NUR332 Exploring Complexity and Acuity PDF

1 NURS 332- Exploring Complexity and Acuity Module 1: Trauma Concepts 2 Chapter 3- Overview of health concepts for medical surgical nursing...

1 NURS 332- Exploring Complexity and Acuity Module 1: Trauma Concepts 2 Chapter 3- Overview of health concepts for medical surgical nursing 2 Chapter 12- Concepts of Emergency and Trauma Nursing 17 Chapter 12: Concepts of Disaster Preparedness 21 Module 2: Oxygenation & Ventilation (Respiratory) 25 Chapter 22: Assessment of the Respiratory System 25 Chapter 14: Concepts of Acid-Base Balance and Imbalance p.271-284 36 Chapter 24: Concepts of Carefor Noninfectious Lower Respiratory Conditions 42 Chapter 25: Concepts of Care for Patients with Infectious Respiratory Conditions 46 Chapter 26: Critical Care of Patients With Respiratory Emergencies 48 Module 3: Cardiovascular System 52 Chapter 27: Assessment of the Cardiovascular System and Hemodynamics 52 Chapter 29: Concepts of Care for Patients With Cardiac Conditions 58 Chapter 28: Concepts of Care for Patients with Dysrhythmias Chapter 32: Critical Care of Patients with Acute Coronary Syndromes 65  2 Module 1: Trauma Concepts Chapter 3- Overview of health concepts for medical surgical nursing Priority concepts nurses focus on when implementing and collaborating to improve patients' needs High acuity: short term, can become more serious if things aren't treated, OBS room/ ER/ ICU/ PICU, higher nursing ratio - Caring for acutely ill adults who have complex disorders and require multiple medical treatments - Responds to immediate and life-threatening conditions - Always have the potential to become unstable Critical care: a specialty that exists to care for vulnerable patients who are experiencing life-threatening health crises within a patient/family-centered model of care - 1:1 nursing - Continually monitored - Lots of people around (doctors, specialties) - Challenges for patients (sensory overload, impaired communication, delirium, pain, sleeping problems, nutrition problems, and anxiety) - Source of read available reference information (trends) Continual assessment of patient status+ patient-centered care Interdisciplinary approach (SBAR, know your role ) Ethical/ moral distress Evidence-based nursing practice - Patient values and priorities - Clinical context - Healthcare Resources - Evidence Clinical judgment model 1. Recognize cues 2. Analyze 3. Prioritize 4. Generate solutions  3 5. Take actions 6. Evaluate outcomes HIGH ACUITY CONCEPTS 1. Acid-base balance The maintenance of arterial blood pH between 7.35- and 7.45 through control of hydrogen ion production and elimination Controlled by the lungs and kidneys Hydrogen ions (acid) and Bicarbonate ions (base) Interrelated with elimination, fluid and electrolyte balance, and nutrition Acidosis occurs if the arterial blood pH falls BELOW 7.35 and is caused by either too many hydrogen ions (respiratory acidosis) or too little bicarbonate (metabolic acidosis) Alkalosis occurs when the pH is GREATER than 7.45 and is caused by either too few hydrogens or too much bicarbonate. The most common risk factors for acid-base imbalance are ○ Poisoning such as excessive salicylate ingestion ○ Medical conditions such as chronic obstructive pulmonary disease (COPD), uncontrolled type 1 diabetes mellitus, and chronic kidney disease ○ Excessive emesis ○ Prolonged diarrhea ○ Hyperventilation ○ Electrolyte imbalances, especially potassium When there is an imbalance the body has a mechanism which are activated to attempt to correct the imbalance: ○ Compensation- ex: patient is acidotic (pH lower than 7.35), the kidneys typically decrease the number of bicarbonate ions (base) excreted through the urine. The lungs may try to rid the body of carbon dioxide (directly related to hydrogen ions) through increased and deeper respirations. In this case, both compensatory mechanisms aim to restore acid-base balance by increasing the blood pH to greater than 7.35 ○ Occurs if the individual has healthy lungs and kidneys Assessment of acid-base balance: ○ Hx of diabetes mellitus or COPD or experiences with an imbalance ○ Present of hx of S+S that could predispose patient of acidosis or alkalosis (vomiting or diarrhea) ○ Current medications ○ Arterial blood gas monitoring informs HCP of pH level.  4 The PO2 level indicates how well the lungs are functioning (normal value is 95 to 100 mm Hg) The PaCO2 level indicates how well the lungs are functioning in blowing off/ returning CO2 (normal value is 35 to 45 mm Hg) The HCO3 level indicates how well the kidneys are excreting or absorbing base as needed The best ways for individuals to remain in an acid-base balance is to promote healthy lifestyle choices and teach patients who are at high risk to be monitored carefully by HCP to assess for fluid, electrolytes, and acid-base imbalances The four common types of imbalances are metabolic acidosis and alkalosis and respiratory acidosis and alkalosis. Interventions are dependent on the type of imbalance that is occurring 2. Cellular regulation The genetic and physiologic processes that control cellular growth, replication, differentiation, and function to maintain homeostasis Cell replication refers to making a copy of a specific cell and cell differentiation refers to the process of the cell becoming specialized to accomplish a specific task Interrelated with immunity and pain When imparied with loss of control over cellular reproduction the result is excessive and abnormal groth of tissue not needed for optimum whole body function ( cancer,fibrosis and excessive scar tissue formation. Inhibition of cellular regulation can reduce cell production for certain substances (insulin or clotting factors Common risk factos include: ○ Older age (55 years and older, with significant potential for abnormal cell development at ages older than 70) ○ Smoking ○ Poor nutrition ○ Physical inactivity ○ Environmental pollutants (such as air, water, and soil) ○ Radiation ○ Selected medications (such as chemotherapy) ○ Genetic predisposition or risk Impaired cellular regulation often results in benign or malignant cell growth ○ Benign masses do not spread to other organs but jabe the ability to obstruct or compress other organs causing other health issues  5 ○ Malignant cells (cancerous) over time grow and invade healthy cells, tissues and organs through tumor formation and invasion Assessment of patients with impairments : ○ Diagnostic tests (MRI & CT) ○ Invasive tests such as colonoscopy or endoscopy ○ Laboratory tests such as tissue biopsies and cell cytology ○ Grading and staging help to explain the severity and growth for the mass, and give insight to necessary diagnosis, test and prognosis Interventions include primary and secondary prevention techniques ○ Primary- minimizing the risk of developing impaired cellular regulation ○ Secondary- proper and regular screening to identify early risks or hazards that could be present ○ Patients with impairments can do chemotherapy, hormonal therapy, targeted therapy, radiation therapy, biologic therapy and bone marrow or hematopoietic stem cell transplants. The course if intervention depends or the severity and rate of growth Excessive: abnormal growth of tissues not needed for optimum whole body function Inhibition: can reduce cell production to certain substances 3. Clotting A complex, multistep process by which blood forms a protein-based structure (clot) in an appropriate area of tissue injury to prevent excessive bleeding while maintaining whole body blood flow (perfusion) The major component of the process involves platelets (thrombocytes). When injury occurs platelets stick together to form a temporary semisolid plug which also triggers a complex process known as the clotting cascade (enzymes and plasma proteins) working together to create a fibrin clot and local blood coagulation. The other process is knwon as the fibrinolytic system and is triggered to cause clot lysis (breakdown) Primary interrelated to mobility and perfusion The inability to form clots can result in bleeding and threaten a persons life. Excessive clotting however can cause platelet stickiness which leads to hypercoagulation which impairs blood flow (blood clots) Common risk factors for increased clotting include immobility or decreased mobility, health problems such as polycythemia, and smoking Polycythemia causes excessive production of RBC which lead to multiple clots. Atrial fibrillation causes the pooling of blood in the atria and leads to embolic stroke  6 Decreased clotting can occur because of an inadequate # of platelets circulating (chemotherapy drugs, corticosteroids, patients with cirrhosis of the liver all contribute to an increase for bleeding) Patients with excessive clotting can form venous thrombosis either superficial or deep vein. When a thrombus becomes dislodged it is known as an embolus and can often travel to the brain causing a stroke or the lungs causing pulmonary embolus For patients with decreased ability to clot prolonged internal (systemic) or external (localized) bleeding may occur (GI tract, hemorrhagic stroke, urinary tracts, external bleeding from the nose, under the skin purpura or prolonged bleeding at site of soft tissue trauma Assessment: ○ Observe for S+S of decreased clotting Purpuric lesions (hemmorhagic) Ecchymosis (bruising) Petechiae (pinpoint purpura) Note prolonged bleeding because of injury or trauma. Bleeding to gums or nose Check urine and stool ○ Observe for S+S of increased clotting Localized redness/hyperpigmentation Pain Swelling Warmth ○ Lab tests that can be completed to measure clotting factors include prothrombin time (PT) and activated partial thromboplastin time (aPTT), international normalized ratio (INR) Be sure to teach patients at risk for increased clotting to: ○ Drink adequate fluids to prevent dehydration. ○ Avoid crossing your legs. ○ Ambulate frequently and avoid prolonged sitting. ○ Explore smoking-cessation programs as needed. ○ Call your primary health care provider if redness/hyperpigmentation, pain, swelling, and warmth occur in a lower extremity. Interventions for patients at increased risk of clotting include anticoagulants or antiplatelet drugs and the teaching of the importance of obtaining these tests and monitoring for changing symptoms A complex multistep process by which blood forms a protein-based structure (clot)  7 Thrombocytopenia =decreased platelet count Polycythemia =abnormally shaped blood cells 4. Cognition The complex integration of mental processes and intellectual function for reasoning, learning, memory, and personality ○ Reasoning is a high-level thinking process that allows individuals to make decisions and judgments ○ Memory is the ability of an individual to retain and recall information for learning or recalling past experiences ○ Personality related to how and individual feels and behaves based on how the individual thinks Interrelated with fluid and electrolyte balance, gas exchange, and perfusion Impaired cognition may be classified into two major categories: global cognitive disorders and focal cognitive disorders that affect a limited part of the brain ○ Dementia (chronic mental confusion)- global ○ Delirium (acute fluctuating mental confusion) - global ○ Delayed intellectual functioning or amnesia (loss in memory caused by acute health problems)- focal Common risk factors include ○ Advanced age (although dementia is not a normal physiologic change of aging) ○ Brain trauma at any age, including at birth ○ Disease or disorder such as brain tumor, hypoxia, or stroke (infarction) ○ Environmental exposure to toxins such as lead ○ Substance use disorder ○ Genetic diseases such as Down syndrome ○ Depression Common S+S of impaired cognition ○ Loss of short- and/or long-term memory ○ Disorientation to person, place, and/or time ○ Impaired reasoning and decision-making ability ○ Impaired language skills ○ Uncontrollable or inappropriate emotions such as severe agitation and aggression ○ Delusions and hallucinations Assessment ○ Mental status assessment (CAM or Mini-Cog)  8 Interventions focus on safety of patient to prevent injury and foster communication. HCP may prescribe psychoactive drug theraoy for psychotic behaviours 5. Comfort A state of physical well-being, pleasure, and absence of pain or stress Interrelated with inflammation and pain Pain and other uncomfortable sensations can disrupt a patient's ability to function physically and mentally Risk factors include physical, emotional and psychosocial causes ○ Decreased comfort can be acute and chronic ○ Persistent pain, nausea, vomiting, dyspnea and GI disturbance The body's flight or fight mechanism helps the individual cope with the source and manifestations of discomfort Assessments: ○ Pain assessment ○ Emotional stress Fight or flight is activated (sympathetic nervous system activated by epinephrine) 6. Elimination The excretion of waste from the body by the GI tract (as feces) and renal/urinary system (as urine) Urinary elimination occurs as a result of multiple kidney processes and ends with the pasage of urine Interrelated with fluid and electrolyte balance, tissue integrity, comfort and nutrition Incontinence of either the bowel or bladder can occur as a result of ahing when the pelvic floor muscles become weaker, patients with neurological disorders, excessive laxative, acute GI infections, irritable bowel syndrome, UTI, spinal or brain injury and chronic kidney diseases Chronic kidney disease can cause changes in the amount of urinary output, depending on the stage of the disease. In the end stage, the patient experiences oliguria (scant urine) or anuria (absence of urine) because the kidneys have lost their ability to make urine Patients with urinary or bowl incontinence are at risk for damage to tissue ○ If not removed promptly from skin stool and urine can cause breakdown, fungal infection and skin irritation Patients with bowel and urinary retention can result in a build-up of toxins and waste products in the body. Common consequences include UTI and partial/ total intestinal obstruction Assessment:  9 ○ Hx of risk factors ○ Assess the perineal area and buttock for skin and tissue breakdown ○ Monitor frequency, amount, characteristics and consistency of urine and stool ○ Lab tests include urinalysis, culture and sensitivity, radiologic testing, and ultrasonography for stones and to detect UTIs; for bowel incontinence stool culture and sensitivity may be done for patients suspected to have C-dif Issues: incontinence, retention, diarrhea or constipation 7. Fluid and electrolyte balance the regulation of body fluid volume, osmolality, and composition and the regulation of electrolytes by the processes of filtration, diffusion, osmosis, and selective excretion Water makes up 55-60% of the total body weight Fluid occupies the inside of the cell (intracellular fluid) and the outside of the cell (extracellular fluid) ○ Extracellular fluid is found in the vascular space (plasma) and interstitial space (fluid in between cells, third space fluid) Interrelated with acid-base balance, elimination, and nutrition Fluid imbalance deficit is caused by dehydration, fluid excess often causes edema Hyponatremia (low serum sodium) Hypernatremia (high serum sodium) Hypokalemia (low serum potassium) Hyperkalemia (high serum potassium) Hypocalcemia (low serum calcium) Hypercalcemia (high serum calcium) Hypomagnesemia (low serum magnesemia) Hypermagnesemia (high serum magnesium) Risk factors that alter fluid and electrolyte balance ○ Acute illnesses (e.g., vomiting and diarrhea) ○ Severe burns ○ Serious injury or trauma ○ Chronic kidney disease ○ Major surgery ○ Poor nutritional intake Consequences of fluid and electrolyte deficit imbalance ○ Lack of poor perfusion (arterial blood flow) ○ A decreased blood volume leads to hypotension ○ In an attempt to compensate the heart rate increases (tachycardia)  10 ○ Peripheral pulses become weak and ready ○ Fever, and delirium ○ For example, a decrease in serum potassium level (hypokalemia) can result in cardiac dysrhythmias (abnormal heart rhythms) and muscle weakness. A decreased sodium level (hyponatremia) can result in changes in mental status and generalized weakness. Consequences of fluid and electrolyte excess imbalance ○ Increased blood pressure to increased blood volume ○ Peripheral pulses are strong and bounding and the jugular vein is distended ○ Peripheral edema and fluid from the vascular space shift to interstitial space ○ For example, an increase in serum potassium (hyperkalemia) or calcium (hypercalcemia) can cause cardiac dysrhythmias. In addition, skeletal muscle spasms are likely. Assessment ○ Health hx ○ Current episodes of nausea, vomiting, or diarrhea ○ Medication hx ○ Monitor vitals (BP, PR, and quality) ○ Weight changes ○ Monitor lab tests ( electrolyte concentration, BUN, and serum osmolality) Interventions ○ For patients with fluid deficit: fluid replacement (orally or parenterally) ○ For patients with fluid overload fluid restriction (diuretic therapy ***diuretics can also cause decreased serum sodium (hyponatremia) and potassium (hypokalemia). If lower extremity edema is present, teach patients the importance of elevating the legs above the heart to promote venous return) ○ Electrolyte deficits are treated by replacing them with IV fluids 8. Gas exchange Oxygen is transported to the cells and carbon dioxide transported away from the cells through ventilation and diffusion. This process begins with ventilation triggered by  11 neurons in the brain sensing the need for gas exchange The neurons stimulate the contraction of skeletal muscles that expand the chest cavity cueing inhalation of oxygen-containing air into blood and RBC The oxygen in RBC bound to hemoglobin and is transported through the blood by a cardiac effort to tissue cells (perfusion) where low oxygen allows release of oxygen from hemoglobin and diffusion or cell metabolism High concentrations of carbon dioxide waste resulting from cellular metabolism allow the diffusion of gas into the blood and RBC Gas exchange allows adequate perfusion and removal of waste gas Adequate ventilation requires a normal functioning brain, spinal cord, neurons, diaphragm, adequate skeletal muscle contractility, and chest thorax Consequences of decreased gas exchange: ○ Inadequate transportation of oxygen to body cells and organs ○ Retention of CO2 resulting in cell dysfunction (ischemia) and possible cell death ○ A build-up of CO2 increases acid causing acidosis Assessment ○ Health hx and focused respiratory assessment ○ Current and hx of lung disease or trauma ○ Assessment of patient breathing effort, rate, O2, cap refill, thoracic expansion, and lung sounds ○ Monitor the presence of cough, SOB, dizziness, chest pain, presence of cyanosis, and adventitious lung sounds ○ Lab results including arterial blood gases and complete blood count ○ When necessary a chest x-ray, CT or V/Q scan Teach patient the importance of using infection control measures, increased risk with smoking, and getting immunizations Interventions ○ Finding underlying cause and treating it with drug therapy (antihistamines, decongestants, glucocorticoids, bronchodilators, mucolytic and antimicrobials ○ Chest expansion improves when the patient is sitting or in semi fowlers positions. Teach the patient to deep breath and coughing to enhance lung expansion further ○ Teach patient to use incentive spirometry and inhalers correctly ○ Administer oxygen and monitor oxygen saturation ti determine its effectiveness Glucose regulation The process of maintaining optimal blood glucose levels  12 Pneumonia =build uo of infection High c-spine injury impaired your ability to breath, making your unable to exchange 9. Immunity Protection from illness or disease that is maintained by the body’s physiologic defense mechanisms Antibody-mediated immunity (humoral immunity) Cell-mediated immunity involves the functions of numerous cells to fight off the antigen, including white blood cells (WBCs), T-cells, natural killer (NK) cells, and multiple cytokines The thymus and lymph nodes contribute to the process Consequences of altered immunity include a wide variety of infections that the body's natural cells cant fight off Assessment ○ Weight, adequate wound healing, cognition, allergic responses (red, watery eyes; nasal congestion; swelling or rashes), and potential or actual organ dysfunction (cardiovascular, respiratory, renal, or musculoskeletal). Monitor laboratory tests such as complete blood count (CBC) with differential, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and allergy testing to identify any susceptibilities that may exist. A complete immune panel, including antinuclear antibody (ANA) and rheumatoid factor (RF) testing, helps to detect autoimmune disease Acquired: immunity that develops during lifetime ○ Active; develops in response to an infection or vaccination Natural; antibodies developed in response to an infection Artificial; antibodies developed in response to vaccination ○ Passive: develops when you receive antibodies for someone or somewhere else Natural: antibodies received from the mother through breast milk Artificial: antibodies received from a medicine Innate immunity: the immune system you're born with ○ 10. Infection The invasion od pathogens into the body that multiply and cause disease or illness Categories of infection ○ Bacteria ○ Viruses  13 ○ Fungi ○ Parasites or protozoa Infections are also categorized as localized or systemic ○ Localized are limited to a specific area of the body ○ Systemic affect the whole body and can cause sepsis, life threatening response of the body to infection and widespread inflammation that can cause multiple organ dysfunction Risk factors of infection ○ Immunocompromised ○ Having chronic illness ○ Advanced age ○ Weight problems ○ Tissue integrity If localized infections arent treated they can spread to the rest of the body and become systemic infections leading to sepsis and decreased perfusion and eventually organ failure Assessment ○ redness/hyperpigmentation, warmth, pain, and swelling. Elevated temperature may be present in patients who have systemic infection. Ask about changes in elimination ○ Elevated WBC count with differential (especially lymphocytes and neutrophils), Increased erythrocyte sedimentation rate (ESR), Increased C-reactive protein, Positive culture and sensitivity and Positive antigen testing for infectious agents 11. Inflammation Syndrome of normal responses to cellular injury, allergy or invasion of pathogens Can be categories as acute or chronic ○ Acute: cholecystitis (inflammation of the gallbladder) and appendicitis (inflammation of the appendix) ○ Chronic: inflammatory bowel disease (e.g., ulcerative colitis) and rheumatoid arthritis (RA) Consequences ○ Redness, warmth, swelling, pain or discomfort ○ Severe inflammation; organ inflammation Assessment ○ S+S of organ dysfunction, serum white blood cell count with differential, C-reactive protein, and erythrocyte sedimentation (ESR) indicate the presence of inflammation ○ Direct visualization using endoscopy  14 Rest, Ice, Compression, Elevation + Local or systemic 12. Mobility The ability for an individual to perform purposeful physical movement of the body Patients who have dysfunction of the musculoskeletal or nervous system are most at risk for decreased mobility or immobility Any person who is bedridden or on prolonged bed rest is at risk for immobility issues 13. Nutrition The process of ingesting and using food and fluid to grow, repair and maintain optimal body functions Malnutrition occurs in adults who are underweight or overweight/obese. Some individuals have generalized malnutrition; others have specific nutrient deficiencies such as lack of vitamin D, iron, or protein Decreased nutrition results in ack of specific nutrients such as vitamin D, iron, and protein 14. Pain Generally defined as an unpleasant sensory and emotional experience Acute pain is short-lived, temporary, and typically confined to an injured area of the body (localized). It serves a biologic purpose to activate the sympathetic nervous system and other physiologic responses. Persistent (chronic) pain does not serve this purpose and tends to last more than 3 months. It is often described as diffuse and not confined to one area of the body. The two major types of persistent pain are persistent cancer pain and persistent noncancer pain Nociceptive pain results from skin or organ damage or inflammation. Neuropathic pain involves a set of mechanisms related to the nervous system with or without tissue damage nerve is potentially compressed 15. Perfusion Adequate arterial blood flow through peripheral tissues (peripheral perfusion and blood that is pumped by the heart to oxygenate major body organs (central perfusion) Without perfusion, there would be cell death Assessment  15 ○ Family hx, S+S of inadequate central perfusion, including dyspnea, dizziness or syncope, and chest pain. Signs and symptoms of decreased cardiac output include hypotension, tachycardia, diaphoresis, anxiety, decrease in cognitive function, and dysrhythmias ○ S+S of chronic decreased peripheral perfusion, including decreased hair distribution, nonlocalized and diffuse pain or discomfort, coolness, decreased capillary refill time, and pallor/ash gray appearance and/or cyanosis of the extremities Peripheral ○ Cool, pale, cyanotic distal extremities ○ Diminished/absent peripheral pulses ○ Skin ulcers ○ Gangrene Central ○ Myocardial infarction ○ Stroke ○ Shock (central organs arent getting blood supply they need) 16. Sensory perception The ability to perceive and interpret sensory input into one or more meaningful responses The 5 senses are vision, hearing, smell, taste and touch Risk factors: aging, chronic diseases, mechanical or chemical trauma, cranial nerves 17. Sexuality a complex integration of physiologic, emotional, and social aspects of well-being related to intimacy, self-concept, and role relationships. 18. Tissue integrity the intactness of the structure and function of the integument (skin and subcutaneous tissue) and mucous membranes Tissue integrity changes can occur as a result of infections, burns, local skin reactions, injury/trauma, growths or lesions, and inadequate peripheral perfusion (decrease in oxygenated blood to a specific area of the body) Tissue integrity alteration can lead to localized (cellulitis) or systemic (sepsis) infection. Both partial- and full-thickness wounds can be very painful and difficult to heal, especially for patients with diabetes and other diseases in which arterial perfusion is diminished Degree of tissue damage: partial thickness or full thickness  16 Summary When the body has an impaired acid-base balance, several compensatory mechanisms attempt to correct the imbalance. Collaborative interventions for the patient who has impaired cellular regulation can include surgery, radiation therapy, chemotherapy, hormonal therapy, targeted therapy, biologic therapy, and bone marrow or stem cell transplants. A patient’s clotting status can be assessed through laboratory testing and monitoring for frank or occult bleeding. Nursing interventions for patients who have impaired cognition focus on safety to prevent injury. Nurses assess patients for impaired comfort, such as pain, and participate in planning collaborative interventions to alleviate it, depending on its cause. Common elimination problems experienced by adults include constipation, diarrhea, and incontinence. Patients experiencing problems with fluid and electrolyte balance can have potentially life-threatening complications, such as hypotension and dysrhythmias. Nursing assessment of a patient’s gas exchange status includes breathing effort and rate, oxygen saturation, capillary refill, thoracic expansion, and lung sounds. Immunity is protection from illness or disease that is maintained by the body’s physiologic defense mechanisms; infection is the invasion of pathogens into the body that multiply and cause illness or disease; inflammation is the normal response of the body to illness, disease, and injury. Nurses collaborate with physical and occupational therapists to increase patient mobility, including teaching patients how to use ADL and ambulatory aids. Nurses collaborate with the registered dietitian nutritionist to promote nutrition for patients at risk for and those who have inadequate nutrition. Nursing assessment of perfusion includes monitoring patients for changes in peripheral and central perfusion. Visual and hearing impairments are the most common sensory-perception problems; for most patients, these impairments can be improved or corrected with devices, drug therapy, and/or surgery. Changes in sexuality may result from a number of factors, including menopause, aging, erectile dysfunction, chronic disease, and antihypertensive drugs. Nurses collaborate with the interprofessional health care team to manage tissue integrity problems; management includes drug therapy, wound débridement, and the use of wound vacuum devices.  17 Chapter 12- Concepts of Emergency and Trauma Nursing Factors affecting response to injury ○ Comorbidities (decreased tissue perfusion, affect the way their bodies recover ○ Substance abuse (drug interactions or symptoms patient showing) ○ Pregnancy (anatomic change, hemodynamic changes, blood volume, and composition) -2 patients ○ Advancing age Blunt trauma: can be less obvious than penetrating, object that doesn't break skin Penetrating trauma: sharp objects and projectiles (shearing, acceleration/ deceleration Primary Survey A. Alertness Airway a. Alertness= AVPU (alert, verbal, pain, unresponsive) b. Airway (bony deformity, burns, edema, fluids, foreign objects, inhalation injury, loose or missing teeth, sounds, tongue obstruction, vocalization) c. *cervical spine stabilization or immobilization* d. Airway interventions include - Jaw thrust maneuver - Oropharyngeal airway (OPA) - Nasopharyngeal airway (NPA) - Endotracheal tube (ETT) e. Normal CO2 (capnography)= 35-45 mmHg B. Breathing Ventilation a. Breath sounds b. Depth, pattern, rate c. Increased work of breathing d. Dyspnea e. Open wounds f. Skin color g. Spontaneous breathing h. Subcutaneous emphysema i. Symmetrical chest rise and fall j. Tracheal deviation C. Circulation hemorrhage control a. Inspect and palpate (color, temp, moisture) b. Palpae pulse (check central pulse) c. Control of hemorrhage  18 D. Disability a. Glasgow coma scale (out of 15) - Best eye opening - Best verbal response - Best motor response b. Pupils c. Glucose E. Exposure Environment a. Remove all clothing and inspect injuries b. Warming measures F. Full set of vitals & family G. Get adjuncts & give comfort a. LMNOP - Laboratory analysis - Monitor cardiac; consider 12 lead ECG - Naso or orogastric tube - Oxygenation and capnography - Pain assessment; consider analgesia and nonpharmacologic comfort Secondary survey H. History a. Signs &symptoms, Allergies, Medications, Past history, Last oral intake/ last menstrual period, Events leading up H. Head to toes a. Inspect, auscultate and palpate - Head - Face - Neck - Chest - abdomen/flanks - pelvis/perineum - Extremities I. Inspect posterior a. Turn, inspect and palpate b. Remove backboard Keep reevaluating - V: vital signs - I: injuries - P: primary survey - P: pain  19 ➔ Chest injuries ◆ Rib fracture ◆ Fail chest ◆ Pulmonary contusions ◆ Tension pneumothorax ◆ Open pneumothorax ◆ Massive hemothorax ➔ Cardiac injuries ◆ Cardiac tamponade ◆ Vascular trauma ◆ Blunt cardiac injury ➔ Abdominal injury ◆ Spleen injury ◆ Liver injury ◆ Hemostasis; temporary closure; prevention of contamination ➔ Head injuries ◆ Direct impact injury ◆ Acceleration- deceleration injury ◆ Shock wave injury ➔ Pelvic injury ◆ Symptoms Perineal ecchymosis Pain on palpation of iliac crests Hematuria Lower extremity rotation ◆ Diagnosis; CT scan ◆ Initial management Treatment of life-threatening hemorrhage Stabilization Trauma triad of death: Lethal triad - Hypothermia: up to 66% of patients arrive with it (blood loss, state of shock, weather) - Blood should be at 36.5- 37.5 - Coagulopathy: too much or too little clotting (usually at the start there is too much clotting, {inflammatory process}, decreased perfusion, cells go into anaerobic metabolism, creating lactic acid, no more clotting factors left leading to bleeding out +++blood loss) - Acidosis; pH of less than 7 ➔ Decreased coagulation ➔ Increased lactic acid in the blood  20 ➔ Decreased heart performance Clotting lots: labs INR, PPT; neuro changes, lower BP, aspirin, heparin Bleeding stage: cyanosis, bruising, increased RR, bleeding out (trauma area and stool, gums); give them platelets, clotting factors, and more blood; Primary survey interventions conducted on a patient suffering a life-threatening injury include which of the following? Select ALL that apply: a) Examining the face, neck and head for lacerations or deformities ( part of head-toe; assessment) b) Initiating or continuing CPR c) Ventilate with bag/ valve mask d) Open airway/ intubate e) Pain assessment (assessment) f) Insert two large-bore IV’s (circulation, to give fluid and blood) Zoe, age 18, is brought to the emergency department following a motor vehicle collision. BP is 80/70 and her pulse is 120 and irregular. Her respirations are 20/ minute Sp02 saturation is 80% on room air. She is alert and responds to simple commands. What is your FIRST nursing action? Why? SELECT ONE ONLY 1. Assess for uncontrolled bleeding 2. Assess GCS &Pupil response 3. Administer supplemental oxygen 4. Palpate for peripheral pulses 5. Auscultate lungs General impression: uncontrolled bleeding, apnea, unresponsiveness ABCDEFG- primary survey Secondary survey  21 Chapter 12: Concepts of Disaster Preparedness Triage: prioritization of care Prioritization; deciding which needs or problems require action immediately and which ones can be delayed till later ➔ Condition change ➔ Changes in stability: vitals, labs (potassium), symptoms ➔ Changes in assessment findings ➔ Sudden acute changes ➔ Diagnoses - How to decide - Nursing process- assessment - Maslow's hierarchy of needs - ABCs Priotization systems MEWS: modified early warning system ○ RR, HR, BP, conscious level, temp, hourly urine for 2 hours ★ Outreach teams: team with extensive care, EMERG nurses, and RT to help prevent something major from happening Triage CTAS, Canadian triage, and acuity scale Triage process: clients with life-threatening problems enter the emergency department. Helps bring order and organization to a chaotic scene CTAS: 5 levels, based on presenting conditions in addition to ‘modifiers’ ○ Level 1: Resuscitation (life-threatening to life or limbs requiring immediate intervention) { serious motor vehicle injury, heart stopping} ○ Level 2: Emergent ( potential threat to life, limb, or function requiring rapid medical interventions) {heart attack and stoke} ○ Level 3: Urgent (potentially progress to a serious problem requiring emergency intervention) {moderate traumas, head injuries, asthma, abdominal pains} ○ Level 4: Less urgent (conditions related to a potential for deterioration that would benefit from intervention) ○ Level 5: Non-urgent (conditions that may be acute but nonurgent and interventions can be safely delayed  22 Disaster Management Resources