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MEETING THE NEEDS OF FAMILY MEMBERS AND SIGNIFICANT OTHERS

Dalam dokumen Assessment and Diagnosis (Halaman 89-93)

The impact of traumatic injury can be devastating for patients  and for family members and significant others. They are faced 

Hemodynamic Instability

• Shock states in the emergency department

• Aggressive resuscitation

• Emergent surgery taking precedence over thorough sec-ondary surveys

Alterations in Consciousness

• Presence of drugs or alcohol intoxication confuses physical assessments and masks physical findings.

• Disoriented patients are challenging to assess.

• Agitation makes diagnostic testing challenging.

• Patients with altered consciousness cannot provide a history of the injury.

BOX 25-13 Factors Contributing to Missed Injuries

Many older adults take daily anticoagulants and/or anti- platelet medications to prevent thrombotic or embolic com-plications  from  preexisting  medical  conditions.  Traumatic  injury  in  conjunction  with  a  prolonged  International  Nor- malized Ratio (INR) greatly increases the risk of major hem-orrhage.  It  is  essential  that  systemic  anticoagulation  be  corrected as soon as possible after admission, and when head  injury is suspected, a CT of the head is urgently obtained.43

Trauma  protocols  are  well-established  for  the  manage-ment  of  young  patients  after  injury.  Clinicians  increasingly  are recognizing that these protocols must be individualized  for  the  older  trauma  patient.  The  best  outcomes  for  this  patient population have been achieved through early, appro-priate,  aggressive  trauma  care,  with  admission  to  a  trauma  center with resources and protocols to provide excellent care  to injured adults regardless of age.43  Clinical practice guide-lines that discuss trauma diagnostic tests and procedures can  be obtained on the websites of the major professional organi-zations that are listed in the Internet Resources Box 25-16.

one of relative independence to one that requires prolonged  rehabilitation  or  skilled  nursing  care.  Discharge  planning  early in the patient’s hospitalization is necessary.

The  concept  of  limited physiologic reserve  in  the  older  trauma  patient  highlights  the  key  difference  between  the  younger trauma patient with normal physiologic reserve and  the older patient with underlying physiologic derangements. 

Age-related  changes  that  occur  in  virtually  every  organ  system may not produce evidence of organ dysfunction in the  resting state. However, the ability of organs to augment func- tion in response to traumatic stress may be greatly compro-mised.  Fluid  resuscitation  is  an  integral  part  of  trauma  resuscitation.  Patients  on  chronic  diuretic  therapy  may  require  more  volume  and  potassium  supplementation  as  a  result of chronic volume and potassium depletion. The assess-ment and management of hypovolemic shock is more complex  in  the  older  trauma  patient.  Many  older  adults  are  taking  beta-blocker  medications,  thereby  limiting  an  increase  in  heart rate in response to blood loss; this obscures one of the  earliest signs of hypovolemia—tachycardia.5  Loss of physio- logic reserve and the presence of preexisting medical condi-tions are likely to produce further conflicting hemodynamic  data. The older patient’s lack of physiologic reserve makes it  imperative that early nutritional support is initiated.

Brief Patient History

Mr. G is a 21-year-old man. He was traveling in the back of a pickup truck that collided with another vehicle. He was ejected onto the side of the road and now is not awake and is barely breathing. He was intubated by emergency services, placed in a collar, and immobilized.

Clinical Assessment

Mr. G is admitted to the emergency department with minimal signs of external injury except for some small abrasions to the side of his face.

Diagnostic Procedures

Admission CT scan shows a large subdural hematoma.

Radiography confirms appropriate placement of the endo-tracheal tube.

Baseline vital signs are blood pressure (BP) 110/60, heart rate (HR) 108 (sinus tachycardia), respiratory rate (RR) 30, temperature (T) 98.3° F, O2 saturation 88%, Glasgow Coma Scale 7.

Medical Diagnosis

Mr. G is diagnosed with subdural hematoma secondary to trauma.

Questions

1. What major outcomes do you expect to achieve for this patient?

2. What problems or risks must be managed to achieve these outcomes?

3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified above?

4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

5. What possible learning needs would you anticipate for this patient?

6. What cultural and age-related factors might have a bearing on the patient’s plan of care?

CASE STUDY Patient with Trauma

• Alterations in visual and auditory acuity

• Deterioration in strength and slower reaction times

• Diminution of cerebral skills

• Diminution of motor skills

• Exacerbation of acute or chronic medical conditions

• Medications that may interfere with safe driving

BOX 25-15 Factors that Predispose Older Adults to Motor Vehicle Crashes

Acute Illness

• Cerebrovascular accidents

• Dysrhythmias

• Syncope

• Diabetes

Cognitive Impairment

• Dementia

Neuromuscular Disorders

• Arthritis

• Lower extremity weakness

• Unstable gait Medications

• Antidepressants

• Benzodiazepines

• Diuretics

• Phenothiazines

BOX 25-14 Risk Factors for Falls in Older Adults

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a systematic review and meta-analysis, Neurocrit Care  20(3):514, 2014.

15.  National Spinal Cord Injury Statistical Center: Spinal cord  injury facts and figures at a glance, 2013. https://

www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/

Facts%202013.pdf. Accessed August 17, 2014.

16.  Como JJ, et al: Practice management guidelines for  identification of cervical spine injuries following trauma: 

update from the Eastern Association for the Surgery of  Trauma practice management guidelines committee, J Trauma  67:651, 2009.

17.  Bracken MB: Steroids for acute spinal cord injury,   Cochrane Database Syst Rev (18):CD001046, 1, 2012.

18.  Walters BC, et al: Guidelines for the management of acute  cervical spine and spinal cord injuries: 2013 update,  Neurosurgery 60(Suppl 1):82, 2013.

19.  Kiraly L, Schreiber M: Management of the crushed chest,   Crit Care Med 38(9):S469, 2010.

20.  Battle CE, Hutchings H, Evans PA: Risk factors that   predict mortality in patients with blunt chest wall   trauma: a systematic review and meta-analysis, Injury  43:8, 2012.

21.  Simon B, et al: Management of pulmonary contusion and flail  chest: an Eastern Association for the Surgery of Trauma  practice management guideline, J Trauma Acute Care Surg  73(5, Suppl 4):S351, 2012.

22.  Mowery NT, et al: Practice management guidelines for  management of hemothorax and occult pneumothorax,   J Trauma 70(2):510, 2011.

23.  Press GM, Miller S: Utility of the cardiac component of FAST  in blunt trauma, J Emerg Med 44(1):9, 2013.

24.  Bock JS, Benitez M: Blunt cardiac injury, Cardiol Clin 30:545,  2012.

25.  Clancy K, et al: Screening for blunt cardiac injury: An Eastern  Association for the Surgery of Trauma practice management  guideline, J Trauma Acute Care Surg 73(5 Suppl 4):S301,  2012.

26.  Neschis DG, Scalea TM, Flinn WR, Griffith BP: Blunt aortic  injury, N Engl J Med 359:1708, 2008.

27.  Kwolek CJ, Blazick E: Current Management of traumatic  thoracic aortic injury, Semin Vasc Surg 23:215, 2011.

28.  Moore CL, Copel JA: Point-of-care ultrasonography, N Engl J Med 364(8):749, 2011.

29.  De Waele JJ, De Laet I, Kirkpatrick AW, Hoste E: Intra-abdominal hypertension and abdominal compartment  syndrome, Am J Kidney Dis 57(1):159, 2010.

30.  Stassen NA, et al: Nonoperative management of blunt hepatic  injury: an Eastern Association for the Surgery of Trauma  practice management guideline, J Trauma Acute Care Surg  73(5 Suppl 4):S288, 2012.

31.  Stassen NA, et al: Selective nonoperative management of  blunt splenic injury: an Eastern Association for the Surgery of  Trauma practice management guideline, J Trauma Acute Care Surg 73(5, Suppl 4):S294, 2012.

32.  Schnüriger B, et al: Serial white blood cell counts in trauma: 

Do they predict a hollow viscus injury? J Trauma 69:302,  2010.

33.  Bjurlin MA, Fantus RJ, Mellett MM, Goble SM:  

Genitourinary injuries in pelvic fracture morbidity and  mortality using the National Trauma Data Bank, J Trauma  67:1033, 2010.

REFERENCES

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Emergency Nurses Association (ENA): www.ena.org ENA—Trauma Nurse Core Course (TNCC): http://www.ena

.org/education/ENPC-TNCC/tncc/Pages/aboutcourse.aspx Eastern Association for the Surgery of Trauma (EAST):

https://www.east.org/resources/treatment-guidelines

BOX 25-16 TRAUMA INTERNET RESOURCES

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C HA P T E R 2 6 

Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Beverly Carlson

SHOCK SYNDROME

Dalam dokumen Assessment and Diagnosis (Halaman 89-93)