanning for a disaster, analyzing potential risk and loss, and putting processes in place to minimize the impact. Preparedness involves active steps taken to prepare to handle an emergency; response involves the actions taken to rescue and care for those affected by a disaster, and recovery involves steps taken to return to normal after the event. 2. Emergency plans dictate specific actions by all members of the interprofessional team such as who should be called when the plan is activated, who should report, where to report, which supplies or equipment carts should be brought to a predesignated location, and which type of paperwork or system should be implemented for patient identification in a large-scale event.

Regardless of age or specific disability, these priority patient problems are common. Additional problems depend on the patient's specific chronic condition or disability. The priority collaborative problems for patients with chronic and disabling health conditions typically include:

1. Decreased mobility due to neuromuscular impairment, sensory-perceptual impairment, and/or chronic pain 2. Decreased functional ability due to neuromuscular impairment and/or impairment in perception or cognition 3. Risk for pressure injury due to altered sensation and/or altered nutritional state 4. Urinary incontinence or urinary retention due to neurologic dysfunction and/or trauma or disease affecting spinal cord nerves 5. Changes in bowel function due to neurologic impairment, inadequate nutrition, or decreased mobility

Three-Tiered Triage System and Examples of Patients Triaged in Each Tier

1. Emergent (life threatening) -Chest pain with diaphoresis -Hemorrhage -Respiratory distress -Stroke -Vital sign instability 2. Urgent (needs quick treatment, but not immediately life threatening) -Abdominal pain (severe) -Fractures (displaced or multiple) -Renal colic -Respiratory infection (especially pneumonia in older adults) -Soft-tissue injuries (complex or multiple) 3. Nonurgent (could wait several hours if needed without fear of deterioration) -Fracture (simple) -Rashes -Strains and sprains -Urinary tract infection

Types of Aphasia

1. Expressive • Referred to as Broca, or motor, aphasia • Difficulty speaking • Difficulty writing 2. Receptive • Referred to as Wernicke, or sensory, aphasia • Difficulty understanding spoken words • Difficulty understanding written words • Speech often meaningless • Made-up words 3. Mixed • Combination of difficulty understanding words and speech • Difficulty with reading and writing 4. Global • Profound speech and language problems • Often no speech or sounds that cannot be understood

Hemorrhagic Stroke

1. In this type of stroke, vessel integrity is interrupted, and bleeding occurs into the brain tissue or into the subarachnoid space. -Intracerebral hemorrhage (ICH) describes bleeding into the brain tissue generally resulting from severe or sustained hypertension. Damage to the brain occurs from bleeding, causing edema, irritation, and displacement, which cause pressure on brain tissue. Cocaine use is one example of a trigger for sudden, dramatic BP elevation leading to hemorrhagic stroke. -Subarachnoid hemorrhage (SAH) is much more common and results from bleeding into the subarachnoid space. This type of bleeding is usually caused by a ruptured aneurysm or arteriovenous malformation (AVM). The patient with an SAH, particularly when the hemorrhage is from a ruptured (leaking) aneurysm, often reports the onset of a sudden, severe headache described as "the worst headache of my life." Additional symptoms of SAH or cerebral aneurysmal and AVM bleeding are nausea and vomiting, photophobia (sensitivity to light), cranial nerve deficits, stiff neck, and change in mental status. -An aneurysm is an abnormal ballooning or blister along a normal artery commonly developing in a weak spot on the artery wall. -An arteriovenous malformation (AVM) is an angled collection of malformed, thin-walled, dilated vessels without a capillary network. This uncommon abnormality occurs during embryonic development. Vasospasm may occur as a result of a sudden and periodic constriction of a cerebral artery, often following an SAH or bleeding from an aneurysm or AVM rupture. This constriction interrupts blood flow to distal areas of the brain.

Depending on stroke severity and/or response to immediate management, the priority collaborative problems for patients with a stroke may include:

1. Inadequate perfusion to the brain due to interruption of arterial blood flow and a possible increase in ICP 2. Decreased mobility and possible need for assistance to perform ADLs due to neuromuscular or impaired cognition 3. Aphasia and/or dysarthria due to decreased circulation in the brain (aphasia) or facial muscle weakness (dysarthria) 4. Sensory perception deficits due to altered neurologic reception and transmission

Management of Neurogenic Bowel

1. Reflex (spastic) -Upper motor neuron spinal cord injury above T12 -Defecation without warning, but may not empty completely -Interventions: .Triggering mechanisms .Facilitation techniques .High-fiber diet .Increased fluids .Laxative use (for some patients) .Consistent toileting schedule .Manual disimpaction 2. Flaccid -Lower motor neuron spinal cord injury below T12 (affects S2-4 reflex arc) -Usually absent stools for patients with complete lesions -Interventions: .Triggering or facilitating techniques .Increased fluids .High-fiber diet .Suppository use .Consistent toileting schedule .Manual disimpaction

Stroke: Interventions

1. Interventions for patients experiencing strokes are determined primarily by the type and extent of the stroke. Nursing interventions are initially aimed at monitoring for neurologic changes or complications associated with stroke and its treatment. The two major treatment modalities for patients with acute ischemic stroke are IV fibrinolytic therapy and endovascular interventions. Regardless of the immediate management approach used, once the patient is stable, provide ongoing supportive care. Provide interventions to prevent and/or monitor for early signs of complications. Implement interventions to prevent patient falls. When the stroke is hemorrhagic and the cause is related to an AVM or cerebral aneurysm, the patient is evaluated for the optimal procedure to stop bleeding. Some procedures can be used to prevent bleeding in an AVM or aneurysm that is discovered before symptom onset or SAH. Reassess patients with acute stroke and after endovascular treatment of stroke symptoms every 1 to 4 hours, depending on severity of the condition. 2. Monitoring for increased intracranial pressure. The patient is most at risk for increased ICP resulting from edema during the first 72 hours after onset of the stroke. Some patients may have worsening of their neurologic status starting within 24 to 48 hours after their endovascular procedure from increased ICP. 3. Ongoing drug therapy. Ongoing drug therapy depends on the type of stroke and the resulting neurologic dysfunction. In general, the purposes of drug therapy are to prevent further thrombotic or embolic episodes (with antithrombotics and anticoagulation) and to protect the neurons from hypoxia. 4. Promoting Mobility and ADL Ability. In collaboration with the rehabilitation therapists, assess the patient's functional ability for bed mobility skills, ambulation with or without assistance, and ADL ability, including feeding, bathing, and dressing. Patients who have had a stroke are at risk for aspiration due to impaired swallowing as a result of muscle weakness. Therefore the best practice for all suspected and diagnosed stroke patients is to maintain NPO status until their swallowing ability is assessed! 5. Promoting Effective Communication. Language or speech problems are usually the result of a stroke involving the dominant (L) hemisphere. The left cerebral hemisphere is the speech center in most patients. Speech and language problems may be the result of aphasia or dysarthria. Aphasia is caused by cerebral hemisphere damage; dysarthria is the result of a loss of motor function to the tongue or the muscles of speech, causing facial weakness and slurred speech. 6. Managing Changes in Sensory Perception. The patient with a stroke is expected to adapt to sensory perception changes in vision, proprioception (body position sense), and/or peripheral sensation and to be free from injury.

Multicasualty vs. mass casualty (disaster) events

1. Multicasualty and mass casualty (disaster) events are not the same. The main difference is based on the scope and scale of the incident, considering the number of victims or casualties involved and the severity of the effects. Both types of disasters require specific response plans to activate necessary resources. In general, a multicasualty event can be managed by a hospital using local resources; a mass casualty event overwhelms local medical capabilities and may require the collaboration of numerous agencies and health care facilities to handle the crisis. State, regional, and/or national resources may be needed to support the areas affected by the event. Trauma centers have a special role in all emergency preparedness activities because they provide a critical level of expertise and specialized resources for complex injury management. 2. To maintain ongoing disaster preparedness, hospital personnel participate in emergency training and drills regularly. Accredited health care organizations are required to take an "all-hazards approach" to disaster planning. Using this approach, preparedness activities must address all credible threats to the safety of the community that could result in a disaster situation. Disaster drills are ideally planned based on a risk assessment or vulnerability analysis that identifies the events most likely to occur in a particular community. For example, a flood is more likely in the Gulf of Mexico, and an avalanche is more likely in ski areas of the Rocky Mountains. Because the threat of gun violence is now a risk in all communities, active-shooter drills are commonplace in health care settings. An evacuation plan is part of fire prevention and preparedness plans for health care facilities. The term "NBC" was coined to describe nuclear, biologic, and chemical threats. In response, emergency medical services (EMS) agencies and hospitals improved safety by upgrading their decontamination facilities, equipment, and all levels of personal protective equipment to better protect staff. ED physicians, providers, and nursing staff now routinely undergo hazardous materials (HAZMAT) training and learn how to recognize patterns of illness in patients who present for treatment that potentially indicate biologic terrorism agents such as anthrax or smallpox.

SCI: Establishing Urinary Continence

1. Neurologic disabilities often interfere with successful bladder control. These disabilities result in two basic functional types of neurogenic bladder: overactive (e.g., reflex or spastic bladder) and underactive (e.g., hypotonic or flaccid bladder). 2. Non-pharmacologic interventions -The nurse can teach a variety of techniques to assist the patient in bladder management, including: • Facilitating, or triggering, techniques • Intermittent catheterization • Consistent scheduling of toileting routines ("timed void") -These techniques may not be as effective in patients with physiologic changes associated with aging, including stress incontinence in women with weak pelvic floor muscles and overflow incontinence in men with enlarged prostate glands.

Brain Herniation Syndromes

1. Of the several types of herniation syndromes, uncal herniation is one of the most clinically significant because it is life threatening. Late findings include dilated and nonreactive pupils, ptosis (eyelid drooping), and a rapidly deteriorating level of consciousness. 2. Central herniation manifests clinically with Cheyne-Stokes respirations, pinpoint and nonreactive pupils, and potential hemodynamic instability. All herniation syndromes are potentially life threatening, and the Rapid Response Team or primary health care provider must be notified immediately when they are suspected!

Maintaining Patient and Staff Safety in the Emergency Department

1. Patient identification -Provide an identification (ID) bracelet for each patient. -Use two unique identifiers (e.g., name, date of birth). -If patient identity is unknown, use a special identification system. 2. Injury prevention for patients -Keep rails up on stretcher. -Keep stretcher in lowest position. -Remind the patient to use call light for assistance. -Reorient the confused patient frequently. -If patient is confused, ask a family member or significant other to remain with him or her. Implement measures to protect skin integrity for patients at risk for skin breakdown. 3. Risk for errors and adverse events -Obtain a thorough patient and family history. -Check the patient for a medical alert bracelet or necklace. -Search the patient's belongings for weapons or other harmful items such as drugs and drug paraphernalia when he or she has an altered mental status or presents with behavioral health concerns. 4. Injury prevention for staff -Use Standard Precautions at all times. -Anticipate hostile, violent patient, family, and/or visitor behavior. -Plan and practice options if violence occurs, including assistance from the security department.

The priority collaborative problems for patients with traumatic brain injury (TBI) vary greatly, depending on the severity of the event. The most common problems include:

1. Potential for decreased cerebral tissue perfusion due to primary event and/or secondary brain injury 2. Potential for decreased cognition, sensory perception, and/or mobility due to primary or secondary brain injury

The priority collaborative problems for patients with an acute spinal cord injury (SCI) include:

1. Potential for respiratory distress/failure due to aspiration, decreased diaphragmatic innervation, and/or decreased mobility 2. Potential for cardiovascular instability (e.g., shock and autonomic dysreflexia) due to loss or interruption of sympathetic innervation or hemorrhage 3. Potential for secondary spinal cord injury due to hypoperfusion, edema, or delayed spinal column stabilization 4. Decreased mobility and sensory perception due to spinal cord damage and edema In addition, the patient with a long-term SCI is at risk for multiple problems caused by prolonged immobility or decreased mobility.

Seizures: Interventions

1. Removing or treating the underlying condition or cause of the seizure manages secondary epilepsy and seizures that are not considered epileptic. In most cases, primary epilepsy is successfully managed through drug therapy. 2. Non-surgical management aka drug therapy -Most seizures can be completely or almost completely controlled through the administration of antiepileptic drugs (AEDs), sometimes referred to as anticonvulsants, for specific types of seizures. -Drug therapy is the major component of management. The primary health care provider introduces one antiepileptic drug (AED) at a time to achieve control for the type of seizure that the patient has. If the chosen drug is not effective, the dosage may be increased, or another drug introduced. At times, seizure control is achieved only through a combination of drugs. The dosages are adjusted to achieve therapeutic blood levels without causing major side effects. Because of these potential side effects, teach patients to: • Follow up on laboratory test appointments to monitor the patient's complete blood count (CBC) and liver enzymes and assess for therapeutic drug levels. Most AEDs can cause leukopenia and liver dysfunction. • Observe for and report beginning gingival hyperplasia and perform frequent oral care to prevent permanent gingival damage. Teach patients to take their drugs on time to maintain therapeutic blood levels and maximum effectiveness. Emphasize the importance of taking their AEDs as prescribed. Instruct patients that they can build up sensitivity to the drugs as they age. If sensitivity occurs, tell them they will need to have blood levels of this drug checked frequently to adjust the dose. In some cases, the antiseizure effects of drugs can decline and lead to an increase in seizures. Because of this potential for "drug decline and sensitivity," patients need to keep their scheduled laboratory appointments to check serum drug levels. Be aware of drug-drug and drug-food interactions. For instance, warfarin should not be given with phenytoin (Dilantin). Document side and adverse effects of the prescribed drugs and report to the health care provider. Teach patients that some citrus fruits, such as grapefruit juice, can interfere with the metabolism of these drugs. This interference can raise the blood level of the drug and cause the patient to develop drug toxicity.

SCI: Preventing Pressure Injury

1. The best intervention to prevent pressure injury and maintain tissue integrity is frequent position changes in combination with adequate skin care and sufficient nutritional intake. Teach staff to assist with turning and repositioning at least every 2 hours if patients are unable to perform this activity independently. This time frame may not be sufficient for people who are frail and have thin skin, especially older adults. To determine the best turning schedule, assess the patient's skin condition during each turning and repositioning. 2. Patients who sit for prolonged periods in a wheelchair need to be repositioned at least every 1 to 2 hours. Each patient is evaluated by the physical or occupational therapist for the best seating pad or cushion that is comfortable yet reduces pressure on bony prominences. Patients who are able are taught to perform pressure relief by using their arms to lift their buttocks off the wheelchair seat for 20 seconds or longer every hour or more often if needed (sometimes referred to as wheelchair push-ups). The PT or OT helps them strengthen their arm muscles in preparation for performing pressure relief. Many patients with neurologic problems have decreased or absent sensation and may not be able to feel the discomfort of increased pressure. Check any areas where there may be pressure, including places such as the lower legs where the leg of the wheelchair could rub against the skin. 3. Adequate skin care is an essential component of prevention. Perform or help patients complete skin care each time they are turned, repositioned, or bathed. Delegate and supervise skin care to assistive personnel (AP), including cleaning soiled areas, drying carefully, and applying a moisturizer. If a patient is incontinent, use topical barrier creams or ointments to help protect the skin from moisture, which can contribute to skin breakdown. To prevent damage to the already fragile capillary system, teach AP to avoid rubbing reddened areas. Instead, carefully observe the areas for further breakdown and relieve pressure on the areas as much as possible. Bed pillows are often good pressure-relieving devices. 4. Sufficient nutrition is needed both to repair wounds and to prevent pressure injuries. Collaborate with the dietitian to assess the patient's food selection and ensure that it contains adequate protein and carbohydrates. Both the nurse and the dietitian closely monitor the patient's weight and serum prealbumin levels. If either of these indices decreases significantly, he or she may need high-protein, high-carbohydrate food supplements (e.g., milkshakes) or commercial preparations. 5. Pressure-relieving or pressure-reducing devices include air mattresses, low-air loss overlays or beds, and air-fluidized beds. Mattress overlays such as air and replacement mattresses are often effective in reducing pressure. The use of any mechanical device (except air-fluidized beds) does not eliminate the need for turning and repositioning.

primary survey

1. The initial assessment of the trauma patient is called the primary survey, which is an organized framework used to rapidly identify and effectively manage immediate threats to life. The primary survey is typically based on a standard ABC mnemonic plus a D and an E for trauma patients: airway/cervical spine (A); breathing (B); circulation (C); disability (D); and exposure (E). Resuscitation efforts occur simultaneously with each element of the primary survey. Even though the resuscitation team may encounter multiple clinical problems or injuries, issues identified in the primary survey are managed before the team engages in interventions of lower priority such as splinting fractures and dressing wounds. There is one notable exception to the standard ABCDE trauma resuscitation approach. Lessons learned from the military and continued research have made it clear that in the presence of massive, uncontrolled external bleeding, hemorrhage control techniques are the highest-priority intervention. In this situation, the sequence of priorities shifts to CAB (circulation, airway, breathing), whereby the initial focus of resuscitation is to effectively stop the active bleeding -A: Airway/Cervical Spine i. Even minutes without an adequate oxygen supply can lead to brain injury that can progress to anoxic brain death. Establishing a patent airway is the highest-priority intervention when managing a trauma patient unless massive, life-threatening external hemorrhage as described previously is present. A nonrebreather mask is generally best for the spontaneously breathing patient. Bag-valve-mask (BVM) ventilation with the appropriate airway adjunct and a 100% oxygen source is indicated for the person who needs ventilatory assistance during resuscitation. A patient with significantly impaired consciousness (Glascow Coma Scale [GCS] score of 3 to 8, which is indicative of severe head injury) requires an endotracheal tube and mechanical ventilation. -B: Breathing i. After the airway has been successfully secured, breathing becomes the next priority in the primary survey. This assessment determines whether or not ventilatory efforts are effective—not only whether or not the patient is breathing. Listen to breath sounds and evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities. Both apneic patients and those with poor ventilatory effort need BVM ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. If cardiopulmonary resuscitation (CPR) becomes necessary, the mechanical ventilator is disconnected, and the patient is manually ventilated with a BVM device. -C: Circulation i. When effective ventilation is ensured, the priority shifts to circulation. The adequacy of heart rate, blood pressure, and overall perfusion becomes the focus of the assessment. Common threats to circulation include cardiac arrest, myocardial dysfunction, and hemorrhage leading to a shock state. Interventions are targeted at restoring effective circulation through cardiopulmonary resuscitation, hemorrhage control, IV vascular access with fluid and blood administration as necessary, and drug therapy. External hemorrhage is usually quite obvious and best controlled with firm, direct pressure on the bleeding site with thick, dry dressing material. This method is effective in decreasing blood flow for most wounds. Tourniquets that occlude arterial blood flow distal to the injury should be used to manage severe, compressible bleeding from extremity trauma when direct pressure fails to achieve hemorrhage control; wound packing and the use of hemostatic dressings (e.g., dressings impregnated with substances that speed the formation of a blood clot) are other essential methods to manage life-threatening hemorrhage. Internal hemorrhage is a less obvious complication that must be suspected in injured patients or in those in a shock state. Anticipate the need for rapid blood component administration in a hemorrhagic shock state using packed red blood cells, fresh frozen plasma, and platelets to both replace blood loss and prevent coagulopathy. However, the priority intervention is always to stop the bleeding. -D: Disability i. The disability examination provides a rapid baseline assessment of neurologic status. A simple method to evaluate level of consciousness is the AVPU mnemonic: • A: Alert • V: Responsive to voice • P: Responsive to pain • U: Unresponsive Another common way of determining and documenting level of consciousness is the Glasgow Coma Scale (GCS), an assessment that scores eye opening, verbal response, and motor response. The lowest score is 3, which indicates a totally unresponsive patient; a normal GCS score is 15. Metabolic abnormalities (e.g., severe hypoglycemia), hypoxia, neurologic injury, and illicit drugs or alcohol can impair level of consciousness. Frequent reassessment is needed for rapid intervention in the event of neurologic compromise or deterioration. -E: Exposure i. The final component of the primary survey is exposure. If evidence preservation is needed, handle items per institutional policy. Evidence may include articles of clothing, impaled objects, weapons, drugs, and bullets. Emergency nurses are often called on to provide testimony in court regarding their recall of the presentation and treatment of patients in the ED. Examples of types of cases in which evidence collection is vital are rape, abuse of a child or older adult, domestic violence, homicide, suicide, drug overdose, and assault.

Comparison of Triage Under Usual Versus Mass Casualty Conditions

1. Triage Under Usual Conditions -Emergent (immediate threat to life) -Urgent (major injuries that require immediate treatment) -Nonurgent (minor injuries that do not require immediate treatment) -Does not apply 2. Triage Under Mass Casualty Conditions -Emergent or class I (red tag) (immediate threat to life) -Urgent or class II (yellow tag) (major injuries that require treatment) -Nonurgent or class III (green tag) (minor injuries that do not require immediate treatment) -Expectant or class IV (black tag) (expected and allowed to die)

Transient Ischemic Attack: Key Features

1. Visual Symptoms • Blurred vision • Diplopia (a condition in which the client has double vision) • Hemianopsia (a condition in which the vision of one or both eyes is affected) • Tunnel vision 2. Mobility (Motor) Symptoms • Weakness (facial droop, arm or leg drift, hand grasp) • Ataxia (lack of muscle control and coordination that affects gait, balance, and the ability to walk) 3. Sensory Perception Symptoms • Numbness (face, hand, arm, or leg) • Vertigo (a feeling of spinning or dizziness) 4. Speech Symptoms • Aphasia (problems with speech and/or language) • Dysarthria (slurred speech caused by muscle weakness or paralysis)

Mass Casualty Triage

A key process in any multicasualty or mass casualty response is effective triage to rapidly sort ill or injured patients into priority categories based on their acuity and survival potential. Once patients are in the triage area of the hospital, they typically receive a special bracelet with a disaster number. Preprinted labels with this number can be applied to chart forms and personal belongings. Digital photos may be used as part of the identification process in some systems. The standard hospital registration process and identification band can be applied after the patient's identity has been confirmed. Automated tracking systems using infrared, radiofrequency, or ultrasound technology are available in some EDs to track a patient's triage priority on arrival, location, and process of care. The interactions the patient has with caregivers can also be tracked. This is an important safety strategy if the patient is later found to have contaminants or a disease that could pose a risk to staff members who had close contact and require decontamination or prophylaxis

Secondary Brain Injury: Increased Intracranial Pressure

A normal level of intracranial pressure (ICP) is 10 to 15 mm Hg. Periodic increases in pressure occur with straining during defecation, coughing, or sneezing but do not harm the uninjured brain. A sustained ICP of greater than 20 mm Hg is considered detrimental to the brain because neurons begin to die. Increased ICP is the leading cause of death from head trauma in patients who reach the hospital alive. It occurs when compensation no longer takes place and the brain cannot accommodate further volume changes. As ICP increases, cerebral perfusion decreases, leading to brain tissue ischemia and edema. If edema remains untreated, the brainstem may herniate downward through the foramen of Monro or laterally from a unilateral lesion within one cerebral hemisphere, causing irreversible brain damage and possibly death (from brain herniation syndromes).

pandemic

A pandemic (an infection or disease that occurs throughout the population of a country or the world) leads a vast number of people to seek medical care, even the "worried well." Although not yet ill, the "worried well" want evaluation, preventive treatment, or reassurance from a health care provider.

seizure

A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior. A single seizure may occur for no known reason. Some seizures are caused by a pathologic condition of the brain, such as a tumor. In this case, once the underlying problem is treated, the patient is often asymptomatic.

stroke

A stroke is caused by an interruption of perfusion to any part of the brain that results in infarction (cell death). A stroke is a medical emergency and should be treated immediately to reduce or prevent permanent disability. Effects of a stroke on the nonaffected side may be the result of brain edema or global changes in brain perfusion. As a result of brain edema, patients may develop increased intracranial pressure (ICP) and secondary brain damage. These secondary changes most commonly occur following a severe traumatic brain injury (TBI).

Nursing Safety Priority 7

A total score of 33 or higher (out of a possible 88) on the Impact of Event Scale—Revised (IES-R) is indicative of probable PTSD. Refer the patient to a psychiatrist, psychiatric mental health nurse practitioner, or qualified mental health counselor. A high score on any IES-R subscale indicates a need for further evaluation and counseling; again, make the appropriate referral to a mental health specialist to evaluate the possibility of current or past trauma, such as abuse or neglect.

Aphasia

A. Aphasia can be classified in a number of ways. Most commonly, it is classified as expressive, receptive, or mixed -Expressive (Broca or motor) aphasia is the result of damage in the Broca area of the frontal lobe. It is a motor speech problem in which the patient generally understands what is said but cannot speak. He or she also has difficulty writing but may be able to read. Rote speech and automatic speech such as responses to a greeting are often intact. The patient is aware of the deficit and may become frustrated and angry. -Receptive (Wernicke or sensory) aphasia is caused by injury involving the Wernicke area in the temporoparietal area. The patient cannot understand the spoken or written word. Although he or she may be able to talk, the language is often meaningless. -mixed or global aphasia (both) B. Usually the patient has some degree of dysfunction in the areas of both expression and reception. Reading and writing ability are equally affected. Few patients have only expressive or receptive aphasia. In most cases, however, one type is dominant.

Differential Features of the Types of Stroke

A. Ischemic (Thrombotic & Embolic) i. thrombotic -evolution: Intermittent or stepwise improvement between episodes of worsening symptoms; Completed stroke -onset: Gradual (minutes to hours) -LOC: Preserved (patient is awake) -contributing associating factors: Hypertension; Atherosclerosis -prodromal symptoms: Transient ischemic attack (TIA) -neurologic deficits: May be deficits during the first few weeks; Slight headache; Speech deficits; Visual problems; Confusion -CSF: Normal; possible presence of protein -seizures: No -duration: Improvements over weeks to months; Permanent deficits possible i. embolic -evolution: Abrupt development of completed stroke; Steady progression -onset: Sudden -LOC: Preserved (patient is awake) -contributing associating factors: Cardiac disease -prodromal symptoms: TIA -neurologic deficits: Maximum deficit at onset; Paralysis; Expressive aphasia -CSF: Normal -seizures: No -duration: Usually rapid improvements B. Hemorrhagic -evolution: Usually abrupt onset -onset: Sudden; may be gradual if caused by hypertension -LOC: Deepening lethargy/stupor or coma -contributing associating factors: Hypertension; Vessel disorders; Genetic factors -prodromal symptoms: Headache -neurologic deficits: Focal deficits; Severe, frequent -CSF: Bloody -seizures: Usually -duration: Variable; Permanent neurologic deficits possible

SCI: Establishing Bowel Continence

A. Neurologic problems often affect the patient's bowel pattern by causing a reflex (spastic) bowel, a flaccid bowel, or an uninhibited bowel. Bowel retraining programs are designed for each patient to best meet the expected outcomes. -Upper motor neuron diseases and injuries such as a cervical or mid-level spinal cord injury (e.g., quadriplegia) may result in a reflex (spastic) bowel pattern, with defecation occurring suddenly and without warning. With this intact reflex pattern, any facilitating or triggering mechanism may lead to defecation if the lower colon contains stool. An example of facilitating or triggering techniques is digital stimulation. For this technique, use a lubricated glove or finger cot and massage the anus in a circular motion for no less than 1 full minute. -Lower motor neuron diseases and injuries (e.g., paraplegia) interfere with transmission of the nervous impulse across the reflex arc and may result in a flaccid bowel pattern, with defecation occurring infrequently and in small amounts. The use of manual disimpaction may get the best results. Some patients also need oral laxatives and/or stool softeners. Digital stimulation or suppositories are usually unsuccessful because of loss of the reflex for elimination. -Neurologic injuries that affect the brain may cause an uninhibited bowel pattern, with frequent defecation, urgency, and reports of hard stool. Patients may manage uninhibited bowel patterns through a consistent toileting schedule, a high-fiber diet, and the use of stool softeners. B. In some cases patients are not able to regain their previous level of control over their bowel function. The rehabilitation team assists in designing a bowel elimination program that accommodates the disability. Collaborate with patients to schedule bowel elimination as close as possible to their previous routine. For example, a patient who had stools at noon every other day before the illness or injury should have the bowel program scheduled in the same way. An exception is the patient who prefers another time that best fits into his or her daily routine. If he or she is employed during the day, a time-consuming bowel elimination program in the morning may not work. The bowel protocol can then be changed to the evening when there is more time. Bowel retraining programs for patients with neurologic problems are often designed to include a combination of methods. Although drug therapy should not be a first choice when formulating a bowel training program, consider the need for a suppository if the patient cannot re-establish defecation habits through a consistent toileting schedule, dietary modification, or digital stimulation. Bisacodyl, a commonly used laxative, may be prescribed either rectally or orally as part of a bowel training program. Suppositories must be placed against the bowel wall to stimulate the sacral reflex arc (if intact) and promote rectal emptying. Results occur in 15 to 30 minutes. Administer the suppository when the patient expects to defecate (e.g., after a meal) to coincide with the gastrocolic reflex. Using the suppository every second or third day is usually effective in re-establishing defecation patterns for patients with upper motor neuron problems where the reflex arc is not damaged.

Summary of Key Personnel Roles and Functions for Emergency Preparedness and Response Plan

A. Personnel Role & Function -Hospital incident commander: Physician or administrator who assumes overall leadership for implementing the emergency plan -Medical command physician: Physician who decides the number, acuity, and resource needs of patients -Triage officer: Physician or nurse who rapidly evaluates each patient to determine priorities for treatment -Community relations or public information officer: Person who serves as a liaison between the health care facility and the media

Craniotomy

A. surgical incision into the cranium to access the brain -Preoperative Care i. The patient having a craniotomy is typically very anxious about having his or her head opened and the brain exposed. Concerns are centered on the possibility of increased neurologic deficits after the surgery and the patient's self-image when part or all of the head is shaved. Teach the patient and family about what to expect immediately after surgery and throughout the recovery period. Some patients require short-term or long-term rehabilitation. -Postoperative Care i. The focus of postoperative care is to monitor the patient to detect changes in status and prevent or minimize complications, especially increased intracranial pressure (ICP). Periorbital edema and ecchymosis (bruising) around one or both eyes are not unusual and are treated with cold compresses to decrease swelling. Irrigate the affected eye(s) with warm saline solution or artificial tears to improve patient comfort. The patient in the critical care unit has routine cardiac monitoring because dysrhythmias may occur as a result of brain-autonomic nervous system-cardiac interactions or fluid and electrolyte imbalance. Regardless of setting, ensure recording of the patient's intake and output for the first 24 hours. Anticipate fluid restriction to 1500 mL daily if there is pituitary involvement in either the tumor or surgical site and SIADH develops. Reposition the patient, being careful not to cause pressure on the operative site. Delegate or provide repositioning and deep breathing every 2 hours. To prevent the development of venous thromboembolism (VTE), maintain intermittent sequential pneumatic devices until the patient ambulates. Check the head dressing every 1 to 2 hours for signs of drainage. Mark the area of drainage once during each shift for baseline comparison, although this practice varies by health care agency. A small or moderate amount of drainage is expected. Some patients may have a Hemovac or Jackson-Pratt drain in place for 24 to 72 hours after surgery. Measure the drainage every 8 hours and record the amount and color. A typical amount of drainage is 30 to 50 mL every 8 hours. Follow the manufacturer's and neurosurgeon's instructions to maintain suction within the drain. ii. The usual laboratory studies monitored after surgery include complete blood count (CBC), serum electrolyte levels and osmolarity, and coagulation studies. The patient's hematocrit and hemoglobin concentration may be abnormally low from blood loss during surgery, diluted from large amounts of IV fluids given during surgery, or elevated if the blood was replaced. Hyponatremia (low serum sodium) may occur as a result of fluid volume overload, syndrome of inappropriate antidiuretic hormone (SIADH), or steroid administration. Hypokalemia (low serum potassium) may cause cardiac irritability. Weakness, a change in LOC, and confusion are symptoms of hyponatremia and hypokalemia. Hypernatremia may be caused by meningitis, dehydration, or diabetes insipidus (DI). It manifests with muscle weakness, restlessness, extreme thirst, and dry mouth. Additional signs of dehydration such as decreased urinary output, thick lung secretions, and hypotension may be present. Untreated hypernatremia can lead to seizure activity. DI should be considered if the patient voids large amounts of very dilute urine with an increasing serum osmolarity and electrolyte concentration. The patient may be mechanically ventilated for the first 24 to 48 hours after surgery to help manage the airway and maintain optimal oxygen levels. If the patient is awake or attempting to breathe at a rate other than that set on the ventilator, drugs such as propofol and fentanyl are given to treat pain and anxiety and promote rest and comfort. Suction the patient as needed. Remember to hyperoxygenate the patient carefully before, during, and after suctioning! Drugs routinely given after surgery include antiepileptic drugs, histamine blockers or proton pump inhibitors for stress ulcer prevention, and glucocorticoids such as dexamethasone to reduce cerebral edema. Give acetaminophen for fever or mild pain. Antibiotics are typically prescribed to prevent infection for several days after surgery.

SCI: Increasing Functional Ability Interventions

ADLs, or self-care activities, include eating, bathing, dressing, grooming, and toileting. Encourage the patient to perform as much self-care as possible. Allow time to complete the task as independently as possible. Collaborate with the occupational therapist (OT) to identify ways in which self-care activities can be modified so the patient can perform them as independently as possible and with minimal frustration. For example, teach a patient with hemiplegia to put on a shirt by first placing the affected arm in the sleeve, followed by the unaffected arm. Slip-on shoes or shoes with Velcro straps may be recommended for some patients. Encourage patients to practice and allow them time to try to be independent in ADLs.

Nursing Safety Priority 13

Before discharge after carotid stent placement, teach the patient and family to report these symptoms to the primary health care provider immediately: • Severe headache • Change in LOC or cognition (e.g., drowsiness, new-onset confusion) • Muscle weakness or motor dysfunction • Severe neck pain • Swelling at neck incisional site • Hoarseness or dysphagia (due to nerve damage)

Nursing Safety Priority 16

After the initial interval, symptoms of neurologic impairment from hemorrhage can progress very quickly, with potentially life-threatening ICP elevation and irreversible structural damage to brain tissue. Monitor the patient suspected of epidural bleeding frequently (every 5 to 10 minutes) for changes in neurologic status. The patient can become quickly and increasingly symptomatic. A loss of consciousness from an epidural hematoma is a neurosurgical emergency! Notify the primary health care provider or Rapid Response Team immediately if these changes occur. Carefully document your assessments and identify any trends.

epidural hematoma

An epidural hematoma results from arterial bleeding into the space between the dura and the inner skull. It is often caused by a fracture of the temporal bone, which houses the middle meningeal artery. Patients with epidural hematomas have "lucid intervals" that last for minutes, during which time the patient is awake and talking. This follows a momentary unconsciousness that can occur within minutes of the injury.

transient ischemic attack (TIA)

Acute ischemic strokes often follow warning signs such as a transient ischemic attack (TIA). A TIA is a temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow. The symptoms of TIA are easy to ignore or miss, particularly if symptoms resolve by the time the patient reaches the emergency department (ED). Typically, symptoms of a TIA resolve within 30 to 60 minutes but may last as long as 24 hours.

Nursing Safety Priority 29

After surgical spinal fusion, assess the patient's neurologic status and vital signs at least every hour for the first 4 to 6 hours and then, if the patient is stable, every 4 hours. Assess for complications of surgery, including worsening of motor or sensory function at or above the site of surgery.

secondary survey

After the ED resuscitation team has addressed the immediate life threats, other activities that the emergency nurse can anticipate include insertion of a gastric tube for decompression of the GI tract to prevent vomiting and aspiration, insertion of a urinary catheter to allow careful measure of urine output, and preparation for diagnostic studies. The resuscitation team also performs a more comprehensive head-to-toe assessment, known as the secondary survey, to identify other injuries or medical issues that need to be managed or that might affect the course of treatment. Splints will be applied to fractured extremities, and temporary dressings will be placed over wounds while the patient undergoes diagnostic testing or preparation for more definitive management.

SCI: Managing the Airway and Improving Breathing

Airway management is the priority for a patient with cervical spinal cord injury! Patients with injuries at or above T6 are especially at risk for respiratory distress and pulmonary embolus during the first 5 days after injury. These complications are caused by impaired functioning of the intercostal muscles and disruption in the innervation to the diaphragm. Depending on the level of injury, intubation or tracheotomy with mechanical ventilation may be needed. Respiratory secretions are managed with manually assisted coughing, pulmonary hygiene, and suctioning. Encourage the non-mechanically ventilated patient to use an incentive spirometer. The nurse and respiratory therapist perform a respiratory assessment at least every 8 hours to determine the effectiveness of these strategies. In some cases, it may be necessary to perform oral or nasal suctioning if the patient cannot clear the airway of secretions effectively. Teach the patient who is tetraplegic to coordinate his or her cough effort with an assistant. The nurse, or other assistant, places his or her hands on the upper abdomen over the diaphragm and below the ribs. Hands are placed one over the other, with fingers interlocked and away from the skin. If the patient is obese, an alternate hand placement is one hand on either side of the rib cage. Have the patient take a breath and cough during expiration. The assistant locks his or her elbows and pushes inward and upward as the patient coughs. This technique is sometimes called assisted coughing, quad cough, or cough assist. Repeat the coordinated effort, with rest periods as needed, until the airway is clear.

Stroke: Assessment

Although an accurate history is important in the diagnosis of a stroke, the first priority is to ensure that the patient is transported to a stroke center. A stroke center is designated by The Joint Commission (TJC) or other organization for its ability to rapidly recognize and effectively treat strokes. Obtaining a history should not delay the patient's arrival to either the stroke center or interventional radiology within the comprehensive stroke center. A focused history to determine if the patient has had a recent bleeding event or is taking an anticoagulant is an important part of the rapid stroke assessment protocol. Several important parts of the history should be collected: • When did symptoms begin? The time of onset of symptoms is essential for making treatment decisions. • What was the patient doing when the stroke began? Hemorrhagic strokes tend to occur during activity. Ischemic strokes tend to occur early in the morning. • How did the symptoms progress? Symptoms of a hemorrhagic stroke tend to occur abruptly, whereas thrombotic strokes generally have a more gradual progression. • Did the symptoms worsen after the initial onset, or did they begin to improve? • What is the patient's medical history (with specific attention directed toward a history of head trauma, diabetes, hypertension, heart disease, anemia, and obesity)? • What are the patient's current medications, including prescribed drugs, over-the-counter (OTC) drugs, herbal and nutritional supplements, and recreational (illicit) drugs? • What is the patient's social history, including education, employment, travel, leisure activities, and personal habits (e.g., smoking, diet, exercise pattern, drug and alcohol use)? During the interview, observe the patient's level of consciousness (LOC) and assess for indications of impaired cognition, mobility, and sensory perception. Question the patient or family member about the presence of sensory deficits or motor changes, visual problems, problems with balance or gait, communication problems, and changes in reading or writing abilities. When LOC is suddenly decreased or altered, immediately determine if hypoglycemia or hypoxia is present because these conditions may mimic emergent neurologic disorders! Hypoglycemia and hypoxia are easily treated and reversed, unlike brain injury from inadequate perfusion or trauma.

Strokes: Cultural/Spiritual Considerations

American Indian and Alaskan Native groups have the highest prevalence of stroke when compared with other populations. Black men and women have more strokes twice as often as white men and women, especially hemorrhagic strokes caused by hypertension. Hispanic or Latino men have more strokes than non-Hispanic men. All of these groups tend to be at a higher risk for hypertension than the Euro-American population. Socioeconomic factors, such as lifestyle (e.g., diet), health care disparities, and genetic or familial factors, may also play a role in stroke risk among these minority groups.

Acute Ischemic Stroke

An acute ischemic stroke (AIS) is caused by the occlusion (blockage) of a cerebral or carotid artery by either a thrombus or an embolus. A stroke that is caused by a thrombus (clot) is referred to as a thrombotic stroke, whereas a stroke caused by an embolus (dislodged clot) is referred to as an embolic stroke.

Embolic stroke

An embolic stroke is caused by a thrombus or a group of thrombi that break off from one area of the body and travel to the cerebral arteries via the carotid artery or vertebrobasilar system. The usual source of emboli is the heart. Emboli can occur in patients with atrial fibrillation, heart valve disease, mural thrombi after a myocardial infarction (MI), a prosthetic heart valve, or endocarditis (infection within the wall of the heart). Another source of emboli may be atherosclerotic plaque or clot that breaks off from the carotid sinus or internal carotid artery. As the emboli block the vessel, ischemia develops, and the patient experiences the signs and symptoms of the stroke. The occlusion (blockage) may be temporary if the embolus breaks into smaller fragments, enters smaller blood vessels, and is absorbed. For these reasons, embolic strokes are characterized by the sudden development and rapid occurrence of neurologic deficits. The symptoms may resolve over a few days. Conversion of an occlusive stroke to a hemorrhagic stroke may occur because the arterial vessel wall is also vulnerable to ischemic damage from blood supply interruption. Sudden hemodynamic stress may result in vessel rupture, causing bleeding directly within the brain tissue. Patients with embolic strokes may have a heart murmur, dysrhythmias (most often atrial fibrillation), and/or hypertension. It is not unusual for the patient to be admitted to the hospital with a blood pressure greater than 180 to 200/110 to 120 mm Hg, especially if he or she has hypertensive bleeding. Although a somewhat higher blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke, pressures above this reading may lead to extension of the stroke.

internal disaster

An event occurring inside a health care facility or campus that could endanger the safety of patients or staff is considered an internal disaster. The event creates a need for evacuation or relocation. It often requires extra personnel and the activation of the facility's emergency preparedness and response plan (also called an emergency management plan). Examples of internal disasters include fire, explosion, loss of critical utilities (e.g., electricity, water, computer systems, and communication capabilities), and violence (e.g., an active-shooter situation). Each health care organization develops policies and procedures for preventing these events through organized facility and security management plans. The most important outcome for any internal disaster is to maintain patient, staff, and visitor safety.

external disaster

An event outside the health care facility or campus, somewhere in the community, that requires the activation of the facility's emergency management plan is considered an external disaster. The number of facility staff and resources may not be adequate for the incoming emergency department (ED) patients. External disasters, like a hurricane, earthquake, or tornado, can be natural, or they can be technologic such as an act of terrorism with explosive devices or a malfunction of a nuclear reactor with radiation exposure. Examples of external disasters include the Coronavirus Disease 2019, also known as COVID-19, pandemic; the mass shootings at the Pulse nightclub in Orlando, Florida in 2016 and at the Las Vegas Harvest Music Festival in 2017; and Hurricane Harvey, which incapacitated parts of Texas in 2017.

TBI: Maintaining Cognition, Sensory Perception, and Mobility Interventions

An overwhelming majority of brain injury survivors have altered cognition, including decreased memory and impaired judgment and reasoning ability. Cognitive impairments may interfere with the brain-injured patient's ability to function effectively in school, at work, and in his or her personal life. Cognitive rehabilitation is a way of helping brain-injured patients regain function in areas that are essential for a return to independence and a reasonable quality of life. If a large lesion of the parietal lobe is present, the patient may experience a loss of sensory perception for pain, temperature, touch, and proprioception, which prevents an appropriate response to environmental stimuli. A hazard-free environment is necessary to prevent injury (e.g., from burns if the patient's coffee is too hot). In collaboration with the rehabilitation therapist, integrate a sensory stimulation program into the comatose or stuporous patient's routine care activities. Sensory stimulation is done to facilitate a meaningful response to the environment. Present visual, auditory, or tactile stimuli one at a time, and explain the purpose and the type of stimulus presented. For example, show a picture of the patient's mother and say, "This is a picture of your mother." The picture is shown several times, and the same words are used to describe the picture. If auditory tapes or DVDs are used, they should be played no longer than 10 to 15 minutes. If the stimulus is presented for a longer period, it simply becomes "white noise" (meaningless background noise). Some patients with TBI experience seizure activity as a result of primary or secondary brain injury. Be sure to initiate Seizure Precautions according to your agency's policy and procedure. Patients with a mild brain injury may be disoriented and have short-term memory loss. Always introduce yourself before any interaction. Keep explanations of procedures and activities short and simple, and give them immediately before and throughout patient care. To the extent possible, maintain a sleep-wake cycle with scheduled rest periods. Orient the patient to time (day, month, and year) and place, and explain the reason for the hospitalization. Reassure the patient that he or she is safe. If the client is hospitalized, ask the family to bring in familiar objects, such as pictures. Provide orientation cues within the environment, such as a large clock with numbers or a single-date calendar.

medical command physician

Another typical role defined in hospital or other health care emergency preparedness plans is that of the medical command physician. He or she focuses on determining the number, acuity, and medical resource needs of victims arriving from the incident scene to the hospital and organizing the emergency health care team response to the injured or ill patients. Responsibilities include identifying the need for and calling in specialty-trained providers such as: • Surgeons (trauma, neuro, orthopedic, plastic, and/or burn) • Anesthesiologists • Radiologists • Pulmonologists • Infectious disease physicians • Industrial hygienists • Radiation safety personnel In smaller hospitals with limited specialty resources, the medical command physician might also help determine which patients should be transported out of the facility to a higher level of care or to a specialty hospital (e.g., burn center).

Stroke: Ongoing Drug Therapy

Antiplatelet drugs such as aspirin and clopidogrel are the standard of care for treatment following acute ischemic strokes and for preventing future strokes. Sodium heparin and other anticoagulants, such as warfarin, are reserved for use in patients who have cardiopulmonary issues such as atrial fibrillation. Anticoagulants are high-alert drugs that can cause bleeding, including intracerebral hemorrhage in the area of the ischemia. An initial low dose of aspirin is safer and recommended within 24 to 48 hours after stroke onset. Aspirin should not be given within 24 hours of fibrinolytic administration. Aspirin is an antiplatelet drug that prevents further clot formation by reducing platelet adhesiveness (clumping or "stickiness"). A calcium channel blocking drug that crosses the blood-brain barrier such as nimodipine may be given to treat or prevent cerebral vasospasm after a subarachnoid hemorrhage. Vasospasm, which usually occurs between 4 and 14 days after the stroke, slows blood flow to the area and causes ischemia. Nimodipine works by relaxing the smooth muscles of the vessel wall and reducing the incidence and severity of the spasm. In addition, this drug dilates collateral vessels to ischemic areas of the brain. Stool softeners, analgesics for pain, and antianxiety drugs may also be prescribed as needed for symptom management. Stool softeners also prevent the Valsalva maneuver during defecation to prevent increased ICP.

Strokes: Etiology and Genetic Risk

As with many health problems, the causes of stroke are likely a combination of genetic and environmental risk factors. The leading causes of stroke include smoking, obesity, hypertension, diabetes mellitus, and elevated cholesterol. Many of these risk factors have a familial or genetic predisposition. For example, first-degree relative (mother, father, sister, brother) stroke risk increases with a strong family history of hypertension, atherosclerotic disease, and a diagnosis of aneurysm. Relatives of a patient with an aneurysm, regardless of vessel location, may be at higher risk for intracranial aneurysms and should consider diagnostic testing and follow-up. Other risk factors for stroke include substance use disorder (especially cocaine and heavy alcohol consumption) and use of oral contraceptives by women who are at risk for cardiovascular adverse effects. Women have a higher incidence of strokes than men, most likely because they tend to live longer. Deaths from stroke have declined over the past 15 years as a result of advances in prompt and effective medical treatment. However, the number of strokes occurring in the younger-adult and middle-age population is increasing. In this group, strokes are associated with illicit drug use because many street drugs cause hypercoagulability, vasospasm, or hypertensive crisis.

Nursing Safety Priority 25

Assess breath sounds every 2 to 4 hours during the first few days after SCI and document and report any adventitious or diminished sounds. Monitor vital signs with pulse oximetry. Watch for changes in respiratory pattern or airway obstruction. Intervene per agency or primary health care provider protocol when there is a decrease in oxygen saturation (SpO 2) to below 95%.

Nursing Safety Priority 21

Assess neurologic and vital signs every 15 to 30 minutes for the first 4 to 6 hours after a craniotomy and then every hour. If the patient is stable for 24 hours, the frequency of these checks may be decreased to every 2 to 4 hours, depending on agency policy and the patient's condition. Report immediately and document new neurologic deficits, particularly a decreased level of consciousness (LOC), motor weakness or paralysis, aphasia, decreased sensory perception, and sluggish pupil reaction to light! Personality changes such as agitation, aggression, or passivity can also indicate worsening neurologic status.

Nursing Safety Priority 22

Assess the patient and the situation before any transfer. Orthostatic, or postural, hypotension is a common problem and may contribute to falls. If the patient moves from a lying to a sitting or standing position too quickly, his or her blood pressure may drop; as a result, he or she can become dizzy or faint. This problem is worsened by antihypertensive drugs, especially in older adults. To prevent this situation, help the patient change positions slowly, with frequent pauses to allow the blood pressure to stabilize. If needed, measure blood pressure with the patient in the lying, sitting, and standing positions to examine the differences. Orthostatic hypotension is indicated by a drop of more than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure between positions. Notify the health care provider and the therapists about this change. If the patient has problems maintaining blood pressure while out of bed, the physical therapist may start him or her on a tilt table to gradually increase tolerance. Low blood pressure is a particularly common problem for patients with quadriplegia because they have a delayed blood flow to the brain and upper part of the body.

SCI: Gastrointestinal and Genitourinary Assessment

Assess the patient's abdomen for symptoms of internal bleeding, such as abdominal distention, pain, or paralytic ileus. Hemorrhage may result from the trauma, or it may occur later from a stress ulcer or the administration of steroids. Monitor for abdominal pain and changes in bowel sounds. Paralytic ileus may develop within 72 hours of hospital admission. During the period of spinal shock, peristalsis decreases, leading to a loss of bowel sounds and to gastric distention. This disruption of the autonomic nervous system may lead to a hypotonic bowel. After the first few days, when edema subsides, the spinal reflexes that innervate the bowel and bladder usually begin to establish function, depending on the level of the injury. Patients with cervical or high thoracic SCIs have upper motor neuron damage that spares lower spinal reflexes, causing a spastic bowel and bladder. Patients with lower thoracic and lumbosacral injuries usually have damage to their lower spinal nerves and therefore have a flaccid bowel and bladder.

Disposition

At the conclusion of the assessment, the provider must make a decision regarding patient disposition (i.e., where the patient should go after being discharged from the ED). Should he or she be admitted to the hospital, transferred to a specialty care center, or discharged to home with instructions for continued care and follow-up?

Blast effect

Blast effect from an exploding bomb also causes blunt trauma. The energy transmitted from a blunt-trauma mechanism, particularly the rapid acceleration-deceleration forces involved in high-speed crashes or falls from a great height, produces injury by tearing, shearing, and compressing anatomic structures. Trauma to bones, blood vessels, and soft tissues occurs.

Nursing Safety Priority 14

Be alert for symptoms of increased ICP in the stroke patient and report any deterioration in the patient's neurologic status to the primary health care provider or Rapid Response Team immediately! The first sign of increased ICP is a declining level of consciousness (LOC).

Preventing Secondary Spinal Cord Injury: Drug Therapy

Because SCI is a physical trauma, the patient is started on a proton pump inhibitor, such as pantoprazole, to help prevent the development of stress ulcers. This drug may be administered IV or orally. Oral doses may be taken with our without food. Centrally acting skeletal muscular relaxants, such as tizanidine, may help control severe muscle spasticity. However, these drugs cause severe drowsiness and sedation in most patients and may not be effective in reducing spasticity. As an alternative to these drugs, intrathecal baclofen (ITB) therapy may be prescribed in a lower dose. This drug is administered through a programmable, implantable infusion pump and intrathecal catheter directly into the cerebrospinal fluid. The pump is surgically placed in a subcutaneous pouch in the lower abdomen. Monitor for common adverse effects, which include sedation, fatigue, headache, hypotension, and changes in mental status. Seizures and hallucinations may occur if ITB is suddenly withdrawn. Other drugs to prevent or treat complications of immobility may be needed later during the rehabilitative phase. For example, celecoxib may be prescribed to prevent or treat heterotopic ossification (bony overgrowth). However, recall that the adverse effects of this drug include an increased risk of myocardial infarction and stroke. Calcium and bisphosphonates may prevent the osteoporosis that results from lack of weight-bearing or resistance activity. Osteoporosis can cause fractures in later years. Early and continued exercise may help decrease the incidence of these complications.

SCI: Health Promotion

Because trauma is the leading cause of SCI, teach people to avoid taking risks, such as ensuring adequate protective measures (e.g., padding and helmets) for sports and recreation. Remind them to wear seat belts at all times when driving and avoid impaired driving caused by alcohol, marijuana, and other substances. Instruct them on the danger of diving into shallow pools or other water when the depth is not known. Water should be at least 9 feet deep before diving is attempted.

Secondary Brain Injury: Hypotension and Hypoxia

Both hypotension, defined as a mean arterial pressure less than 70 mm Hg, and hypoxemia, defined as a partial pressure of arterial oxygen (PaO 2) less than 80 mm Hg, restrict the flow of blood to vulnerable brain tissue. Hypotension may be related to shock or other states of reduced perfusion to the brain such as that caused by clot formation. Hypoxia can be caused by respiratory failure, asphyxiation, or loss of airway and impaired ventilation. These problems may occur as a direct result of moderate-to-severe brain injury or secondary to systemic injuries and comorbidities. Low blood flow and hypoxemia contribute to cerebral edema, creating a cycle of deteriorating perfusion and hypoxic damage. Patients with hypoxic damage related to moderate or severe brain injury face a poor prognosis and eventually experience impaired cognition.

SCI: Cardiovascular and Respiratory Assessment

Cardiovascular dysfunction results from disruption of sympathetic fibers of the autonomic nervous system (ANS), especially if the injury is above the sixth thoracic vertebra. Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood pressure below 90 mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition. A patient with a cervical SCI is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist (RT), if available, perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation, every 8 to 12 hours. An oxygen saturation of 92% or less and adventitious breath sounds may indicate a complication such as atelectasis or pneumonia. Autonomic dysreflexia (AD), sometimes referred to as autonomic hyperreflexia, is a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI. The causes of AD are typically GI, gynecologic-urologic (GU), and vascular stimulation. Specific risk factors are bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel distention or impaction from constipation, or irritation of hemorrhoids. Pain; circumferential constriction of the thorax, abdomen, or an extremity (e.g., tight clothing); contact with hard or sharp objects; and temperature fluctuations can also cause AD. Patients with altered sensory perception are at great risk for this complication.

SCI: Care Coordination & Transition Management

Care coordination and transition management begin at the time of the patient's admission. If the patient is transferred from a hospital to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF), orient him or her to the change in routine and emphasize the goal of optimal independence in performing self-care activities. When the patient is admitted, a case manager and/or occupational therapist (OT)/physical therapist (PT) assess his or her current living situation at home. Together with the patient and family or significant others, they determine the adequacy of the current situation and the potential needs after discharge to home. The patient with chronic conditions and disability may require home care, assistance with ADLs, nursing care, or physical or occupational therapy after discharge. Other health care professionals may be necessary to meet the patient's needs. For example, patients with traumatic brain injury (TBI) may benefit from life planning—a process that examines and plans to meet lifelong needs.

Nursing Safety Priority 18

Check pupils of TBI patients for size and reaction to light, particularly if the patient is unable to follow directions, to assess changes in level of consciousness. Document any changes in pupil size, shape, and reactivity and notify the Rapid Response Team or primary health care provider immediately because they could indicate an increase in ICP!

Stroke: Diagnostics

Clinical history, physical assessment, and a National Institutes of Health Stroke Scale (NIHSS) score are usually enough to identify a stroke once it has occurred. No definitive laboratory tests confirm its diagnosis. Elevated hematocrit and hemoglobin levels are often associated with a severe or major stroke as the body attempts to compensate for lack of oxygen to the brain. An elevated white blood cell (WBC) count may indicate the presence of an infection or a response to physiologic stress or inflammation. In addition to other routine lab oratory testing, the primary health care provider typically requests a prothrombin time (PT), an international normalized ratio (INR), and an activated partial thromboplastin time (aPTT) to establish baseline information before fibrinolytic or anticoagulation therapy may be started. For definitive evaluation of a suspected stroke, a computed tomography perfusion (CTP) scan and/or computed tomography angiography (CTA) is used to assess the extent of ischemia of brain tissue. Magnetic resonance angiography (MRA) and multimodal techniques such as perfusion-weighted imaging enhance the sensitivity of the MRI to detect early changes in the brain, including confirming blood flow. Ultrasonography (carotid duplex scanning) may also be performed.

triage officer

Closely affiliated with the medical command physician is the triage officer. This person is generally a physician in a large hospital who is assisted by triage nurses. When physician resources are limited, an experienced nurse may assume this role. The triage officer rapidly evaluates each person who presents to the hospital, even those who come in with triage tags in place. Patient acuity is re-evaluated for appropriate disposition to the area within the ED or hospital best suited to meet the patient's needs.

TIA: Causes

Common causes of a TIA or stroke are carotid stenosis (hardening and narrowing of the artery, which decreases blood flow to the brain), often with atherosclerotic plaque buildup, and atrial fibrillation. Atherosclerotic plaque consists of fat and other substances that adhere to the arterial wall and obstruct or restrict blood flow.

Seizures: Older Adult Considerations

Complex partial seizures are most common among older adults. These seizures are difficult to diagnose because symptoms appear similar to those of dementia, psychosis, or other neurobehavioral disorders, especially in the postictal stage (after the seizure). New-onset seizures in older adults typically are associated with conditions such as hypertension, cardiac disease, diabetes mellitus, stroke, dementia, and recent brain injury. Primary or idiopathic epilepsy is not associated with any identifiable brain lesion or other specific cause; however, genetic factors most likely play a role in its development. Secondary seizures result from an underlying brain lesion, most commonly a tumor or trauma. They may also be caused by: • Metabolic disorders • Acute alcohol withdrawal • Electrolyte disturbances (e.g., hyperkalemia, water intoxication, hypoglycemia) • High fever • Stroke • Head injury • Substance abuse • Heart disease Seizures resulting from these problems are not considered epilepsy. Various risk factors can trigger a seizure, such as increased physical activity, emotional stress, excessive fatigue, alcohol or caffeine consumption, or certain foods or chemicals.

Disaster: Ethical/Legal Considerations

Creativity and flexibility of nursing leaders and nursing staff are essential to provide the staffing coverage necessary for a large-scale or extended incident. The willingness of staff to come to work is directly affected by personal concerns. When called to respond to work during a disaster, mass casualty event, or pandemic infectious disease outbreak, nurses may experience ethical and moral conflict among their own personal preparedness for disaster response, family obligations, and professional responsibilities. The American Nurses Association (ANA) Code of Ethics for Nurses With Interpretive Statements (2015) offers general guidance that can be helpful to nurses. Each nurse has to make a personal choice about whether to be involved in helping during the emergency or when to become involved. A personal emergency preparedness plan developed in advance of a disaster by each individual nurse can help in such situations. It should outline the preplanned specific arrangements that are to be made for child care, pet care, and older adult care if the need arises, especially if the event prevents returning home for an extended period.

Seizure Management

The actions taken during a seizure should be appropriate for the type of seizure. It is not unusual for the patient to become cyanotic during a generalized tonic-clonic seizure. The cyanosis is generally self-limiting, and no treatment is needed. Some primary health care providers prefer to give the high-risk patient (e.g., older adult, critically ill, or debilitated patient) oxygen by nasal cannula or facemask during the postictal phase. For any type of seizure, carefully observe the seizure and document assessment findings.

Seizures: Diagnosis

Diagnosis is based on the history and physical examination. A variety of diagnostic tests are performed to rule out other causes of seizure activity and to confirm the diagnosis of epilepsy. Typical diagnostic tests include an electroencephalogram (EEG), CT scan, MRI, or SPECT/PET scan. Laboratory studies are performed to identify metabolic or other disorders that may cause or contribute to seizure activity.

Nursing Safety Priority 23

Do not use digital stimulation for patients with cardiac disease because of the risk for inducing a vagal nerve response. This response causes a rapid decrease in heart rate (bradycardia).

Neurogenic Bladder: Pharmacologic Interventions

Drugs are not commonly used for urinary elimination problems. Mild overactive bladder problems may be treated with antispasmodics such as oxybutynin, solifenacin, or tolterodine to prevent incontinence on a short-term basis. Patients with symptomatic UTIs are managed with short-term antibiotics such as trimethoprim or trimethoprim/sulfamethoxazole. Patients who have frequent UTIs may be placed on pulse antibiotic therapy in which they alternate 1 week of antibiotic therapy with 3 weeks without antibiotics. Report progress in bladder training to the rehabilitation team so the best decision regarding drug therapy can be made.

Role of Nursing in Health Care Facility Emergency Preparedness and Response

During an actual disaster, the ED charge nurse, trauma program manager, and other ED and hospital nursing leadership personnel act in collaboration with the medical command physician and triage officer to organize nursing and ancillary services to meet patient needs. Nursing roles in a disaster extend to all areas within a health care facility. The level of involvement is determined by the scope and scale of the disaster. In any mass casualty event, nurses from critical care and medical-surgical nursing units may be asked, in collaboration with the health care provider, to recommend patients for transfer or discharge to free up inpatient beds for disaster victims. Patients who are the most medically stable may be discharged early, including those who: • Were admitted for observation and are not bedridden • Are having diagnostic evaluations and are not bedridden • Are soon scheduled to be discharged or could be cared for at home with support from family or home health care services • Have had no critical change in condition for the past 3 days • Could be cared for in another health care facility such as rehabilitation or long-term care General staff nurses also may be recruited to collaborate in providing care for stable ED patients, thus allowing ED nurses to focus their efforts on caring for the mass casualty victims. Critical care unit nurses need to identify patients who can be transferred out of the unit to rapidly expand bed capacity. They can supplement ED nurses in the resuscitation setting or assist in monitored care and transport to critical care units. Hospital and ED nurse leaders also typically direct the ancillary departments to deliver supplies, instrument trays, medications, food, and personnel to meet service demands. The key concept is that staff members are expected to remain flexible in a mass casualty situation and perform at their highest level and scope of practice to address the needs of the health care system and the patients. The greatest good for the greatest number of people is still the organizing principle when considering roles and responsibilities in mass casualty events—not necessarily individual staff preferences. However, the safety of all patients is vital. During a community disaster, nurses and other emergency personnel may be needed for triage, first aid or emergency care, and shelter assistance. The initial action of first responders in a disaster is to remove people from danger, both the injured and uninjured. Firefighters and other disaster-trained emergency personnel typically manage this job; unless they have had specific prehospital search-and-rescue training, nurses are not usually involved in this process. After removal from danger, victims are triaged by health care personnel as described earlier in this chapter. After triage, nurses often provide on-site first aid and emergency care. They may also be involved in teaching and supervising volunteers.

Preventing Secondary Spinal Cord Injury: Spinal Immobilization and Stabilization

During the immediate care of the patient with a suspected or confirmed cervical spine injury, a hard cervical collar, such as the Miami J or Philadelphia collar, is placed immediately and maintained until a specific order indicates that it can be removed. A daily inspection of skin beneath the collar is recommended while a primary health care provider helps to maintain neck alignment when the collar is removed. Padding at pressure points beneath and at the edges of the collar, particularly at the occiput, may be necessary to sustain skin integrity. Until the spinal column is stabilized, a jaw-thrust maneuver is preferable to a head-tilt maneuver to open the airway should the patient need an airway intervention. Maintain spinal alignment at all times with log rolling to change position from supine to side-lying. The patient may be placed in fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury, often after surgical stabilization. The most commonly used device for immobilization of the cervical spine is the halo fixator device, also called a halo crown, which is worn for 6 to 12 weeks. This static device is affixed by four pins (or screws) into the outer aspect of the skull and is connected to a vest or jacket. For patients not having surgery, the addition of traction helps reduce the fracture. Nonsurgical treatment of thoracic and lumbosacral injuries is often challenging. Most primary health care providers choose to refer the patient for surgery and then immobilize the spine with lightweight, custom-fit thoracic-lumbar sacral orthoses (TLSOs) to prevent prolonged periods of immobility.

Stroke: Core Measures

Eight core measures and quality indicators are associated with the care of stroke patients by the interprofessional health care team. Certification as a primary stroke center or a comprehensive stroke center is tied to consistent performance in achieving satisfactory core measures. The core measures may have additional implications in terms of reimbursement in the future. The eight core measures for ischemic stroke care for all patients include: • Venous thromboembolism (VTE) prophylaxis • Discharge with antithrombotic therapy • Discharge with anticoagulation therapy for atrial fibrillation/flutter • Thrombolytic therapy as indicated • Antithrombotic therapy re-evaluated by end of hospital day 2 • Discharge on statin medication • Stroke education provided and documented • Assessment for rehabilitation

Demographic Data and Vulnerable Populations

Emergency department staff members provide care for people across the life span with a broad spectrum of needs, illnesses, and injuries, as well as varying cultural, spiritual, and religious beliefs and practices. Vulnerable populations who visit the ED include the homeless, the poor, patients with mental health needs, those with substance use concerns, and older adults.

Stroke: Endovascular Interventions

Endovascular procedures to improve perfusion include intra-arterial thrombolysis using drug therapy, mechanical embolectomy (surgical blood clot [thrombosis] removal), and carotid stent placement. Intra-arterial thrombolysis has the advantage of delivering the fibrinolytic agent directly into the thrombus within 6 hours of the stroke onset. It is particularly beneficial for some patients who have an occlusion of the middle cerebral artery or those who arrive in the ED after the window for IV alteplase. Patients having either fibrinolytic therapy or endovascular interventions are admitted to the critical care setting for intensive monitoring. Carotid artery angioplasty with stenting is common to prevent or, in some cases, help manage an acute ischemic stroke. This interventional radiology procedure is usually done under moderate sedation. It may be performed by a cardiovascular surgeon or interventional radiologist. The device catches any clot debris that breaks off during the procedure. Placement of a carotid stent is performed to open a blockage in the carotid artery. Throughout the procedure, carefully assess the patient's neurologic and cardiovascular status.

SCI: Planning and Implementation

The desired outcomes of patient-centered collaborative care following acute SCI are to stabilize the vertebral column, manage damage to the spinal cord, and prevent secondary injuries.

Green-tagged patients

Green-tagged patients have minor injuries that can be managed after a delay, generally more than 2 hours. Examples of green-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions. Green-tagged patients are often referred to as the "walking wounded" because they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle. Green-tagged patients usually make up the greatest number in most large-scale multicasualty situations. Therefore they can overwhelm the system if provisions are not made to handle them as part of the disaster plan. A related concern is that green-tagged patients who self-transport may unknowingly carry contaminants from a nuclear, biologic, or chemical incident into the hospital environment, with potentially disastrous consequences. ED staff must anticipate these issues and collaborate to devise emergency response plans accordingly, including appropriate decontamination measures.

Stroke: Assessment cont.

First-responder personnel (e.g., paramedics, emergency medical technicians) perform an initial neurologic examination using well-established stroke assessment tools. Nurses also perform a complete neurologic assessment on arrival to the ED. The National Institutes of Health Stroke Scale (NIHSS) is a commonly used valid and reliable assessment tool that nurses complete as soon as possible after the patient arrives in the ED. This tool is used as one assessment to determine eligibility for IV fibrinolytics. Although the NIHSS is the standard tool for assessing neurologic status after an acute stroke, there is no standard for when and how often to use the tool. As the patients are transitioned from the ED to other settings, the most important area to assess is the patient's LOC. Use the Glasgow Coma Scale or a modified NIHSS to frequently monitor for changes in LOC throughout the patient's acute care. Strokes and other neurologic injuries, including brain tumors or traumatic brain injury, can cause an impaired airway defense, or an inability to clear one's airway. This impairment can cause inadequate cough and dysphagia (difficulty swallowing), which can lead to aspiration (causing aspiration pneumonia) or death. Therefore assess the client's ability to effectively cough. Some agencies also allow nurses to use a one of a variety of screening tools to assess for the presence of dysphagia. Stroke symptoms can appear at any time of the day or night. In general, the five most common symptoms are: • Sudden confusion or trouble speaking or understanding others • Sudden numbness or weakness of the face, arm, or leg • Sudden trouble seeing in one or both eyes • Sudden dizziness, trouble walking, or loss of balance or coordination • Sudden severe headache with no known cause More specific stroke symptoms depend on the extent and location of the ischemia and the arteries involved. Assess the patient's reaction to the illness, especially in relation to changes in body image, self-concept, and ability to perform ADLs. In collaboration with the patient's family and friends, identify any problems with coping or personality changes. Assess for emotional lability (uncontrollable emotional state), especially if the frontal lobe or right side of the brain has been affected. In such cases the patient often laughs and then cries unexpectedly for no apparent reason. Explain the cause of uncontrollable emotions to the family or significant others so they do not feel responsible for these reactions.

Stroke: Promoting Mobility & ADL Ability

Follow agency guidelines for screening or use an evidence-based bedside swallowing screening tool to determine if dysphagia is present. Refer the patient to the speech-language pathologist (SLP) for a swallowing evaluation per stroke protocol as needed. If dysphagia is present, develop a collaborative plan of care to prevent aspiration and support nutrition. Collaborate with the registered dietitian nutritionist to ensure that nutritional needs are met. Monitor the patient's weight daily and serum prealbumin levels to detect any decrease from baseline. Many patients who have an untreated stroke often have flaccid or spastic paralysis. It is not unusual for the patient to eventually have a flaccid arm and spastic leg on the affected side because the affected leg often regains function more quickly than the arm. Be sure to support the affected flaccid arm of the stroke patient, and teach assistive personnel (AP) to avoid pulling on it. Position the arm on a pillow while the patient is sitting to prevent it from hanging freely, which could cause shoulder subluxation. The physical therapist or occupational therapist provides a slinglike device to support the arm during ambulation. Patients begin rehabilitation as soon as possible to regain function and prevent complications of immobility, such as pneumonia, atelectasis, and pressure injuries. Another major complication of impaired mobility is the development of venous thromboembolism (VTE), especially deep vein thrombosis (DVT), which can lead to a pulmonary embolism (PE). This risk is highest in older patients and those with a severe stroke.

Nursing Safety Priority 15

For ischemic strokes, if the stroke patient's systolic BP is more than 185 mm Hg, notify the Rapid Response Team or primary health care provider immediately and anticipate possible prescription of an IV antihypertensive medication. Monitor the patient's BP and mean arterial pressure (MAP) (normal MAP is 70 to 100 mm Hg; at least 60 mm Hg is necessary to perfuse major organs) every 5 minutes until the systolic BP is adequate to maintain brain perfusion. Avoid a sudden systolic BP drop to less than 120 mm Hg with drug administration, which may cause brain ischemia.

Paramedics

For patients who require care that exceeds BLS resources, paramedics may be dispatched. Paramedics are advanced life support (ALS) providers who can perform advanced techniques, which may include cardiac monitoring, advanced airway management and intubation, needle chest decompression, establishing IV or intraosseous access, and administering drugs en route to the ED.

Care of Patients With Aphasia

For patients with moderate-to-severe aphasia or dysarthria, consult with the speech-language pathologist (SLP), who can complement your patient care with specialized knowledge of speech and language problems. The SLP may identify additional patient problems that could trigger the need for other team members to achieve positive outcomes for the patient who experienced a stroke. According to the Interprofessional Education Collaborative (IPEC) Expert Panel's Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care.

Stroke: Fibrinolytic Therapy

For selected patients with acute ischemic strokes, early intervention with IV fibrinolytic therapy ("clot-busting drug") is the standard of practice to improve blood flow to viable tissue around the infarction or through the brain. The success of fibrinolytic therapy for a stroke depends on the interval between the time that symptoms begin and treatment is available. IV (systemic) fibrinolytic therapy (also called thrombolytic therapy) for an acute ischemic stroke dissolves the cranial artery occlusion to re-establish blood flow and prevent cerebral infarction. IV alteplase is the only drug approved at this time for the treatment of acute ischemic stroke. The most important factor in determining whether or not to give alteplase is the time between symptom onset and time seen in the stroke center. Currently, the U.S. Food and Drug Administration (FDA) approves administration of alteplase within 3 hours of stroke onset. The American Stroke Association endorses extension of that time frame to 4.5 hours to administer this fibrinolytic for patients unless they fall into one or more of these categories: • Age older than 80 years • Anticoagulation regardless of international normalized ratio (INR) • Imaging evidence of ischemic injury involving more than one-third of the brain tissue supplied by the middle cerebral artery • Baseline National Institutes of Health Stroke Scale (NIHSS) score greater than 25 • History of both stroke and diabetes • Evidence of active bleeding Fibrinolytic therapy is explained to the patient and/or family member, and informed consent is obtained. The dosage of alteplase is based on the patient's actual weight at 0.9 mg/kg. The 2018 Clinical Practice Guidelines for management of patients with acute ischemic stroke recommend IV alteplase 90 mg over 60 minutes, with the initial 10% of that dose given as a bolus over the first minute. In some cases, the patient's blood pressure may be too high to give the medication. In this instance, the patient receives a rapid-acting antihypertensive drug until the blood pressure is below 185/110 mm Hg. This level must be maintained during fibrinolytic therapy.

Spinal Cord: Assessment of Functional Ability

Functional ability refers to the ability to perform activities of daily living (ADLs) such as bathing, dressing, eating, using the toilet, and ambulating. Instrumental activities of daily living (IADLs) refer to activities necessary for living in the community such as using the telephone, shopping, preparing food, and housekeeping. Functional assessment tools are used to assess a patient's abilities. Rehabilitation nurses, physiatrists, or rehabilitation therapists complete assessment tools to document functional levels.

Nursing Safety Priority 2

Help patients move slowly from a supine to an upright position. Assist when ambulating. When the patient is on a stretcher, confirm that side rails are up and locked, that the call light is within reach, and that a patient's fall risk is communicated clearly to staff members who may assume responsibility for care, as well as caregivers. Older adults who are on beds or stretchers should always have side rails up and the bed or stretcher in the lowest position. Access to a call light is especially important; instruct the patient to call for the nurse if assistance is needed rather than attempting independent ambulation. Some older adults have difficulty adjusting to the noise and pace of the ED and/or have illnesses or injuries that cause delirium, an acute state of confusion. Reorient the patient frequently and reassess mental status. Undiagnosed delirium increases the risk for mortality for older adults who are admitted to the hospital. Assess the need for a caregiver or safety companion to stay with the patient to prevent falls and help with reorientation.

Secondary Brain Injury: Hemorrhage

Hemorrhage, which causes a brain hematoma (collection of blood) or clot, may occur as part of the primary injury and begin at the moment of impact. It may also arise later from vessel damage. Classically, bleeding is caused by vascular damage from the shearing force of the trauma or direct physical damage from skull fractures or penetrating injury. All hematomas are potentially life threatening because they act as space-occupying lesions and are surrounded by edema. Three major types of hemorrhage after TBI are epidural, subdural, and intracerebral hemorrhage. Subarachnoid hemorrhage may also occur.

ED: Older Adult Considerations 2

If discharge from the emergency department (ED) to home is possible, ensure that safety issues are considered. For example, collaborate with the ED provider to evaluate the patient's current prescriptions and over-the-counter medications to determine if the drug regimen should be continued. Involve the ED-based pharmacist if one is available for consultation when necessary. If the drug regimen needs to be changed, be sure that the patient and caregiver have the new information in writing and that it is explained verbally. If needed, assess whether the patient has someone who can pre-sort and place drugs into a medication dispenser to ensure accuracy and prevent adverse drug events. Consider a social services or case-management referral for patients in need of financial resources to obtain prescribed drugs. To prevent future ED visits, screen older adults per agency policy for functional assessment, cognitive assessment, and risk for falls. Depression screening is also critical because suicide rates are two times higher among older adults compared with younger adults. Older adult males who are white are at the highest risk. Older adults are often admitted to the hospital directly from the ED. If hospitalization is needed, determine if the patient has advance directives or is able to make decisions about advance directives before admission. If the patient was admitted from a nursing home, contact the facility to let them know the patient's status. If the patient was receiving home health services, notify the agency about the hospital admission. Contact the patient's primary health care provider and designated caregiver if he or she is not present with the patient.

Death in the Emergency Department

If the patient dies before family members arrive, ED staff members will usually prepare the body and the room for viewing by the family. However, certain types of ED deaths may require forensic investigation or become medical examiner's cases. Therefore, ED staff may not be able to remove IV lines and indwelling tubes or clean the patient's skin if these actions could potentially damage evidence. Trauma deaths, suspected homicide, or cases of abuse always fall into this category. In these situations, cover the body with a sheet or blanket while leaving the patient's face exposed and dim the lights before family viewing. When dealing with family members in crisis, simple and concrete communication is best. Words such as death or died, although seemingly harsh, create less confusion than terms such as expired or passed away.

Nursing Safety Priority 27

If the patient experiences AD, raise the head of the bed immediately to help reduce the blood pressure as the first action. Notify the Rapid Response Team or primary health care provider immediately for drug therapy to quickly reduce blood pressure as indicated.

Preventing Secondary Spinal Cord Injury

If the patient has a fractured vertebra, the primary concern of the health care team is to reduce and immobilize the fracture to prevent further damage to the spinal cord from bone fragments. Nonsurgical techniques include external fixation or orthotic devices, but surgery is often needed to stabilize the spine and prevent further spinal cord damage. Assess the patient's neurologic status, particularly focusing on mobility (motor) and sensory perception function, vital signs, pulse oximetry, and pain level, at least every 1 to 4 hours, depending on his or her overall condition. Document your assessments carefully and in detail, particularly changes in motor or sensory function. Failure to do so may prevent other staff members from quickly recognizing deterioration in neurologic status. Regardless of the level of SCI, keep the patient in proper body alignment to prevent further cord injury or irritability. Devices such as traction, orthoses, or collars may be used to keep the spine immobilized during healing and rehabilitation.

Nursing Safety Priority 24

In acute SCI, monitor for a decrease in sensory perception from baseline, especially in a proximal (upward) dermatome and/or new loss of motor function and mobility. The presence of these changes is considered an emergency and requires immediate communication with the primary health care provider using SBAR or other agency-approved protocol for notification. Document these assessment findings in the electronic health record.

Spinal Cord: Psychosocial Assessment

In addition to determining cognition , assess the patient's body image and self-esteem through verbal indicators and descriptions of self-care. Encourage the family to allow the patient to independently perform as many functions as possible to build feelings of self-worth. Assess the patient's use of defense mechanisms and manifestations of anxiety. If indicated, ask him or her to describe feelings concerning the loss of a body part or function. Assess for the presence of any stress-related physical problem. Some patients have symptoms such as fatigue, a change in appetite, or feelings of powerlessness. This may be the result of adjusting to a new disability or signs of depression.

Nursing Safety Priority 12

In addition to frequent monitoring of vital signs, carefully observe for signs of intracerebral hemorrhage and other signs of bleeding during administration of fibrinolytic drug therapy.

Care of Patients With Spinal Cord Injury

In collaboration with the rehabilitation team, teach or reinforce teaching for bed mobility skills and bed-to-chair transfers. Patients with paraplegia are usually able to transfer from the bed to chair or wheelchair with minimal or no assistance unless balance is a problem (seen in patients with high thoracic injuries). Techniques to improve balance are usually taught by occupational therapists. Tetraplegic patients may learn how to transfer using a slider, also called a sliding board. This simple boardlike device allows the patient to move from the bed to chair or vice versa by creating a bridge. When using the slider, remind patients to lift the buttocks while moving incrementally and slowly across the board. Patients with severe muscle spasticity have more challenges when learning transfer skills, and contractures are common. Contractures may be prevented or minimized with splints and range-of-motion exercises. Consult with the physical therapist (PT) and occupational therapist (OT) for optimal scheduling for placing and removing splints (typically individually molded to the patient's extremity), applying pressure to trigger points to relieve spasticity, and positioning to maintain joint function. According to the Interprofessional Education Collaborative (IPEC) Expert Panel's Competency of Interprofessional Communication, be sure to use language that is easily understood by the patient when coordinating care. Avoid discipline-specific terminology when possible.

Nursing Safety Priority 5

In mass casualty or large-scale disaster situations, implement a military form of triage with the overall desired outcome of doing the greatest good for the greatest number of people. If resources are severely limited, this means that patients who are critically ill or injured and might otherwise receive attempted resuscitation during usual operations may be triaged into an "expectant" or "black-tagged" category and allowed to die or not be treated until others have received care.

Nursing Safety Priority 11

In the ED, assess the stroke patient within 10 minutes of arrival. This same standard applies to patients already hospitalized for other medical conditions who have a stroke. The priority is assessment of ABCs—airway, breathing, and circulation. Many hospitals have designated stroke teams and centers that are expert in acute stroke assessment and management.

Nursing Safety Priority 6

Include emergency contact names, addresses, and telephone numbers to use in a crisis as part of a personal emergency preparedness plan. In addition, preassemble personal readiness supplies or a go bag (disaster supply kit) for the home and automobile with clothing and basic survival supplies, which allows for a rapid response for disaster staffing coverage. Go bags are needed for all members of the family, including pets, in the event the disaster requires evacuation of the community or people to take shelter in their own homes.

Neurogenic Bladder Interventions: Intermittent catheterization

Intermittent catheterization may be needed for a flaccid or spastic bladder. Initially a urinary catheter is inserted to drain urine every few hours—after the patient has attempted voiding and has used the Valsalva and Credé maneuvers. If less than 100 to 150 mL of postvoid residual is obtained, the nurse typically increases the interval between catheterizations. The patient should not go beyond 8 hours between catheterizations. If intermittent self-catheterization is needed at home after discharge from the rehabilitation facility, the patient may use a specialized appliance to help perform the procedure, especially if he or she has problems with manual dexterity. For those who cannot catheterize themselves, a family member or significant other may need to be taught how to perform the procedure. Most patients who need intermittent catheterization have chronic bacteriuria (bacteria in the urine with a positive culture), especially those with spinal cord injury (SCI). Unless the patient has symptoms of a urinary tract infection (UTI) such as fever or burning when voiding, the infection is not treated. Older adults may become acutely confused as the only indication of a UTI.

SCI: Monitoring for Cardiovascular Instability

Maintain adequate hydration through IV therapy and oral fluids as appropriate, depending on the patient's overall condition. Carefully observe for manifestations of neurogenic shock, which may occur within 24 hours after injury, most commonly in patients with injuries above T6. This potentially life-threatening problem results from disruption in the communication pathways between upper motor neurons and lower motor neurons. Dextran, a plasma expander, may be used to increase capillary blood flow within the spinal cord and prevent or treat hypotension. Atropine sulfate is used to treat bradycardia if the pulse rate falls below 50 to 60 beats/min. Hypotension, if severe, is treated with continuous IV sympathomimetic agents such as dopamine or other vasoactive agent. In addition to observing the patient for shock or hypotension, monitor the patient who has a high-level SCI injury for the additional risk of autonomic dysreflexia (AD). AD is a neurologic emergency and must be promptly treated to prevent a hypertensive stroke! Be sure to reduce potential causes for this complication by preventing bladder and bowel distention, managing pain and room temperature, and monitoring for early vital sign changes.

Seizures: Gender Health Considerations

Management of women with epilepsy is often challenging. Hormonal changes from menstrual cycling and the interaction of oral contraceptives with antiepileptic drugs (AEDs) require the primary health care provider and patient to be aware of a variety of guidelines and to more frequently monitor drug effectiveness. AEDs can also contribute to osteoporosis in menopausal women. As a result, coordination among the neurologist, the woman's primary health care provider, and the patient is required for safe, effective care. Nurses can facilitate patient education, communication, and collaboration to promote safe, effective care.

TBI: Drug Therapy

Mannitol, an osmotic diuretic, is often used to treat cerebral edema by pulling water out of the extracellular space of the edematous brain tissue. It is most effective when given in boluses rather than as a continuous infusion. Furosemide, a loop diuretic, is often used as adjunctive therapy to reduce the incidence of rebound from mannitol. It also enhances the therapeutic action of mannitol, reduces edema and blood volume, decreases sodium uptake by the brain, and decreases the production of CSF at the choroid plexus. Although mannitol decreases intracranial pressure, research suggests that it does not improve mortality from TBI. Administer mannitol through a filter in the IV tubing or, if given by IV push, draw it up through a filtered needle to eliminate microscopic crystals. For the patient receiving either osmotic or loop diuretics, monitor for intake and output, severe dehydration, and indications of acute renal failure, weakness, edema, and changes in urine output. Serum electrolyte and osmolarity levels are measured every 6 hours. Mannitol is used to obtain a serum osmolarity of 310 to 320 mOsm/L, depending on primary health care provider preference and the desired outcome of therapy. Insert an indwelling urinary catheter to maintain strict measurement of output every hour. Check the patient's serum and urine osmolarity daily. Opioids such as fentanyl may be used with ventilated patients to decrease pain and control restlessness if the agitation is caused by pain. Fentanyl has fewer effects on blood pressure and heart rate than morphine and therefore may be a safer agent to manage pain for the TBI patient. Propofol and midazolam (GABA-receptor agonists) provide sedation to decrease ICP but are not as effective for pain control. Most mechanically ventilated patients receive a combination of these drugs.

TBI: Neurologic Assessment

Many hospitals use the Glasgow Coma Scale (GCS) to document neurologic status. A change of 2 points is considered clinically important; notify the primary health care provider if the change is a 2-point or more deterioration of GCS values. The most important variable to assess with any brain injury is LOC! A decrease or change in LOC is typically the first sign of deterioration in neurologic status. A decrease in arousal, increased sleepiness, and increased restlessness or combativeness are all signs of declining neurologic status. Early indicators of a change in LOC include behavior changes (e.g., restlessness, irritability) and disorientation, which are often subtle in nature. Report any of these signs and symptoms immediately to the primary health care provider or Rapid Response Team! Pupillary changes or eye signs differ depending on which areas of the brain are damaged. Pinpoint and nonresponsive pupils are indicative of brainstem dysfunction at the level of the pons. The ovoid pupil is regarded as the mid-stage between a normal-size and a dilated pupil. Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as herniation of the brain from increased ICP until proven differently. Pupils that are fixed (nonreactive) and dilated are a poor prognostic sign. Patients with this problem are sometimes referred to as having "blown" pupils. Monitor for additional late signs of increased ICP. These manifestations include severe headache, nausea, vomiting (often projectile), and seizures. Papilledema is edema and hyperemia (increased blood flow) of the optic disc. It is always a sign of increased ICP. Headache and seizures are a response to the injury and may or may not be associated with increased ICP. Always remember that the patient with a brain injury is at risk for potentially devastating ICP elevations during the first hours after the event and up to 3 to 4 days after injury when cerebral edema can occur. Assess for bilateral motor responses. The patient's motor loss or dysfunction usually appears contralateral (opposite side) to the site of the lesion, similar to that of a stroke. For example, a left-sided hemiparesis reflects an injury to the right cerebral hemisphere. Deterioration in mobility or the development of abnormal posturing or flaccidity is another indicator of progressive brain injury. Assess for brainstem or cerebellar injury, which may cause ataxia, decreased or increased muscle tone, and weakness. Remember that absence of motor function may also be an indicator of a spinal cord injury. Carefully observe the patient's ears and nose for any signs of cerebrospinal fluid (CSF) leaks that result from a basilar skull fracture. Suspicious ear or nose fluid can be analyzed by the laboratory for glucose and electrolyte content. CSF placed on a white absorbent paper or linen can be distinguished from other fluids by the "halo" sign, a clear or yellowish ring surrounding a spot of blood. Although other body fluids can be used, a halo sign is most reliable when blood is in the center of the absorbent material because tears and saliva can also cause a clear ring in some conditions. Palpate the patient's head gently to detect the presence of fractures or hematomas. Look for areas of ecchymosis (bruising), tender areas of the scalp, and lacerations. Raccoon's eyes are purplish discoloration around eyes that can follow fracture of the skull's base. When CT scans are used with head and brain injury, these fractures are often visualized before bruising appears.

SCI: Older Adult Considerations cont.

Many rehabilitation patients are at high risk for constipation, especially older adults. Encourage fluids (at least eight glasses a day) and 20 to 35 g of fiber in the diet. Teach patients to eat two to three daily servings of whole grains, legumes, and bran cereals and five daily servings of fruits and vegetables. Do not offer a bedpan for toileting. Instead, be sure that the patient sits upright on a bedside commode or bathroom toilet to facilitate defecation.

Stroke: Key Features

Middle Cerebral Artery Strokes (most common) • Contralateral (opposite side) hemiparesis (one-sided weakness) or hemiplegia (one-sided paralysis); typically the arm is flaccid and the leg is spastic if both extremities are affected • Dysphagia • Contralateral sensory perception deficit (numbness, tingling, unusual sensations) • Ptosis • Nystagmus • Homonymous hemianopsia • Unilateral neglect or inattention • Dysarthria • Aphasia • Anomia • Apraxia • Agnosia • Alexia, agraphia, and/or acalculia • Impaired vertical sensation • Visual and spatial deficits • Memory loss (amnesia) • Altered level of consciousness: drowsy to comatose Posterior Cerebral Artery Strokes • Perseveration (word or action repetition) • Aphasia, amnesia, alexia, agraphia, visual agnosia, and ataxia • Loss of deep sensation • Decreased touch sensation • Increased lethargy/stupor, coma Internal Carotid Artery Strokes • Contralateral hemiparesis • Sensory perception deficit • Hemianopsia, blurred vision, blindness • Aphasia (dominant side) • Headache • Carotid bruit Anterior Cerebral Artery Strokes • Contralateral hemiparesis: leg more than arm • Bladder incontinence • Personality and behavior changes • Aphasia and amnesia • Positive grasp and sucking reflex • Sensory perception deficit (lower extremity) • Memory impairment • Ataxic gait Vertebrobasilar Artery Strokes • Headache and vertigo • Possible coma • Memory loss and confusion • Flaccid paresis or paralysis (quadriparesis affecting all four extremities) • Ataxia • Vertigo • Cranial nerve dysfunction (such as dysphagia from cranial nerve IX involvement) • Visual deficits (one eye) or homonymous hemianopsia • Sensory loss: numbness

Nursing Safety Priority 26

Monitor the patient with acute spinal cord injury at least hourly for indications of neurogenic shock: • Pulse oximetry (SpO 2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability to clear airway) • Symptomatic bradycardia, including reduced level of consciousness and deceased urine output • Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg Notify the Rapid Response Team or primary health care provider immediately if these symptoms occur because this problem is an emergency! Respiratory compromise from aspiration may be treated with intubation or bronchial endoscopy. Similar to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize the patient.

Nursing Safety Priority 10

To prevent additional tonic-clonic seizures or cardiac arrest, a loading dose of IV phenytoin is given and oral doses are administered as a follow-up after the emergency is resolved. Initially give phenytoin at no more than 50 mg/min using an infusion pump. If the drug is piggybacked into an existing IV line, use only normal saline as the primary IV fluid to prevent drug precipitation. Be sure to flush the line with normal saline before and after phenytoin administration.

Nursing Safety Priority 28

Never move or turn the patient by holding or pulling on the halo device. Do not adjust the screws holding it in place. Check the patient's skin frequently to ensure that the jacket is not causing pressure. Pressure is avoided if one finger can be inserted easily between the jacket and the patient's skin. Monitor the patient's neurologic status for changes in movement or decreased strength. A special wrench is needed to loosen the vest in emergencies such as cardiopulmonary arrest. Tape the wrench to the vest for easy and consistent accessibility. Do not use sharp objects (e.g., coat hangers, knitting needles) to relieve itching under the vest; skin damage and infection will slow recovery. Common complications of the halo device are pin loosening, local infection, and scarring. More serious but less common complications include osteomyelitis (cranial bone infection), subdural abscess, and instability. Hospital policy is followed for pin-site care, which may specify the use of solutions such as saline. Vaseline dressings may also be used. Monitor vital signs for indications of possible infection (e.g., fever, purulent drainage from the pin sites) and report any changes to the primary health care provider immediately.

TBI: Assessment cont.

No two brain injuries are alike. The patient with a TBI may have a variety of signs and symptoms depending on the severity of injury and the resulting increase in intracranial pressure (ICP). For any patient having a TBI, assess for signs of increased ICP, hypotension, hypoxemia (decreased blood level of oxygen), hypercarbia (PaCO 2 greater than 40 to 45 mm Hg or increased partial pressure of carbon dioxide in arterial blood), or hypocarbia (PaCO 2 less than 40 to 45 mm Hg or decreased partial pressure of carbon dioxide in arterial blood). Hypercarbia can cause cerebral vasodilation and contribute to elevated ICP. Hypocarbia is caused by hyperventilation and can lead to profound vasoconstriction with resulting ischemia. Carbon dioxide levels in an intubated patient can be determined with an end-tidal carbon dioxide (ETCO 2) monitor, or capnography. The early detection of changes in the patient's neurologic status enables the health care team to prevent or treat potentially life-threatening complications. Be aware that subtle changes in blood pressure, consciousness, and pupillary reaction to light can be very informative about neurologic deterioration! The first priority is the assessment of the patient's ABCs—airway, breathing, and circulation! Because TBI is occasionally associated with cervical spinal cord injuries, all patients with head trauma are treated as though they have cord injury until radiography proves otherwise. Older adults are especially prone to cervical injuries at the first or second vertebral level, a life-threatening problem. Assess for indicators of spinal cord injury, such as loss of mobility and sensory perception, tenderness along the spine, and abnormal head tilt. Injuries to the brainstem may cause a major life-threatening change in the patient's breathing pattern, such as Cheyne-Stokes respirations and/or apnea. In the unconscious patient, an artificial airway provides protection from aspiration and a route for oxygenation. Mechanical ventilation is often needed to support inadequate client respiratory effort.

TBI: Health Promotion

Nurses can educate the public on ways to decrease the incidence of TBI by using safe driving practices such as not driving while impaired and wearing seat belts. Teach people at risk about how alcohol and illicit drug use, including marijuana, affect driving ability. Promote the use of helmets for skateboarding and bicycle and motorcycle riding. Help prevent falls by providing a safe environment, especially for older adults. People need to be aware of environmental factors that may increase the likelihood of falls such as inadequate lighting and loose rugs. When possible, install safety equipment in bathtubs and showers. Evaluate balance and coordination as part of a fall prevention strategy inside the hospital and at home.

TBI: Assessment

Obtaining an accurate history from a patient who has sustained a TBI may be difficult because of changes in the patient's cognition. If the patient cannot provide information, the history can be obtained from first responders or witnesses to the injury. Always ask when, where, and how the injury occurred. Did the patient lose consciousness; if so, for how long? Has there been a change in the level of consciousness (LOC)? If trauma is related to drug or alcohol consumption, it may be difficult to differentiate neurologic changes caused by head trauma from those produced by intoxication. Determine whether the patient had fluctuating consciousness or seizure activity and whether there is a history of a seizure disorder. Obtain precise information about the circumstances of falls, particularly in the older patient. Recognize that many factors can contribute to death in older adults from TBI. Other pertinent information includes hand dominance, any diseases of or injuries to the eyes, and any allergies to drugs or food. Inquire about a history of alcohol or drug use because these substances may interfere with the neurologic baseline assessment. Consider whether the patient is a victim of violence if he or she lives in residential care or has a caregiver.

ED: Older Adult Considerations

Older adults often visit the ED because of worsening of an existing chronic condition or because the condition affects their ability to perform ADLs. Older adults are also sometimes admitted from nursing homes or assisted-living facilities for procedures (e.g., insertion of a percutaneous endoscopic gastrostomy [PEG] tube or peripherally inserted central catheter [PICC]) or treatments (e.g., blood transfusions). Some hospitals plan direct admission of the patient to same-day surgery or hold a bed for the procedure or treatment to bypass the ED. This arrangement decreases the patient's wait time and therefore decreases the risks for adverse events such as pressure injury development or hospital-acquired infection (HAI). Incorporating caregivers of older adults into the process of care can aid in overall patient evaluation, decision making, and satisfaction with the ED experience.

TIA: Diagnosis

On admission to the ED, a complete neurologic assessment is performed. The interprofessional health care team administers the National Institutes of Health Stroke Scale (NIHSS; see later discussion under Stroke) and other agency-specific assessment tools. Routine laboratory tests, including coagulation tests (prothrombin time [PT], international normalized ratio [INR], activated partial thromboplastin time [aPTT]) and lipids, ECG, and imaging scans are performed. The initial scan is typically a head CT, followed by MRI brain scan without contrast. Depending on agency protocol and the patient's assessment, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) of the brain and neck is also performed to determine the patency of the carotid arteries, which provide perfusion to the brain, and arterial circulation within the brain.

concussion

One type of mild TBI is a concussion. A concussion is a traumatic injury to the brain caused by a blow to the head and may or may not result in some period of unconsciousness. Military personnel and people who participate in recreational or professional sports are especially at risk for concussions. Some patients report no immediate symptoms until later, which typically include impaired cognition (such as memory or thinking processes) and headache.

TIA: Interventions

Patients diagnosed with TIA may or may not be admitted, depending on their neurologic and cardiovascular status. Management of the patient who had a TIA includes treating the cause, if determined. Depending on the patient, collaborative interventions may include: • Performing traditional or minimally invasive surgery to remove atherosclerotic plaque buildup within the carotid artery and increase perfusion to the brain • Performing a carotid angioplasty with stenting to increase perfusion to the brain • Prescribing antiplatelet drugs, typically aspirin or clopidogrel, to prevent thrombotic or embolic strokes (may be placed on a combination of both drugs) • Reducing high blood pressure (the most common risk factor for stroke) by adding or adjusting drugs to lower blood pressure • Controlling diabetes (if present) and keeping glucose levels within a target range, typically 100 to 180 mg/dL • Promoting lifestyle changes, such as smoking cessation, eating more heart-healthy foods, and increasing mobility and physical activity

Spinal Cord: Neurologic Assessment

Patients may have dysphasia (slurred speech) or aphasia (inability to express thoughts verbally or comprehend) because of damage to the language centers of the brain commonly occurring in those with a stroke or traumatic brain injury (TBI). Determine if the patient has paresis (weakness) or paralysis (absence of movement). Observe the patient's gait. Identify changes in sensory perception such as visual acuity that could contribute to risk for injury. Assess his or her response to light touch, hot or cold temperature, and position change in each extremity and on the trunk. For a perceptual assessment, evaluate the patient's ability to receive and understand what is heard and seen and the ability to express appropriate motor and verbal responses. During this part of the assessment, begin to assess short-term and long-term memory. Assess the patient's cognitive abilities, especially if there is a brain injury or stroke. The Confusion Assessment Method (CAM) is used to determine if the patient has delirium, an acute confusional state.

Nursing Safety Priority 1

Patients or visitors who display hostile behaviors also pose injury risks to staff members. Be alert for volatile situations or people who demonstrate aggressive or violent tendencies through verbal or nonverbal behaviors. Follow the hospital security plan, including identifying the nearest escape route, attempting de-escalation strategies before harm can occur, and notifying security and supervisory staff of the situation. Emergency visits resulting from gang or domestic violence can produce particularly hazardous conditions. Report all episodes of assaultive or violent behaviors through the hospital event documentation process so leaders and risk managers are aware of the scope of the problem and can plan safety strategies, including staff education, accordingly.

SCI: Managing Decreased Mobility

Patients with an SCI are especially at risk for pressure injuries due to altered sensory perception of pressure areas on skin below the level of the injury. They are also at risk for venous thromboembolism (VTE), contractures, orthostatic hypotension (especially in patients with high SCI), and fractures related to osteoporosis. Frequent and therapeutic positioning not only helps prevent complications but also provides alignment to prevent further SCI or irritability. Assess the condition of the patient's skin, especially over pressure points, with each turn or repositioning. Turning may be performed manually, or the patient may be placed on an automatic rotating bed. Reduce pressure on any reddened area and monitor it with the next turn. Reposition patients frequently (every 1 to 2 hours). When sitting in a chair, the patient is repositioned or taught to reposition himself or herself more often than every hour. Paraplegic patients usually perform frequent "wheelchair push-ups" to relieve skin pressure. Use a pressure-reducing mattress and wheelchair or chair pad to help prevent skin breakdown. Prevent VTE, including using interventions of intermittent pneumatic compression stockings and low-molecular-weight heparin (LMWH). Patients with cervical cord injuries especially are at high risk for orthostatic (postural) hypotension, but anyone who is immobilized may have this problem. If the patient changes from a lying position to a sitting or standing position too quickly, he or she may experience hypotension, which could result in dizziness and falls. Because of interrupted sympathetic innervation caused by the SCI, the blood vessels do not constrict quickly enough to push blood up into the brain. The resulting vasodilation causes dizziness or light-headedness and possible falls with syncope ("blackout"). All patients with an SCI require bowel and bladder retraining, including adequate fluids and stool softeners to prevent constipation from immobility and the injury itself. Those with upper motor neuron lesions (usually cervical and high thoracic injuries) have spastic bowel and bladder function with an intact spinal reflex for elimination. However, voiding patterns may be uncontrollable and require long-term indwelling or external catheters. Rectal suppositories are often successful to promote regular bowel elimination. The patient with a lower motor neuron lesion has a flaccid bowel and bladder. Intermittent urinary catheterizations, manual pressure over the bladder area, and bowel impaction on a regular basis help to establish a routine.

TBI: Psychosocial Assessment

Patients with any level of TBI usually have varying degrees of psychosocial changes that may persist for a year or for a lifetime, depending on the severity of the injury and the person's response. Emotional lability and/or personality changes manifesting with temper outbursts, depression, risk-taking behavior, and denial of disability can occur. All these changes in health status may lead to difficulties within the family structure and with social and work-related interactions.

TBI: Spine Precautions

Patients with blunt trauma to the head or neck are typically transported from the scene of the injury to the hospital with a rigid cervical collar and a long spine board. The expected outcome is to prevent new and secondary spine injury. Spine precautions require placing the patient supine and aligning the spinal column in a neutral position so there is no rotation, flexion, or extension. The long spine board is removed as soon as possible on arrival at the emergency department (ED) or ICU. The rigid cervical collar is maintained until definitive diagnostic studies to rule out cervical spine injury are completed. Once the spine board is removed, spinal precautions are maintained until the primary health care provider indicates that it is safe to bend or rotate the cervical, thoracic, and lumbar spine. Spinal precautions include: (1) bedrest; (2) no neck flexion with a pillow or roll; (3) no thoracic or lumbar flexion; (4) manual control of the cervical spine anytime the rigid collar is removed; and (5) use of a "log-roll" procedure to reposition the patient. A hard, rigid cervical collar is used to maintain cervical spine ("C-spine") precautions and immobilization with a confirmed cervical injury. If the collar is ill-fitting or soiled, it may be changed according to hospital guidelines while a second qualified person maintains C-spine immobilization. Frequent assessment of the skin under the collar is important to monitor for skin breakdown. Spine clearance is a clinical decision made by the primary health care provider, often in collaboration with the radiologist. Spine clearance includes determining the absence of acute bony, ligamentous, and neurologic abnormalities of the cervical spine based on history, physical examination, and/or negative radiologic studies.

SCI: Assessment of Patients for Long-Term Complications

Patients with complete SCI are at a high risk for complications that result from prolonged impaired mobility, including pressure injuries and venous thromboembolism (VTE). Assess skin integrity with each turn or repositioning. Monitor for signs of VTE with vital signs, including lower extremity deep vein thrombosis (DVT). Bones can become osteopenic and osteoporotic without weight-bearing exercise, placing the long-term SCI patient at risk for fractures. Another complication of prolonged immobility is heterotopic ossification (HO) (bony overgrowth, often into muscle). Assess for swelling, redness, warmth, and decreased range of motion (ROM) of the involved extremity. The hip is the most common place where HO occurs. Changes in the bony structure are not visible until several weeks after initial symptoms appear.

SCI: Increasing Mobility Interventions

Patients with neurologic disease or injury (e.g., stroke, brain injury, spinal cord injury, tumor), amputations, or other condition resulting in disability usually experience some degree of decreased or impaired physical mobility. Coordinate care with physical and occupational therapists as the key rehabilitation team members in helping patients meet their mobility outcomes. Before learning to become independent, patients with decreased mobility in any health care setting or at home often need assistance with positioning in bed and transfers such as from a bed to a chair, commode, or wheelchair. Patients may not be able to bear full weight due to paralysis or poor strength and/or may have inadequate balance. The person with a mobility limitation must be assessed for the level of assistance needed for the specific mobility activity (e.g., bed to chair). The necessary safe patient-handling equipment (e.g., stand-assist device, total lift assistance, friction-reducing surface) must be used to prevent work-related musculoskeletal disorders (MSDs), most often back and shoulder injuries, which can often be prevented. There is strong evidence that implementation of safe patient-handling practices by nurses reduces occupational-related patient-handling injuries. Because each patient has unique needs and characteristics, assess his or her mobility level with a standardized tool to plan interventions for safe patient handling and mobility (SPHM). Before moving the patient, assess the environment for potential hazards that could cause injury, such as a slippery or uneven floor. For patients who are learning to become independent in transfer or bed mobility skills, the physical or occupational therapist usually consults with the nurse on the procedure for these maneuvers. For example, a patient with quadriplegia may use a sliding board for transfer, whereas a patient with paraplegia may be able to transfer when the wheelchair arms are removed. A patient may be taught to turn independently using the side rails. In any case, for safety always plan or teach the patient to plan the transfer technique before initiating it. The desired outcome is that the patient will eventually be able to transfer safely, providing his or her maximum effort while assistance is provided by equipment and caregivers as needed. It is important to include the family or caregiver when teaching the patient mobility and transfer skills. Caregivers commonly report physical strain from efforts to assist older family members. Cognitive impairment can also present unique safety and mobility concerns in the rehabilitation setting. Cognitive impairment can manifest as agitated behavior that may be unpredictable. This behavior can occur as a result of traumatic brain injury but can also be present with other injury to the brain as a result of cancer or stroke. When caring for a patient with cognitive impairment, nurses must implement strategies to prevent injury of the patient and workplace injuries of the nurse. Patients with cognitive impairment may not move as directed or may respond with agitated behavior such as striking, biting, or kicking. Successful nursing care of agitated patients involves assessing patterns of agitation and identifying what is causing the agitation (referred to as the trigger). Once the trigger has been identified, the nurse should attempt to decrease exposure to it. For example, if bladder fullness causes agitation, a scheduled bladder management program may be implemented. Monitoring agitation and preventing triggers can decrease safety risks for the patient and the nurse. Identification of triggers and the interventions that decrease agitation are incorporated into a plan of care that is shared with the patient and the family. Weight gain as a result of a decreased metabolic rate is another potential problem for patients with decreased mobility . Excessive weight hinders transfers both for the health care professional or caregiver who is assisting with mobility and for the patient who is learning to transfer independently. Weight is usually checked every week to monitor gains or losses. If needed, collaborate with the dietitian to develop a weight-reduction plan.

Stroke: Managing Changes in Sensory Perception

Patients with right hemisphere brain damage typically have difficulty with visual-perceptual or spatial-perceptual tasks. They often have problems with depth and distance perception and with discrimination of right from left or up from down. Because of these problems, patients can have difficulty performing routine ADLs. Caregivers can help the patient adapt to these disabilities by using frequent verbal and tactile cues and by breaking down tasks into discrete steps. Always approach the patient from the unaffected side, which should face the door of the room! Unilateral neglect (or inattention), occurs most commonly in patients who have had a right cerebral stroke. However, it can occur in any patient who experiences hemianopsia, in which the vision of one or both eyes is affected. This problem places the patient at additional risk for injury, especially falls, because of an inability to recognize his or her physical impairment on one side of the body or because of a lack of proprioception. • Teach the patient to touch and use both sides of the body. • When dressing, remind the patient to dress the affected side first. • If homonymous hemianopsia is present, teach the patient to turn his or her head from side to side to expand the visual field because the same half of each eye is affected. This scanning technique is also useful when the patient is eating or ambulating. Place objects within the patient's field of vision. A mirror may help visualize more of the environment. If the patient has diplopia, a patch may be placed over the affected eye and changed every 2 to 4 hours. The patient with a left hemisphere lesion generally has memory deficits and may show significant changes in the ability to carry out simple tasks, such as eating and grooming. Help with ADLs but encourage the patient to do as much as possible independently. To assist with memory problems, reorient the patient to the month, year, day of the week, and circumstances surrounding hospital admission. Establish a routine or schedule that is as structured, repetitious, and consistent as possible. Provide information in a simple, concise manner. Apraxia may be present. Typically the patient with apraxia exhibits a slow, cautious, and hesitant behavior style. The physical therapist helps the patient compensate for loss of position sense.

SCI: Sensory Perception and Mobility Assessment

Perform a detailed assessment of the patient's mobility and sensory perception status to determine the level of injury and establish baseline data for future comparison. The level of injury is the lowest neurologic segment with intact or normal motor and sensory function. Tetraplegia (also called quadriplegia) (paralysis) and quadriparesis (weakness) involve all four extremities, as seen with cervical cord and upper thoracic injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions. The patient may report a complete sensory loss, hypoesthesia (decreased sensory perception ), or hyperesthesia (increased sensory perception ). The primary health care provider may also test deep tendon reflexes (DTRs), including the biceps (C5), triceps (C7), patella (L3), and ankle (S1). It is not unusual for these reflexes, as well as all mobility or sensory perception, to be absent immediately after the injury because of spinal shock. After spinal shock has resolved, the reflexes may return.

Nursing Safety Priority 4

Remove all clothing to allow for thorough assessment. Always carefully cut away clothing with scissors: • During resuscitation when rapid access to the patient's body is critical • When manipulating a patient's limbs to remove clothing could cause further injury • When thermal or chemical burns have caused fabrics to melt into the patient's skin

Spinal Cord: Skin Assessment

Persons with mobility impairments are at high risk for alteration in skin and tissue integrity. This may be magnified by other conditions, such as urinary or fecal incontinence, or poor nutrition. Identify actual or potential interruptions in skin and tissue integrity. To maintain healthy skin, the body must have adequate food, water, and oxygen intake; intact waste-removal mechanisms; sensation; and functional mobility. Changes in any of these variables can lead to rapid and extensive skin breakdown. If a pressure injury or other change in tissue integrity develops, accurately assess the problem and its possible causes. In the inpatient setting inspect the skin every 8 to 12 hours. Teach the patient or caregiver to inspect the skin daily at home. Measure the depth and diameter of any open skin areas in inches or centimeters, depending on the policy of the facility or country. Assess the area around the open lesion to determine the presence of cellulitis or other tissue damage. Determine the patient's knowledge about the cause and treatment of skin conditions and his or her ability to inspect the skin and participate in maintaining tissue integrity .

Nursing Safety Priority 19

Position the TBI patient to avoid extreme flexion or extension of the neck and to maintain the head in the midline, neutral position. Log roll him or her during turning to avoid extreme hip flexion ,and keep the head of the bed (HOB) elevated at least 30 degrees or as prescribed by the primary health care provider. Generally, HOB elevation in patients with TBI is at 30 to 45 degrees to prevent aspiration. However, if increasing head elevation significantly lowers systemic blood pressure, the patient does not benefit from drainage of venous blood or CSF out of the skull from this position. If hypotension accompanies an elevated backrest position, the patient may be harmed. Avoid sudden vertical changes of the HOB in the older patient because the dura is tightly adhered to the skull and may pull away from the brain, leading to a subdural hematoma.

Seizure Precautions

Precautions are taken to prevent the patient from injury if a seizure occurs. Side rails are rarely the source of significant injury, and the effectiveness of the use of padded side rails to maintain safety is debatable. Follow agency policy about the use of side rails because they may be classified as a restraint device. Padded tongue blades do not belong at the bedside and should NEVER be inserted into the patient's mouth because the jaw may clench down as soon as the seizure begins! Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk for aspirating tooth fragments than prevent the patient from biting the tongue. Furthermore, improper placement of a padded tongue blade can obstruct the airway.

Primary Brain Injury

Primary brain damage occurs at the time of injury and results from the physical stress (force) within the tissue caused by blunt or penetrating force. A primary brain injury may be categorized as focal or diffuse. A focal brain injury is confined to a specific area of the brain and causes localized damage that can often be detected with a CT scan or MRI. Diffuse injuries are characterized by damage throughout many areas of the brain. They begin at a microscopic level and are not initially detectable by CT scan. MRI has greater ability to detect microscopic damage, but these areas may not be imaged until necrosis occurs. Primary brain injuries are also classified as either open or closed. An open traumatic brain injury occurs when the skull is fractured or when it is pierced by a penetrating object. Damage may occur to the underlying vessels, dural sinuses, brain, and cranial nerves. In a closed traumatic brain injury, the integrity of the skull is intact, but damage to the brain tissue still occurs as a result of increased intracranial pressure.

Seizures: Assessment

Question the patient or family about how many seizures the patient has had, how long they last, and any pattern of occurrence. Ask the patient or family to describe the seizures that the patient has had. Signs and symptoms vary, depending on the type of seizure experienced, as described earlier. Ask about the presence of an aura before seizures begin (preictal phase). Question whether the patient is taking any prescribed drugs or herbs or has had head trauma or high fever. Assess any alcohol and/or illicit drug history. Ask about any other medical condition such as a previous stroke or hypertension. If the seizure is a new symptom, ask the patient or family if any loss of consciousness or brain injury has occurred, in both the recent and distant past.

Nursing Safety Priority 3

Recognize that you must clear the airway of any secretions or debris with a suction catheter or manually if necessary. Respond by protecting the trauma patient's cervical spine by manually aligning the neck in a neutral, in-line position and using a jaw-thrust maneuver when establishing an airway. Provide supplemental oxygen as ordered for patients who require resuscitation.

SCI: Care Coordination and Transition Management

Rehabilitation begins in the acute or critical care unit when patients are hemodynamically stable. They are usually transferred from the acute care setting to a rehabilitation setting, where they learn more about self-care, mobility skills, and bladder and bowel retraining. Assist in verbalizing feelings and fears about body image, self-concept, role performance, self-esteem, and sexuality. The patient should be told about the expected reactions of those outside the security of the hospital environment. Role playing or anticipating responses to potential problems is helpful. For example, the patient can practice answering questions from children about why he or she is in a wheelchair or cannot move certain parts of the body. For young men with SCI, sexuality is a major issue. Many patients are concerned about their ability to have sexual intercourse and have children. Most hospitals do not have psychological social workers or counselors to discuss sexuality issues. By contrast, rehabilitation programs often include a sexuality /intimacy counselor as part of the interprofessional team approach to patient care. Many patients with previous SCIs are admitted to the acute care or long-term care setting for complications of immobility, such as pressure injuries or fractures resulting from osteoporosis. Pressure injuries contribute to local infection, including osteomyelitis and septicemia. Priorities in care may need to be re-evaluated as complications occur and resolve. If the patient is discharged home or returns home for a weekend visit from the rehabilitation setting, the environment must be assessed to ensure that it is free from hazards and can accommodate the patient's special needs (e.g., a wheelchair). The occupational or physical therapist, in collaboration with rehabilitation and the home care nurse, usually assesses the patient's temporary or permanent home environment. Ease of accessibility is particularly important at the entrance of the home and in the bathroom, kitchen, and bedroom. The height of the patient's bed may need to be adjusted to allow a smooth transfer into and out of the bed. All adaptive devices that the patient will use at home should be requested and delivered to the rehabilitation facility. This enables the nurse and other therapists to ensure that the items fit correctly and that the patient and family know how to use them correctly.

Secondary Brain Injury

Secondary injury to the brain includes any processes that occur after the initial injury and worsen or negatively influence patient outcomes. Secondary injuries result from physiologic, vascular, and biochemical events that are an extension of the primary injury. Some patients may not have been diagnosed as having a TBI because they are not symptomatic. However, later they may be diagnosed with chronic traumatic encephalopathy (CTE), an uncommon degenerative brain disease that occurs most often in military veterans, athletes, and others who experienced repetitive trauma to the brain. CTE can lead to dementia, depression, suicidal thinking, and substance use disorder. Although the disease is usually diagnosed by history and clinical presentation, it can only be confirmed at autopsy when the classic tau neurofibrillary tangles are evident. For patients with moderate or severe TBI, the most common secondary injuries result from hypotension and hypoxia, intracranial hypertension, and cerebral edema. Damage to the brain tissue occurs primarily because the delivery of oxygen and glucose to the brain is interrupted from cerebral edema and increasing pressure.

Nursing Safety Priority 8

Seizure precautions include ensuring that oxygen and suctioning equipment with an airway are readily available. If the patient does not have an IV access, insert a saline lock, especially if he or she is at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure.

Emergency Care: Acute Seizures

Seizures occurring in greater intensity, number, or length than the patient's usual seizures are considered acute. They may also appear in clusters that are different from the patient's typical seizure pattern. Treatment with lorazepam or diazepam may be given to stop the clusters to prevent the development of status epilepticus. IV phenytoin or fosphenytoin may be added.

SCI: Self-Management Education

Sexuality is associated with sexual and reproductive function. Sexual function after SCI depends on the level and extent of injury. Incomplete lesions allow some control over sensory perception and mobility. Complete lesions disconnect the messages from the brain to the rest of the body and vice versa. However, men with injuries above T6 are often able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the patient's partner will not get an infection. To prevent autonomic dysreflexia (AD), prophylactic administration of a vasodilator may be needed before intercourse. Women with an SCI have a different challenge because they have indwelling urinary catheters more commonly than men. However, some women do become pregnant and have full-term children. For others, ovulation stops in response to the injury. In this case, alternate methods for pregnancy, such as in vitro fertilization, may be an option. Some women also report vaginal dryness. Recommend a water-soluble lubricant for both partners to promote comfort. For patients who choose not to have intercourse, intimate pleasure can be achieved in other ways, including kissing, hugging, fondling, masturbation, and oral sex. Variations in positioning may be needed to accommodate weak or paralyzed parts of the body. An understanding partner can help the patient adjust to his or her physical changes.

ED: Older Adult Considerations 1

Some older adults may not be able to provide an accurate history because of memory loss or acute delirium. If possible, review their prior hospitalization records to obtain past histories or ask a caregiver for pertinent information. Older adults may have pre-existing conditions (comorbidities) that must be considered as part of the assessment. Knowing the history is important because these conditions might adversely affect or complicate the cause for the ED visit. For example, a patient who has rib fractures but has a history of severe chronic obstructive pulmonary disease (COPD) may not be able to maintain adequate gas exchange without endotracheal intubation and mechanical ventilatory support in the ED.

Types of Strokes

Strokes are generally classified as ischemic (occlusive) or hemorrhagic. Acute ischemic strokes are either thrombotic or embolic in origin. Most strokes are ischemic.

Preventing Secondary Spinal Cord Injury: Surgical Management

Surgery within 24 hours of injury to stabilize the vertebral spinal column, particularly if there is evidence of spinal cord compression, results in decreased secondary complications. Emergent surgery also removes bone fragments, hematomas, or penetrating objects such as a bullet. Typical procedures include wiring and spinal fusion for cervical injuries and the insertion of steel or metal rods (e.g., Harrington rods) to stabilize thoracic and lumbar spinal injuries. The patient wears a halo vest to immobilize the spine during the healing process.

trauma-informed care (TIC)

TIC is a model of care that ensures patient safety through four key practices: "realizing the widespread effect of trauma, recognizing the signs and symptoms of trauma, responding by fully integrating trauma knowledge into practices and procedures, and seeking to actively resist retraumatization". Practicing according to the model of trauma-informed care allows the nurse to better understand the patient's symptoms and behaviors based on what the patient experienced during and as a result of the trauma event

Preventing and Detecting Secondary Brain Injury

Take and record the patient's vital signs every 1 to 2 hours or more often based on patient acuity. The primary health care provider may prescribe IV fluids or drug therapy to prevent severe hypertension or hypotension. Document and report the presence of cardiac dysrhythmias, hypotension, and hypertension to the primary health care provider. Obtain the target range for blood pressure and heart rate from the provider and monitor parameters. The patient with a brain injury may develop a fever as a result of systemic trauma, blood in the cranium, or a generalized inflammatory response to the injury. Fever from any cause is associated with higher morbidity and mortality rates. Therapeutic hypothermia may be started, regardless of the presence of fever. The purpose of therapeutic hypothermia is to rapidly cool the patient to a core temperature of 89.6°F to 93.2°F (32°C to 34°C) for 24 to 48 hours after the primary injury. Rewarming to a normal core temperature requires specialized knowledge and skill because rapid fluid and electrolyte shifts can cause cardiac dysrhythmias and changes to systemic and cerebral pressures. The rationale for therapeutic hypothermia is to reduce brain metabolism and prevent the cascade of molecular and biochemical events that contribute to secondary brain injury in moderate-to-severe TBI. Arterial blood gas (ABG), oxygen saturation (SpO 2), and end-tidal carbon dioxide (ETCO 2) values are all used to evaluate respiratory status and guide mechanical ventilation therapy. Hyperventilation for the intubated patient during the first 24 hours after brain injury is usually avoided because it may produce ischemia by causing cerebral vasoconstriction. Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. Prevent intermittent and sustained hypoxemia. Monitor peripheral oxygen saturation continuously in moderate-to-severe TBI. Hypoxemia damages brain tissue and contributes to cerebral vasodilation and increased ICP. Arterial oxygen levels (PaO 2) are maintained between 80 and 100 mm Hg to prevent secondary injury. If available, hyperbaric oxygen therapy (HBOT) may be used to provide high-dose oxygen to treat ischemia and hypoxia. HBOT may be used as part of early management of TBI or in the chronic stage of the injury. If the patient is intubated, provide 100% oxygen before and after each pass of the endotracheal suction catheter. Avoid overly aggressive hyperventilation with endotracheal suctioning because of the potential for hypocarbia. Cerebral ischemia caused by even transiently decreased oxygen and either high or low carbon dioxide levels contributes to secondary brain injury. Lidocaine given IV or endotracheally may be used to suppress the cough reflex; coughing increases ICP. Patients with severe TBI often die. As the physiologic deterioration begins, keep in mind that the patient may be a potential organ donor. Before brain death is declared, contact the local organ-procurement organization. Determine if the patient consented to be an organ donor. This information is typically on a driver's license or other state-issued card or advance directive. The patient's wishes should be followed unless he or she has a medical condition that prevents organ donation.

Nursing Safety Priority 30

Teach the SCI patient and his or her family or other caregiver about the name, purpose, dosage, timing of administration, and side effects of all drugs. Make sure they understand the possible interaction of prescribed drugs with over-the-counter drugs or alcohol and illegal drugs.

Nursing Safety Priority 20

Teach the patient who has sustained a mild brain injury that symptoms that disturb sleep; affect enjoyment of daily activities, work performance, mood, memory, and ability to learn new material; and cause changes in personality require follow-up care. Provide the patient and family with education materials that will alert them to symptoms and management options. A good source of written instructions is available from the CDC.

Hospital Incident Command System

The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS). In this system, roles are formally structured under the hospital or long-term care facility incident commander with clear lines of authority and accountability for specific resources.

trauma

The general public tends to use the term trauma to mean any type of crisis, ranging from a heart attack to psychological stress. Among health care professionals, trauma refers to bodily injury. njuries can be categorized as either intentional (i.e., assault, homicide, suicide) or unintentional (i.e., accidents). Unintentional injury such as poisoning or a motor vehicle crash is the leading cause of death for Americans younger than 35 years and is one of today's most significant public health problems. Trauma nursing is a field that encompasses the continuum of care from injury prevention and prehospital services to acute care, rehabilitation, and ultimately community reintegration. Injury management is a key component of ED services.

SCI: Initial Assessment

The initial and priority assessment focuses on the patient's ABCs ( a irway, b reathing, and c irculation). After an airway is established, assess the patient's breathing pattern. The patient with a cervical SCI is at high risk for respiratory compromise because the cervical spinal nerves (C3-5) innervate the phrenic nerve controlling the diaphragm. Evaluate pulse, blood pressure, and peripheral perfusion such as pulse strength and capillary refill. Multiple injuries may contribute to circulatory compromise from hemorrhagic hypovolemic shock. Assess for indications of hemorrhage. All symptoms of circulatory compromise or hypovolemic shock must be treated aggressively to preserve tissue perfusion to the spinal cord. Use the Glasgow Coma Scale or other agency-approved assessment tool to assess the patient's level of consciousness (LOC). Cognitive impairment as a result of an associated traumatic brain injury (TBI) or substance use disorder can occur in patients with traumatic SCIs. Spinal shock, also called spinal shock syndrome, occurs immediately as the cord's response to the injury. The patient has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks. Spinal shock is not the same as neurogenic shock.

S/S of strokes in the L cerebral hemisphere

The left cerebral hemisphere is the center for speech, language, mathematic skills, and analytic thinking. Therefore problems in these areas are expected for patients who have a left-sided stroke.

Craniotomy: Preventing and Managing Postoperative Complications

The major complications of surgery are increased ICP from cerebral edema or hydrocephalus and hemorrhage. Symptoms of increased ICP include severe headache, deteriorating LOC, restlessness, and irritability. Dilated or pinpoint pupils that are slow to react or nonreactive to light are late signs of increased ICP. Hydrocephalus (increased CSF in the brain) is caused by obstruction of the normal CSF pathway from edema, an expanding lesion such as a hematoma, or blood in the subarachnoid space. Rapidly progressive hydrocephalus produces the classic symptoms of increased ICP. Slowly progressive hydrocephalus manifests with headache, decreased LOC, irritability, blurred vision, and urinary incontinence. An intraventricular catheter may be placed to drain CSF during surgery or emergently after surgery for rapidly deteriorating neurologic function (ventriculostomy). If long-term treatment is required for chronic hydrocephalus, a surgical shunt is inserted to drain CSF to another area of the body.

Mechanism of Injury

The mechanism of injury (MOI) describes how the patient's traumatic event occurred, such as a high-speed motor vehicle crash, a fall from a standing height, or a gunshot wound to the torso. Knowing key details about the MOI can provide insight into the energy forces involved and may help trauma care providers predict injury types and, in some cases, patient outcomes. Prehospital care providers report the MOI as a communication standard when handing off care to ED and trauma personnel. Similarly, patients who come to the ED for medical care will often relate the MOI by describing the particular chain of events that caused their injuries. Two of the most common injury-producing mechanisms are blunt trauma and penetrating trauma.

TBI: Vital Signs

The mechanisms of autoregulation are often impaired as the result of a TBI. The more serious the injury, the more severe is the impact on autoregulation or the ability of cerebral vasculature to modify systemic pressure such that blood flow to the brain is sufficient. Monitor the patient's blood pressure and pulse frequently based on agency protocol and patient status. The patient may have hypotension or hypertension. Cushing triad, a classic but very late sign of increased ICP, consists of severe hypertension, a widened pulse pressure (increasing difference between systolic and diastolic values), and bradycardia. This triad of cardiovascular changes usually indicates imminent death.

Preventing Staff Acute Stress Disorder and Posttraumatic Stress Disorder Following a Mass Casualty Event

• Use available counseling. • Encourage and support co-workers. • Monitor each other's stress level and performance. • Take breaks when needed. • Talk about feelings with staff and managers. • Drink plenty of water and eat healthy snacks for energy. • Keep in touch with family, friends, and significant others. • Do not work more than 12 hours per day.

TBI: Etiology

The most common causes of TBI in the United States are falls and motor vehicle crashes, followed by colliding with a stationary or moving object. Alcohol and illicit drugs are significant contributing factors to the causes of TBI. Summer and spring months, evenings, nights, and weekends are associated with the greatest number of injuries. Young males are more likely than young females to have a TBI. Men tend to play more sports, enroll in the military service, take more risks when driving, and consume larger amounts of alcohol than women. Falls are the most common cause of TBI in older adults.

postconcussion syndrome

The most common secondary injury from mild TBI, such as a concussion, is postconcussion syndrome. In this syndrome, the patient reports that headaches, impaired cognition, and dizziness continue to occur for weeks to months after the initial brain injury. Other patients who have been diagnosed with concussions may experience only posttraumatic headaches or posttraumatic vertigo (feeling of spinning or dizziness) for weeks to months after the initial injury.

Craniotomy: Care Coordination & Transition Management

The patient with a brain tumor is managed at home if possible. Maintaining a reasonable quality of life is an important outcome for recovery and rehabilitation. Unless the patient has a significant degree of disability, no special preparation for home care is needed. Patients with hemiparesis need assistance to ensure that their home is accessible according to their method of mobility (e.g., cane, walker, or wheelchair). The environment should be made safe to prevent falls. For example, teach caregivers to remove scatter rugs and to place grab bars in the bathroom. Information about the selection of rehabilitation or chronic care facility, if needed, can be obtained from the case manager (CM) or discharge planner. The selected facility should have experience in providing care for neurologically impaired patients. A psychologist should be available to provide input in the evaluation of the cognitive disabilities that the patient may have. Seizures are a potential complication that can occur at any time for as long as 1 year or more after surgery. Provide the patient and family with information about seizure precautions and what to do if a seizure occurs. Teach the need for follow-up appointments to monitor for therapeutic levels of antiepileptic drugs (AEDs).

TBI: Care Coordination & Transition Management

The patient with a mild brain injury recovers at home after discharge from the emergency department (ED) or hospital. The patient with a severe brain injury requires long-term case management and ongoing rehabilitation after hospitalization. Behavioral interventions are used by cognitive and brain injury rehabilitation specialists to help both the patient and family members develop adaptive strategies. Communicate the patient's plan of care, including drug therapy, to the receiving nurse or provider during each transition in care. Many patients continue on antiepileptic drugs (AEDs) to control seizure activity. Other drugs may be prescribed to help stabilize emotional behaviors or manage depression. The major overall desired outcome for rehabilitation after brain injury is to maximize the patient's ability to return to his or her highest level of functioning. Activities such as occupational therapy, physical therapy, and speech-language therapy may continue in the home after discharge from the hospital or rehabilitation facility. Adaptation of the home environment to accommodate the patient safely may be needed. For example, smoke and fire alarms must function properly because the patient with a brain injury often loses the sense of smell. Home evaluations and referrals to outside agencies are completed before discharge. Be sure to refer the patient and family to the registered dietitian nutritionist for health teaching regarding healthy nutrition to prevent weight gain from decreased activity or stress eating. Many patients with TBI gain significant weight within a year of their injury, most likely because of inactivity. Collaborate with the case manager (CM) to provide the patient and family with both written and verbal instructions for discharge. The teaching plan includes a review of safety at home and strategies to adapt to sensory dysfunction. Discuss issues related to personality or behavior problems that may arise and how to cope with them. Explain the purpose, dosage, schedule, and route of administration of drug therapy. Teach the family to encourage the patient to participate in activities as tolerated. Demonstrations and return demonstrations of care activities help family members become more skillful. Patients with personality and behavior problems respond best to a structured and consistent environment. Instruct the family to develop a home routine that provides structure, repetition, and consistency.

TBI: Maintaining Cerebral Tissue Perfusion Interventions

The patient with a severe TBI is admitted to the critical care unit or trauma center. Patients with moderate TBI are admitted to either the general nursing unit or the critical care unit, where they are closely observed for at least 24 hours. Those with mild TBI are usually sent home from the emergency department with instructions for home-based observation and primary health care provider follow-up. In some cases, the patient is hospitalized for 23-hour observation by staff. Cerebral perfusion is not typically affected by a mild TBI. As with any critically injured patient, priority is given to maintaining a patent airway, breathing, and circulation. Specific nursing interventions for the patient with a TBI are directed toward preventing or detecting secondary brain injury or the conditions that contribute to secondary brain injury such as increased ICP, promoting fluid and electrolyte balance, and monitoring the effects of treatments and drug therapy. Providing health teaching and emotional support for the patient and family are vital parts of the plan of care.

SCI: Increasing Mobility Interventions cont.

The physical therapist works with patients for gait training if ambulation is a realistic goal. While regaining the ability to ambulate, patients may need to use assistive devices such as a variety of canes or walkers. The specific device selected for each patient depends on the amount of weight bearing that is allowed or tolerated. When working with patients who are using these devices, also known as ambulatory aids, the physical therapist ensures that there is a level surface on which to walk. The therapist or nurse may use a gait belt to guide him or her during ambulation to help prevent falls. Reinforce the physical therapist's instructions and encourage practice, with the outcome being optimal mobility for the person. Some patients never regain the ability to walk because of their impairment such as advanced multiple sclerosis or complete spinal cord injury. They may require the use of a wheelchair and need to learn wheelchair or motorized-scooter mobility skills. With the help of physical and occupational therapy, most patients can learn to move anywhere in a wheelchair or electric scooter. One way to increase mobility is through range of motion (ROM) exercises. ROM techniques are beneficial for any patient with decreased mobility.

TBI: Diagnostics

The primary health care provider immediately requests CT of the brain to identify the extent and scope of injury. This diagnostic test can identify the presence of an injury that requires surgical intervention, such as an epidural or subdural hematoma. An MRI may be done to detect subtle changes in brain tissue and show more specific detail of the brain injury. MRI is particularly useful in the diagnosis of diffuse axonal injury, but it is not recommended for patients with ICP-monitoring devices.

SCI: Laboratory and Imaging Assessment

The primary health care provider may request basic laboratory studies for the patient with an SCI to establish baseline data. A spine CT and MRI are performed to determine the degree and extent of damage to the spinal cord and detect the presence of blood and bone within the spinal column. In addition, patients may have a series of x-rays of the spine to identify vertebral fractures, subluxation, or dislocation.

S/S of strokes in the R cerebral hemisphere

The right cerebral hemisphere is more involved with visual and spatial awareness and proprioception (sense of body position). A person who has a stroke involving the right cerebral hemisphere is often unaware of any deficits and may be disoriented to time and place. Personality changes include impulsivity (poor impulse control) and poor judgment.

hospital incident commander

The roles and responsibilities of health care personnel in a mass casualty event or disaster are defined within the institution's emergency response or preparedness plan. Each plan is as individualized as the particular facility's operations, yet virtually all plans identify certain key functions. One of the primary roles to be established at the onset of an incident is that of a hospital incident commander who assumes overall leadership for implementing the institutional plan. This person is usually either a physician in the ED or a hospital administrator who has the authority to activate resources. This role can also be fulfilled by a nursing supervisor functioning as the on-site hospital administrator after usual business hours until hospital leadership personnel arrive. The hospital incident commander's role is to take a global view of the entire situation and facilitate patient movement through the system, while bringing in personnel and supply resources to meet patient needs. For example, a hospital incident commander might dictate that all patients due to be discharged from an inpatient unit be moved to a lounge area immediately to free up hospital beds for mass casualty victims. He or she could also direct departments such as physical therapy or a surgical clinic to cancel their usual operations to convert the space into a minor treatment area. The incident commander assists in the organization of hospital-wide services to rapidly expand hospital capacity, recruit paid or volunteer staff, and ensure the availability of medical supplies. When the last major casualties have been treated and no more are expected to arrive in numbers that could overwhelm the health care system, the incident commander considers "standing down" or deactivating the emergency response plan. Although the casualties may have left the ED, other areas in the hospital may still be under stress and need the support of the supplemental resources provided by emergency plan activation. Before terminating the response, it is essential to ensure that the needs of the other hospital departments have been met and all are in agreement to resume normal operations. A vital consideration in event resolution is staff and supply availability to meet ongoing operational needs.

Stroke: Self-Management Education

The three areas that should be included in patient and family education are disease prevention, disease-specific information, and self-management. The teaching plan may include lifestyle changes, drug therapy, ambulation and transfer skills, communication skills, safety precautions, nutritional management, activity levels, and self-management skills. Health teaching should focus on tasks that must be performed by the patient and the family after hospital discharge. Return demonstrations help to evaluate the family members' competency in tasks required for the patient's care. Provide both written and verbal instruction in all these areas. Specific teaching for stroke patients (and their families) includes: • Provide information about prescribed drugs to prevent another stroke and control hypertension. Instruct the patient and the family in the name of each drug, the dosage, the timing of administration, how to take it, and possible side effects. • Teach the patient how to climb stairs safely, if he or she is able; transfer from the bed to a chair; get into and out of a car; and use any aids for mobility. • Provide important information regarding what to do in an emergency and who to call for nonemergency questions. As part of the discharge process, teach the family about the signs and symptoms of depression that may occur within 3 months after a stroke. The strongest predictors of poststroke depression (PSD) are a history of depression, severe stroke, and poststroke physical or cognitive impairment. Patients may not exhibit typical signs of depression because of their cognitive, physical, and emotional impairments. PSD is associated with increased morbidity and mortality, especially in older men. Patients who have had a TIA or stroke are at risk for a new stroke. Teach family members to observe for and act on signs of a new stroke using the FAST mnemonic: • Face drooping • Arm weakness • Speech or language difficulty • Time to call 911 Families may feel overwhelmed by the continuing demands placed on them. Family member caregivers are often uncertain about the progress of the patient and can become depressed the longer they care for him or her. Therefore family members need to spend time away from the patient on a routine basis to continue to provide full-time care without sacrificing their own physical and emotional health. Refer the family to social services or other community resources for further support, counseling, and possible respite care.

Nursing Safety Priority 17

The upper cervical spinal nerves innervate the diaphragm to control breathing. Monitor all TBI patients for respiratory problems and diaphragmatic breathing, as well as for diminished or absent reflexes in the airway (cough and gag). Hypoxia and hypercapnia are best detected through arterial oxygen levels (partial pressure of arterial oxygen [PaO 2]), oxygen saturation (SpO 2), and end-tidal volume carbon dioxide measurement (ETCO 2). Observe chest wall movement and listen to breath sounds. Provide respiratory support including oxygen therapy and bed positioning. Report any sign of respiratory problems immediately to the Rapid Response Team or primary health care provider!

emergency medicine physician

These medical professionals receive specialized education and training in emergency patient management. Emergency medicine is a recognized physician specialty practice. Even though other physician specialists may be involved in ED patient treatment, the emergency medicine physician typically directs the overall care in the department.

Thrombotic strokes

Thrombotic strokes account for more than half of all strokes and are commonly associated with the development of atherosclerosis in either intracranial or extracranial arteries (usually the carotid arteries). Atherosclerosis is the process by which fatty plaques develop on the inner wall of the affected arterial vessel. Rupture of one or more atherosclerotic plaques can promote clot formation. When the clot is of sufficient size, it interrupts blood flow to the brain tissue supplied by the vessel, causing an ischemic (occlusive) stroke. Because of the gradual nature of clot formation when atherosclerotic plaque is present, thrombotic strokes tend to have a slow onset, evolving over minutes to hours.

trauma system

Trauma centers save lives, but a trauma center is only as good as the overall trauma system that supports it. A trauma system is an organized and integrated approach to trauma care designed to ensure that all critical elements of trauma care delivery are aligned to meet the injured patient's needs. These elements include: • Access to care through communication technology (e.g., an enhanced 911 service) • Timely availability of prehospital emergency medical care • Rapid transport to a qualified trauma center • Early provision of rehabilitation services • System-wide injury prevention, research, and education initiatives The overall desired outcome of an organized trauma system is to enable an injured patient not only to recover from trauma but also to return to a productive role in society.

SCI: Etiology

Trauma is the leading cause of spinal cord injuries (SCIs), with more than a third resulting from vehicle crashes. Other leading causes are falls, acts of violence (usually gunshot wounds [GSWs]), and sports- or recreation-related accidents. SCIs from falls are particularly likely among older adults. Spinal cord damage in adults can also result from nontraumatic vertebral fracture and diseases such as benign or malignant tumors. Almost 80% of all SCIs occur in young males, with the majority being Euro-American. Cervical cord injuries are more common than thoracic or lumbar cord injuries. The most common neurologic level of injury is C5. In paraplegia, T12 and L1 are the most common levels.

debriefing

Two general types of debriefing, or formal systematic review and analysis, occur after a mass casualty incident or disaster. The first type entails bringing in crisis support teams to provide sessions for small groups of staff, to promote effective coping strategies. The second type of debriefing involves an administrative review of staff and system performance during the event to determine whether opportunities for improvement in the emergency management plan exist.

black-tagged patients

Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury necessitating mechanical ventilation. The rationale for this very difficult decision is that limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expense of many others.

Spinal cord injuries (SCIs): Mechanisms of Injury

When enough force is applied to the spinal cord, the resulting damage causes many neurologic deficits. Sources of force include direct injury to the vertebral column (fracture, dislocation, and subluxation [partial dislocation]) or penetrating injury from violence (gunshot or knife wounds). Although in some cases the cord itself may remain intact, at other times it undergoes a destructive process caused by a contusion (bruise), compression, laceration, or transaction (severing of the cord, either complete or incomplete). The causes of SCI can be divided into primary and secondary mechanisms of injury.

SCI: Older Adult Considerations

When urinary antispasmodic drugs are used in older adults, observe for, document, and report hallucinations, delirium, or other acute cognitive changes caused by the anticholinergic effects of the drugs.

Spinal cord injuries (SCIs)

are classified as complete or incomplete. A complete SCI is one in which the spinal cord has been damaged in a way that eliminates all innervation below the level of the injury. Injuries that allow some function or movement below the level of the injury are described as an incomplete SCI. Incomplete injuries are more common than complete SCIs. Loss of or decreased mobility, sensory perception, and bowel and bladder control often result from an SCI.

Forensic nurse examiners (RN-FNEs)

are educated to obtain patient histories, collect forensic evidence, and offer counseling and follow-up care for victims of rape, abuse, and domestic violence—also known as intimate partner violence (IPV). They intervene on the patient's behalf. Forensic nurses who specialize in helping victims of sexual assault are called sexual assault nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs). Interventions performed by forensic nurses may include providing information about developing a safety plan or how to escape a violent relationship. Forensic nurse examiners document injuries and collect physical and photographic evidence. They may also provide testimony in court as to what was observed during the examination and information about the type of care provided.

Prehospital care providers

are typically the first caregivers that patients see before transport to the ED by an ambulance or helicopter. The prehospital provider is a key source for valuable patient data. Emergency nurses rely on these providers to be the "eyes and ears" of the health care team in the prehospital setting and to ensure communication of this information to other staff members for continuity of care.

Neurogenic Bladder Interventions: Facilitating (triggering) techniques

are used to stimulate voiding. If there is an upper motor neuron problem but the reflex arc is intact (reflex bladder pattern), the voiding response can be initiated by any stimulus that sends the message to the spinal cord level S2-4 that the bladder might be full. Such techniques include stroking the medial aspect of the thigh, pinching the area above the groin, massaging the peno-scrotal area, pinching the posterior aspect of the glans penis, and providing digital anal stimulation. When the patient has a lower motor neuron problem, the voiding reflex arc is not intact (flaccid bladder pattern), and additional stimulation may be needed to initiate voiding. Two techniques used to facilitate voiding are the Valsalva maneuver and the Credé maneuver. For the Valsalva maneuver, teach the patient to hold his or her breath and bear down as if trying to defecate. This technique should not be used by a spinal cord-injured patient who is at risk for bradycardia as a result of loss of vagus nerve control. Help the patient perform the Credé maneuver by placing his or her hand in a cupped position directly over the bladder area. Then instruct him or her to push inward and downward gently as if massaging the bladder to empty.

overactive spastic (upper motor neuron) bladder

causes incontinence with sudden voiding. The bladder does not usually empty completely, and the patient is at risk for urinary tract infection. Neurologic problems affecting the upper motor neuron typically occur in patients with strokes or with high-level spinal cord injuries (cervical) or those above the mid-thoracic region. These injuries result in a failure of impulse transmission from the lower spinal cord areas to the cortex of the brain. When the bladder fills and transmits impulses to the spinal cord, the patient cannot perceive the sensation. Because there is no injury to the lower spinal cord and the voiding reflex arc is intact, the efferent (motor) impulse from a distended bladder is relayed, and the bladder contracts.

nonurgent triage

category can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include patients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections.

emergent triage

category implies that a condition exists that poses an immediate threat to life or limb. With this system, a patient experiencing crushing substernal chest pain, shortness of breath, and diaphoresis would be classified as emergent and triaged immediately to a treatment room within the ED. Similarly, a critically injured trauma patient or a person with an active hemorrhage would also be prioritized as emergent.

urgent triage

category indicates that the patient should be treated quickly but that an immediate threat to life does not exist at the moment. Reassessment is needed if a health care provider cannot evaluate the patient in a timely manner. In case of clinical deterioration, triage priority may be upgraded from urgent to emergent. Examples of patients who typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C).

psychiatric crisis nurse team

evaluates patients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate facility. These nurses interact with patients and families when sudden illness, serious injury, or death of a loved one may have precipitated a crisis.

Hydrocephalus

is an abnormal increase in CSF volume in the brain. It may be caused by impaired reabsorption of CSF at the arachnoid villi (from subarachnoid hemorrhage or meningitis), called a communicating hydrocephalus. It may also be caused by interference or blockage with CSF outflow from the ventricular system (from cerebral edema, tumor, or debris) (called a noncommunicating hydrocephalus). Ultimately, if not treated, this increase may lead to increased ICP.

community relations or public information officer

is an especially important role to delineate in advance. Mass casualty incidents tend to attract a large amount of media attention. This staff member can draw media away from the clinical areas so essential hospital operations are not hindered. He or she can also serve as the liaison between hospital administration and the media to release only appropriate and accurate information.

Triage

is an organized system for sorting or classifying patients into priority levels, depending on illness or injury severity. The key concept is that patients in the ED with the highest-acuity needs receive the quickest evaluation; treatment; and prioritized resource utilization such as x-rays, laboratory work, and computed tomography (CT) scans. These patients also have priority for hospital service areas such as the operating room or cardiac catheterization laboratory. A person with a lower-acuity problem may wait longer in the ED because a high-acuity patient is moved to the "head of the line." Whatever triage model is used, triage nurses must use a systematic approach, apply solid clinical decision-making skills, and maintain a caring ethic. Compassion fatigue, or burnout, can hinder objectivity in working with patients in the ED. A biased approach threatens the ED nurse's ability to triage patients accurately. Mistriage is a patient safety risk that can be the "root cause" of delayed or inadequate treatment, with potentially deadly consequences.

Penetrating trauma

is caused by injury from sharp objects and projectiles. Examples are wounds from knives, ice picks, other comparable implements, and bullets (gunshot wounds [GSWs]) or pellets. Fragments of metal, glass, or other materials that become airborne in an explosion (shrapnel) can also produce penetrating trauma. Each mechanism has the risk for specific injury patterns and severity that the trauma team considers when planning diagnostic evaluation and management strategies. Certain injury mechanisms such as a gunshot wound to the chest or abdomen or a stab wound to the neck are so highly associated with life-threatening consequences that they automatically require trauma team intervention for a rapid and coordinated resuscitation response.

Some of the most common reasons that people seek ED care are:

• Abdominal pain • Breathing difficulties • Chest pain • Fever • Headache • Injuries (especially falls in older adults) • Pain (the most common symptom)

Many hospitals have developed transition-of-care systems to improve patient and family education, patient and family satisfaction, and 30-day hospital readmission rates. For example, Ross et al. (2017) implemented a nurse-driven quality improvement (QI) project to improve patient education and reduce readmissions by:

• Using a teach-back method for patient and family education • Conducting a follow-up phone call to the patient and family at 72 hours after discharge The QI project did not improve patient satisfaction scores but did improve the 30-day readmission rate and the patient's perception of discharge education.

Traumatic Brain Injury

is damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions. TBI can lead to temporary and permanent impairment in cognition, mobility, sensory perception, and/or psychosocial function. A force produced by a blow to the head is a direct injury, whereas a force applied to another body part with a rebound effect to the brain is an indirect injury. The brain responds to these forces by movement within the rigid cranial vault. It may also rebound or rotate on the brainstem, causing diffuse nerve axonal injury (shearing injuries). The brain may be contused (bruised) or lacerated (torn) as it moves over the inner surfaces of the cranium, which are irregularly shaped and sharp. Movement or distortion within the cranial cavity is possible because of multiple factors. The first factor is how the brain is supported by cerebrospinal fluid (CSF) within the cranial cavity. When external force is applied to the head, the brain can be injured by the internal surfaces of the skull. The second factor is the consistency of brain tissue, which is very fragile, gel-like, and prone to injury. Brain injury occurs both from initial forces on the cranium and brain and as a result of secondary injury related to mechanical pressure or cerebral edema. The type of force and the mechanism of injury contribute to TBI. An acceleration injury is caused by an external force contacting the head, suddenly placing the head in motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. These forces may be sufficient to cause the cerebrum to rotate about the brainstem, resulting in shearing, straining, and distortion of the brain tissue, particularly of the axons in the brainstem and cerebellum. TBI is further defined as mild, moderate, or severe. Generally, the determination of severity of TBI is the result of the Glasgow Coma Scale (GCS) score immediately following resuscitation, the presence (or absence) of brain damage imaged by CT or MRI following the trauma, an estimation of the force of the trauma, and symptoms in the injured person.

disaster

is defined as an event in which illness or injuries exceed resource capabilities of a health care facility or community because of destruction and devastation. This kind of event can be either internal to a health care facility or external from situations that create casualties in the community. Both internal and external disasters can occur simultaneously, such as when Hurricane Michael incapacitated health care facilities in the Florida Panhandle.

Epilepsy

is defined by the National Institute of Neurological Disorders and Stroke as a chronic disorder in which repeated unprovoked seizure activity occurs. It may be caused by an abnormality in electrical neuronal activity; an imbalance of neurotransmitters, especially gamma aminobutyric acid (GABA); or a combination of both.

intracerebral hemorrhage (ICH)

is the accumulation of blood within the brain tissue caused by the tearing of small arteries and veins in the subcortical white matter. It often acts as a space-occupying lesion (e.g., a tumor) and may be potentially devastating, depending on its location. ICH may also produce significant brain edema and ICP elevations. A traumatic brainstem hemorrhage occurs as a result of a blow to the back of the head, fractures, or torsion injuries to the brainstem (vital sign center). Brainstem injuries have a very poor prognosis.

Neurogenic Bladder Interventions: Consistent toileting routines

may be the best way to re-establish voiding continence when the patient has an overactive bladder. Assess the patient's previous voiding pattern and determine his or her daily routine. At a minimum the nurse or nursing staff helps the patient void after awakening in the morning, before and after meals, before and after physical activity, and at bedtime. Remind the staff to toilet the patient every 2 hours during the day and every 3 to 4 hours at night. Consider the patient's bladder capacity, which may range from 100 to 500 mL; mobility limitations; and restrictive clothing. Bladder capacity is determined by measuring urine output. Ensure that the patient is aware of nearby bathrooms at all times or has a call system to contact the nurse or assistive personnel for assistance.

Emergency medical technicians (EMTs)

offer basic life support (BLS) interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs. Some units carry automatic external defibrillators (AEDs) and may be authorized to administer selected drugs such as an epinephrine autoinjector, intranasal naloxone (Narcan), or nitroglycerin based on training and established protocols.

red-tagged patients

red-tagged patients have immediate life-threatening conditions such as airway obstruction or shock and therefore require immediate attention.

Blunt trauma

results from impact forces such as those sustained in a motor vehicle crash; a fall; or an assault with fists, kicks, or a baseball bat.

subdural hematoma (SDH)

results from venous bleeding into the space beneath the dura and above the arachnoid. It occurs most often from a tearing of the bridging veins within the cerebral hemispheres, from a laceration of brain tissue. Bleeding from this injury occurs more slowly than from an epidural hematoma. SDHs are subdivided into acute, subacute, and chronic. Acute SDH presents within 48 hours after impact; subacute SDH between 48 hours and 2 weeks, and chronic SDH from 2 weeks to several months after injury. SDHs have the highest mortality rate because they often are unrecognized until the patient presents with severe neurologic compromise. The incidence of chronic SDHs (sometimes written as cSDH) nearly doubles when people are between 65 and 75 years of age and continues to increase in patients over 80 years old. Common causes of chronic SDHs in older adults include head trauma resulting from a fall and anticoagulant or antiplatelet therapy. Typical signs and symptoms include worsening headaches, paresis, acute confusion, and seizures. In some cases, patients may experience a decreased level of consciousness, including coma.

underactive flaccid or flexic (lower motor neuron) bladder

results in urinary retention and overflow (dribbling). Injuries that damage the lower motor neuron at the spinal cord level of S2-4 (e.g., multiple sclerosis, spinal cord injury or tumor below T12) may directly interfere with the reflex arc or may result in inaccurate interpretation of impulses to the brain. The bladder fills, and afferent (sensory) impulses conduct the message via the spinal cord to the brain cortex. Because of the injury, the impulse is not interpreted correctly by the bladder center of the brain, and there is a failure to respond with a message for the bladder to contract. Patients who cannot completely empty their bladder are at risk for postvoid residual urine and subsequent possible urinary tract infection. Postvoid residual (PVR) is the amount of urine remaining in the bladder after voiding. PVR assessments using a noninvasive ultrasound device called the BladderScan are performed by nurses at the bedside. The residual amount measured is accurate if the device is used correctly. Obesity may interfere with accuracy. The outcome of bladder ultrasonography is to prevent the unnecessary use of an indwelling urinary catheter. Long-term urinary catheters cause urinary tract infections that are often chronic.

Evidence-Based Nursing Interventions During and After IV Administration of Alteplase

• Admit the patient to a critical care or specialized stroke unit. • Perform a double check of the drug dose. Use a programmable pump to deliver the initial dose of 0.9 mg/kg (maximum dose 90 mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. Do not manually push this drug. • Perform neurologic assessments, including vital signs, every 10 to 15 minutes during infusion and every 30 minutes after that for at least 6 hours; monitor hourly for 24 hours after treatment. Be consistent regarding the device used to obtain blood pressures because blood pressures can vary when switching from a manual to a noninvasive automatic to an intra-arterial device. • If systolic blood pressure is 185 mm Hg or greater or diastolic is 110 mm Hg or greater during or after alteplase, give antihypertensive drugs, such as labetalol, as prescribed (IV is recommended for faster response). • To prevent bleeding, do not place invasive tubes, such as nasogastric (NG) tubes or indwelling urinary catheters, until the patient is stable (usually for 24 hours). • Discontinue the infusion if the patient reports severe headache or has severe hypertension, bleeding, nausea, and/or vomiting; notify the primary health care provider immediately. • Obtain a follow-up CTA or CTP scan after fibrinolytic therapy and before starting antiplatelet or anticoagulant drugs.

The ACLS course builds on the BLS content to include:

• Advanced concepts in cardiac monitoring • Invasive airway-management skills • Pharmacologic and electrical therapies • Intravascular access techniques • Special resuscitation situations • Postresuscitation management considerations

In addition to the NIH score, patients are often evaluated using the ABCD assessment tool to determine their risk of having a stroke in the days and weeks after the TIA. The following factors are scored:

• Age greater than or equal to 60 (stroke risk increases with age) • Blood pressure (BP) greater than or equal to 140/90 mm Hg (either systolic or diastolic or both) • Clinical TIA features (unilateral [one-sided] weakness increases stroke risk) • Duration of symptoms (the longer the TIA symptoms last, the greater the risk of stroke)

Social media continue to be used more frequently in times of disaster for citizen reporting, community organizing, problem solving, and volunteer recruitment. For such incidents, the National Guard, the American Red Cross, the public health department, various military units, a Medical Reserve Corps (MRC), or a Disaster Medical Assistance Team (DMAT) can be activated by state and federal government authorities:

• An MRC is made up of a group of volunteer medical and public health care professionals, including physicians, providers, and nurses. They offer their services to health care facilities or to the community in a supportive or supplemental capacity during times of need such as a disaster or pandemic disease outbreak. This group may help staff hospitals or community health settings that face personnel shortages and establish first aid stations or special-needs shelters. As a means to alleviate ED and hospital overcrowding, the MRC may also set up an acute care center (ACC) in the community for patients who need acute care (but not intensive care) for days to weeks. • A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours. DMATs are part of the National Disaster Medical System (NDMS) in the United States. They provide relief services ranging from primary health care and triage to evacuation and staffing to assist health care facilities that have become overwhelmed with casualties. Because licensed health care providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states. Additional examples of services provided by the NDMS include: • Disaster Mortuary Operational Response Teams (DMORTs) to manage mass fatalities • National Veterinary Response Teams (NVRTs) for emergency animal care • International Medical Surgical Response Teams (IMSURTs) to establish fully functional field surgical facilities wherever they are needed in the world

Most strokes are preventable. The CDC and other cardiovascular professional organizations recommend to apply the ABCS of heart health to prevent strokes:

• Aspirin use when appropriate • Blood pressure control • Cholesterol management • Smoking cessation Lifestyle changes include smoking cessation, if needed; a heart-healthy diet rich in fruits and vegetables and low in saturated fats (including red meats); and regular activity, including planned exercise. Teach patients about the importance of identifying and managing risk factors such as hypertension, obesity, substance use disorder, and diabetes mellitus that contribute to the potential for a major stroke.

Basic Supplies for Personal Preparedness (3-Day Supply)

• Backpack • Clean, durable weather-appropriate clothing; sturdy footwear • Potable water—at least 1 gallon per person per day for at least 3 days • Food-nonperishable, no cooking required • Headlamp or flashlight—battery powered; extra batteries and/or chemical light sticks (N ote : a headlamp is superior because it allows hands-free operation) • Pocket knife or multitool • Personal identification (ID) with emergency contacts and phone numbers, allergies, and medical information; lists of credit card numbers and bank accounts (keep in watertight container) • Towel and washcloth; towelettes, soap, hand sanitizer • Paper, pens, and pencils; regional maps • Cell phone and charger • Sunglasses; protective and/or corrective eyewear • Emergency blanket and/or sleeping bag and pillow • Work gloves • Personal first aid kit with over-the-counter (OTC) and prescription medications • Rain gear • Roll of duct tape and plastic sheeting • Radio—battery powered or hand-crank generator • Toiletries (toothbrush and toothpaste, comb, brush, razor, shaving cream, mirror, menstrual supplies, deodorant, shampoo, soap, lip balm, sunscreen, insect repellent, toilet paper) • Plastic garbage bags and ties, resealable plastic bags • Matches in a waterproof container • Whistle • Household liquid bleach for disinfection

Use of a Halo Fixator With Vest

• Be aware that the weight of the halo device alters balance. Be careful when leaning forward or backward. • Wear loose clothing, preferably with hook and loop (Velcro) fasteners or large openings for head and arms. • Bathe in the bathtub or take a sponge bath. (Some primary health care providers allow showers.) • Wash under the liner of the vest to prevent rashes or sores; use powders or lotions sparingly under the vest. • Have someone change the liner if it becomes odorous. • Support the head with a small pillow when sleeping to prevent unnecessary pressure and discomfort. • Try to resume usual activities to the extent possible; keep as active as possible. (The weight of the device may cause fatigue or weakness.) However, avoid contact sports and swimming. • Do not drive because vision is impaired with the device. • Keep straws available for drinking fluids. • Cut meats and other food into small pieces to facilitate chewing and swallowing. • Before going outside in cold temperatures, wrap the pins with cloth to prevent the metal from getting cold. • Have someone clean the pin sites as recommended by the primary health care provider or hospital protocol. • Observe the pin sites daily for redness, drainage, or loosening; report changes to the primary health care provider. • Increase fluids and fiber in the diet to prevent constipation. • Use a position of comfort during sexual activity.

TBI: Older Adult Considerations

• Brain injury is the fifth leading cause of death in older adults. • The 65- to 75-year age-group has the second highest incidence of brain injury of all age-groups. • Falls and motor vehicle crashes are the most common causes of brain injury. • Factors that contribute to high mortality are: -Falls causing subdural hematomas (closed head injuries), especially chronic subdural hematomas -Poorly tolerated systemic stress, which is increased by admission to a high-stimulus environment -Medical complications, such as hypotension, hypertension, and cardiac problems -Decreased protective mechanisms, which make patients susceptible to infections (especially pneumonia) -Decreased immunologic competence, which is further diminished by brain injury

Common ED procedures include:

• Central line insertion • Chest tube insertion • Endotracheal intubation and initiation of mechanical ventilation • Fracture management • Foreign body removal • Lumbar puncture • Paracentesis • Pelvic examination • Wound closure by suturing

Increased Intracranial Pressure (ICP): Key Features

• Decreased level of consciousness (LOC) (earliest sign) • Behavior changes: restlessness, irritability, and confusion • Headache • Nausea and vomiting (may be projectile) • Aphasia • Change in speech pattern/dysarthria • Change in sensorimotor status: -Pupillary changes: dilated and nonreactive pupils ("blown pupils") or constricted and nonreactive pupils (very late sign) -Cranial nerve dysfunction -Ataxia • Seizures (usually within first 24 hours after stroke) • Cushing triad (very late sign): -Severe hypertension -Widened pulse pressure -Bradycardia • Abnormal posturing (very late sign): -Decerebrate -Decorticate

Best practices for preventing or managing increasing ICP for patients experiencing a stroke include:

• Elevate the head of the bed per agency or primary health care provider protocol to improve perfusion pressure. • Provide oxygen therapy to prevent hypoxia for patients with oxygen saturation less than 95% or per agency or primary health care provider protocol or prescription. • Maintain the head in a midline, neutral position to promote venous drainage from the brain. • Avoid sudden and acute hip or neck flexion during positioning. Extreme hip flexion may increase intrathoracic pressure, leading to decreased cerebral venous outflow and elevated ICP. Extreme neck flexion also interferes with venous drainage from the brain and intracranial dynamics. • Avoid the clustering of nursing procedures (e.g., giving a bath followed immediately by changing the bed linen). When multiple activities are clustered in a narrow time period, the effect on ICP can be dramatic elevation. • Hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries. • Provide airway management to prevent unnecessary suctioning and coughing that can increase ICP. • Maintain a quiet environment for the patient experiencing a headache, which is common with cerebral hemorrhage or increased ICP. • Keep the room lights low to accommodate any photophobia the patient may have. • Closely monitor blood pressure, heart rhythm, oxygen saturation, blood glucose, and body temperature to prevent secondary brain injury and promote positive outcomes after stroke.

Triage functions may be performed by EMS providers in the field such as:

• Emergency medical technicians (EMTs) and paramedics • Nurse, provider, and physician field teams that are called from the hospital to a disaster scene to assist EMS providers • Nurse, provider, and physician hospital teams to assess and reassess incoming patients

Most mass casualty response teams in the field (at the disaster site) and in the hospital setting use a disaster triage tag system that categorizes triage priority by color and number:

• Emergent (class I) patients are identified with a red tag. • Patients who can wait a short time for care (class II) are marked with a yellow tag. • Nonurgent or "walking wounded" (class III) patients are given a green tag. • Patients who are expected (and allowed) to die or are dead are issued a black tag (class IV).

Evaluate the care of the patient with an SCI based on the identified priority patient problems. The expected outcomes are that the patient:

• Exhibits no deterioration in neurologic status • Maintains a patent airway, a physiologic breathing pattern, and adequate ventilation • Does not experience a cardiovascular event (e.g., shock, hemorrhage, autonomic dysreflexia) or receives prompt treatment if an event occurs • Does not experience secondary spinal cord injury, including VTE and heterotopic ossification • Is free from complications of decreased mobility • Performs mobility skills and basic ADLs as independently as possible with or without the use of assistive-adaptive devices

Some of the most common patient safety issues noted in the ED are:

• Fall risk • Medical errors or adverse events • Patient misidentification • Skin breakdowng

Mild Brain Injury: Patient and Family Education

• For a headache, give acetaminophen every 4 hours as needed. • Avoid giving the person sedatives, sleeping pills, or alcoholic beverages for at least 24 hours after TBI unless the primary health care provider instructs otherwise. • Do not allow the person to engage in strenuous activity for at least 48 hours. • Teach the caregiver to be aware that balance disturbances cause safety concerns and that he or she should provide for monitored or assisted movement. • If any of these symptoms occur, take the person back to the emergency department or call 911 immediately: -Seizure -Severe, or worsening, headache -Persistent or severe nausea or vomiting -Blurred vision -Clear drainage from the ear or nose -Increasing weakness -Slurred speech -Progressive sleepiness -Unequal pupil size • Keep follow-up appointments with the primary health care provider.

Evaluate the care of the patient with stroke based on the identified priority patient problems. The expected outcomes are that the patient:

• Has adequate cerebral perfusion to avoid long-term disability • Maintains blood pressure and blood glucose within a safe, prescribed range • Performs self-care and mobility activities independently, with or without assistive devices • Learns to adapt to sensory perception changes, if present • Communicates effectively or develops strategies for effective communication as needed • Has adequate nutrition and avoids aspiration

Based on the triage priority, patients may be rushed into a treatment room, directed to a lower-acuity area within the ED, or asked to sit in the waiting room. Variations include:

• Triage nurse-initiated protocols for laboratory work or diagnostic studies that may be performed before the patient is actually evaluated by an ED provider of care • Initiation of care while the patient is on a stretcher in the hallway of a crowded ED

Secondary injury worsens the primary injury. Secondary injuries include:

• Hemorrhage • Ischemia (lack of oxygen, typically from reduced/absent blood flow) • Hypovolemia (decreased circulating blood volume) • Impaired tissue perfusion from neurogenic shock (a medical emergency) • Local edema Hemorrhage into the spinal cord may manifest with contusion or petechial leaking into the central gray matter and later into the white matter. Systemic hemorrhage can result in shock and decrease perfusion to the spinal cord. Edema occurs with both primary and secondary injuries, contributing to capillary compression and cord ischemia. In neurogenic shock, loss of blood vessel tone (dilation) after severe cord injury may result in hypoperfusion. Patients who have SCI have a decreased life expectancy owing to complications of immobility or, more often, some type of infection. The major causes of death are pneumonia and septicemia.

Five primary mechanisms may result in an SCI:

• Hyperflexion: a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck. This is often the result of a head-on motor vehicle collision or diving accident. Flexion injury to the lower thoracic and lumbar spine may occur when the trunk is suddenly flexed on itself, such as occurs in a fall on the buttocks. • Hyperextension occurs most often in vehicle collisions in which the vehicle is struck from behind or during falls when the patient's chin is struck. The head is suddenly accelerated and then decelerated. This stretches or tears the anterior longitudinal ligament, fractures or subluxates the vertebrae, and perhaps ruptures an intervertebral disk. As with flexion injuries, the spinal cord may easily be damaged. • Axial loading or vertical compression injuries resulting from diving accidents, falls on the buttocks, or a jump in which a person lands on the feet can cause many of the injuries attributable to axial loading (vertical compression). A blow to the top of the head can cause the vertebrae to shatter. Pieces of bone enter the spinal canal and damage the cord. • Excessive rotation results from injuries that are caused by turning the head beyond the normal range. • Penetrating trauma is classified by the speed of the object (e.g., knife, bullet) causing the injury. Low-speed or low-impact injuries cause damage directly at the site or local damage to the spinal cord or spinal nerves. In contrast, high-speed injuries that occur from gunshot wounds (GSWs) cause both direct and indirect damage.

Health Teaching for the Patient With Epilepsy

• Know drug therapy information: -Name, dosage, time of administration -Actions to take if side effects occur -Importance of taking drug as prescribed and not missing a dose -What to do if a dose is missed or cannot be taken • Understand importance of having blood drawn for therapeutic or toxic levels as requested by the primary health care provider. • Do not take any drug, including over-the-counter drugs, without asking your primary health care provider. • Wear a medical alert bracelet or necklace or carry an identification card indicating epilepsy. • Follow up with your neurologist or other primary health care provider as directed. • Be sure that a family member or significant other knows how to help you in the event of a seizure and knows when your primary health care provider or emergency medical services should be called. • Investigate and follow state laws concerning driving and operating machinery. • Avoid alcohol and excessive fatigue. • Contact the Epilepsy Foundation (www.epilepsy.com) or other organized epilepsy group for additional information. Epilepsy Canada (www.epilepsy.ca) also provides resources and support.

When obtaining a history from a patient with an acute SCI, gather as much data as possible about how the accident occurred and the probable mechanism of injury once the patient is stabilized. Questions include:

• Location and position of the patient immediately after the injury • Symptoms that occurred immediately with the injury • Changes that have occurred subsequently • Type of immobilization devices used and whether any problems occurred during stabilization and transport to the hospital • Treatment given at the scene of injury or in the emergency department (ED) (e.g., medications, IV fluids) • Medical history, including osteoporosis or arthritis of the spine, congenital deformities, cancer, and previous injury or surgery of the neck or back • History of any respiratory problems, especially if the patient has experienced a cervical SCI

Use these general SPHM practices and teach staff members to:

• Maintain a wide, stable base with your feet. • Place the bed at the correct height—waist level while providing direct care and hip level when moving patients. • Keep the patient or work directly in front of you to prevent your spine from rotating. • Keep the patient as close to your body as possible to prevent reaching. • Use the appropriate safe patient-handling equipment.

Evaluate the care of the patient with TBI based on the identified priority problems. Expected outcomes are that the patient:

• Maintains cerebral tissue perfusion • Learns to adapt to altered mobility and sensory perception changes, if any • Has minimal alterations in cognition or understands how to compensate for cognition changes when necessary

The teaching plan for the patient with an SCI includes:

• Mobility skills • Pressure injury prevention • ADL skills • Bowel and bladder program • Education about sexuality and referral for counseling to promote sexual health • Prevention of autonomic dysreflexia with appropriate bladder, bowel, and skin-care practices and recognition of early signs or symptoms of autonomic dysreflexia This information should be reinforced with written handouts, CDs, DVDs, or other patient-education material that the patient and family members can use after discharge to the home. A full-time caregiver or personal assistant is sometimes required if the patient with tetraplegia returns home. The caregiver may be a family member or a nursing assistant employed to help provide care and companionship. A patient who is paraplegic is often able to function without assistance after an appropriate rehabilitation program. ADL and mobility training for the patient with an SCI includes a structured exercise program to promote strength and endurance. One promising therapy in rehabilitation is functional electrical stimulation (FES). FES uses small electrical pulses to paralyzed muscles to restore or improve their function. It is commonly used for exercise; but it is also used to assist with breathing, grasping, transferring, standing, and walking. The occupational therapist instructs the patient in the correct use of all adaptive equipment and therapies. In collaboration with the therapists, instruct family members or the caregiver in transfer skills, feeding, bathing, dressing, positioning, bowel and bladder training, and skin care.

Emergency Care of the Patient Experiencing Autonomic Dysreflexia: Immediate Interventions

• Place patient in a sitting position (first priority!), or return to a previous safe position. • Assess for and remove/manage the cause: -Check for urinary retention or catheter blockage. -Check the urinary catheter tubing (if present) for kinks or obstruction. -If a urinary catheter is not present, check for bladder distention and catheterize immediately if indicated. (Consider using anesthetic ointment on tip of catheter before catheter insertion to reduce urethral irritation.) • Determine if a urinary tract infection or bladder calculi (stones) are contributing to genitourinary irritation. • Check the patient for fecal impaction or other colorectal irritation, using anesthetic ointment at rectum. Disimpact if needed. • Examine skin for new or worsening pressure injury symptoms. • Monitor blood pressure every 10 to 15 minutes. • Give nifedipine or nitrate as prescribed to lower blood pressure as needed. (Patients with recurrent autonomic dysreflexia may receive clonidine or other centrally acting alpha-agonist agent prophylactically)

To help communicate with the patient with aphasia, use these guiding principles:

• Present one idea or thought in a sentence (e.g., "I am going to help you get into the chair."). • Use simple one-step commands rather than asking patients to do multiple tasks. • Speak slowly but not loudly; use cues or gestures as needed. • Avoid "yes" and "no" questions for patients with expressive aphasia. • Use alternative forms of communication if needed, such as a computer, handheld mobile device, communication board, or flash cards (often with pictures). • Do not rush the patient when speaking.

Care of the Patient During a Tonic-Clonic or Complex Partial Seizure

• Protect the patient from injury. • Do not force anything into the patient's mouth. • Turn the patient to the side to prevent aspiration and keep the airway clear. • Remove any objects that might injure the patient. • Suction oral secretions if possible without force. • Loosen any restrictive clothing the patient is wearing. • Do not restrain or try to stop the patient's movement; guide movements if necessary. • Record the time the seizure began and ended. • At the completion of the seizure: -Take the patient's vital signs. -Perform neurologic checks. -Keep the patient on his or her side. -Allow the patient to rest. • Document the seizure: -How often the seizures occur: date, time, and duration of the seizure -Whether more than one type of seizure occurs • Observations during the seizure: -Changes in pupil size and any eye deviation -Level of consciousness -Presence of apnea, cyanosis, and salivation -Incontinence of bowel or bladder during the seizure -Eye fluttering or blinking -Movement and progression of motor activity -Lip smacking or other automatism -Tongue or lip biting -How long the seizure lasts -When the last seizure took place -Whether the seizure was preceded by an aura -What the patient does after the seizure -How long it takes for the patient to return to pre-seizure status

Nurse's Role in Responding to Health Care Facility Fires

• Remove any patient or staff from immediate danger of the fire or smoke. • Discontinue oxygen for all patients who can breathe without it. • For patients on life support, maintain their respiratory status manually until removed from the fire area. • Direct ambulatory patients to walk to a safe location. • If possible, ask ambulatory patients to help push wheelchair patients out of danger. • Move bedridden patients from the fire area in bed, by stretcher, or in a wheelchair; if needed, have one or two staff members move patients on blankets or carry them. • After everyone is out of danger, seek to contain the fire by closing doors and windows and using an ABC extinguisher (which can put out any type of fire) if possible. • Do not risk injury to yourself or staff members while moving patients or attempting to extinguish the fire.

Most patients with moderate-to-severe TBI are discharged with varied long-term physical and cognitive disabilities. Changes in personality and behavior are very common. A qualitative study by Kivunja et al. (2018) identified six themes that summarized the experiences of patients living with TBI:

• Seeking personhood to determine who they are after the injury • Navigating challenging behaviors • Valuing the skills and competence that one has • Struggling with changed family responsibilities • Maintaining productive and successful relationships • Reflecting on workplace culture As evident in the study, the patient and family must learn to cope with the patient's increased fatigue, irritability, temper outbursts, depression, loneliness, and memory problems. These patients often require constant supervision at home, and families may feel socially isolated. Provide support and encouragement for the family and patient to help them get through each day. Teach the family about the importance of regular respite care, either in a structured day-care respite program for the patient or through relief provided by a friend or neighbor. Family members, particularly the primary caregiver, may become depressed and have feelings of loneliness. In addition, they may feel angry with the patient because of the physical, financial, and emotional responsibilities that his or her care has placed on them. To help the family cope with these problems, suggest that they join and actively participate in a local brain-injury support group.

Providing a concise but comprehensive report of the patient's ED experience is essential for the hand-off communication process and patient safety . Information should include the patient's:

• Situation (reason for being in the ED) and admitting diagnosis • Pertinent medical history, including implantable devices and any history of organ transplant • Assessment and diagnostic findings, particularly critical results • Transmission-Based Precautions and safety concerns (e.g., fall risk, allergies) as indicated • Interventions provided in the ED and response to those interventions Many agencies use the SBAR method (situation, background, assessment, response) or some variation of that method to ensure complete and clearly understood communication .

Autonomic Dysreflexia: Key Features

• Sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia • Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity • Goose bumps above or possibly below the level of the lesion • Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders • Blurred vision • Spots in the patient's visual field • Nasal congestion • Onset of severe, throbbing headache • Flushing about the level of the lesion with pale skin below the level of the lesion • Feeling of apprehension