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450 Exam 1 - Review for the first exam
Cardiac/ICU (Nebraska Methodist College)
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Hemodynamic Monitoring:
Objectives: Define hemodynamics, identify the indications for monitoring hemodynamic values in the critically ill patient, identify different
hemodynamic measurements reflecting preload, afterload, contractility, and cardiac output, discuss insertion methods, assessments,
complications and nursing care for arterial lines and pulmonary artery catheters, identify proper measurement techniques using hemodynamic
measurement equipment, and identify normal parameters and common conditions that may alter hemodynamic values.
Hemodynamic Monitoring:
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The measurement of pressure, flow, and oxygenation within the cardiovascular system.
○
Assesses heart function, fluid balance, and effects of drugs on CO.
■
How we measure oxygen in the body.
Contractility:
●
The strength of ventricular contraction (effectiveness of the pump).
○
Heart has to be able to contract to pump effectively.
■
DIRECTLY affects cardiac output.
Preload: The Stretch
●
Volume of blood within the ventricle at the end of the diastole.
○
PAWP: (Wedge Pressure) Reflects LV end diastolic pressure.
○
CVP: Reflects RV end diastolic pressure.
●
The amount of blood in the heart before contraction (full sponge).
Hemodynamic Monitoring Terminology:
Afterload: Resistance (forces opposing ventricular ejection).
●
Systemic Vascular Resistance (SVR):
○
To the body.
○
SVR and arterial pressure indicate LEFT ventricular afterload.
●
Pulmonary Vascular Resistance (PVR):
○
BOTH: Opposition to blood flow by systemic and pulmonary vasculature.
○
PVR and pulmonary arterial pressure indicate RIGHT ventricular afterload.
●
CO: Volume of blood pumped by the heart in one minute.
○
How to calculate:
■
CO = stroke volume X heart rate
●
CI: CO adjusted for BSA (specific CO).
○
How to calculate:
■
CI = cardiac output - body surface area
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SV: Volume ejected with each heartbeat.
●
EF: % measurement of how much blood the LV pumps out with each contraction.
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Perfusion: The delivery of oxygen and nutrient rich blood to the body’s tissues.
Non-Invasive Monitoring:
●
Pulse, HR, SPO2, Cap refill, skin color, urine output, mentation, echocardiograms, daily weights.
○
Daily weights is the most accurate way to see how the body is moving blood throughout.
Invasive Monitoring:
●
Systemic and pulmonary arterial pressures, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), blood gases,
and mixed venous oxygenation saturation (SvO2).
○
Why Invasive Monitoring?
■
Accurate treatment, monitor trends over time, guides fluid replacement therapy, guides diuretic therapy, guides
vasopressor/inotropic agent therapy.
●
EX: Pulmonary Artery Catheter, Central Venous Pressure, Arterial Line.
Principles of Invasive Pressure Monitoring:
●
Equipment MUST be referenced and zero balanced to environment and dynamic response characteristics optimized.
○
Referencing: Positioning transducer so zero reference point is at level of atria of heart of phlebostatic axis.
■
Phlebostatic Axis: 4th IC space, leveled with right atria (where the transducer goes).
Crucial Transducer Placement:
●
What is a Transducer?
A hand-held device called a transducer is placed on the chest and transmits high frequency sound waves (ultrasound).
○
These sound waves bounce off the heart structures, producing images and sounds that can be used by the doctor to detect
heart damage and disease.
●
Inverse Relationship:
○
Too Low: Abnormally high-pressure valve.
○
Too High: Abnormally low-pressure valve.
●
When should we check transducer placement?
○
Recheck, recalibrate, re zero.
○
Square waveform test.
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Laser Test (level)
Zeroing:
○
Confirms that when the osmotic pressure within the system is zero, the monitor reads zero.
○
Done by opening the reference stopcock to room air.
○
With initial setup and periodically thereafter (Q shift).
Arterial Blood Pressure Indications:
●
Acute Hypertensive/Hypotensive, Respiratory Failure, Shock, Neurological Injury, Cardiac Interventions, Vasoactive Drug Infusions,
Frequent Blood Sampling (ABGs).
Mean Arterial Pressure: (MAP)
●
Average perfusion pressure created by arterial blood during the cardiac cycle.
○
Normal Range: 70-110 mmHg
●
This value is oftentimes used to guide fluid replacement and vasopressor/inotropic agent therapy in higher acuity patients.
○
Standard order: Start Neosynephrine drip, titrate to keep MAP >65 mmHg
○
GOAL: 65
Arterial Pressure Monitoring:
●
High and low pressure alarms.
●
Risks/Complications:
○
Hemorrhage, infection, thrombus formation, neurovascular impairment, loss of limb.
●
Continuous flush irrigation system:
○
Pressure bag at 300 = delivers 3 mL of saline/hour.
■
Maintains line patency/ limits thrombus formation.
●
Assess neurovascular status distal to arterial insertion site hourly.
Central Venous (right atria) Pressure Monitoring:
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Measurement of right ventricular preload.
○
Reflects fluid volume.
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Obtained from: Central venous catheter or PA catheter.
Central Venous Pressure (CVP): “blood pressure” of the right atrium.
●
Also known as Right Atrial Pressure (only reflects the function of the right side of the heart).
●
CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system.
○
Fluid Status/Preload:
■
Indication: Monitor intravascular fluid volume; can guide treatments for patients who are both hypovolemic and
hypervolemic.
●
Normal Parameters: 2 - 8 mmHg
○
High: too much fluid.
○
Low: too little fluid.
Systemic Vascular Resistance:
●
Increased SVR = vasoconstriction.
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Decreased SVR = vasodilation.
Pulmonary Artery Catheter (Swan- Ganz):
●
Pulmonary artery catheterization, or right heart catheterization, is the insertion of a catheter into a pulmonary artery.
●
It’s purpose is diagnostic; it is used to detect heart failure or sepsis, monitor therapy, and evaluate the effects of drugs.
●
The pulmonary artery catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary
artery, and the filling pressure of the left atrium.
○
Who needs a PA catheter?
■
Pulmonary Hypertension, shock, pericardial illnesses (cardiac tamponade/ pericarditis), planned cardiac
surgeries.
●
Allows for precise manipulation of preload.
Pulmonary Artery Flow-Directed Catheter:
●
Distal lumen port is in the pulmonary artery, the balloon is inflated to measure
PAWP, the two proximal lumens to measure CVP, inject fluid for CO, draw
blood, administer fluids or drugs.
Pulmonary Artery Pressure Monitoring: (PAWP monitoring)
●
When measurements are obtained:
○
PA: at end expiration
○
PAWP: slowly inflate balloon with up to 1.5 mL of air until PA
waveform changes to PAWP waveform.
○
Do not inflate for more than four respiratory cycles or 8-15
seconds.
Complications with PA Catheters:
●
Infection and Sepsis:
○
Asepsis for insertion and maintenance/
●
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●
●
○
Change flush bag, pressure tubing, transducer, and stopcock every 96 hours (4 days).
Air Embolism: (Disconnection)
○
Monitor for balloon integrity; Luer-Lock connections; alarms on.
Pulmonary Infarction or PA Rupture:
○
IMMEDIATE surgery
○
Do not inflate balloon with >1.5 mL
○
Monitor waveforms continuously.
○
Maintain continuous flush systems.
Ventricular Dysrhythmias:
○
Monitor during insertion and removal.
○
Also for migration of PA catheters.
Airway Management and Mechanical Ventilation:
Oxygenation Devices:
●
Nasal cannula, high flow nasal cannula, mask, venturi mask, Airvo, BiPAP, CPAP, Ambu Bag.
Artificial Airways:
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Placement of a tube into trachea to bypass upper airway and laryngeal structures.
○
Endotracheal Tube (ET): via mouth or nose past larynx.
○
Tracheostomy: via stoma in neck.
When to Intubate:
●
Upper airway obstruction (tumor), apnea, inability to protect airway, ineffective clearance of secretions, respiratory distress.
Continuous Positive Airway Pressure (CPAP):
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Restores FRC (functional residual capacity).
●
Pressure delivered continuously during spontaneous breathing.
●
Used to treat obstructive apnea.
●
Administered noninvasively with mask, ET, or tracheal tube.
Bilevel Positive Airway Pressure (BiPAP):
●
Noninvasive (via tight-fitting face mask, nasal mask, or nasal pillows).
●
Patients must be able to breathe spontaneously and cooperate.
●
Bilevel positive airways pressure.
○
Delivers oxygen and two levels of positive pressure support.
■
Higher inspiratory positive airway pressure.
■
Lower expiratory positive airway pressure.
●
Helps with alveolar expansion (exhaling).
AIRVO:
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Spontaneous breathing required humidity high flow up to 60 L/min.
Oral ET Intubation:
●
Procedure of choice, airway can be secured rapidly, larger diameter tube can be used, decreases work of breathing (WOB), easier to
remove secretions and perform bronchoscopy.
Nasal ET Intubation:
●
ET tube is placed blindly, use of oral intubation is not possible, unstable cervical spine injury, dental abscess, epiglottis.
○
ET Intubation Procedure:
■
Consent, patient teaching (once they are weaned off), self-inflating bag valve mask attached to oxygen,
suctioning equipment (oral secretions out of the lungs), IV access (sedate patient).
■
Before intubation:
●
Sniffing position (roll behind neck; opens up the throat).
●
Preoxygenate using BVM with 100% O2 for 3-5 minutes.
●
Limit each intubation attempt to <30 seconds.
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Ventilate patients between successive attempts using BVM with 100% oxygen.
■
Rapid sequence intubation:
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Rapid, concurrent administration of sedative and paralytic agents.
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Decreases risks of aspirating and injury to patients.
●
Not indicated for cardiac arrest or difficult airway.
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Monitor O2.
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Inflate the cuff and confirm placement of the ET tube.
○
End-tidal CO2 detector.
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Auscultate lungs bilaterally.
○
Auscultate epigastrium.
○
Observe chest wall movement.
○
Monitor SPO2.
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Following proper ET tube placement:
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Connect tube to mechanical ventilator, secure airway, suction ET tube pharynx, insert bite block (if
indicted), can compromise oral mucosal integrity, insert oral gastric tube (low intermittent suction),
obtain x-ray (2 - 6 cm above carina).
●
Maintaining Correct Tube Placement:
○
Continuously monitor, prevention of self extubation, confirm exit mark on ET tube remains constant, observe chest wall
movement, auscultate bilateral breath sounds, monitor ABGs.
Nursing and Interprofessional Management:
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Maintaining tube patency:
○
Only suction clients.
■
Visible secretions in the ET tube, sudden onset of respiratory distress, suspected aspiration of secretions,
increased RR rate with or without sustained coughing, sudden decrease in SPO2, increased peak airway
pressure, adventitious breath sounds.
Complications of Suctioning:
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Hypoxemia, bronchospasms, increased intracranial pressure, dysrhythmias, increased/decreased BP, mucosal damage, bleeding, pain,
infection.
Indications for Mechanical Ventilation:
●
Apnea, inability to protect the airway, acute RR failure, severe hypoxia, RR muscle fatigue, palliative care team, ethical decision.
Mechanical Ventilation: Types:
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Positive Pressure Ventilation (PPV):
○
Used primarily in acutely ill patients.
○
Delivers air into lungs under positive pressure during inspiration.
■
Expiration occurs passively.
Modes of Ventilation:
●
Assist control (letting the patient breathe on their own but forces you to take enough breaths).
●
Synchronized Intermittent Mandatory Ventilation:
○
Make sure 8/15 breaths are deep enough and happening.
●
Pressure Support Ventilation.
●
Airway Pressure Release Ventilation.
●
CPAP.
Vent Settings/ Vent Alarms:
●
Settings:
○
RR, tidal volume, FiO2, PEEP, sensitivity, I:E ratio, high-pressure limit.
●
Alarms:
○
High pressure limit
○
Low pressure limit
■
High tidal volume, minute ventilation, or RR.
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Low tidal volume or minute ventilation.
■
Ventilator inoperative or low battery.
Positive End Expiratory Pressure (PEEP):
●
Applied to the airway during exhalation, preventing alveolar collapse.
○
Increases lung volume and functional residual capacity and improves oxygenation.
●
GOAL: Titrate to point oxygenation improves without compromising hemodynamics.
○
Physiologic PEEP: = 5 cm H2O
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Replaces glottic mechanism, helps maintain normal functional residual capacity and prevents alveolar collapse.
Prone Positioning:
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Patient on stomach with face down.
○
Improves lung recruitment.
■
Gravity reverses effects of fluid in dependent parts of lungs.
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Heart rests on the sternum; uniformity of pleural pressures.
Mechanical Ventilation: HFOV
●
High frequency oscillatory ventilation.
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Delivery of a small V at rapid RR.
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Used for refractory hypoxemia.
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Must sedate and paralyze patients.
Ventilator Associated Pneumonia (VAP):
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Occurs 48 hours or more after intubation.
○
Risk Factors:
■
Contaminated respiratory equipment, inadequate hand washing, environmental factors, impaired cough,
colonization of oropharynx.
●
Biggest risk factor: Oral care.
■
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Preventing VAP:
○
Consistent oral care with CHG, minimizing sedation, repositioning, early exercise and mobilization, subglottic secretion
drainage port, HOB elevated to 30-45 degrees, no routine changes of ventilator circuit tubing, strict hand washing (wear
gloves), and daily CHG bathing.
Ventilator Management ICU Liberation: ABCDEF Bundle: Patient needs to meet these criteria for extubation.
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A: Assess, prevent, and manage pain.
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B: Both spontaneous awakening trial and spontaneous breathing trial.
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C: Choice of analgesia and sedation.
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D: Assess, prevent, and manage delirium.
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E: Early mobility and exercise.
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F: Family engagement and empowerment.
Common Medications:
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Pain management:
○
Fentanyl (sedation too), Morphine, Ofirmev (IV acetaminophen), Oxycodone.
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Sedatives:
○
Propofol, Dexmedetomidine (Precedex), Midazolam (Versed), Lorazepam.
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PPI/ Ulcer Prevention:
○
Pantoprazole, Famotidine.
●
DVT Prevention:
○
Heparin, Enoxaparin.
RASS Scale: Richmond Agitation Sedation Scale
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-1/ -2 are the most common.
○
The more you sedate, the worse outcomes are.
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ICU Delirium Management:
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Non Pharmacological interventions are best.
○
Encourage family involvement.
○
Manage pain.
○
Group cares.
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Daytime light, nighttime dark.
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Update information board.
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Early mobility.
○
Remove unnecessary tubes.
Sedation Awakening Trial:
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Chronic vent dependent?
○
SPO2 <90%
○
FiO2 > 60%
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PEEP >8 ?
○
Hemodynamically unstable?
○
Positive for brain death?
■
If there are any of these things do NOT take patients off the vent.
Spontaneous Breathing Trial and Weaning Process:
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Process of: Decreasing ventilator support and resuming spontaneous breathing.
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During Trial Evaluation:
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RR >35 or <8
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Minute ventilation < 10 L
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Hemodynamically unstable
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SPO2 < 90%
Mechanical Ventilation: Extubation
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Hyperoxygenate and suction, loosen ET tapes or holder, deflate cuff and remove tube at peak of deep inspiration, encourage patient to
deep breath and cough, supplemental O2, careful monitoring after extubation.
Critical Care Environments:
Critical Care:
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Higher acuity, specialized
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High risk patients:
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Require frequent assessments and monitoring.
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EX: Vital signs and neurological assessments every hour.
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Patients who require 1:1-2 ratio.
Intermediate Care- Step Down Units:
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High acuity, specialized.
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At risk patients:
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Lower than critically ill.
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EX: Vital signs every 4 hours, neurological assessment every 2 hours.
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Patients are considered more clinical “stable”.
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Ratio is generally 1:3-4.
The Critical Care Nurse:
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Knowledgeable:
○
Frequent assessments, recognizes trends.
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Critical Thinking:
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Provides psychological support to patients and caregivers.
○
Communicate and collaborate.
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Works as part of a multidisciplinary team:
○
Multiple physician specialists, dieticians, social workers, respiratory therapists, physical/occupational/speech therapists,
family members.
Adult Intensive Care:
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Critical care units (CCU) or Intensive Care Units (ICU).
●
Different types of Adult ICUs:
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Neuro, Cardiac, Surgical, Medical, Trauma
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Level 0: Normal acute ward care
■
Level 1: Acute ward care, with additional advice and support from the critical care team.
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Level 2: More detailed observation or intervention.
■
Level 3: Advanced respiratory support alone, or basic respiratory support together with support of at least two
organ systems.
Pediatric Intensive Care Unit (PICU):
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Children ages 3 months to 18.
○
Levels of Care:
■
Level 1: Most severely ill patient population, multidisciplinary care, complex, progressive, and rapidly changing
medical illness.
■
Level 2: Moderately ill patients, provide stabilization and transfer.
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Cares include maintaining developmental stages.
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Kids crash quicker than adults but also heal quicker than adults.
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Working with patients and parents.
Neonatal Intensive Care Unit (NICU):
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Level 1: Basic care, neonatal resuscitation at delivery, stabilize infants >35 weeks and transport.
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Level 2: Speciality care for infants > 32 weeks or >1500 grams, moderately ill with problems that are expected to resolve rapidly, vent
to CPAP for less than 24 hours.
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Level 3: Sustained life support and comprehensive care for infants <32 weeks and <1500 g, and all critically ill infants. Provide a full
range of respiratory support, ECMO and minor surgeries.
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Level 4: Capability to provide surgical repair of complex congenital or acquired conditions. Immediate onsite access to pediatric
medical and surgical subspecialties and anesthesiologists .
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Care for infants between birth and 3 months developmentally.
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Main focus of care is to meet developmental needs of a newborn.
Family in the ICU:
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The experience of having a friend or relative in the ICU is physically and emotionally difficult.
○
Encourage family involvement!
■
Get them resources!
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Parents of the Critically Ill Infant & Child:
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Experience episodes of extreme stress:
○
Loss of parental role, loss of normal family functions, foreign medical terms and technology, eye witness to traumatic
events, financial concerns, isolation, separation from child, fear of losing the child.
Intensive Care Induced Anxiety:
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Overall health and/or prognosis, total loss of control, noise, equipment, pain, impaired communication, family stressors.
Nursing Care:
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Talk to the patient, therapeutic touch, communicate with family, encourage items from home, medications, non-pharmacological.
Cultural Competence:
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Treat everyone equally and nonjudgmentally, ask if there are any cultural practices they would like to continue while in the hospital,
use a translator or translating device if they speak different language than you, ensure meals and eating practices include cultural
practices, allow spiritual support and religious rituals to continue while hospitalized, offer caregiver support, ensure the medical team,
patient and family agree with pain management.
○
MARTI: Ensure patients understand and are more comfortable with translation.
ICU Delirium: Approximately 80% of ICU patients
experience delirium.
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Effectively manage pain (on the clock schedule)
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Clock and calendar (tell month and date)
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Reorient often
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Early mobilization
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Family visitation (pictures, cards, teddy bears)
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Lower alarm volumes (stimulation)
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Explain procedure steps
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Haldol and Dexmedetomidine (helps patient
disassociate from situation)
CAM Tool:
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Do every shift.
○
Checking for a hospital acquired
delirium!
■
Acute change of baseline.
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CAM Positive: care plan; management strategy.
Pain in the ICU:
●
Pain medications should be around the clock.
Immobility:
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Nursing Cares: majority comes from the nurse (mobilize joints Q2H), walk the patient as much as possible.
○
Pain, pressure ulcers, pneumonia, DVTs, contractures.
Nutrition:
●
Critical illness leads to increased metabolic demands and catabolism.
○
Providing nutrition Enteral Route:
■
Temporary: NG tubes/ OG tubes.
■
Long term: PEG tube.
○
Challenges: Ileus and diarrhea
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Parenteral Route:
■
TPN/ Central Line Access.
Promoting Proper Nutrition:
●
Consult Dietician:
○
Caloric needs evaluation: nutritional requirements calculated by dietician.
●
Assess GI System:
○
Bowel sounds
○
Nausea/ vomiting
○
Passing flatus/ stool
■
How to assess tolerance of intake:
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Not stooling, residual check, monitor lab values, proteins, Ca+, ionized calcium, BUN, albumin,
daily weights.
Living Will Challenge:
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CPR, mechanical ventilation, tube feeding, dialysis, ABX or antiviral medications, comfort care (palliative), organ and tissue
donations, donating your body for scientific study.
End of Life Cares:
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Individualized death and dying care plans, comfort measures, palliative teams, crisis interventions, grief counseling.
○
Emergency and Trauma Nursing:
Emergency Services: Treatment of life threatening problems and sometimes not so life threatening.
Legal Issues:
●
Emergency Protective Custody: Police are usually there.
●
Restraints:
○
Agitated or violent patients.
○
Danger to self or others.
●
Mandatory Reporting:
○
Federal, state, local police departments (GSW, injuries from assault).
○
Department of Public Health (communicable diseases).
○
Department of Motor Vehicles (KVC injuries and death).
○
Human Society (animal bites, rabies exposure).
■
Suicidal/ homicidal is automatically admitted.
Triage and Fast Track:
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ESI Triage Algorithm:
Trauma Primary Survey:
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A: Airway/Alertness
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B: Breathing
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C: Circulation
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D: Disability
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E: Environment
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F: Full set of vitals/family
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G: Get resuscitative adjuncts
○
Primary Survey (ABCDEF): Uncontrolled external hemorrhage: Reprioritized CAB
■
Direct pressure, pressure dressing, and applying a tourniquet.
Alertness:
●
Determine LOC
●
Assess patient response to verbal and/or painful stimuli.
○
AVPU: How do they respond?
■
A= alert
■
V= voice
■
P= pain
■
U= unresponsive
Airway Obstruction: Cause of nearly all immediate trauma deaths.
●
Patients at risk for airway compromise.
○
Seizures, drowned, anaphylaxis, foreign body obstruction, cardiopulmonary arrest.
■
Protect Airway:
●
Suction, unconscious patients (insert nasopharyngeal or oropharyngeal airway), ET tube, emergency
trach.
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Jaw Thrust Maneuver:
●
IF: Suspected cervical spine trauma in any patient with face, head, neck trauma and/or significant upper chest injuries.
○
Stabilize cervical spine:
■
Cervical collar (C-collar)
■
Cervical immobilization device (CID)
Breathing:
●
Assess for dyspnea, cyanosis, paradoxical/asymmetric chest wall movements, decreased/absent breath sounds, visible wound to the
chest wall, cyanosis, tachycardia, hypotension.
○
Administer high flow oxygen via nonrebreather mask.
■
For life-threatening conditions:
●
Bag-valve mask (BVM) ventilation with 100% O2.
●
Needle decompensation.
●
Intubation.
●
Treatment of underlying cause.
Circulation:
●
Check central pulse:
○
Peripheral pulses may be absent because of injury or vasoconstriction.
○
Assess quality and rate.
●
Assess skin:
○
Color, temp, moisture.
●
Assess for signs of shock:
○
Mental status, check for delayed cap refill.
●
I/O access (poor IV access, poor BP, no intravascular volume), insert 2 large bore IVs, initiate aggressive fluid resuscitation using
normal saline or LR.
Disability:
●
Brief Neuro Exam.
○
Glasgow Coma Scale (standardized for consistent communication among care team members)
●
Pupillary response.
Exposure and Environmental Control:
●
Remove clothing to perform physical assessment.
●
Do NOT remove impaled objects.
●
Prevent heat loss.
●
Maintaining privacy.
Full Set of Vitals/ Family Involvement
Get Resuscitation Adjuncts:
●
LMNOP:
○
L= Laboratory studies.
○
M= Monitor ECG.
○
N= Nasogastric tube or orogastric tube.
■
UNLESS a patient has a head trauma.
○
O= Oxygenation and ventilation assessment.
○
P= Pain management.
Secondary Survey:
●
Brief, systematic process to identify all injuries.
○
History (SAMPLE):
■
S: Symptoms
■
A: Allergies
■
M: Medication history
■
P: Past health history
■
L: Last meal/ oral intake
■
E: Events of environmental factors leading to illness or injury
Head, neck, and face, chest, abdomen and flanks, pelvis and perineum, musculoskeletal, inspect posterior surfaces.
●
Head, Neck, and Face:
○
Disconjugate Gaze: Failure of the eyes to turn together in the same direction.
○
Battle’s Sign: Bruise behind the ear that indicates a fracture at the bottom of the skull.
○
Racoon’s Eyes: Results from facial injury/trauma.
○
Ears: Blood and CSF drainage.
■
Look inside the ears and nose.
■
If you see CSF drainage do NOT stop it! Let it drain (decreases ICP).
●
Nursing Management: Brain Injuries
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CSF Drain Placement, ICP monitoring (drill in the skull), strict blood pressure monitoring and management, implement
seizure precautions, positioning, prevent shivering.
■
Keep head midline and straight.
Spinal Cord Injuries:
●
Injury where sudden flexion, hyperextension, vertebral fracture, compression, or direct injury to the spinal cord.
○
Obtain a CT scan initially, MRI when the patient is stable.
■
Stabilize the head with a collar/halo.
Thoracic Injuries:
●
Paradoxical chest movements.
●
Large sucking chest wounds.
●
Pneumothorax, hemothorax, hemo-pneumothorax, rib fractures, pulmonary contusion, blunt cardiac injury.
●
Cardiac tamponade.
○
Pneumothorax:
■
Closed: Collapsed lung in which the chest wall remains intact.
■
Open: Sucking chest wound (stab wound).
■
Tension: A tension pneumothorax is a life-threatening condition caused by a pleural injury which acts as a
one-way valve. As a result, air can enter the pleural space during inspiration, but is unable to escape during
expiration. The accumulated air in the pleural space compresses the lungs, blood vessels, and other structures of
the chest cavity.
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A tension pneumo causes a deviated trachea.
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Leads to cardiac arrest.
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Needs needle decompensation immediately.
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Nursing Management for Thoracic Injuries:
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Manage airway, intubate if needed, STAT CXR, chest tube placement/needle aspiration, apply appropriate dressings, apply
oxygen, administer pain meds, administer blood products to improve oxygen carrying capacity, prepare for surgery.
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Dressing for pneumothorax:
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Tegaderm taped on 3 sides, leaving one side open.
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Allows for air to escape.
Cardiac Tamponade: Compression of the heart due to fluid buildup in the sac surrounding the heart.
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Blood leaks into the pericardial sac, hypotension, narrowed pulse pressure, jugular vein distension (jugular vein is bounding), muffled
heart sounds, pulsus paradoxus.
Abdominal Injuries:
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Frequent evaluation for subtle changes is essential.
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Blunt trauma, penetrating trauma.
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Auscultate, inspect, percuss, palpate.
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Impaled Object: Stabilize and do NOT remove.
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FAST: Ultrasound for intra abdominal hemorrhage.
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Nursing Management:
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Complete the primary and secondary survey, take VS Q15 minutes until stable, support BP, manage hypothermia,
coagulopathy, CT scan, monitor for peritonitis/evisceration, prepare for surgery.
Pelvic Injuries:
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High fatality risk because of aorta and iliac arteries.
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Cavity can hold up to 4L of blood, and may affect the kidneys, pelvis and peritoneum.
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Gently palpate the pelvis.
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Do NOT rock the pelvis.
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Pain may indicate pelvic fracture/cxr.
STABILIZE!
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Inspect the genitalia.
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Quality of or inability to void.
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Can be done by the physician.
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Nursing Management of Pelvic Injuries:
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Administer fluids/blood, vasopressors, stabilize the pelvis, place foley if indicated, assess leg length and splint, CT scan of
abdomen and pelvis, prepare for emergent surgery, administer pain meds, administer abx.
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Fractured leg will be shorter in length.
Musculoskeletal Injuries:
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Closed vs. Open Injuries:
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Point tenderness, crepitus, deformities.
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A pulseless extremity is a time critical emergency.
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Limb will die.
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Compartment Syndrome: 6 P’s
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Pain
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Pallor
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Pulselessness
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Paresthesia
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Paralysis
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Poikilothermia
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Nursing Management:
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Immobilize, elevate, assessing the 6 ps, tetanus prophylaxis, wound care, apply ice, antibiotics for open fractures.
Inspect the Posterior Surfaces:
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Logroll the patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces.
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Requires 3-4 people, support the head.
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Ecchymosis, abrasions, puncture wounds, cuts, obvious deformities.
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Palpate the entire spine.
Burns Nursing Management:
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Administer humidified oxygen (100% if carbon monoxide injury).
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Administer bronchodilator and mucolytic agents.
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2 large bore IVs and administer fluids.
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Escharotomy
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Elevate affected extremities, administer pain meds, wound care, administer abx.
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What did the burns do to the patient internally?
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Smoke dries out the lungs -----> vasoconstriction/mucous -----> bronchodilators and mucolytic agents.
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Oxygenation is critical.
Drowning Nursing Management:
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Administer 100% oxygen, remove wet clothes, apply blankets, administer warm IV fluids.
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High PEEP and RR
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Bronchoscopy.
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Fluid causes the airway to collapse; bronchoscopy sucks fluid out.
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