Advanced Directives

- Communication that specifies a person’s preference about medical treatment should that person become incapacitated (pt is physically or mentally unable to communicate a willful and knowing health care decision)

- Failure to follow an advanced directive may result in a lawsuit

Living will

- This provides a mechanism by which individuals can authorize which specific treatments can be withheld or desired in the event they become incapacitated.

- Individuals can change their directive anytime 

Durable power of attorney

- It’s more protective in the patient’s interest regarding medical treatment than is the living will. Legal document?

- Patients can legally designate an agent whom they trust, like a family member or friend, to make decisions on their behalf should they become incapacitated.

- They also deal more with the finances

- This can be a surrogate or a proxy

- Communication and shared decision making among the patient, family, and health care team regarding end-of-life issues are key

- The critical care nurse is legally responsible for providing care according to the advance directives  

Autonomy

- All persons should be free to govern their lives to the greatest degree possible

- It implies a strong sense of self-determination and an acceptance of responsibility for one’s own choices and actions

- To respect the autonomy of others it means to respect their freedom of choice and to allow them to make their own decisions

Beneficience

- The duty to provide benefits to others when in a position to do so the help balance harms and benefits AKA benefits of action should outweigh the burdens 

Justice

- Health care resources be distributed fairly and equitably among groups of people 

Veracity

Persons are obligated to tell the truth in their communication with others

Fidelity

Requires that one has a moral duty to be faithful to the commitments that one makes to others

Confidentiality

Respect for an individual’s autonomy and the right of individuals to control the information relating to their own health

Cultural Beliefs (p. 49/Slide 5)

- It’s necessary to understand how cultural and ethnic differences affect crucial end-of-life decision-making processes and communication preferences in diverse groups, and how these may vary during stressful situations

- Better understanding of these cultural differences in end-of-life care preferences will lead to more effective and satisfying care and communication with patients and families.

- Religious doctrine and beliefs profoundly influence patients and families choices for end-of-life care.

- Caucasians prefer less invasive and aggressive treatments options near the end of life while African Americans tend to choose more aggressive treatments 

End of Life Care (p. 49 box 4-4)

- Assess patient’s and family members’ understanding of the condition and prognosis to address educational needs

- Educate family members about what will happen when life support is withdrawn to decrease their fear of the unknown

- Assure the family members that the patient will not suffer or be abandoned

- Provide for emotional support and or spiritual care resources, such as grief counselors and spiritual care providers

- Facilitate physician communication with the family

- Provide visitation/ presence of family and extended family. Most family members do not want the patient to die alone.

Surrogate and Proxy (Slide 9)

Surrogate

Designated by patient as part of advanced directive

They are to act as patient would have acted in similar situation

Proxy

Legally designated decision maker

State statute may designate order of succession 

End of Life Care (Cont)

                                             i.     Religious doctrine may affect decision making at the end of life

                                             ii.     Factors related to aggressive care at end of life

1.     Failure to discuss death and dying by patients, families, and health care team members

2.     Lack of assessment tools to provide early identification of end-of-life patients

3.     Identification of end-of-life patients is subjective

4.     Cultural influences at end of life vary by group and region

                                            iii.     Presence of advance directives and end-of-life care desires should be shared with significant others well before needed

                                            iv.     Dimensions of end of life care:

1.     Palliation

a.     Elements of palliative care

b.     Early identification of end-of-life patients

c.     Pain management as “fifth vital sign”

d.     Pharmacologic and nonpharmacologic interventions to:

e.     Relieve pain

f.      Control anxiety

g.     Control other distressing symptoms

h.      

2.     Communication and conflict resolution

3.     Withdrawal, limiting, or withholding therapy

4.     Emotional care to patient and family

5.     Organizational support

                                             v.     Time and unit staffing may impact the delivery of optimal end-of-life care

                                            vi.     Establish bereavement programs

                                          vii.     Provide caregiver support

                                         viii.     Provide education on end-of-life issues to health care providers and the public

Surrogate & Proxy

  Surrogate 

Designated by patient as part of advanced directive

They are to act as patient would have acted in similar situation

Proxy

Legally designated decision maker

State statute may designate order of succession 

Futulity & Negligence

(p. 32, 29)

Futility

- Care should not be given if it is futile in terms of improving comfort or the medical outcome

- Medical futility: situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient’s health condition

Negligence

- It’s defined as, 1) “the failure to exercise the standard of care that a reasonable prudent person would have exercised in the same situation, “ and 2) “a tort grounded in this failure, usually expressed in terms of the following elements: duty, breach of duty, causation, and damages.”

- Failure to practice standards of care frequently results in injury to patients, resulting in nurses being sued under tort law.

- Torts are civil lawsuits brought against people for monetary damage.

- Lawsuits for medical malpractice often occur months or years after the event that caused the damage to the client

- Thorough and accurate documentation is of prime importance

- Documentation must le legible because lawsuits have been won because of an inability of medical professionals to read their handwriting

Elements of informed consent 

(p. 33)

- There are three primary elements that must be present for a person’s consent or decline of medical treatment or research participation to be considered valid: competence, voluntariness, and disclosure of information

- Competence:

it’s the persons ability to understand information regarding a proposed medical or nursing treatment

It’s a legal term and it’s defined in court

- The ability of patients to understand relevant information is an essential prerequisite to their participation in the decision making process and should be carefully evaluated as part of the informed consent

- Voluntary

- Consent must be given voluntarily, without coercion or fraud, for the consent to be legally binding

- There should be freedom of pressure from family members, health care providers, and payers

- Information

- A diagnosis of the patient’s specific health problem and condition

- The nature, duration, and purpose of the proposed treatment of proposed treatment procedure

- The probable outcome of any medical or nursing intervention

The benefits of medical or nursing interventions

- The potential risks that are generally considered common or hazardous

- Alternative treatments and their feasibility

- Short-term and long-term prognoses if the proposed treatment or treatments are not provided

- The nurse’s job is not to provide a patient with the information to obtain informed consent- this is the role of the physician.

- The nurse has to witness the signature

- If the patient asks questions to the nurse and the nurse believes the patient does not understand the procedure enough to give consent, it is the nurse’s duty to have the physician or assigned medical professional explain the procedure again to the patient 

Withdrawing and withholding treatment

( pg. 46 and slides)

- It’s not euthanasia or assisted suicide

- Withdrawal of treatment: discontinuation of life-sustaining therapies in a terminally ill ot persistently vegetative state

- Withholding of treatment: failure to initiate life-sustaining therapies in a terminally ill or persistently vegetative patient

- Life-sustaining therapies that may be withdrawn or withheld: respiratory support, vasopressors, dialysis, nutritional support, hydration, antibiotics and other medications, blood

- Withholding life-sustaining treatment is moral equivalent of withdrawing treatment

- Any treatment with patient and family consent may be withheld

- Any dose of analgesic or anxiolytic medication may reasonably be used to relive suffering, even if the medication has the potential to hasten death

- Signs of suffering are dyspnea, tachypnea, diaphoresis, grimacing, accessory muscle use, nasal flaring and restlessness

- Life-sustaining treatment should not be withdrawn while a patient is receiving paralytic agents

Nursing interventions for Witholding and Withdrawing Medical Treatment

- Provide anticipatory guidance to patient and family

- Anticipate distressing symptoms and medicate to relieve symptoms

- Titrate therapy to relive emotional and physical distress

- Ongoing assessment of response to therapy and comfort 

Pharmacological interventions for witholding and withdrawing medical treatment

- IV benzodiazepine for anxiety

- IV morphine for dyspnea and pain

- Medication titration to relieve symptoms often with protocol 

Terminal Weaning

- Titration of ventilator to minimal levels

- Removal or ventilator while maintaining artificial airway

- Complete extubation

- Symptoms control of pain, dysnpnea, and axiety

Ethical Dilemmas

(Risk factors slide)

- Warning Signs

- Emotionally charged

- Significant change in patients condition

- Confusion about facts

- Hesitancy about what is right

- Deviation from customary practice

- Need for secrecy regarding proposed actions

- Dilemmas can result in moral distress 

Palliative Care

Definition: it’s the provision of care interventions that are designed to relieve symptoms of illness or injury that negatively impact the quality of life of the patient and or family

- This is not limited to dying

- Common distressing symptoms that may occur with multiple disease states include pain, anxiety, hunger/thirst, dyspnea, diarrhea, nausea, confusion/agitation, and disturbance in sleep patterns. 

-Elements of palliative care

-Relief of distressing symptoms should always be provided whenever possible, even when the primary focus of care is lifesaving or aggressive treatment.

- An important part of palliative care consists of “simple” nursing interventions like frequent repositioning, good hygiene and skin care, and creation of a peaceful environment to the extent possible in the critical care setting.

- The use of palliative care experts to assist in managing patient’s care decrease hospital lengths of stay and resource utilization.

- Improved patient/family communication and better management of pain and other symptoms are additional benefits noted.

- Earlier identification of patient’s who are unlikely to benefit from further aggressive care, and improved management of pain and other symptoms, are effective strategies to improve end-of-life care.

- Frequently nursing assessment for symptoms of pain should be considered the “fifth vital sign” and nurses should be aware of the fact that people express pain in different ways

- There are pharmacological and nonpharmacological interventions to relieve pain, control anxiety and control other distressing symptoms. 

Criteria for brain death

(pg. 39 box 3-6)

- Absence of spontaneous respiration

- Absence of spontaneous movement

- Cessation of brain function, including absence of all functions of the brainstem and cerebral hemisphere, and verified by:

- No response on neurological examination

- Isoelectric electroencephalogram

- Bilateral absence of cortical response to median somatosensory-evoked potentials

- Absence of cerebral blood flow in the absence of hypothermia or drug-induced states 

Transplant rejection

(signs and symptoms of cardiac, renal rejection slides

Cardiac)

- Usually they get a biopsy done every week for the first few weeks

- Biopsy is graded based on severity of interstitial infiltration of lymphocytes

- Symptoms of rejection may be subtle and include:

- Weight gain- the heart not pumping and holding on to the fluids which results in the added weight

- SOB- holding on to the fluids

- Fatigue

- Abdominal bloating

- Fever

Renal:

- Compliance and immunosuppressive medication is essential to avoid or decrease the incidence of rejection

- Acute rejection (days to months) accounts for 90% of rejection episodes

- s/s: fever, edema, gross hematuria, pain over graft site, increased BUN or weight gain, fluctuations in U/O, hypertension

based on biopsy findings 

Cardiac Rejection Diagnosis

1. Biopsy 4-6 weeks post transplant

2.     Then increasingly longer periods based on recipients clinical presentation

3.     Biopsy is graded based on severity of interstitial infiltration of lymphocytes

4.     Standard grading for rejection (0= no rejection; 4= severe rejection)

5.     Symptoms of rejection may be subtle and include- weight gain, SOB, fatigue, abdominal bloating, or fever

6.     In the cardiac patient - cardiac allograft vasculopathy or chronic rejection is accelerated diffuse arteriosclerosis and is one of the limiting factors to long term survival in cardiac transplant

7.     Can result in myocardial ischemia, infarction, heart failure, ventricular dysrhythmias, and death

8.     Other risk factors for rejection in addition to immunological mechanisms include: smoking, obesity, DM, hyperlipidemia, hypertension, older donor and older recipient

Transplant medications

(immunosuppressant, side effects, ) slides

- The medications consist of T-cell proliferation and differentiation, deplete lymphocytes, and inhibit macrophages

- Antirejection meds:

-- Steriod (methylprednisone)

- Antiproliferation agent aka antorejection meds

- CellCept, Imuran, or siroimus

- Immunosuppressants

- Cyclosporine (Neoral)

- Used for arthritis and Crohn’s disease and want to give in low doses

- Tacrolimus (prograf)

- Can not have with grapefruit juice (side note: also can’t have with statins)

Complications of Anti-Rejection Medication

- Nephrotoxicity- check BUN and creatinine

- Hypertension

- Hyperlipidemia- cholesterol

- Bone loss

- Infection

***Give immunosuppressants 4 hours before giving CellCept

- Also if drug comes in liquid give it with orange juice

- It’s the same meds for all the transplants 

Treatment for hypovolemia

(pg. 661 and slides )

- Since the most common cause of hypotension is from acute blood loss the first thing you want to do is stop the bleeding

- Initial interventions are to apply pressure to control the bleeding, replacing circulatory volume with crystalloid and blood products and determining definitive treamtment.

- You want to start two large-bore IVs (central line may be needed) to get the fluid in first

- Administration of crystalloids and blood products

- Lactated Ringer’s are the fluid of choice

- Blood administration is based on the response to initial fluid resuscitation and lab values

- 3:1 ratio

- 3 ml of crystalloids to every 1 ml of blood lost

- You want 50ml/hr of urine for hypovolemia so you know that the patients fluid status is ok

BENZODIAZEPINES

(Pain meds and anti-anxiety meds pg. 69-71)

- They are sedatives and hypnotics that block new information and potentially unpleasant experiences at that moment

- The patients age, prior alcohol abuse, concurrent drug therapy, and current medical condition affect the intensity and duration of drug activity

- It should be titrated to a predefined end point

- Hemodynamically unstable patients may become hypotensive with the initiation of sedation

- Patients receiving continuous infusions must be monitored for the effects of oversedation 

Propofol

(Pain meds and Anti-anxiety meds p. 69-71)

- It’s sedative and hypnotic effects are achieved at lower doses

- It has a rapid onset and short duration of sedation once it is discontinued

- Adverse effects include hypotension, bradycardia, and pain when the drug is infused through a peripheral IV site

- Long-term high dose infusions may result in high triglyceride levels, metabolic acidosis, or dysrhythmias

- It requires a dedicated IV catheter for continuous infusion because of the risk of incompatibility and infection 

Dexmedetomidine

(Pain and anxiety meds p. 69-71)

- It’s approved for short-term use as a sedative in pts receiving mechanical ventilation

- Bradycardia and hypotension may develop, especially in the presence of hypovolemia, in patients with severe ventricular dysfunction and in the elderly 

Pain and Anxiety Meds p. 69-71

Midazolam (Versed)

Diazepam (Valium)

Lorazepam (Ativan)

Propofol (Diprivan)

Dexmedetomidine (Precedex)

Opioids

(Pain and Anxiety Meds)

- The benefits of opioids include rapid onset, ease of titration, lack of accumulation, and low cost

- Respiratory depression is a concern in non-intubated patients

- Hypotension may occur in hemodynamically unstable patients or in hypovolemic patients

- A depressed LOC and hallucinations leading to increased agitation may be seen in some patients

- Gastric retention and ileus may occur as well

- Renal or hepatic insufficiency may alter opioid and metabolite elimination

- Titration to the desired response and assessment of prolonged effects are necessary 

Epidural Analgesia 

(Pain and Anxiety Meds)

- This has been shown to decrease postoperative analgesic requirements, decrease pain, enable patients to get more rest, allow patients to move within 24 hours after surgery, improve pulmonary function, decrease the number of days patients require mechanical ventilation, and decrease critical care and hospital stays

- Patients receiving epidural analgesia are carefully assessed to determine the appropriateness of spinal analgesia

- Contraindications are coagulopathies, cardiovascular instability, sepsis, spinal injury, infection or injury to the skin at the proposed insertion site, patient refusal, inability to lie still during catheter insertion, and alcohol or drug intoxication

- It’s difficult to place an epidural catheter in obese patients or patients with compression fractures of the lumbar spine

- Potential side effects of spinal analgesia with opioids include respiratory depression, sedation, nausea and vomiting, and urinary retention

- Potential side effects of spinal analgesia with local anesthetics include sympathetic blockade, motor weakness, sensory block, and urinary retention

NSAIDS

(Pain and Anxiety Medications)

- Potential to cause significant adverse effects including gastrointestinal bleeding, bleeding secondary to platelet inhibition, and renal insufficiency

- NSAID’s should not be administered to patients with asthma and aspirin sensitivity

- Fentanyl (Sublimaze [IV], Duragesic [patch]

- Has the fastest onset and the shortest duration. The patch provides consistent drug delivery, but the extent of absorption varies depending on permeability, temperature perfusion, and thickness of skin 

List some NSAIDS

Hydromorphone (Dilaudid)

Longer duration of action

Morphine

Longer duration of action

Asprin

Ketorolac (Toradol)

In IV form

Acetaminophen (Tylenol)

Used cautiously in patients with renal or hepatic dysfunction

Patient controlled analgesia  and critical care patient pg. 73

- It’s medication delivery system in which the patient is able to control when medication is given

- It involves a special type of infusion pump that has a “locked” supply of opioid medication

- When the patient feels pain the patient can depress a button on the pump that will deliver a prescribed bolus amount of medication

- This type of pain management is rarely appropriate for the critically ill patient because most patients are unable to depress the button or they are too ill to manage their pain effectively

- However some patients in the surgical critical care unit after an elective operation may benefit from PCA therapy to manage postoperative incisional pain

SUPPORT

(study finding slides)

- This was Landmark Research- study to understand prognoses and preferences for outcomes and risk of treatment (1995)

- The main conclusion: there was a lack of communication between patients and health care providers

- Disparity between patient preferences and care provided

- Aggressive care frequently implemented

- Pain and suffering experienced by patients

- Research on care of dying patients in critical care is lacking and must be national priority 

Truama

 -  5th leading cause of death overall

-   Major cause of death and disability ages 16 to 44 years of age

-  Often associated with drugs and alcohol

                                  1.     Treatment

Blunt Truama

•     Common vehicular trauma, assault with blunt objects, falls, and sports
•  Severity depends on kinetic energy dissipated to the body
•  Acceleration
• Deceleration
•  Shearing
•  Crushing
• Compression

•     This is the most common mechanism if injury

  - It’s often from MVC but it also occurs from assaults with blunt objects, falls from heights, sports-related activities, and pedestrians hit by a car

  - The severity depends on the amount of kinesthetic energy dissipated to the body and its underlying structures

  - This is usually a coup-contrecoup injury

  - Low density porous tissues and structures like lungs, tolerate energy transference and often experience little damage because of their elasticity

  - But organs like the heart, spleen, and liver are less resilient because of the high-density tissue and the decreased ability to release energy without resultant tissue damage 

Penetrating Trauma

•  Impalement of foreign objects into the body
•  Stab wounds are low velocity injuries
•  Gunshot wounds are high velocity injuries
•  Cavitation
•  Injuries depend on body part(s) involved and on the trajectory of the impaled (or sharp) object or bullet

•     This results from the impalement of foreign objects into the body

  - Stab wounds are low-velocity

  - Important considerations of a stabbing are the length and width of the impaling object

  - Bassistic trauma is considered medium or high velocity injuries

  - Medium velocity- is like handguns and some rifles

  - High velocity- are like assault weapons and hunting rifles

  - As bullets travel through tissue, damage to the surrounding tissues and organs may occur

  - Entrance wound is usually smaller than the exit wound

  - Blast Injuries

  - They are forms of blunt and penetrating trauma

  - Energy exchanged from the blast causes tissue and organ damage 

Trauma Triage pg. 654-655

- Definition: sorting the patients to determine which patients need specialized care for actual or potential injuries

- This is essential for determining if patient needs to be transferred to a level I trauma center

- Triage decisions are often made by prehospital personnel based on knowledge if the mechanisms of injury and rapid assessments of the patients clinical status

- It’s important to know that happened in the field (time before the hospital)

- The EMT’s are usually the ones that are collecting the infomation

- Trauma is classified as minor or major depending on the severeity of injury

- Minor trauma- single-system injury that does not pose a threat to life or limb

- Major trauma- a serious multiple system injury that requires immediate intervention to prevent disability, loss of limb or death

- A score of 1 indicates minor injury and a score of 6 is fatal

- Triage decisions are based on abnormal findings in the patient’s physiological functions, the mechanism of injury, the severity of injury, the anatomical area of injury, or the evidence of risk factors such as age and preexisting disease

Levels of Trauma Care 

(p. 652)

- The development of trauma systems has reduced the preventable death rate from unintentional injuries from 40% 30 years ago to less than 4% today

- The goal of a trauma system is to match the needs of injured patients to the resources and capabilities of the trauma facility 

LEVEL 1

Levels of Trauma Care

- Regional resource that has tertiary care hospitals.

- It has maximal resources across the spectrum of trauma care including prevention programs, acute treatment, rehabilitation, and trauma-related research, and most of them are university-based teaching hospitals.

- Patients who are most severely injured should be cared for in a Level I trauma center 

LEVEL II

(Levels of Trauma Care p. 652)

- They provide definitive care to severely injured patients, but they may not be able to provide the same comprehensive trauma care as a Level I because of limited resources

- It may care for complex patients, but transport to a Level I hospital may be necessary 

LEVEL III

(Levels of Trauma Care) 

- They are often in the communities where no Level I or II exist

- They provide prompt assessment, resuscitation, emergency surgery, and stabilization of a patient until transfer of the patient to a higher level of trauma care is arranged. 

Level IV

- They provide advanced trauma life support and prepare for immediate transport of the patient 

Blunt versus  Penetrating 

(Trauma pg. 656)

- Blunt: caused by acceleration, deceleration, shearing, crushing, and compressing forces

- Brain tissue strikes the cranium and is thrown back against the opposite side of the cranial vault, resulting in coup-contrecoup injury

- Shearing forces of the cerebral tissue and the skull causes vessels to stretch and exceed their elasticity, resulting in tears, dissection, or rupture

- Penetrating: impalement of a foreign object into the body 

Airways

(when use oral pg. 192-193)

Oral airways

The oropharyngeal airway prevents the tongue from falling back and obstructing the pharynx

It’s indicated when the patient has a depressed LOC, resulting in loss of muscle tone and airway obstruction

- It’s contraindicated in patients who are awake because it stimulates the gag reflex, resulting in discomfort, agitation, and possibly emesis

- It’s important to choose the proper airway size

- If it’s too short, it forces the patient’s tongue back into the pharynx

- An airway that’s too long stimulates the gag reflex

- Nasopharyngeal airway

- It’s a soft rubber tube that’s placed in the nose and extends to the posterior portion of the pharynx

- It’s used if the patient’s jaw is tight during a seizure, or if oral trauma is present

- Complications include insertion into the esophagus if the airway is too long, nosebleeds, and ulceration of the nares

- Extended use is not recommended because of an increased risk for sinusitis or otitis 

Primary Survey

- It’s the most crucial assessment tool in trauma care

- It’s a rapid, 1 to 2 minute evaluation to designate life-threatening injuries accurately, establish priorites, and provide simultaneous therapeutic interventions

- It’s a systematic survery (ABCDE’s)

- Airway patency with cervical spine immobilization

- Breathing and ventilation

- Circulation with hemorrhage control

- Disability or neurological status

- Exposure/environmental conditions

- All major life-threatening conditions must be treated before one proceeds to the secondary survey 

Secondary Survey

- It’s amethodical head-to-toe evaluation using assessment techniques of inspection, palpation, percussion, and auscultation to identify all injuries

- The secondary survey is initiated after the primary survey has been completed and all actual or potential life threatening injuries have been identified and addressed

- Heart rate, auscultated blood pressure, core body temperature, respiratory effort, and LOC are obtained as a baseline for analysis of trends during the resuscitation phase

- Features of the secondary assessment (FGHI)

- Full set of vitals, five interventions (cardiac monitor, pulse oximetrey, urinary catheter, nasogastric tube, lab tests) and facilitate family presence

- Give comfort

- History and head-to-toe assessment

- Inspect posterior 

Basilar Skull Fracture

(Complications p. 408)

- They are linear fractures at the skull base

- It’s difficult to conform on an x-ray study and is diagnosed with the clinical presentation of the patient:

- Battle’s sign ( bruising behind the ear)

- Raccoon eyes (bilateral periorbital edema and bruising)

- Dural tears are common with a basilar skull fracture and may lead to meningitis

- Drainage of CSF from the nose, postnasal drainage, or drainage of the - - -- CSF from the ear may indicate a dural tear

- If CSF is suspected a sample of the drainage is sent to the laboratory

- Nothing should be placed in the nose but tissues can be placed underneath to absorb the drainage

- The pt can’t blow their nose 

Trauma an Cardiac output

(p. 667)

- Cardiac output is impaired because of decrease venous return 

•  Cardiac Tamponade
•  Bleeding into pericardial space
•  Impairs pumping ability of heart
•  May be difficult to diagnose
• Beck’s triad
• a.     Hypotension
• b.     Muffled heart sounds
• c.     Elevated venous pressure
• Suspect in patient with symptoms of decreased cardiac output who does not respond to treatment
• 6.     Treated by pericardiocentesis
•                                                i.     Complications include raccoon eyes, preorbital edema,
•                                              ii.     Trauma and cardiac output: hypovolemic shock occurs when the circulating blood volume is inadequate to fill the vascular network. Maybe caused by external and internal losses of either blood or fluid.
•                                             iii.      External loss of blood: GI hemorrhage, surgery and trauma
•                                             iv.     External loss of fluid: Diarrhea, diuresis, burns 
•                                              v.     Clinical presentation:  increase HR, decrease BP, Tachypnea, oliguria, cool, pale skin, decrease mentation flat neck veins, decrease CO, CL, RAP, PAP, PAOP, increase SVR, decrease SV02, and increase hematocrit: if from dehydration and DECAREAS hematocrit if from blood loss.
•                                             vi.     Hemodynamic: Preload is the degree of ventricular stretch prior to the next contraction and is influenced by the volume of blood in the ventricles at the end of diastole.  Afterload: the amount of resistance the ventricles must overcome to deliver the stroke volume into the receiving vasculature (the pressure, or resistance to blood flow, out of the ventricle
•                                           vii.      cardiac output : 4-8 l/min, APC 2-6mmHg, Pulmonary artery occlusion pressure: 8-12mmHg.
• Management: eliminate and treat the cause replace lost volume with appropriate fluid 

Treatment of hemorrhage 

- Assess for internal bleeding slides

- Do an ongoing assessment of vital signs, UO, mental status, and hemodynamic parameters

- You want to stop the bleeding and have venous access of 2 large bore IVs (maybe a central line may be needed)

- Administration of crystalloids and blood products

- Lactated ringers are the fluid of choice

- Blood administration is based on the response to initial fluid resuscitation and laboratory values

- There the 3:1 ratio which is 3 mls of crystalloids per 1 ml of blood lost

- Massive Fluid Resuscitation

- Administration greater than 10 units od packed red blood cells in 24 hours

- 1:1:1 ratio of blood, platelets, plasma

- This restores oxygen transport to tissues

- Stops progress of shock

- Prevent complication 

ABGs

- Effects of PaCo2 on cerebral blood volume 661

- When a patient presents with multiple systemic injuries, hemorrhagic shock, chest trauma, and/or central nervous system trauma must be assessed for impaired gas exchange

- These conditions have the potential to affect the pt’s volume status (decreased) and oxygen–carrying capacity, interfere with the mechanics of ventilation, or interrupt the autonomic control of respirations

- You want the PaCo2 to be between 35-45 mmHg

Lab values 

(electrolytes, Calcium, Lactate) pg. 664

Electrolytes

- Imbalance can lead to hypocalcemia, hypomagnesemia, and hyperkalemia or hypokalemia

- It can also lead to changes in myocardial function, laryngeal spasm, and neuromuscular and central nervous system hyperirritability

- Sodium 135-145 mEq/L

- Potassium 3.5-5 mEq/L

Calcium

- Decreased calcium levels may lead to ineffective coagulation because calcium is a necessary cofactor in the coagulation cascade

- 8.2-10.2 mEq/dL

Lactate

-Anything that deprives the tissues of oxygen disrupts the Kreb’s cycle, resulting in anaerobic metabolism and lactic acidosis

- High serum lactate levels are noted in pts with hypoperfusion like in shock states

- Normal levels is less than 1 mEq/L

-It may be useful in guiding fluid resuscitation in the hypoperfused patient 

Needle Thoracostomy and chest tubes

(pg. 668) 

- In a tension pneumothorax, immediate decompression of the intrathoracic pressure is accomplished by needle thoracostomy

- The physican inserts a 14 gauge needle into the second intercostals space at the midclavicular line on the injured side

- This converts a tension pneumothorax to a simple pneumothorax

- In a hemothorax placement of a chest tube facilitates removal of blood from the pleural space with resolution of ventilation and gas exchange abnormalities

- Nursing interventions include management of the chest tube, close observation of the amount of blood drained from the pleural space, and monitoring the patient’s hemodynamic response

- A chest tube is placed in an open pneumothorax 

Complications of large amount of volume replacement

(pg. 664)

- Acid- base abnormalities; metabolic acidosis

- Fluid-electrolyte imbalances that may develop include hypocalcemia, hypomagnesemia, and hyperkalemia or hypokalemia

- This may lead to changes in the myocardial function, laryngeal spasm, and neuromuscular and central nervous system hyperirritability

- Hypothermia

- Dilutional coagulopathy may occur with excessive IV fluid resuscitation and extensive blood loss.

- Banked blood has high levels of citrate which may induce hypocalcemia and calcium plays a role in the clotting cascade

- Monitoring the hemoglobin level, hematocrit value, plasma fibrinogen level, platelet count, prothrombin time, and partial thromboplastin time is essential

- Organ dysfunction because the blood is being shunted to the vital organs which are the heart and brain

- Volume overload from third spacing of aggressive fluid resuscitation

- In hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules.

- So with aggressive fluid resuscitation, the change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third-spacing)

- Then hypovolemia occurs in the intravascular space so the pt needs more fluid, but as more fluids are given to support systemic circulation, fluids continue to migrate to the interstitial spaces causing edema

DVT

(treatment pg. 672)

•                                                i.     Complication of traumatic injury
•                                              ii.     Assess risk factors
•                                             iii.     Prevention of complications
•                                             iv.     Diagnosis:
• 1.     Doppler flow studies
• 2.     Duplex scanning
•                                              v.     Impedance plethysmography
•                                             vi.     DVT prophylaxis
• 1.     Early ambulation
• 2.     Compression devices
• 3.     Low-dose anticoagulant
• 4.     Filter in inferior vena cava

•     DVT prophylaxis

  - Early ambulation

  - Compression devices

  - Low-dose antocoagulant

  - Filter in inferior vena cava

  - Prevention is essential in the management of trauma patients 

PE –signs and symptoms

(pg. 295 pg. 464)

- Massive PE is manifested by clinical indications of right ventricular failure ( jugular venous distension, periperal edema, hepatomegaly)

- Dyspnea, hemoptysis, and chest pain have been called the “classic” signs of symptoms for a PE

- It should be expected if the pt has unexplained cardiorespiratory complaints and has any risk factors for VTE (venous thromboembolism)

-The pt may also be anxious with a feeling of impending doom

Other s/s: chest wall tenderness, chest pain aggrevated by deep inspiration, tachypnea, decreased SpO2, tachycardia, cough, crackles, wheezing, and hemoptysis

Treatment of bone fractures pg. 670 

• Closed or open reduction; may need traction
• Treatment of hypovolemia and blood loss
• Wound care
•  Tetanus prophylaxis
• Possible antibiotics
•  Assess for neurological and/or vascular injury

• Early treatment of a fracture involves immobilization with splints or application of traction

  - Treatment of hypovolemia and blood loss

  - Wound care because puncture wounds carry a heightened risk of infection

  - Punture wounds shouldn’t be closed until treatment for infection with local and systemic antibiotics has been completed 

Rhabdomyolysis

(pg. 672)

- It’s a syndrome of hypoperfusion and ischemia, followed by reperfusion, in which injured muscle tissue releases myoglobin into the circulation, compromising renal blood flow

- Causes can be from crush injuries, compartment syndrome, burns, and injuries from being struck by lightening

- Myloglobinuria (the excretion of myoglobin through the urine) is an effective marker of this syndrome and causes the urine to be a dark tea color

- Myloglobin is toxic to the renal tubules in high amount, causing acute tutbular necrosis, electrolyte and acid-base imbalances, and eventually acute renal failure

- Treatment is aggressive fluid resuscitation to flush the myloglobin from the renal tubules

- Common protocol includes titration of IV fluids to achieve a UO of 100-200 ml/hr

- Giving osmotic diuretics and adding sodium bicarbonate to IV fluids may be used to protect th renal tubules in patients with myoglobinuria 

Assessment for Ineffective Breathing 

1.     Ongoing assessment is essential
2.     Respiratory status
3.     Arterial blood gases (ABG)
4.     Chest x-rays
5.     Computed tomography (CT) imaging

Assessment for Impaired Gas Exchange

1.     Ongoing assessment
2.     Oxygen saturation, respiratory status, secretion removal
                                

Assessment for Hypovolemia

Assessment for Spinal Cord Injury

Assessment for Head Injury

Assessment for Musculoskeltal Injuries

1.     Assess the five Ps:
a.     Pain
b.     Pallor
c.     Pulses
d.     Paresthesia
e.     Paralysis

2.     Assess for neurological and/or vascular injury

Assessment for Abdominal Injuries

1.     FAST—focused assessment with sonography for trauma

2.     Ongoing assessment essential

Assessment for Postoperative Management

ICP

•    i.     Monitor and Treat ICP

1.     Less than 20 mm Hg

•  ii.     Normal range & High range
• 1.     0-15 mm Hg
• 2.     Increased is 20 or greater for over 5 minutes
• 3.     Can lead to herniation syndromes.
•                                             iii.     Treatment:
• 1.     Turning and positioning
• 2.     Hygiene measures
• 3.     Elevating the head of the bed up to 30 degrees and keeping the head in a neutral midline position in relation to the body facilitates venous drainage and decreases the risk of venous obstruction
• 4.     Raising head of bed may decrease MAP, thereby decreasing CPP
• 5.     Adequate oxygenation and ventilation
• 6.     Cautious, limited use of hyperventilation
• 7.     Osmotic and loop diuretics
• 8.     Euvolemic fluid administration
• 9.     Maintenance of BP
• 10.  Reducing metabolic demands
• b.     Book
•                                                i.     Nursing Management of ICP
•                                              ii.     Keep CPP > 70 mm Hg
•                                             iii.     Space activities
•                                             iv.     Positioning to maximize CPP ( CPP = MAP-ICP)  NORMAL 60-100. Must remain > 70
• 1.     Monitor best head of bed elevation to achieve CPP
• 2.     Neutral head position
• 3.     Careful side-to-side rotation
•                                              v.     Suctioning
• 1.     Preoxygenate
• 2.     Limit attempts to < 10 seconds
•                                             vi.     Assess response to family members
•                                           vii.     Airway or Hyperventilation
•                                          viii.     Intubate and ventilate as needed
•                                             ix.     Goals
• 1.     PaO₂ > 80 mm Hg
• 2.     PaCO₂ 35 to 45 within normal limits
•                                               x.     Hyperventilation
• 1.     Limited use
•                                             xi.     Diuretics
•                                            xii.     Osmotic diuretics: mannitol (can cause electrolyte imbalances
• 1.     Withdraw fluid from extracellular space to plasma
• 2.     Work in 20 minutes
• 3.     May cause rebound cerebral edema
•                                          xiii.     Hypertonic saline
•                                          xiv.     Loop diuretics: furosemide
•                                            xv.     Reduce rate of CSF production
•                                          xvi.     Fluid Administration
•                                         xvii.     Optimal fluid administration
• 1.     Optimize MAP
• 2.     Maintain intravascular volume
• 3.     Normalize CPP
•                                       xviii.     Isotonic solutions
•                                           xix.     Strict intake and output
•                                            xx.     Keep osmolarity between 310 and 320 mOsm/L
•                                           xxi.     Blood Pressure Management
•                                         xxii.     Avoid both hypotension and hypertension
• 1.     Hypertension may be needed; must monitor patient’s response
•                                        xxiii.     Keep MAP 70 to 90 mm Hg
•                                        xxiv.     Sustain CPP of at least 70 mm Hg
•                                         xxv.     CCP affected by MAP, ICP, JVP
•                                        xxvi.     Reduce Metabolic Demands
•                                      xxvii.     Treat fever
•                                     xxviii.     Sedation
• 1.     Propofol is newer agent; short acting
• 2.     Morphine
•                                        xxix.     Seizure prophylaxis (i.e. Dilantin - check INR)
•                                          xxx.     Analgesics
•                                        xxxi.     Neuromuscular blockade
• 1.     Always sedate
•                                       xxxii.     Barbiturate therapy
•                                     xxxiii.     Surgical Management
•                                     xxxiv.     Surgical interventions may be needed as determined by diagnosis
• 1.     Mass removal
• 2.     Hematoma removal
• 3.     Decompression hemicraniotomy
• 4.     Ventriculostomy
•                                       xxxv.     Nursing Priority - infection

Glasgow coma scale

(pg. 383)

- It’s a standardized tool that assesses neurological status

- It scores two aspects of the pts LOC: arousal and cognition

- The components are eye opening, best verbal response, and best motor response

- The pt is asked to follow a verbal command and if they are unresponsive, a noxious stimulus is used to elicit a response

- GCS ranges from 3 (deep coma) to 15 (normal functioning)

            A GCS of 8 or less is consistent with coma

Coumadin – INR

- This is indicated for A fib, myocardial reinfarction, prosthetic cardiac valve component, PE, thrombosis, and venous thrombosis

- Action: it interferes with the hepatic synthesis of vitamin K dependent clotting factors

- INR: Normal INR when not on anticoagulants is 0.08-1.2, and INR of 2.5-3.5 is recommended for patients at a high risk of embolization, lower levels are acceptable when risk is lower, prolonged INR of 2-4.5 without hemorrhage is good. 

Flail chest

(pg. 668-669) 

- This occurs when two or more adjacent ribs are broken in two or more places, creating a free-floating segment of the rib cage

- The flail segment “floats” freely and results in paradoxical chest movement

- It contracts inward with inhalation and expands outward with exhalation

The uncoordinated chest movement with flail chest impairs the ability of the body to generate effective changes in intrathoracic pressure for ventilation

- Clinical presentation is paradoxical chest movement, increased WOB, tachypnea, and eventual signs and symptoms of hypoxemia

- Management: endotracheal intubation and mechanical ventilation with pain control 

Typical injuries from trauma

(i.e. scalp, lacerations, contusions) 

- Scalp lacerations

- They are a common traumatic injury and are often associated with skull fracture

- The scalp is very vascular and can be the source of significant blood loss

- The wound is cleansed, debrided, and inspected for a depressed skull fracture, then sutured closed

- Inattention to these details can lead to infection

- Contusion

- It the result of coup and contrecoup injuries, accompanied by bruising and generalized hemorrhage into brain tissue

- Lacerations of the cortical surface associated with contecoup injuries may be greater than those seen directly under the point of impact

- s/s are variable, depending on location and extent of bleeding