High-Acuity Nursing 332 Lecture Notes - University of Saskatchewan

Introduction to High- Acuity Brooklyn Derksen, BSN, RN, DTN, MN, ENC(C) Lecturer University of Saskatchewan College of Nursing Nursing 332 Image: https://i.pinimg.com/1200x/31/c4/30/31c43095c69a166ba131aefdb5b4ac7d.jpg...

Introduction to High- Acuity Brooklyn Derksen, BSN, RN, DTN, MN, ENC(C) Lecturer University of Saskatchewan College of Nursing Nursing 332 Image: https://i.pinimg.com/1200x/31/c4/30/31c43095c69a166ba131aefdb5b4ac7d.jpg Derksen Objectives 1. Introduction to course 2. Syllabus review Course content Exams 3. What is high-acuity nursing? 4. Clinical Judgment Model: learning to use the knowledge in this class to “think like a nurse” 5. A quick look at high-acuity concepts Derksen How the class is structured: I believe in activities to make sense of the concepts. I try to cover the basics in theory and then do an activity to apply it. Case studies and in class activities Course manual→ objectives for each unit. The references in the course manual are for Self directed reading/learning (required) interest only, not required readings. Some self directed asynchronous virtual modules 3 Canvas exams/quizzes (in person, always) The course is jam packed! Tons of variety in content. Work to understand, not memorize Derksen Course Components need to pass) (HEsl) done by : - complete lang (no 1 attempt only - Derksen  High Acuity What is it? Image: https://wallpapercave.com/wp/wp10236740.jpg Derksen  Acute Care: Definition - acute care/pts ol lots of 01 things going on 02 03 - book def - Caring for acutely ill Responds to ~ “… - a branch of healthcare where a person receives active adults who have immediate and life- but short-term treatment for a * complex disorders threatening severe injury or episode of illness, an urgent medical and require multiple conditions condition, or during recovery medical or surgical from surgery. In general terms, care for acute health conditions treatments is the opposite from chronic care, or longer term care.”1 ⑭ Derksen  Complex high acuity patients High Acuity Patients Diverse health challenges & underlying *Always have the potential to chronic illness become unstable!* Acute (sudden) exacerbation ex) COPD , asthma chronic conditions/illness ↳ could be Acuity (serious to critical illness) periods of but has acule scene. Receive care in many settings Home Hospice Hospital (ward to Intensive Care) Long term Care residence Derksen Critical Care… what is it? “Critical care is a specialty which exists to care for vulnerable patients who are experiencing life- threatening health crises within a patient/family centered model of care. Critical care nurses require advanced problem-solving abilities using specialized knowledge regarding the human response to critical illness…”2 ICU, ER, CCU, Cardiac PICU, NICU… care unit Derksen  What types of patients are in ICUs? 1 to 1 ratio ( 1 to 2 if short staff ) Pts that are continuously monitored Pts are in a glass wall room ( why? Nurses need to see them all the time / see whats up ) Lots of people/ professions around Image: https://images.theconversation.com/files/117015/original/image-20160331-28462-qliwnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=926&fit=clip Derksen  What kind of care can be provided in the ICU? beeps all around, all the monitors, pts’ bodies are getting assessed every 4 hours. Therefore, causing delirium. Nurses need to wake them up all the time, on top of overstimulation. Benefits Challenges (for patients) - Allows for close/ immediate Sensory overload monitoring of patient. Impaired communication Pts here sometimes have - trachea tubings, they could Provides programs to diagnose Delirium -mostly be sedated also. due to - patient disorders s ruined sleep sched Overstimulation Source of readily available Pain V reference information (trends) Sensory perceptual problems - Technological advances Sleep problems connected · routnes? surroundings to the assess, / meds etc = nurses ,. v Life saving most Nutrition problems theres always doctors /nurses (professions) - Anxiety ! are around ↳ DONT FORGET ↳ care for people around the pts too !! Derksen  Registered Nurses in High Acuity Settings Concepts and Competencies Image: https://img.goodfon.com/wallpaper/big/a/ee/nurse-doctor-medicine.jpg Derksen  Continual assessment of the patient’s status= PATIENT CENTERED CARE Culture of safety Technology and Informatics - Interdisciplinary approach What skills do you need to work on? with the team - SBAR - you are always canny for pts. -know role and who the experts on the ets current state. your Image: https://www.intelligentcio.com/eu/wp-content/uploads/sites/20/2018/10/AdobeStock_124144255_1000px.png Derksen  Ethics in Acute Care Consider the advances in science People are living longer; surviving illnesses they may not have 20 years ago Ethical principles Moral Distress: can maybe prolonging - we someone's AACN (2004) 4As to rise above moral -ain - distress Image: https://journals.sagepub.com/cms/10.1177/09697330221114328/asset/images/large/10.1177_09697330221114328-fig4.jpeg Derksen  ex no chest tube Implementing Evidence-Based Nursing ↳ used cathether and made holes used it on it , chest Practice as a tube Patient values and Clinical Context priorities Critical Thinking A all four boxes = used to Shared Decision Making make a decision Healthcare Resources Evidence Derksen Guidance for High-Quality Nursing Practice: !!' your practice RESOURCES always ⑪ know HEALTH POLICY PROFESSIONAL SCOPE OF CLINICAL PRACTICE RESEARCH EVIDENCE OUR OWN ABILITY TO (PROVINCIAL, REGIONAL, PRACTICE (LAW, GUIDELINES CRITICALLY THINK….. UNIT SPECIFIC POLICY AND COMPETENCY PROCEDURE) FRAMEWORKS) Derksen  Critical Thinking vs Clinical Judgement/Reasoning Image: https://d3i71xaburhd42.cloudfront.net/7a280b4d3ec6d2fcd8280430cc45d3d50e0c5623/3-Table1-1.png Image 2: https://www.researchgate.net/publication/342603263/figure/fig1/AS:1159721599930369@1653510584977/Relationship-between- critical-thinking-clinical-reasoning-and-clinical-judgment.png Derksen  Clinical Judgement Model EX) COPD US Regular pt's SPO2 Image: https://www.atitesting.com/images/default-source/educator/ngn/process.png Derksen  High Acuity Concepts An overview of some overarching principles we will cover Derksen  ROME respiratory Acid-base opposite metbric equal balance 7:35 ↓ ph 7:45 ↑ PH - Acidosis occurs if Alkalosis occurs if ph 7 z5. - 7. 45 arterial blood pH level arterial blood pH level 102 35 - 45 falls below 7.35 is above 7.45 BLO2 22 : 28 Too many hydrogen Too few hydrogen ions in the body ions in the body (respiratory acidosis), (respiratory alkalosis), or or Too little bicarbonate Too much bicarbonate (metabolic acidosis) (metabolic alkalosis) Derksen Cellular Regulation ↳ now fast cells are growing Genetic and physiologic processes that control cellular growth, replication, differentiation, and function to maintain homeostasis4 Excessive→ abnormal growth of tissue not needed for optimum whole-body function Benign or malignant tumors (cancer) Fibrosis Excessive scar tissue formation Inhibition → can reduce cell production of certain substances (such as insulin or clotting factors) to levels that cannot support homeostasis Derksen  & Clotting A complex, multistep process by which blood forms a protein-based structure (clot) Platelet aggregation → clotting cascade Physiologic Consequences: what do see with… ben Increased clotting? of zips Decreased clotting? Risk factors → increased or excessive clotting Immobility or decreased mobility Polycythemia absome blood Jessi a round Smoking Certain chronic health problems – examples? Risk factors → decreased clotting Thrombocytopenia Liver cirrhosis Rare genetic diseases Image: https://www.heart.org/-/media/Images/News/2022/September-2022/0919CoronavirusBloodClots_SC.jpg Derksen Cognition4 impaired Impaired cognition “… the complex integration of mental processes Global cognitive disorders and intellectual function for the purposes of Dementia (chronic) reasoning, learning, memory, and personality.” 4 Delirium (acute) Focal cognitive disorders Delayed intellectual functioning; amnesia TBI, stroke Derksen  Comfort State of physical well-being, pleasure, and absence of pain/stress Physical and emotional dimensions Risk factors Physical Emotional Psychosocial Physiologic and psychosocial consequences Can result in emotional stress and discomfort “fight or flight” activated Persistent pain, anxiety may develop Image: https://coloradopaincare.com/wp-content/uploads/2019/05/Chronic-Pain-blog-image.jpg Derksen  Elimination Excretion of waste from the body GI tract and renal/urinary system Issues: Incontinence Retention Diarrhea Constipation Image: https://www.wellspect.us/globalassets/digizuite/54484-en-aid0054484.jpg?width=930&quality=80 Derksen  bath aeve ⑧ Fluid & Electrolyte Balance - “Regulation of body fluid volume, osmolality, and composition; and electrolyte regulation by the process of filtration, diffusion, osmosis, selective excretion.”4 Fluid imbalances Dehydration, fluid overload Electrolyte imbalances a dansw Hypokalemia, hyperkalemia, etc. Derksen  Gas Exchange Process of oxygen transport to cells and carbon dioxide transport away from cells through ventilation and diffusion Risk factors: Acute or chronic problems affecting central neurons, normal diaphragm function, adequate skeletal muscle contractility, and intact chest thorax Ex: Pneumonia, high C-spine injury Aging (loss of pulmonary alveoli elasticity) Lung diseases (asthma, COPD) Smoking Environmental pollutant exposure Prolonged immobility Image: https://img.favpng.com/18/25/21/pulmonary-alveolus-gas-exchange-lung-capillary-respiration-png-favpng-Jcf3FpKmV7abz5kxyhdsePm4q.jpg Derksen  & Immunity 7 in Protection from respons to sorting illness or disease; maintained by the body’s physiologic defense - W mechanisms im i from mokies e) with Image: ex(best https://cdn.sketchbubble.com/pub/media/catalog/product/optimized1/8/e/8e0d0609dd18df690ece7100eb700a74e0a8460f07b5a405745e87f4a09e9db2/t ypes-of-immunity-mc-slide1.png Derksen  Invasion of pathogens (harmful microbes) into the Infection body that multiply and cause disease or illness Image: https://i0.wp.com/helalmedical.com/wp-content/uploads/2023/03/Classification-of-infectious-diseases-based-on-their-causative- agents.png?fit=800%2C450&ssl=1 Derksen  Acalized vs. systemic effects whole - Inflammation body (full body response sepsis - Syndrome of normal responses to cellular injury, allergy, or invasion by pathogens Classifications Acute Chronic Risk factors Everyone! Image: https://www.verywellhealth.com/thmb/3Yygr0vVmlSU_MY8de5SGb2tG2g=/1500x0/filters:no_upscale():max_bytes(150000):strip_icc()/signs-of- inflammation-4580526_FINAL-5c6f21adc9e77c0001be5177.png Derksen Mobility Ability of an individual to perform purposeful physical movement of the body: Functional Ability Risk factors Dysfunction of the musculoskeletal or nervous system Severe brain or spinal cord injuries Bedridden or prolonged bedrest Physiological Consequences Pressure injuries Disuse osteoporosis Constipation Weight loss or gain Muscle atrophy Atelectasis/Pneumonia VTE/PE Urinary system calculi Derksen Nutrition Process of ingesting and using food & fluids to grow, repair, and maintain optimal body functions Proteins, carbohydrates, fats, vitamins, minerals Poor nutrition status Malnutrition (generalized or specific) Risk factors: Older adults Obesity Lack of money Anorexia or bulimia Derksen  ⑪ Pain a cute or chronic An unpleasant sensory and emotional experience Subjective Types (duration) Acute Persistent (chronic) Type (Mechanism) nors Nocioceptive Hund sliverpain results from skin or organ damage Nocioceptive amp or inflammation. Neuropathic Neuropathic and long pain involves a set of mechanisms related to the no e tissuebut singamaged nervous system with or without tissue damage Image: https://images.rawpixel.com/image_png_800/cHJpdmF0ZS9sci9pbWFnZXMvd2Vic2l0ZS8yMDIyLTEwL3B4MTA2MDYyMS1pbWFnZS1qb2IxMjY3XzIucG5n.png Derksen Perfusion Adequate arterial blood flow through peripheral tissues (peripheral perfusion) and blood pumped by the heart to oxygenate major body organs (central perfusion) = (when pt needs central blood flow C Physiologic Consequences Peripheral Cool, pale, cyanotic distal extremities Diminished/absent peripheral pulses Skin ulcers Gangrene Central CO2 is not getting central organ sa ex) heart lungs brain , , Myocardial infarction Stroke Shock 5) Derksen  Sensory Perception The ability to perceive and interpret sensory input into one or more meaningful responses Vision, hearing, smell, taste, touch Risk factors: Aging Chronic diseases Mechanical or chemical trauma Cranial nerve II (optic) or VIII (auditory) damage Drug therapy (i.e. ototoxicity) Occupational exposures (i.e. loud noise) Genetic risk Image: https://t3.ftcdn.net/jpg/03/11/07/96/360_F_311079621_50hWxGjsRfjTILFsWYmXr7EVjQROfZxa.jpg Derksen  Tissue Integrity Intactness of structures and function of integument and mucous membranes Intact vs impaired Degree of tissue damage: Partial-thickness Full-thickness Image: https://www.hopkinsmedicine.org/-/media/images/health/1_-conditions/skin/skin-layers- diagram.jpg?h=300&iar=0&mh=400&mw=670&w=300&hash=780E16459F3F2101F362AF67E260D11E Derksen References 1. Alberta Health Services [AHS] (2023).Continuing Care Glossary. https://www.albertahealthservices.ca/cc/Page15500.aspx 2. Canadian Association of Critical Care Nurses [CACCN] (2017). Standards for Critical Care Nursing Practice. https://caccn.ca/wp- content/uploads/2019/05/STCACCN-2017-Standards-5th-Ed.pdf 3. Institute for Healthcare Improvement [IHI] (2023).Improvement capability. https://www.ihi.org/improvement-areas/improvement- capability 4. Ignatavicius, D., Rebar, C. & Heimgartner, N. (2024). Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care. (11th ed.). Elsevier. Derksen  Trauma Nursing 332 Brooklyn Derksen, BSN, RN, DTN, MN, ENC(C) Lecturer University of Saskatchewan College of Nursing Objectives 1. Overview of trauma 2. Primary Survey (ABCDE)-- with additional FG 3. Secondary Survey (HI) 4. Select traumatic injuries 5. Trauma Triad of Death Who experiences trauma? Age the older they are, the older their organs. Economic and gender inequality ( probably has comorbidities too) males (around 20’s) Workers ( hazardous environment ) Alcohol and substance abuse people that are living in active warzones Domestics abuse environment ( women have higher number here) Ethnicity all types of abusement Income (poverty, unemployment) Geography Unsafe work environments Factors Affecting Response to Injury Comorbidities Substance abuse Pregnancy Anatomic changes, hemodynamic changes, blood volume and composition Advancing age  Blunt vs Penetrating Trauma A type of trauma resulting from no stabs impact forces such as a motor break in the skin vehicle accident, fall, or assault. It penetrated in the skin Blunt Trauma Penetrating Trauma Can be less-obvious than penetrating Sharp objects and projectiles caused by : Forces Associated: The most common organs injured are the small bowel - (50%), large bowel (40%), liver (30%), and intra- Shearing tear of skin tissue organs e i - and deceleration forces duet, , Acceleration , abdominal vascular (25%). ~ trauma Compression force When the injury is close range, there is more kinetic Examples? energy than those injuries sustained from a distance. ex) Gunshot wounds→ depend on the type of bullet and abrasions (ex scrape knees gun (close vs far range) > some gun shots go through - your - - Associated with unpredictable injuries the body - bruises - Secondary cavitation injuries some stop > - and gets blast trauma in the Stab wounds that penetrate thestuck abdominal body wall are difficult to assess. Occult injuries can be missed The Trauma Nursing Process: Preparation and triage General impression Primary survey (A–E) with the corresponding intervention as necessary; F-G as additional interventions Reevaluation (consideration of transfer/need for higher level of care) Secondary survey (H–I) Reevaluation (J) and post-resuscitation care Definitive care, transfer, or discharge  First…. What you want in the room: Crash cart, blood, xtray scan, meds? ( for rapis sequence intubation), fluids ( lactate?/ not usually normal saline) incubation supplies, wound supplies Preparation and Triage Activate the trauma team - Prepare for patient arrival full PPE (DON'T KNOW ANYTHING ABOUT T.. HE PT YET) EX. OPEN WOUNDS, VIRUSES? FIRST THING PPE and safety ALLERGIES? PROTECTION AND PREPAREDNESS! to > General impression - LOOK FOR : 1) Uncontrolled external lot? hemorrhage? they bleeding out are a 2) Unresponsive/apneic? (not breathing at all)  ⑭ ALWAYS IDENTIFYLIFE THREATENING ISSUES FIRST AND FIX THAT FIRST!!!! Unless theres bleeding - (hemorging externally) - do this first!!! Primary Survey Finding the Biggest Issues: the A-G assessment PRIORITY (NORMALLY) ~ ↳ A B C D E F G Alertness Breathing Circulation Disability Exposure Full set of Get adjuncts Airway Ventilation Hemorrhage Environment vitals & & Give control Family comfort ⑨ You start here if Pt is bleeding -  Identifies life-threatening conditions EXAMPLES? ex) blocked airway , eve. If life-threatening conditions are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey. -  d they respond with these? - ↳4 Alertness = AVPU (alert, verbal, pain, unresponsive) Airway: No head, tilt, chin lift in trauma. could break their neck (you don't know if they can lift/ move their heads Bony deformity Burns causes lol of Edema↓ if : there is airway edeman constricts Alertness & Fluids (blood, vomit, or secretions) Foreign objects Airway Inhalation injury (burns, singed facial hair, soot) Loose or missing teeth Is the passage really open? Broken teeth, fluids? Sounds ( snoring- airway gets blocked by the tougue) Sounds (snoring, gurgling, stridor) (gargle - fluuids in the airway! Suction it) (stridor - airway has been narrowed) Tongue obstruction Vocalization *cervical spine stabilization or immobilization*  NPA EXCEPT MEASURE; FROM THE NOSE TO THE TIP OF THE EAR, LUBRICATE IT TOO Airway Interventions EET SECURE BOTH UPPER AND LOWER AIRWAY, IF both aren't working or jaw thrust isn't working. goes through trachea up until then broncloes. Putting it and pulling it out isn't part of nurses' practice. You can ⑨ Jaw-thrust maneuver assist tho. Instead! So the tongue doesn't fall back and block the airway Oropharyngeal Airway (OPA) Measurement: from mouth to mandible Nasopharyngeal Airway (NPA) Goes to the nose ( open passage from nose to pharynx Endotracheal tube (ETT) measure Verify ↳ placement↳(CO2 detector; observe chest rise & fall; auscultate epigastrium and bilat head injury breath sounds) used of pot - Score) when 13 out 10 has severe Glascoma Image:BruceBlaus (https://commons.wikimedia.org/wiki/File:Endotracheal_Tube.png), https://creativecommons.org/licenses/by-sa/4.0/legalcode OPA ~ stopping tongue from blocking epiglottis. CO2 (capnography) Why is CO2 important when evaluating ETT placement? Can use qualitative devices or quantitative monitors Normal: 35-45 mmHg exhalation air - & change in color coz return > purple inadeq -  Breath sounds (decreased, absent) Depth, pattern, rate Increased work of breathing Dyspnea Diff-breathing Open wounds or deformities Breathing Skin color (pallor, cyanosis) Ventilation Spontaneous breathing Subcutaneous emphysema Symmetrical chest rise and fall Tracheal deviation or JVD If you can’t get past the A and B… - INTUBATION ALWAYS pre-oxygenate! ~ NOT a nurses role → RT/MD/ACP (advanced case paramedics Anticipate and assist Confirm placement and monitor  Inspect and palpate Color Temperature Moisture Circulation & Palpate a pulse central (caratoid , femoral , brachial) Check central pulse (peripheral pulses may be control of absent because of injury or vasoconstriction) Control of hemorrhage hemorrhage apply tourniquet for pressure ( apply above the wound) rniquet to Arterial bleeds : strong ( cuz it shoots out O L o more pressure ) Venous bleed: weak ( not a lot of - wound pressure) T A tourniquet stops the blood flow = less blood lost Image: https://unifirstfirstaidandsafety.com/wp-content/uploads/2018/08/Types-of-Bleeding-1.jpeg  - Glasgow Coma Scale (out of 15) → done with “D” for more in-depth assessment Best eye opening Best verbal response Disability do they respond **AVPU Best motor response to : → done with “A” to get general - if GCS less than 8 , then intubate pain unresponsive (neurologic alert , verbal , alertness level** , Pupils status) Glucose (BGM) Image: https://cdn-acgla.nitrocdn.com/bvIhcJyiWKFqlMsfAAXRLitDZjWdRlLX/assets/static/optimized/rev-5131b73/wp-content/uploads/2020/10/gcs.jpg  Remove all clothing Inspect - for injuries Warming measures ~why ? - blood loss Blankets snock Exposure & - Increase room temperature - ↓ blood toxygen Warmed IV fluids Environment Warming lights control Image: https://i5.walmartimages.com/asr/61f09773-926e-417e-9511- 1c789e57bfb6.8ea13bcf2616497d6e50e66d9f5a0c03.jpeg?odnHeight=612&odnWidth=612&odnBg=FFFFFF  im ot not moniloryef. - you obnyut on rglvg Obtain a full set of vital signs Facilitate family presence Full set of vitals & Family presence Image: https://theapprenticedoctor.com/wp-content/uploads/2017/12/Depositphotos_34564495_XL-scaled.jpg  Use LMNOP OL: Laboratory analysis OM: Cardiac monitor; consider 12-lead - ECG Stomach decompress &N: Consider naso- or orogastric tube Get adjuncts O: OOxygenation and capnography; consider weaning oxygen & Give &P: Assess pain using appropriate scale Consider analgesia comfort - Nonpharmacologic comfort  w ent Head Secondary Survey (H-I) History (SAMPLE) Head-to-toe Inspect Posterior & anticipate Interventions  Pre-hospital personnel More about what hepappehee Patient or family generated SAMPLE history: S Signs & symptoms History A M Allergies Medications P Past medical history L Last oral intake/last menstrual period E Events leading up  Focus: Manage the injuries Optimize respiratory and cardiac function Head-to-Toe Assessment: Inspect, auscultate, and palpate Head to toe Head Face assessment Neck Chest Abdomen/flanks Pelvis/perineum Extremities  Unless contraindicated by known or suspected spine or pelvic injury Turn, inspect and palpate Remove backboard *no longer routinely used* Inspect Posterior. Image: https://clinical.stjohnwa.com.au/images/default-source/clinical-skill-images/trauma/logroll1.png?sfvrsn=b28f4916_4 ✓  Anticipate: a patient has a deformity of the right upper arm. What do you think might happen? - Xray Splint Anticipate Ortho consult Interventions Image: https://smmc.sx/portals/0/Images/Brochures/ComputedTomography(CT)Scan-01.jpg  V: Vital signs I: Injuries and interventions P: Primary survey P: Pain Just Keep How often is a primary survey carried out on a Reevaluating patient / victim ? Continously ! X Once? Twice in 15 minutes? What would you do?  Select Traumatic Injuries Image: https://smartcdn.gprod.postmedia.digital/thestarphoenix/wp-content/uploads/2019/07/250546903-saskatoon_helipad_opening_2_copy-w.jpg common (due - > 2 or more ubs broken That Broken skeleton goes Chest Injuries opposite to: what it should be ( ex. When inhaling instead of ribs inflating it Rib fractures would depress instead. Flail chest Pulmonary contusions long tissue damage ana Tension pneumothorax → Tension Pneumothorax air the trap in pleval cauty cuising tension Open pneumothorax - air pleural in the cavity -) other long pushes Over Massive hemothorax - blood in the chest cavity Image: https://d16qt3wv6xm098.cloudfront.net/c3hj_17_Tgq-ZVWDmRKWq9GLScukzv-l/_.png  Cardiac Injuries Cardiac tamponade is Vascular trauma cause by blunt or penetrating Blunt cardiac injury - bleeding in the abdomenal cavity for ex) spleen , liver (abdominal damages Cardiac tampode - fluid or bleeding - around the2y - accumulate in the perisal - compressing Image: https://upload.wikimedia.org/wikipedia/commons/thumb/9/9f/Blausen_0164_CardiacTamponade_02.png/250px- the heart Blausen_0164_CardiacTamponade_02.png - Cardiac out put Abdominal Injuries Spleen injuries Liver injuries Damage control surgery* Hemostasis; temporary closure; prevention of contamination  Head Injuries Image: https://www.santephysique.com/wp-content/uploads/2017/07/types-of-tramatic-brain-injury-TBI--750x480.jpg  Pelvic Injuries Femoral arteries can be nipped in this. ex) pelvic fructures The pelvic cavity also holds lots of blood. Arteries have more pressure, it pumps out blood heavier and faster. Blood can easily be lost. Symptoms Perianal ecchymosis Pain on palpation of iliac crests Hematuria (blood Urine) in Lower extremity rotation or paresis Diagnosis: CT scan Initial management Treatment of life-threatening hemorrhage Stabilization with an external fixation device, internal fixation Fractures Open vs Closed Potential Interventions in Acute Trauma Rapid sequence tracheal intubation EET Chest tube insertion Control of bleeding Insertion of two large bore IV’s Insertion of foley catheter Type and X match Rapid fluid administration Blood product administration ECG monitoring continuously – 12 lead ECG X-rays Orogastric/ Nasogastric intubation Continuous Pulse oximetry  We give clots factors as well, (platelets ) for peeps in trauma they used up they're bleeding clots already so it is important to give platelets as well Clues that they're clotting a lot: 1. Do labs - ptt Sa trauma you get results faster Trauma Triad of Death: Lethal Triad 2. Neurochnaging? Hard to tell still 3. Give heparin p If pt is done clotting, they're clotting na what would you see: 1. Bleeding out nonstop even venous and from other areas (urine, gums, stools, etc. 2. Give them platelets, clotting factors and also blood since they have lost them as well Patient decompensation in the presence of acute blood loss resulting in: Hypothermia – up to 66% of patients are good loss hypothermic on arrival to hospital hypopellmic shock blocks perfusion 2 Coagulopathy -cloting & wereacti acid Acidosis inflammatory proces has been actuated = lol of mini S blood in 17 Cob. - Significantnot cause of mortality blocks small - heart pumping efficially. capilli are Treating hypothermia KEY in the presence of fluid , loss (hypovolemia) Inhibits platelet function Slows coagulation factor activation Uncontrolled bleeding leading cause of death among trauma patients Image: https://media.licdn.com/dms/image/D4E12AQF45Z5fRSZkxw/article-cover_image- shrink_720_1280/0/1663609284731?e=2147483647&v=beta&t=azQlevTgqRbwDgfwWcb_y81i2uK31C6U3xci3Fg10QI  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 andofhead head fortolacerations - its part cut the or deformities intervention Question an not - b) Initiating or continuing CPR - c) Ventilate with bag/ valve mask - d) Open airway/ intubate - e) Pain assessment not primary surveyEFG - "think of ABCD - f) Insert two large bore IV’s part of ( I  Zoe, age 18, is brought to the emergency department following a motor vehicle collision. BP isOt 80/70 and her T 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? Question SELECT ONE ONLY ⑨ Munotdenrodaencontented beedung 2 1. Assess for uncontrolled bleeding - aphear O2. Assess GCS &Pupil response conresponse 3. Administer supplemental oxygen 4. Palpate for peripheral pulses 5. Auscultate lungs References Khan, M.; Azim, A.; Tang, AL.; Jehan, F.; Vercruysse, G.; Gries, L; Jain, A; Joseph, B. (2017). Trimodal Distribution of Trauma Deaths Is No More. Journal of the American College of Surgeons 225(4):p S64-S65. DOI: 10.1016/j.jamcollsurg.2017.07.132 Emergency Nurses Association [ENA] (2024). Trauma nursing core course: Provider manual (9th ed). Ignatavicius, L.M., Rebar, C. & Heimgartner, N. (2024). Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care. (11th ed.). Elsevier. Triage and Disaster Management: prioritization in acuity Nursing 332 Brooklyn Derksen, BSN, RN, DTN, MN, ENC(C) Lecturer University of Saskatchewan College of Nursing Image: https://pbs.twimg.com/media/EFoxXaXXkAApiO1?format=jpg&name=4096x4096 Objectives 1. Overview of triage 2. Prioritization systems: PASS CTAS Kanadian Triage and Aevity Scale) ETAT 3. Disaster: Types 4 phases of emergency management Disaster triage– compared to conventional triage The nursing role Start - Triage = Priority Setting Assigning prioprtty wgi would you see first and who would you not see, French verb “trier” means to sort - Assigns priorities depending on resources ~ Prioritization: Deciding which needs or problems require action immediately, and which ones can be delayed until later Basic nursing competency (develop that skill in this class/rotation!) Decision making tool Which tools/frameworks do you know? Based on how stable or unstable they are: look at the vitals!!! Acute changes from the assessments In their baseline diagnosis Together with your partnered RN, You start your shift with your list of 6 patients in the observation unit How do you decide who you will see first? How do you know what is most important to do?  How do you decide? Need to know normal vs abnormal 17 Nursing Process→ ASSESSMENT is key starting point! e Maslow’s Hierarchy of Needs a wee · ABCs!! not us ↳ Image: https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.thoughtco.com%2Fmaslows-hierarchy-of-needs- 4582571&psig=AOvVaw1irfqF6EjB1MzWPy8M966- &ust=1703788785112000&source=images&cd=vfe&opi=89978449&ved=0CBIQjRxqFwoTCLi6vIeisIMDFQAAAAAdAAAAABAD Prioritization Systems  CHAS und tes al other assessucti Modified Early warning system (MEWS)2 A screening and scoring tool to identify hospitalized patients at risk for deterioration unuary put LOC , vitals , out Determine a patient’s condition using level of consciousness & RR, systolic blood pressure, temperature, heart rate, oxygen saturation, and hourly urinary output Image: https://upload.wikimedia.org/wikipedia/commons/thumb/1/15/Ambox_warning_pn.svg/2356px-Ambox_warning_pn.svg.png The higher the number the more your pt deteriorating  - ~ The higher the number the more ⑪ your pt deteriorating - Iggy 2024. FIG. 31.2 Modified Early Warning System (MEWS). (Used with permission from Glan Clwyd Hospital, Rhyl, Denbighshire, Wales.)  John is a 48-year-old male who is admitted to the surgical ward with pancreatitis. You are the student assigned to him. Upon taking his vital signs on morning rounds, he is alert and complaining of epigastric pain, 7/10. His vitals are as follows: systolic Temp- 37.5 BP- & 168/72 Example RR- 22 ↑ 2 O2- 96% on 3L np HR- 102 ↑ 1 Urine output: 50ml/hr - ↑ What is his MEWS score? What actions would you make? ③  I It is now noon, and when you go to check on John he responds to your voice, stating that he - is still experiencing pain despite 2 doses of S morphine. You recheck his vitals: Temp- 38.5 I BP- 120/64 RR- 28 2 O2- 92% on 3L np Continued… HR- 115 2 Urine output: 35ml/hr I adve I What is his MEWS score? ⑦ What actions would you make? What member(s) from the interdisciplinary team would you like to have involved? FCE , Energ call an outreach team a team with intensive care /roses ( - OUTRACE TEAM > Triage  you go to a triambe nurse, gets visuals, assess, answer questions, and get a number Triage Process Clients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED) Helps to bring order and organization to a chaotic scene. It identifies and provides care to those who are in greatest need Assure that resources are used in the most effective manner Helps make the difficult decisions easier - relieve emotional burde  ↑ montzatie Niage in CTAS emergency - - other countries 5-level scale Too complicated to go into depth for this course; an but still have time additional course for experienced RNs Based on presenting condition in addition to “modifiers” (i.e. pain level, vitals, bleeding disorders, hemodynamic stability, etc.) Used in many countries Image: https://www.cmh.ca/images/Photos/CTAS.jpg  Resusitation Energet Urgent Less-urgent Non-ugat M (polential ~ simple interventins - interventors potential progress can be delayed treat) to threat of not Or ask other Seem RN 20 so tren & > 2 - symp. a25(3 9) infectivecompromised - related conditions distes Suspected · serve resp - - stroke · age - moderate resp distress - - Symptomatic Hin Systle T220) Diast 7 130/ (more) **suspected stroke is CTAS 2! Triage Reassessment3 Resucitation emeight urgent less urgent iron-urgent Level 1 Level 2 Level 3 Level 4 Level 5 Condition Threat to life or Potential threat Potential to May progress to Acute or chronic limb; immediate to life, limb, or progress to urgent status but not urgent assessment function serious problem "Asthma , + 40f required Time to RN and Immediate 15min 30min 60min 120 min physician assessment Recommended Continuous Ever 15min Every 30min Every 60min Every 120 min re-evaluation "suspected tungs" Rn assess pt sees pt every 15 mins until doctor see them then rn can check them every 4 hrs unless said otherwise or based on nursing judgment. Interagency Integrated Triage Tool [IITT]4 Triage tool (2020) developed by WHO, the International Committee of the Red Cross (ICRC) and Médecins Sans Frontières (MSF) For routine triage in emergency departments of adults and children (LMICs) There is one tool for adults, one for children < 12 years, and a reference card that defines high-risk signs (all posted to Canvas). 3-colour system: red (high acuity; need to be seen immediately), yellow (moderate acuity; need to be seen soon), and green (low acuity; can wait). Disaster Management  Disaster Planning What about when we are in the field? resources < needs “A sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material and economic losses that exceed the community’s or society’s ability to cope using its own resources.” ~International Federation of Red Cross and Red Crescent Societies Internal VS external disaster ? Smith, bronchold Multi-casualty event VS mass-casualty event > - james Car accident with 5 passenger but they can be managed by the facility - overwhelmed the system Natural Disasters Human-made disasters Examples? Chemical agents Rapid onset Shelter-in-place vs evacuation Lethal in small doses Nerve agent SLUDGE Biological agents Delayed onset Spread is a public health emergency Radiological/nuclear Exposure versus contamination Time, distance, shielding Explosives Levels of blast injury  no space, no ambulance to transport the people Not ready (ex. Pandemic) Resources < Need Infrastructure limitations Inadequate hazard preparation Limited transport capabilities Multiple agencies responding Ex. War (govemrinet responds, red cross, individiulas, etc Hospital Resources overwhelmed  Disaster Cycle ~ ② ⑪ ~ The cycle repeats Multiple disaster cycles may overlap or happen concurrently Disaster phases may vary in ⑪ ⑤ duration/severity Which phase occurs when you receive notification of a 20-car pileup? Image: https://hbr.org/resources/images/article_assets/2021/12/W210607_JACKMAN_DISASTER_360.png  Mitigation (prevention) A foundation to limit the potential impact of a disaster Done BEFORE to reduce/minimize impact Name one of the top hazards that could affect your facility What preventative measures have been instituted to mitigate this hazard? Image: https://wikifinancepedia.com/wp-content/uploads/WikiFinancepedia-Risk-Mitigation-%E2%80%93-Plan-Strategies-Techniques-Template-Examples.png  Preparedness Disaster plans Training/drills Supplies Image: https://www.wechu.org/sites/default/files/your-environment/Emergency/Are-You-Prepared.jpg Response DURING a disaster; implement plans identified prior (preparation) Aim: Space Supplies Staffing System Safe lives Reduce suffering Alleviate economic losses Patients are starting to arrive…  Multi-casualty incident Multiple vehicle crash on nearby highway 20 vehicles involved 10‒15 patients The Helicopter transport not available emergency bypass ( ruh will take nay other pts aren't decompress Th emerg, units upstairs will take pts even Sa hallway, OTs discharges situation… more supplies, Cal, for some prior Staffing multiple RN’s and atlwest one pts ⑮ Space, staffing and resources  ontay a not lacing enoe “The greatest good o for the greatest number” START Triage: Capefell “30,2, Can do” E do - they can - RR ~ Image: https://canadiem.org/wp-content/uploads/2018/08/rpm-30-2-can-do_24015212.jpg START Adult Triage Jump START Pediatric Triage Istop breathing untreg ~Used of lots of resources and leave anything to our reds, save more Image: https://chemm.hhs.gov/chemmimages/StartPediatricTriageAlgorithm.gif Triage Tag soap ? r Pre-hospital (can be used in-hospital) - Basic info: injuries, vitals, meds, decontamination, but vercly not boteased parent/child connection can - Once triaged: bottom torn off (triage is lowest category Decontamination UP TO 95% OF HAZARDOUS MATERIAL IS SOAP AND WATER IN MASS-CASUALTY REMOVED BY TAKING OFF CLOTHING AND WASHING SKIN  48 years old Crushing chest pain and SOB Non-ambulatory RR: 23 yo Patient #1 Pulse: 90 Cap refill 2s M: Follows commands  51 years old Right upper quadrant abdominal pain Ambulatory to RR: 26 Patient #2 Pulse: 116 Cap refill 2s M: follows commands Green -  49 years old Obvious head injury; ++blood to multiple lacerations to head ↳ RR: apneic (after airway repositioning) Patient #3 Pulse: no radial pulse Cap refill 4s M: unresponsive  12 years old Difficulty breathing with paradoxical chest movement Extricated from car Patient #4 RR: 52 Pulse: weak, 150 Cap refill 3s M: alert and confused  64 years old Left arm pain with obvious deformity Ambulatory RR: 20 Patient #5 Pulse: 110 Cap refill 2s M: follows commands  4 years old Right leg pain; crying, non-consolable Not ambulatory - RR: 34 Patient #6 Pulse: 126 Cap refill 2s M: alert yellow  37 years old Head injury with actively bleeding laceration to occiput Not ambulatory Patient #7 RR: 33 Pulse: weak, 134 Cap refill 3s M: confused  20 years old Chest and upper back injuries RR: apneic (after airway repositioned) Pulse: weak, 40 Patient #8 Cap refill 4s M: unresponsive  36 years old, female Carrying a crying infant She is ambulatory RR 20 Patient #9 Pulse: 67 Cap refill 2s M: Obeys commands  Adult female driver still in the bus, trapped by her lower legs under caved-in dash RR 24 Pulse: 140 Patient #10 Cap refill 4 sec M: Moans with physical stimulus  SHA “codes” Code Red – Fire Code Orange – Incoming mass casualties ~ Code Green – Evacuation Code Black – Bomb Threat Code Purple – Hostage taking Code White – Violent act Code Silver – active assailant with weapon Code Yellow – Missing Patient / Resident Code Blue – Cardio-Respiratory arrest Code Brown – Hazardous Material or Spill in exams not Code T Alert – Tornado - Service Disruption Image: https://www.lloydminster.ca/en/news/resources/Images/multi-purpose/Saskatchewan-Health-SHA-logo.jpg  Mass Shooting What types of injuries do you anticipate? How do you respond if an assailant enters your department? What do you do for your patients? Tell them to play dead, lock the door, turn of the lights, But at the end of the day, do run hide… Image: https://nonprofitquarterly.org/wp-content/uploads/2019/09/run-hide-fight.jpg  Recovery Regular patient volumes continue, in addition to the lingering situations after the large-scale incident Mass fatality response Family reunification Psychological triage (visitors, patients, staff) Critical incident stress management (CISM) Image: https://colohouse.com/wp-content/uploads/2020/04/Disaster-Recovery-.png References 1. Emergency Nurses Association [ENA] (2024). Trauma nursing core course: Provider manual (9th ed). 2. Ignatavicius, D., Rebar, C. & Heimgartner, N. (2024). Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care. (11th ed.). Elsevier. 3. CTAS (2014; updated 2016). The Canadian Triage and Acuity Scale: Education Manual. 4. World Health Organization [WHO] (2023). Interagency Integrated Triage Tool. https://www.who.int/publications/m/item/IITT