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Nursing Trauma

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Ackowledgement

First of all, I would like to praise ALLAH THE ALL MIGHTHY. His will, I will not be able to complete the assignment.

I would like to express my gratitute to all who gave me the possibility to complete this assignment. I want to thank the Dean of Nursing Faculty, I for giving the support, encouragement towards compliting the assignment.

I deeply indebted to my tutor who gave an idea and suggestion and encouragement, helped me at the time of writing the assignment.

My colleagues from Nursing Faculty who supported me in my assignment work. I thank them for all their support, help, interest and valuable hints.

Last but not least, I would like to thank my family especially my husband whose patient love enable me to complete this work.

Table of Content

| | |Page No. |
|1. |Introduction |1 – 2 |
|2. |Clinical Assessment |3 – 6 |
|3. |Management Related To Head Injury |7 - 8 |
|4. |Immediate Care And Management Of Patient |9 - 12 |
|5. |Conclusion |12 |
|6. |Appendixs |13 - 14 |
|6. |References |15 - 16 |

Introduction

Head injury is refers to trauma to head. Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull. The injuries can range from a minor injury on the skull such as bruises to serious brain injury such as hemorrhages or fracture. According to Olson D.A (2010), head injury can be defined as any alteration in mental or physical functioning related to a blow to the head. Head injury is defined by National Institutes for Health and Clinical Excellence (NICE) as any trauma to the head, other than superficial injuries to the face. According to Gravell & Johnson (2002), Head injury may be defined as any injury causing traumatic brain injury (TBI), although the two phrases are typically used synonymously.

Head injury can be classified as either closed or open (penetrating) head injury. A closed head injury happens when a person received a hard blow to the head from striking an object and there is no break in the tissue (scalp and skull). The other type is an open head injury; where there is break in tissue which separate the intracranial content from the external environment. Head injuries are also commonly referred to as brain injury, or traumatic brain injury (TBI), depending on the extent of the head trauma. Mild head injury is described as a brief period of unconsciousness, (Guerrero et al., 2000). Moderate head injury is defined as loss of consciousness for between 15 minutes and six hours’ (Headway, 2001). Severe head injury occurs where a patient has been in a coma for six hours or longer (Abelson-Mitchell, 2006).

Head injury cases may causes brain damage but it may not be apparent at the time of injury and bumps on the head may eventually cause a fatal brain hemorrhage (George S.M, 1980). The results of severe impact, however, may be immediately could cause: concussion, in which the brain is shaken, another type is contusion, which is a bruise on the brain and lacerations of the brain, skull fracture, or diffuse brain damage. The complex nature of the patient with a head injury means that they are prone to complications such as hypoxia, hypotension, raised intracranial pressure (ICP) and cerebral vasospasm (Jastremski, 1998)

Incidence

The main causes of head injury are road traffic accident, falls and assaults (Jennett, 1996). The number of persons surviving from head injury is rapidly increasing and disability is as common after apparently mild head injuries, compared with more severe ones (Thornhill et. al., 2000). Head injuries are a frequent cause of death and disability in western society with the first 72 hours being an important period for prevention of further brain damage (Johnson, 1999). Morbidity and mortality for head injury victim can be significant reduced by improve organization of care, at beginning of injury site.

The highest percentage incidence is in the age group 16–25 years (41%) in Hillier et al. (1997) and in the 21–30 year group (26%) according to Wagner et al. (2000).

CLINICAL ASSESSMENT OF THE PATIENT

Assessment of the head-injured patient begins with a protocol of ensuring patency of the airway with cervical spine control whilst maintaining good oxygenation and tissue perfusion. This aims to prevent the development of secondary brain injury. Assessments of patient in Emergency Department are divided into two parts: Initial assessment and focus assessment. Initial assessment is the primary assessment when receive patient in Emergency Department. Aim for these assessments is to identify and intervene in life-threatening injuries. Interventions may need to be undertaken if a threat to these elements is discovered (Parkinson, 2008). Following the initial assessment, the nurse can continue with a focused assessment, usually directed by presenting signs and symptoms, or the mechanism of injury (Parkinson, 2008). Mr. Kumar involved in the automobile accident, so the mechanism of injury is significant. The assessment steps for significant mechanisms of injury besides the initial assessment are: Rapid Trauma assessment, Baseline vital signs, SAMPLE history; and re-evaluate (Ho S.E, 2010) the assessment that need to be done to him is the clinical examination of a patient involves not just physical examination, but also the collection of data through diagnostic or laboratory tests.

Initial Assessment

When receiving emergency patient in the Emergency Department first thing that need to be assess is patient level of consciousness. Unconscious will not be able to maintain patency of the airway. Call the patients by name to check whether he is alert, confused or unconscious. Importance of maintaining an adequate airway is to assure of an adequate blood supply to the brain. Tongue falling backward in an unconscious will obstruct the airway. An airway obstruction may increase expiratory pressure and raise the level of carbon dioxide in the blood, which in turn may aggravate the cerebral edema (George, 1980). In Mr. Kumar condition his level of consciousness is decreased.

Next, important assessment is the airway. Assess for any obstruction of the passage that can lead to insufficient pulmonary ventilation. TALK to the patient to assess conscious level of the patient. Unconscious or semi-conscious patient are potential lost their ability to maintain their airway passage. LOOK for any object in the mouth that may obstruct airway. LISTEN for any abnormal breath sounds and FEEL for the breath to confirm that patient is breathing and airway is patent. Airway should be assessing while maintaining head position. Head should be immolize with sand-bag while waiting for proper cervical immobilization such as hard cervical collar.

If the airway is patent, assess for the breathing to make sure of adequate ventilation. By using LOOK, LISTEN and FEEL, assess patient breathing effort, rate and depth. Expose the patient to look for any injury to the lung that might compromise breathing effort. Assess for breathing and any life-threatening chest injury such as penetrating object at thoracic cavity that might cause internal bleeding and pneumothorax to patient. Look for the chest expansion whether symmetry or asymmetry. Asymmetrical chest expansion could be due to lung collapse or pneumothorax due to the mechanism of injury. Listen for the breath sound and auscultation of both lungs to listen to the air entry. Assess the breathing rate, breathing pattern, use of accessory muscle and flaring of nostril to indicate problem in adequate ventilation. Mr. Kumar respiratory rate is 12/min. He might not be able to maintain adequate pulmonary ventilation and cerebral ventilation as patient show evidence of restlessness that maybe due to cerebral hypoxia or carbon dioxide retention.

Once the airway is stabilize proceed to next assessment which is the circulation and haemorrhage control. Check for any physical bleeding and take action to control the bleeding. Assess vital sign. Observations on the blood pressure, pulse and respiratory rate are also essential, not only to ensure cardiorespiratory stability of the patient, but also to indicate possible brainstem compromise (Flannery & Buxton, 2001). Check blood pressure whether there is any decrease of blood pressure that may indicate patient is shock. Assess for pulse peripheral and central for regularity and volume. Assess perfusion by observe the color of the skin, pallor might indicate poor perfusion, patient temperature, cold and clammy might indicates patient in shock and check for the capillary refill. Normal capillary refill should be less than 3 seconds. If capillary refill more than 3 seconds indicate poor in perfusion. Once the bleeding is controlled than proceed to the next assessment.

Disability (disorder of consciousness and dysfunction). The severity of the head injury can be based on this initial GCS score (Flannery & Buxton, 2001). Assess neurological status by using Glasgow Coma Scale (GCS). Check for eye opening responses, motor response, verbal response and check pupil size and response as a baseline. Asymmetrical pupil size and reduced reaction to light may indicate brain injury from either diffuse injury or an intra-cranial heamatoma (Flannery & Buxton, 2001). Call patient by name to assess without touching the patient. Assess eye opening eye to call or spontaneously. Give pain to assess whether eye opening to pain and chart at the Glasgow Coma Scale Chart. Assess the motor response by asking the patient to elevate one limb at a time. This is to see any disability of the limb and ability of the patient to obey command. Then assess patient orientation to time and place by asking him whether he is aware of the surrounding. At the same time we are checking the verbal responses. Lastly, check both pupil for size and responses. GCS scoring system is a guide to rapid evaluation of severely injured patient whose status may change quickly (Morton et. al., 2005).

Interpretations for GCS scoring are as follow:
|Total scoring (15) |Indicator |
|3 and below |Completely unresponsive |
|3 – 8 |Severe neurological impairment associate with coma |
|9 – 12 |Moderate neurological impairment |
|13 – 15 |Mild neurological impairment |

(Lee WL, 2010)

Focused Assessment/ Rapid Trauma Survey

There are three major component of focused assessment: Medical history, Baseline vital signs and Physical examination. The objective of focused assessment is to decide on the severity of the patient’s condition.

Head to toe examination should be done to the patient. Exposure of the patient to examine for any other injuries is then made, including a thorough inspection of the patient’s scalp for lacerations, compound fractures and contusions (Flannery & Buxton, 2001). Physical examination to all body parts front and back should be done to identify other injury related to the mechanism of injury (MOI). Place patient on supine position for physical examination. Starting from the head, inspect and palpate for any deformities, contusion, abrasion, puncture, burns, tenderness, laceration and swelling (DCAP-BTLS). No evidence of any external bleeding from nose or ears seen from Mr. Kumar. Next, assess the neck. Inspect patient’s neck anterior and posteriorly. Observe the trachea for any midline shift or deviated. This may be due to present of pneumothorax causing atelactesis. Observe for any jugular veins distended or flat and presence of any signs of trauma to the neck. Apply a cervical spinal immobilization collar to prevent any injury to the cervical and spinal related to MOI. Then move down to assess the chest. Expose, inspect and palpate the chest for DCAP-BTLS. Watch the chest rise and fall with breathing. Auscultate chest bilaterally to check for air entry and compare sound from side to side. Feel for any grating bones as patient breathes to detect any fracture rib. Check heart sounds and assess the rate. Expose, inspect and palpate abdomen DCAP–BTLS. Check for any distension of abdomen may indicate internal bleeding. Expose, inspect and palpate pelvis with gentle pressure downward and inward at the pelvic bone and DCAP-BTLS. Expose, inspect and palpate all four extremities DCAP-BTLS. Check the distal pulses, motor function and sensory function of the extremities. Lastly, turn patient by log rolling to inspect the back for DCAP-BTLS and any open wound.

Once completed on the physical examination, a brief history should be taken from patient, next of kin or any person that were at the scene. History taken using mnemonic SAMPLE. “S” meaning sign and symptom from the patient. “A”, drug allergies that the patient might have. “M”, any prescribe medication or unprescribe medication taken during the incidence. “L”, last meal taken before the incidence incase patient need to go for urgent operation. “E”, event leading to incidence.

MANAGEMENT RELATED TO HEAD INJURY

Blood Investigation

All patients with head injury will have other multiple injuries and those with head injuries, should have blood samples analysed for baseline estimations - full blood count, coagulation screen, blood group (and save), electrolytes and urea, blood gases and alcohol level. Electrolyte imbalance and haemoglobin deficiencies should be corrected, if present.

Imaging

Base on assesment result doctor will order for various investigation to identify patient’s actual problem. Investigation includes skull x-ray to demonstrate fracture, computed tomography and magnetic resonance imaging (MRI) of the brain to identify cerebral contusion or laceration or intracranial hematoma.

With the greater availability of CT, more head-injured patients are being scanned. Imaging of the head injured patient relied on skull radiographs. The CT scan has become the diagnostic procedure of choice when evaluating acute head trauma (Master et. al., 1987). CT scanning is recommended for patients at high risk for intracranial injury. This includes all patients with a GCS score < 15 and patients with focal neurologic deficits or clinical signs of basilar or depressed skull fractures. Abnormalities noted on CT imaging include subdural hematomas, subarachnoid hemorrhage, intracerebral hematomas, cerebral infarcts, diffuse brain injury, and generalized cerebral edema often with shift of midline structures, effacement of cortical sulci, and ventricular compression.

Medical Management

Initial Management of patient with head injury are same as any other injury which is airway, breathing and circulation. But in head injury, patient are potentialy having cervical injury due to head injury. Therefore, head should not be mobilized to prevent futher injury to cervical and spinal cord. An immobilizer should be applied immediately either using sandbag until a cervical collar can be obtained or using a proper size of cervical collar. Lateral cervical spine xray should be obtain before any attempt to remove patient’s head or immobization device are removed.

IV (intravenous) line should be inserted with branula gauge 14-16 at peripheral for possible IV fluids and medication administration. A intravenous Mannitol 20% may be given to severely head-injured patients to reduce associated cerebral oedema (Flannery & Buxton, 2001). Replacement of Dextros 50% intravenously are given if the blood sugar level indicates reading less than 45mg/dl. Hyperglycaemia increases osmotic pressure and may cause further cerebral ischaemia, depriving cells of energy leading to secondary brain damage (Woodrow, 2000). An intracranial pressure monitoring probe may be inserted into the brain through the skull to measure the ICP pressure. If the pressure rises too high, surgical decompression of the brain may be the option. Intravenous medications may be used to control intracranial pressure as a temporizing measure until the crisis resolves or surgery is performed.

Patient with head injury possible may have changes in intracranial pressure (ICP). Management focus on maintaining cerebral perfusion and reduce intracranial pressure. Blood pressure and oxygenation is important in mantianing cerebral perfusion. IV fluids of isotonik solutions are given to stabilize the systole blood pressure to over 90mmHg. Besides that, oxygen is given to provide an adequate cerebral perfusion. Patient with GCS < 8- 9/15 should be intubated in maintaining cerebral perfusion. Beside oxygenation, in order to reduce cerebral metabolic rate, medication are prescribe such as sedatives, paralytic agent, antipyretics and barbiturates. Sedative such as Morphine is order to reduce pain and to depress respiration if patient under mechanical ventilation. Sedation will reduce ICP and will help to dampen the effect of any potential stimuli that may increase ICP. Paralytic agent for example Propofol may be used to promote adequate ventilation.

IMMEDIATE CARE AND MANAGEMENT OF THE PATIENT

Maintaing Effective Airway Clearance And Gas Exchanges With Protection of The Cervical Spine

Assess mouth for any object that might obstruct the airway patency. Position head to maintain airway patency and prevent brain damage due to lack of oxygen but at the same time prevent head hyperextension to prevent injury to the cervical spine. The cervical spine should be stabilize manually by apply sandbag at both side of the head to limit the head movement during neck examination. Open patient’s mouth by using jaw thrust to immobilize the neck while waiting for rigid cervical collar to be applied. Apply a rigid cervical collar on the patient unless during neck examination. Mr. Kumar has decrease level of consciousness this will lead to potential lost the airway patency.

The tongue commonly obstructs the airway in unconscious patients, but the airway can be opened by using the chin lift maneuver. False teeth and any solid foreign object should be removed from the oral cavity. Insert oropharyngeal airway to make sure that airway passage is not obstructed and patency is well maintain. Do suction to clear the airway. Remove any secretion or vomitus in the oral cavity by using sucker to prevent aspirations of vomitus. If patient having vomiting, turn patient in a log rolling to prevent from cervical injury. Turning the patient into the recovery position may exacerbate a cervical injury.

Airway patency will provide an adequate brain perfusion. If the airway is completely obstructed, permanent brain damage will occur within 3 to 5 minutes secondary to hypoxia (Smeltzer & Bare, 2004). As patient respiration rate was 12/min oxygen therapy may be given oxygen to improve pulmonary ventilation. Monitor oxygen saturation via using pulse oxymetry to check for oxygenation level. Check for presence of gag reflex. If there is no gag reflex intubation should be done by doctor using cuffed endotracheal tube and ventilate the patient to protect the airway. Intubation may require as patient respiration rate indicates low (12/min). Low respiration may induce hypercarbia in patient. Provide 100% of oxygen during the first hour ventilation and subsequently reducing the rate according to blood gasses result. Mechanical ventilation will improve pulmonary gas exchange and promote cerebral perfusion. Wright (1999) states that a rapid sequence intubation should be carried out on all head-injured patients, with adequate anaesthetic and neuromuscular blockade drugs, to reduce changes systemic and cerebral blood flow that may be detrimental. Head injuries with a GCS of 8 or below require intubation and mechanical ventilation, which subsequently requires admission to intensive care unit (Hillman and Bishop, 1996).

Maintaining Effective Cerebral Perfusion

Assess patient neurological parameter by using Glasgow Coma Scale (GCS) upon admission to Emergency Department to patient to check on patient neurological status . Record the initial finding serves as base for ongoing comparative assessment so that even a slight change may be readily recognized. During the initial assessment GCS was 9/15 and patient having decreased level of consciousness. GCS 9/15 is in the category of moderate neurological impairment. It is important to observe if the patient's level of consciousness is stable or improving or if is now deteriorating. This may show that patient having cerebral edema or intracranial hematoma (Poehland T, 1979). All head injury cases is nurse for possibility of having cervical @ spinal injury. As stated earlier head immobilization is to prevent injury to cervical and this is routinely for all head injury patient. Elevate head 30% to reduce intracranial pressure (ICP). Elevation of the head to a 30° angle is a common practice (Klein, 1999). For every 10° of head elevation, the ICP is thought to drop by 1mmHg (Wong, 2000). Monitor GCS repeated at half-hour to hourly interval for at least 24 hours. The interval between assessments is gradually lengthened depending on patient progress.

Observe for any sign of decreased in cerebral perfusion such as decreased level of consciousness and decreased in GCS level. Inform doctor urgently if there is any decrease of GCS level for possible surgical intervention. Give oxygen 5L/min via nasal prong to improve cerebral oxygenation and reduce cerebral congestion. Prepare for intubation and supported with menchanical ventilation. Give hyperosmolar therapy such as Mannitol 20% as order by doctor to reduce ICP with promotes osmotic diuresis. Hall (1997) explains that Mannitol decreases the blood viscosity which then increases the cerebral tissue oxygen availability. Monitor blood pressure every 15 min to detect any reduction in blood pressure due to diuresis effect.

Circulation And Haemorrhage Control

Check for any obvious bleeding. Any open wound should be covered with sterile dressing and visible bleeding should be stop or controlled by giving local pressure, elevation of the affected site to encourage blood return and reduce blood flow to the site or by using tourniquet. A tourniquet is applied only as a last resort when external hemorrhage cannot be controlled in any other way (Smeltzer & Bare, 2004). Attach cardiac monitoring and record pulse and blood pressure. Insert two intravenous lines with needle gauge 14 at peripheral for any infusion needed later. Blood specimens should be taken for group and cross-matching, and for determining full blood count and urea and electrolyte concentrations. Blood investigation is required as a baseline and to check any abnormality that might cause hazard to patient. A specimen of arterial blood should also be taken to determine asid-base balance and oxygenation level in the blood. A colloid solution for example Ringer’s Lactate is usually given in the first instance to maintain the fluid balance. If there are any signs of hypovolaemia, 2 litres of colloids should be given rapidly while the vital signs are being monitored. The need for further fluids and their rate of flow are determined by the vital signs. Blood is required after a major injury or when there has been a limited response to 4 litres of colloid. Blood should be warmed before use. Check for blood sugar level. Replacement of Dextros 50% intravenously are given if the blood sugar level indicates reading less than 45mg/dl. Hyperglycaemia increases osmotic pressure and may cause further cerebral ischaemia, depriving cells of energy leading to secondary brain damage (Woodrow, 2000).

Injury Prevention Related To Restlessness

Assess the patient to ensure that oxygenation is adequate. Hypoxia can cause restlesness. Padded side rail to prevent patient from injured himself. Wrap the patient’s hand in mitten to prevent patient from pulling all the lines and injured himself. Noise may increased patient agitation and restlessness. Minimize environmental stimuli by keeping the room quiet, limit visitor and talk calmly. Closed family member should be allowed to be with the patient to keep the patient calm and relaxs.

Wound Cleaning

Any open wound should be covered with sterile dressing. The area around wound is cleaned with normal saline solution. Wound is irrigated gently and copiously with sterile isotonic saline solutio to remove dirt.

CONCLUSION

Assessment is dynamic processes as patients improves or deteriorate while in the care at the Emergency Department (ED). Nurses in collaboration with other members of the team play an important role in the care of patients with Head Injuries. Even minor head injuries can cause long-term problems, so correct and early management in ED is crucial to patient recovery. In the acute phase, accurate assessment, monitoring and early interventions is crucial in detecting further deterioration and preventing complications.

APpENDIx

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