PCU 33 Neuro & Trauma Surgery Unit

• PCU 33 functions as a Neuro & Trauma Surgery Unit with 31 beds, including 6 Close Observation Beds
• The interdisciplinary team includes a Unit Manager, Clinical Nurse Educator, AHN, Unit Clerks, Pharmacist, Dietician, Physiotherapist, Occupational Therapist, and Social Worker

Trauma Services - Edmonton Zone

• The trauma team includes Trauma Surgeons and Trauma Staff
• Trauma Staff includes a Trauma Manager and Trauma Coordinator who reviews patient charts on the unit

Surgical Teams

• Orthopedic, Ortho Spine, and Neuro Spine surgeons/fellows are part of the teams

Weekly Unit Specifics:

• Monday, Friday, Saturday and Sunday are regular days
• On Tuesdays and Thursdays, UM Quality Huddles take place in AM
• On Wednesdays, Pressure Injury Prevention rounds occur for all patients, ensuring correct bed placement, dressings, and consults

Common Surgeries on Unit 33

• Spine surgeries include Laminectomy, Anterior Cervical Discectomy (ACD), Osteotomy, and Vertebrectomy
• Ortho surgeries involve Open reduction internal fixation of long bones, Closed reduction of Femur fractures, and Pelvis, ulnar, radial, etc repairs
• Trauma involves care for Blunt trauma, also known as blunt force trauma or non-penetrating trauma, resulting from a forceful impact without skin penetration, unlike penetrating trauma

Unit Routine Patient Assessments

• The Confusion Assessment Method (CAM) is used for all patients aged 65 and older every 8 hours
• A prescriber must be notified for a Delirium Investigation order set in Connect Care if CAM is positive
• Violence Aggression and Screening Tool (VAST) is performed on all new admissions using the Admission Navigator and PRN

Emergency Phone Numbers (Internal)

• Code Red is dial 66#
• Code Blue is dial 33#
• Security STAT (all other codes) is dial 10#
• To reach RRT, dial 0 and ask the operator to connect you, remain on the line

Code Blue - Red Box Contents

• Contains oral airways (x3 sizes), bagger with oxygen wall regulator, various sizes of Resuscitation Masks, suction canister with wall regulator, suction catheter and tubing, tonsil suction (yaunker), and face shields
• The Red Box is located across from the nursing station on a cart that includes a CPR backboard

Common Spine Conditions

• Herniated Disk involves the soft center of an intervertebral disc bulging out
• Results from trauma or degenerative changes; common in the cervical and lumbar regions
• Symptoms: pain, abnormal sensation, and motor weakness
• Spinal Stenosis includes narrowing of the spinal canal which can compress the spinal nerves due to congenital/age-related changes like thickening of spinal ligaments/growth of arthritic bony spurs
• Spinal Myelopathy refers to compression of the spinal cord due to spinal stenosis
• Scoliosis is an abnormal spinal curvature, severe if over 40 degrees
• Can lead to heart and lung complications
• Cauda Equina Syndrome involves compressed nerve roots
• Causes: herniated lumbar disc (L4-5), spinal stenosis, lesions/tumours, lower back trauma, hemorrhage
• Symptoms: lower back pain, motor weakness, urinary/bowel incontinence, sexual dysfunction
• Central Cord Syndrome is the most common cervical incomplete spinal cord injury
• Symptoms: loss of motion/sensation in arms/hands, bladder dysfunction/retention, painful sensations
• Causes: high force trauma, hyperextension injury w/ cervical spondylosis/bony instability

Common Spine Surgeries

• Micro discectomy: Minimally invasive procedure removing part/all of an affected spinal disc, lasts 1-2 hours, generally discharged within 24 hours, return to work in 6 weeks
• Laminectomy: the lamina is removed via posterior incision to decrease spinal cord/nerve compression, lasts 1-3 hours, generally discharged within 24-72 hours
• Spinal Fusion/Instrumentation: 2+ vertebrae are connected using bone tissue/surgical hardware, generally discharged in 3-4 days, fusion may take up to 3 months to heal

Post-Op Care of the Spine Trauma or Surgery Patient

• Routine Post-op Vitals and Spinal Signs ordered
• Complete Head to Toe Assessment is required
• Review Chart for Anesthetic type, TOTAL Fluid Intake/Output in OR, Anesthetic record, PARR & MNRA forms
• Assess pain on arrival Q2H x 24h, then Q4h and PRN
• Provide sponge bath, encourage mobilization after anesthesia wears off
• Apply wound dressings as needed, Foley catheter discontinued POD 1, drains removed POD 1/2
• PT/OT Consult if needed with spinal precautions as ordered and braces with ensure x-rays, patients generally return to work in 6 weeks per surgeon follow-up

Monitoring Post-Op

• Monitor for neurological deficits, Dura Tear & Cerebral Spinal Fluid Leak (Strict flat bedrest!), Hematoma, Pulmonary Embolism, Deep Vein Thrombosis (DVT), Pneumonia, Infection, Chronic Pain and Urinary retention (assess using PVRs)

Surgical Drains

• Three main types include: G/J tubes, Jackson Pratt (JP), Davol (Hemovac)
• G/J Tubes: G-tubes drain the stomach early post-op, J-tubes drain the jejunum and may be used for feeding, common in esophagectomies
• Jackson Pratt (JP) Drains: Closed system exerting constant low pressure when bulb is compressed; holds ~200mL; re-primed once per shift (or as ordered) through clean technique
• Use sterile technique for JP drains near head, neck or spine
• Davol (Hemovac) drains are closed systems with constant low-pressure suction to evacuate fluid around the wound and incision

Post-Op Mobility

• Typically Activity as Tolerated (AAT):
  • Avoid lifting over 5-10 lbs, twisting, bending, prolonged static positions, activities that jar the back and straight leg raises
  • Do not use trapeze bar

Turning in Bed

• Direct patient to bend their knees and hips
• Have them roll their entire body from head to feet at the same time, like a log

To go from Lying to Sitting

• Direct patient to logroll onto their side
• Then, push up using their elbow and other hand as they swing their legs off the bed

To go from Sitting - Lying

• Direct the patient to the edge of the bed
• Assist them to lie on their side while lowering down onto their elbow
• Keeping their back straight

Post-Op Care for Neuro Trauma/Surgical Patients

• Monitor Neuro Vital Signs, HOB at 30 degrees, conduct Head-to-toe Assessments
• Care for Head Dressing, Drains, Arterial Line (in OBS only) and Peripheral IV and Foley (Ins/Outs)
• Pneumatic TEDS, Psychosocial support, ensure calm environment and seizure precautions

Post-op Complications

• Hemorrhage, Hypovolemic shock and Cardiac arrhythmias
• Increased intracranial cerebral pressure and Cerebral edema
• Respiratory problems and Hydrocephalus
• Gastric ulceration, DVT, and Diabetes Insipidus
• Sudden of Inappropriate Antidiuretic Hormone (SIADH)

Post-op Deficits

• Diminished LOC, Communication deficits, Motor and sensory deficits, Headache
• Diminished gag/swallow reflexes Periorbital edema, Visual disturbances and Personality changes
• Elevation in temperature

Neurovitals Assessment

• Prompt recognition is key to prevent brain damage
• Slight changes in GCS (sleepiness, decreased LOC, confusion, agitation) may indicate increased intracranial pressure
• Increased brain swelling/intracranial pressure raises risks of hemorrhage, seizures and has poor prognoses
• Baseline NVS on admission are very important

Pupil Assessment

• Include size, shape, equality and reactivity to light, turn lights off to assess
• Check the pupil initial size and if round/oval/uneven shape, shine light into one eye and Check the reaction of the pupil
• Check for consensual reaction when light is applied in other eye, and remove the light
• Reactivity, if sluggish, fixed or normal
• If Dilated/non-reactive, it may be swelling/pressure, compression on the oculomotor nerve
• If Pinpoint/nonreactive, it may be loss of sympathetic nervous system control
• Extremely small pupils may indicate narcotic OD/brainstem compression

Neuro-vital Assessment Components

Eye Opening

• 4. Spontaneously: Opens eyes when you enter the room
• 3. To Speech: Opens eyes when you call their name
• 2. To Pain: Opens eyes when painful stimuli applied (nail bed pressure)
• 1. None: No eye opening

Best Motor Response

• 6. Obeys: follows commands appropriately
• 5. Localizes: pushes away stimuli purposefully
• 4. Withdraws: responds to painful stimuli non purposefully
• 3. Abnormal Flexion: Flexion of the upper extremities and extension and internal rotation of the lower extremities on the side of the brain lesion, patients with interruption of cortical nerve fibers but intact pathways through the brainstem
• 2. Abnormal Extension: wrists and hands are pronated, Legs are stiffly extended with plantar flexion of the feet meaning disruption of motor fibers in the midbrain and brainstem
• 1. None: No response to painful stimuli

Best Verbal Response

• 5. Oriented: person, time and place
• 4. Confused Speech: Conversing in sentence but some confusion
• 3. Inappropriate Words: Speaking in words that are not related to the topic at hand or a "word salad"
• 2. Incomprehensible: Makes more noises but not able to understand the words
• 1. None – No attempts to verbalize

CIWA Alcohol Withdrawal Protocol

• Withdrawal is a pattern of physiological responses to the discontinuation of a drug/substance Tolerance happens with consistent long-term substance use leading to cellular adaptation, needing increasing amounts to produce the desired effect
• Most CNS depressants produce similar effects

For Alcohol withdrawals at the RAH

• Practitioners need a pre-printed care order (PPCO)
• The PPCO includes lab work, medications to stop withdrawals (diazepam or lorazepam) thiamine and multivitamin
• There is a nursing assessment form with PPCO to know when to give the benzodiazepine

Alcohol Withdrawal

• It is a primary CNS depressant substance with a life threatening withdrawal
• Mortality rate is ~20% if delirium tremens (DT's) occur, and left untreated
• Involves CNS excitation, Respiratory alkalosis, Low serum magnesium levels
• CNS is increasingly depressed as alcohol is consumed, leading to a sleep state
• Reticular activation system in the brain attempts to counteract the sleepiness and CNS depression, uses neurotransmitters to create brain and body alertness
• Tolerance is built, and an increased amount of alcohol is required to achieve CNS depression
• When no alcohol is consumed for 24 hours, an over-stimulated state is experienced as the reticular activating system continues to produce the neurotransmitters to maintain alertness with no CNS depressant (alcohol) to counteract
• This over-stimulated state leads to the development of alcohol withdrawal symptoms after 48 hours
• Death can occur due to the increased activity of neurotransmitters that cause excitation of the nervous system (delirium tremens)

Delirium Tremens

• Considered a medical emergency, mortality rate can be as high as 35% if left untreated, and less than 5% is recognized and treated early

• Symptoms can last for 72 hours that includes Altered mental status (mental dullness, disorientation, confusion, hallucinations), Marked psychomotor agitation, Loss of muscle coordination, Positional nystagmus, Hypertension and Tachycardia

• Tachypnea, High fever and Diaphoresis may occur

• With treatment, patients with DT's usually show improvement within 24 hours; Not improving within 24 hours may be due to existing conditions or complications (ex. Subdural hematoma)

Alcohol Withdrawal Stages and Symptoms

• Can begin within 12-24 hours of admission, up to 2 weeks after a person stops drinking
• Early stage: Within 24 hours of last drink, mild symptoms and Late stage: alcohol delirium, begins 72-96 hours after last drink, lasts around 2 weeks
• Prophylactic Treatment will be started if indicated, with high doses of benzodiazepines for sedating effect, controlling tremors or seizures

Treatment of Acute Alcohol Withdrawal

• Electrolyte monitoring and replacement, there may be low potassium, calcium, magnesium, and phosphorus if have chronic alcohol use and Administer before patient first eats food once hospitalized
• Thiamine given parenterally the first 3 days and Multivitamins and folic acid given to assist with serum electrolyte deficiencies
• Continously Assess dehydration, monitor blood pressure, intake/output, urine concentration, weight loss and mucous membrane with Nausea and vomiting
• Avoid caffeine as it stimulates the CNS, maintain quiet environment, using restraints to assess limb circulation and skin integrity
• Position patient to prevent aspiration and maintain skin integrity when using restraints

CIWA-Ar Scale

• Provides dosage guidance to treat DT’s, a bedside assessment tool to evaluates ~10 factors associated with alcohol withdrawal

AHS Recommended Frequency of Assessment:

• CIWA-Ar score 0-9, reassess every 4 hours and PRN until discontinued
• If CIWA-Ar score 10+, reassess every hour until less than 10 on 3 consecutive measurements
• If CIWA-Ar score 20+ on 2 consecutive measurements, reassess every hour and continue benzodiazepines, and for respiratory rate <10 hold benzodiazepines

Restraints

• Prioritize alternatives to restraints that adhere to the “Restraints as a Last Resort” policy from Alberta Health Services.

• Follow eight procedures for specific patient populations

• Staff must follow as a last resort by only using the least restrictive restraints and obtaining proper consent

• A physician/NP order is required except in emergencies and require Q24h reassessment

• Document: assessment, rationale, obtained consent and the plan for continuous monitoring of: pressure injuries, circulation, hygiene, behaviour/agitation

All nurses should

• Report behaviour changes to the physician to rule out physiological causes in order to Utilize alterative strategies

• All restraint use shall include ongoing assessment and monitoring for signs of discomfort/pressure/injury associated with the application of the restraint and using alternatives such as bed alarms, lowering beds, comfort

• Fasten quick-release knots and refrain from securing them to movable parts of the bed while ensuring side rails are up and available

• Release and supervise Q2h, if not safe document every 30 minutes or 15 if using 4/5-point restraints

Documentation

• Clinical Assessment, Environmental assessment and Planning with a discussion for how to discontinue restraints and obtain consent
• Informed consent is required with constant monitoring

Traction

• Use an RN to hold the head maintaining cervical alignment, neutral alighment and prevent digging

Caring for Weights and Ropes

• Always use proper weights and preform adjustments before and after assessment with ropes, ensure they aren't resting or creating excess pressure and always maintain tension
• Assess ropes for frays or teats, and they must never be stuck or off the midline
• When transferring: tape the ropes and when repositioning do not create tension

Traction- types

• Three basic types: Manual, Skin and Skeletal.

Skin vs Skeletal

• Manual: Hands are used to align bone structure
• Skin: traction boots are used
• Skeletal: 20-30 lbs of pressure is used to ensure alignment that runs for 3-4 months

Precautions for traction

• Don't change weights, never touch the floor, check for pulleys, allow for skin assessment
• Move the patient, dont move the head in excess, ensure head is always lower than 20 degrees and encourage foot exercises to prevent clots

Care

• Pin sites are cleansed daily or with orders

• Use good hand hygiene, remove dressing and sterile saline

• Clean debris form site, don't scrub scabs, swap the area and use a dry cotton swap

• The ARCH team is a physician-led service that serves patients with alcohol use

• They connect the patient within hospital Supervised Consumption Services on Unit 38 in the Womens Centre

• Resources from the unit incude: Insite, provincial or surgical services, lipincott.lexicomp manual.CNE or RRT and the unit manger