332: intro/trauma/triage and disaster

• High Acuity Patients always...


  Have the potential to become unstable
• What is critical care?

  • for vulnerable patients who are experiencing life-threatening health crises within a patient/family centered model of care.

  • CC nurses require advanced problem-solving abilities using specialized knowledge regarding the human response to critical illness.
• BENEFITS of care provided in the ICU

  • close/immediate monitoring of patient.
  • programs to diagnose patients disorders.
  • source of readily available reference information (trends)
  • technological advances
  • life saving
• CHALLENGES of care provided in the ICU?


  -sensory overload

  -impaired communication

  -delirium ("ICU" delirium, unaware if day or night because constantly stimulated)

  -pain

  -sensory perceptual problems

  -sleep problems

  -nutrition problems

  -anxiety
• Acute care definition (1)

  caring for acutely ill adults who have complex disorders and require multiple medical or surgical treatments.
• acute care definition (2)


  responds to immediate and life threatening conditions.
• acute care definition (3)


  patients receives active but short-term treatment for a severe injury or episode if illness, an urgent medical condition, or during recovery from surgery.
• physical complications with critically ill patients

  
  

  sepsis, multi organ failure, embolisms, immobility, hospital associated infection.
• culture of safety


  technology and informatics
• patient centered care


  continual assessment of the patients status
• what types of patients are in ICU


  unstable

  respiratory issues

  cardiac issues

  low GCS (cant protect own airway)

  cardiac bypass

  ongoing hemodialysis

  therapeutic hypothermia

  addition monitoring
• quality improvement


  -QI= process we use to measure health care outcomes and seek solutions to improve the care we deliver.

  -always pushing the limits to get better.

  -incident reporting

  -science of improving
• science of improvement (quality improvement)

  -"what are we trying to accomplish"

  -"how will we known a change is an improvement"

  -"what changes can we make that will result in an improvement"

  ex) central line care bundles
• evidence based nursing practice

  patient values and priorities

  clinical context

  healthcare resources

  evidence

  all = critical thinking shared decision making
• ethics in acute care


  -considers the advances in science

  -people are living longer, surviving illnesses they may not have 20 years ago

  -ethical principles (is it ethical to send a end stage cancer pt to ICU, to perform CPR on a 95 year old?)

  -moral distress: AACN (2004) 4As to rise above moral distress
• framework to address moral distress

  addressing moral distress requires making changes. the change process occurs in stages and is cyclic in nature, meaning that the stages in the cycle may need to be repeated before there is success. The diagram illustrates the process.
• 1. ASK (moral distress)


  "Am i feeling distressed or showing signs of suffering? IS the source of my distress work related? Am i observing symptoms of distress within my team?"

  Goal: you become aware that moral distress is present.
• 2. AFFIRM (moral distress)


  >affirms your distress and your commitment to take care of yourself.

  >validate feelings and perceptions with others.

  >affirm professional obligation to act.

  Goal: you make a commitment to address moral distress.
• 3> ASSESS (moral distress)


  >identify sources of your distress (personal? environmental?)

  >determine the severity of your distress.

  >contemplate your readiness to act.

  -your recognize there is an issue but may be ambivalent about taking action to change it.

  -you analyze risks and benefits.

  Goal: you are ready to make an action plan.
• 4. ACT (moral distress)


  >prepare to act: prepare personally and professionally to take action.

  >take action: implement strategies to initiate the changes you desire.

  >maintain desired change: anticipate and manage set-backs. Continue to implement the 4 A's to resolve moral distress.

  Goal: your preserve your integrity and authenticity.
• The 4 parts to address moral distress


  creation of a healthy environment when critical care nurses make their optimal contributions to patients and families
• family centered care


  psychosocial crisis occurs during time of illness (anxiety, vulnerability, fear).
• Engels stages of grieving: (family centered care)


  shock and disbelief

  developing awareness

  restitution

  resolution

  idealization

  outcome
• Clotting


  -a complex, multistep process by which blood forms a protein-based structure (clot)

  -platelet aggregation -> clotting cascade

  -risk factors -> increased or excessive clotting

  -immobility or decreased mobility

  -polycythemia

  -smoking

  -certain chronic health problems

  -risk factors -> decreased clotting

  -thrombocytopenia

  -chemotherapeutic agents, corticosteroids

  -liver cirrhosis

  -rare genetic disorders
• clotting


  -physiological consequences -> increased clotting? decreased clotting?

  -assessment findings (what are the cues?)
• cellular regulation


  genetic and physiologic processes that control cellular growth, replication, differentiation, and function to maintain HOMEOSTASIS

  >excessive -> abnormal growth of tissue not needed for optimum whole body function: benign or malignant tumors (cancer), fibrosis, excessive scar tissue formation

  >inhibition -> can reduce cell production of certain substances (such as insulin or clotting factors) to levels that cannot support homeostasis.
• who experiences trauma?


  -ANYONE CAN!

  -age (very young or very old)

  >kids: tiny airways, more likely to have airway issues, take more risk. >elderly: more frail, impaired cognition, increased risk of dementia/impaired cognition.

  >adolescents: more risk taking activity, especially males.

  -economic and gender inequality

  -alcohol and substance abuse

  -ethnicity

  -income (poverty, unemployment)

  -geography

  -unsafe work environments (blue collar workers, more equipment)
• who experiences trauma part 2

  -alcohol and substance abuse>reduce inhibition, greater chance for risky activity, wrong crowds.-ethnicity-income (poverty, unemployment)>low income people may take greater risks to make ends meet.-geography>human trafficking. -unsafe work environments (blue collar workers, more equipment)
• factors affecting response to injury


  -comorbidities

  -substance abuse

  -pregnancy -> anatomic changes, hemodynamic changes, blood volume and composition

  -advancing age
• blunt trauma


  >can be less obvious than penetration (ex: hit on the leg with something)

  >does not mean less dangerous, it is still dangerous

  examples: concussion, airbags, getting hit by something such as baseball bat, falls

  >forces associated: shearing, acceleration and deceleration forces, compression force.
• penetrating trauma


  >breaks the skin barrier -> sharp objects and projectiles such as guns, machetes, MVA

  >the most common orangs injured are the small bowel (50%), large bowel (40%), liver (30%), and intra-ABD vascular (25%).

  >a lot of trauma happens in "the box" (neck to torso).
• penetrating trauma part 2

  >when the injury is close range, there is more kinetic energy than those injuries sustained from a distance

  >gunshot wounds -> depends on the type of bullet and gun: associated with unpredictable injuries, secondary cavitation injuries

  >stab wounds that penetrate the ABD wall are difficult to assess. Occult injuries can be missed.
• the trauma nursing process


  >preparation and triage: who is most important, who is seen 1st, 2nd, 3rd?

  >general impression: first point of contact with patient, what are we seeing?

  >primary survey (A-G) with the corresponding intervention as necessary

  >re-evaluation (consideration of transfer/need for higher level of care)

  >secondary survey (H-I)

  >re-evaluation (J) and post resuscitation care

  >definitive care, transfer or discharge
• first..


  >preparation and triage: activate the trauma team, prepare for patient arrival, full PPE and safety until better known information about pt.

  >general impression: uncontrolled external hemorrhage?, unresponsive/apneic? responding to anything or not?
• primary survey- finding the biggest issues: A-G assessment


  A: alrtness, airway

  B: breathing, ventilation

  C: circulation, hemorrhage control

  D: disability

  E: exposure environment

  F: full set of vitals, family

  G: get adjuncts and give comfort
• life-threatening conditions


  >examples: airway obstruction, not breathing, massive hemorrhage

  >if life threatening conditions are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey.

  >if an issue is noted when doing ABCDE you stop and correct that issue before moving onto the next part of ABCDE, example if right away issue with airway resolve before moving on to look at breathing.
• alertness & airway


  >alertness = AVPU (alert, verbal, pain, unresponsive)

  >air way: bone deformity, burns, edema, fluids (blood, vomit, or secretions), foreign objects, inhalation injury (burns, singed facial hair, soot), loose or missing teeth, sounds (snoring, gurgling, stridor), tongue obstruction, vocalization.

  **cervical spine stabilization or immobilization**

  >most trauma pt will have cervical spine immobilization.
• airway interventions

  >jaw-thrust maneuver

  >oropharyngeal airway (OPA): tip of the OPA should sit at the angle of the mandible, pick OPA color that way.

  >nasopharyngeal tube (ETT): verify placement (CO2 detector, observe chest rise & fall, auscultate epigastrium and bilat breath sounds)
• CO2 (capnography)


  >why is CO2 important when evaluating ETT placement.

  >can use qualitative devices or quantitative monitors.

  >normal: 35-45 mmHg
• Breathing ventilation


  >breath sounds (decreased, absent)

  >depth, pattern, rate

  >increased WOB

  >dyspnea

  >open wounds or deformities

  >skin color (pallor, cyanosis)

  >spontaneous breathing

  >Subq emphysema (feels like rice Krispie)

  >symmetrical chest risk and fall

  >tracheal deviation or JVD