Fluid resuscitation following multiple trauma

The initial minutes and hours of nursing care of the trauma victim make a critical difference in the patient's chance for recovery. The critical care and ED nurse's ability to provide fluid resuscitation rapidly to augment the patient's flagging vascular volume is critical to the maintenance of circulation. By administering the most appropriate solution to meet the trauma patient's physiologic requirements, the nurse ensures that the patient will have an adequate circulating volume to meet the oxygenation and nutritional requirements of body tissues. Early, rapid fluid resuscitation is essential to stave off noncompensatory, irreversible shock. By implementing specific nursing care strategies to increase the flow of IV solutions to the patient, the nurse combats the nursing diagnosis appropriate for almost every multiple trauma victim: Fluid Volume Deficit.     

Blunt renal trauma

Severe blunt renal injuries threaten the patient's life with severe complications such as hemorrhage, infection, and the loss of renal function. The critical care nurse's role in the assessment of the patient focuses on evaluating the patient's response to the initial injury, the ongoing assessment of the patient's urinary function, assessing the degree and quality of the patient's pain, and observing the patient's trend in vital signs. The nurse is also responsible for determining the patient's response to diagnostic procedures, providing emotional support, and explaining diagnostic tests and procedures. By supporting compensatory mechanisms, the critical care nurse minimizes the potential for hemodynamic compromise, infection, and diminished renal function. Another important patient care consideration is the maintenance of urinary drainage, to allow assessment of urine and promote excretion of wastes. In all of these aspects of patient care, the critical care nurse is a key member of the trauma team who has a strong impact on the recovery of the patient with blunt renal trauma.     

The septic syndrome. An oncologic treatment challenge

The septic syndrome has three phases, characterized by alterations in tissue perfusion (phase I), fluid volume (phase II), and cardiac output (phase III). It must be viewed as a continuum: the degree of illness and the rate of mortality increase with each stage. Each phase must be clearly understood by health-care professionals for them to be able to intervene actively to prevent a patient's progressive deterioration. Since the septic syndrome frequently cannot be treated effectively in the advanced stage, the nurse's role must focus on early detection of infection, thorough evaluation of all the parameters, and expeditious initiation of treatment in collaboration with the physician. The high mortality of cancer patients who develop septic shock is an incentive for nurse and physician to work together to prevent this serious condition and provide maximum support if it should occur. The nurse's ability to make critical judgments derived from a knowledgeable assessment of clinical data can positively influence the outcome. The timeliness of the nursing intervention may determine the patient's fate.     

Principles of prehospital care of musculoskeletal injuries

Prehospital management of musculoskeletal injuries in the traumatized patient is based on the application of a few basic principles in an orderly but expeditious manner. The patient must be assessed for immediate life-threatening conditions involving airway, respiratory, and circulatory functions while the cervical spine is protected. Resuscitative efforts to reestablish and preserve an adequate circulating volume of oxygenated blood must follow, using airways, oxygen therapy, and fluid replacement through MAST trousers and intravenous fluids. Cardiac function must be maintained as well. Respiratory function must be monitored and assisted as required. Finally, neurologic status must be assessed and monitored. Secondary assessment of all pertinent history and physical findings is made to delineate all other injuries that do not pose an immediate threat to the life or limb of the patient. Definitive care follows but is limited to basic resuscitation, stabilization, and immobilization techniques under medical control through telemetry and radio communication. Immediate definitive care of the traumatized patient requires the expeditious intervention of the trauma team in a hospital setting with surgical, blood banking, radiographic, laboratory, and other hospital-based capabilities available. Field management of the traumatized patient is directed at the expeditious delivery of the viable patient to the trauma team. In the multiply traumatized patient with severe injuries to several organ systems, prehospital care may need to be expedited to provide this patient the in-hospital care required to save his or her life. Appropriate treatment in such life-threatening trauma situations will consist of a rapid primary assessment, airway and cervical spine control, appropriate respiratory and cardiovascular assistance, gross whole body fracture immobilization using a backboard, and immediate transport. For less severely injured patients, primary assessment, resuscitation, stabilization, full secondary assessment, initial definitive care, and immobilization should be completed before transport begins.     

Chylothorax: a complication of thoracic trauma or surgery.

Chylothorax is a troublesome complication of thoracic trauma and surgery. The critical care nurse's assessment of respiratory changes is frequently the first sign that this serious complication is occurring. Chylothorax may cause a previously stable thoracic patient to develop sudden, potentially serious respiratory problems.     

Antihypertensive treatment for the neurological patient: a nursing challenge.

The neuroscience nurse's role in hypertensive management for patients with neurological injury can be challenging. This is especially true for patients whose cerebral autoregulation is affected by chronic hypertension or a cerebral insult. Hypertensive management involves more than the mere administration of medications. The nurse is responsible for monitoring the effects of drugs, lowering the blood pressure to a safe level and observing for any neurological deficits which may ensue from cerebral hypoperfusion. The nurse must collaboratively be able to determine if the patient's hypertensive episodes are caused by ineffective antihypertensives or a new cerebral insult. Knowledge of hypertension management helps maintain adequate cerebral perfusion and ultimate neurological functioning of the patient.     

Cognitive assessment parameters and tools for the critically injured adult

No one parameter or tool is the best. The AACN standards for practice currently recommend various assessment criteria. Initial assessments must be done to establish a baseline, and follow-up data collection will then reveal any trend. What criteria, test or tool the nurse chooses is often dictated by the patient's level of consciousness, stability, the equipment available, the nurse's expertise, and the other personnel involved in the patient's care. The key to successful patient outcome is to appreciate what clinical parameters, diagnostic tests, and pencil and paper tools are available and to select the most appropriate. The nurse must recognize the strengths and limitations of all assessment devices and choose knowledgeably among them.     

Abdominal and genitourinary trauma in children

Children, especially multitrauma victims, are at significant risk for abdominal and GU trauma. Frequently, external indicators of trauma to these systems may be subtle or nonspecific. Expert assessment skills and a knowledge of potential injuries are required. Nonoperative management of these injuries is frequently the treatment of choice, requiring the nurse to understand the type of injury sustained, as well as potential complications of the injury. The nurse is often the first to detect subtle signs of deterioration in the child's condition and must be able to intervene appropriately to promote optimal outcomes for the child. The families of children who sustain abdominal or GU trauma have special teaching needs related to inhospital or home management, as well as long-term outcomes of the injury. It is the responsibility of the nurse to identify and address these needs in a timely fashion to promote optimal outcomes as well as appropriate development for the child.     

The perfectionistic patient.

Family members, residents, and care givers often react negatively when perfection is demanded by the geriatric patient. This type of reaction presents a challenge to the nurse providing care. When a geriatric patient is perfectionistic, it is important to step back, to observe and assess, and to plan appropriate strategies that will facilitate the patient's adjustment. When the behavior is related to situational stressors, it may be appropriate to respond to the stressors and ignore the behavior. When the behavior results from a feeling of loss of control and powerlessness, intervention should be directed in that direction. In any case, actions of the nurse should respond to the patient's need for self-esteem and improved ability to cope with the environment. Responding to the perfectionistic geriatric patient presents a particular challenge to the nurse in long-term care, and the nurse's strategic intervention can significantly increase the patient's ability to adjust to the ongoing changes that accompany the aging process.     

Physical, personal, and cognitive responses to trauma

This article has presented an overview of important physical, personal, and cognitive responses to trauma that are necessary to provide enlightened critical care for the multiple trauma patient. The nurse who understands the full range of responses to trauma is better able to harness the patient's natural healing ability and promote optimal recovery. The unique pattern of responses that characterize the critically ill trauma patient provides a special challenge for the critical care nurse.     

Pulmonary considerations in the critical care phase

Spinal cord injuries create alterations in ventilatory mechanics that range from complete ventilator dependence in high cervical injuries to the need for an assisted cough to clear secretions in low thoracic injuries. The initial nursing assessment should include the degree of respiratory muscle impairment, the effectiveness of the patient's inspiratory efforts, and the ability to cough. Once the mechanisms responsible for respiratory difficulty have been determined, nursing interventions can be planned to compensate for impaired function. This may involve assisted coughing, frequent chest physiotherapy and suctioning, monitoring vital capacity and ABGs, and use of kinetic beds. Perhaps the greatest challenge for both the nurse and the patient is weaning from mechanical ventilation. Weaning requires a coordinated plan, based on trust between patient and nurse, in order to achieve maximum independence from ventilatory support.     

Maintaining health in persons with HIV infection

Despite the inroads that have been made in the treatment and diagnosis of HIV infection, many health care providers have an attitude of hopelessness and pity. Those of us who believe ourselves to be healthy have goals, aspirations, plans, and projects that guide our living. These are our reasons for living: they provide hope, meaning, and substance to our lives. Each of us conducts our life according to individualized personal choices and priorities as do individuals with HIV infection.

The patient's autonomy provides a freedom of choice that extends to benign and harmful methods of maintaining health and preventing illness. The individual chooses what will be of most help.³⁴ The nurse assesses the patient's activities toward health from the patient's perspective. When these activities involve alternative methods, the nurse needs to assess whether or not these are harmful. Providing a nonjudgmental environment for assessment and care will facilitate the patient's providing information about all activities being used to promote or maintain health or prevent illness. Studies have begun to establish that responses to specific stress situations can result in impaired immunity, so the nurse's effort in helping individuals maintain the highest level of health possible has become even more important. The nurse provides a critical link between the individual and the health care complex for optimum communication, comfort, and care in the pursuit of health.     

Living forensics: a natural evolution in emergency care

'Throughout history, health care professionals have been called upon to assist the legal system in the prosecution of cases where patient care overlaps with the law and physiological realities collide' (Lynch 1995). Working for the last 21 years in the Accident & Emergency setting, the author is dedicated to increasing the awareness and assisting in the establishment of basic forensic evidence collection guidelines for the emergency care provider. Due to the nature of the clientele and setting, emergency personnel will inevitably care for 'victims of violence'. Domestic violence injuries, abuse and neglect in the elderly and young, the addictive client seeking emergency care, the sexual assault victim, and sufferers of occupational injuries, are but a few of the cases that would be classified in the forensic arena. Holistic care dictates looking after the patient as a whole. The nurse must meet the patient's physical and psychosocial needs. The forensic nurse ensures that the patient's civil and constitutional rights are also met. This forensic health care role can be achieved and strengthened by recognizing potential evidence and maintaining a 'chain of custody' of this evidence.     

The physiologic changes of aging.

It is estimated that by the year 2030, 21.2% of the United States population will be 65 years of age or older. The elderly are the fastest growing segment of the population and use health care services extensively. Today 30% of all hospitalized individuals are elderly. The professional nurse must therefore be able to assess and assist elderly persons during the course of hospitalization. An important component of assessment is the ability to differentiate the normal physiologic changes of aging from the pathologic changes. To effectively intervene in a therapeutic plan of care the nursing professional must be aware of the limitations brought on by aging.     

Initial assessment and management of a patient with a gunshot wound to the femur.

As the number of violent crimes rise, the likelihood increases that the nurse will be faced with patients presenting with gunshot injuries. These wounds pose a significant challenge to the nurse working in the acute care setting. Unlike other penetrating trauma, gunshot wounds produce a myriad of associated injuries related to the mechanism of injury. Nurses must be aware of the specific trauma associated with these wounds to assess and manage the victim in an organized and systematic fashion.     

What to do when the end is near: ethical issues in home health care nursing

As managed care shortens the length of hospital stays, home settings for the practice of nursing will become increasingly important. In spite of community health nursing's long tradition of family-centered care delivered in the home, many discussions of the nurse/patient relationship in the medical ethics literature assume the hospital setting for the practice of nursing and seem to neglect the impact of family and significant others for the nurse/patient relationship. Through a case-based analysis, this article highlights the special ethical and legal issues encountered in caring for patients who are dying at home. This analysis demonstrates that traditional frameworks for the nurse/patient relationship are inadequate for capturing the richness of the relationship the home health care nurse has with both patient and family. By developing a new framework for the nurse/patient/family relationship that (a) recognizes the patient's decision-making authority and autonomy, (b) allows the exercise of the nurse's moral rights, and (c) recognizes the patient's relationships to significant others, the authors attempt to resolve some challenging legal and ethical questions concerning who should be allowed to decide what to do when the end is near. The discussion details the implications of this framework for nursing assessment in the home care setting.     

Nurses' unique roles in randomized clinical trials.

Nurses are in an ideal position to promote patients' awareness of the role played by clinical trials in the advancement of health science and the subsequent improvement of patient care. The history of clinical trials and the four phases of clinical trials are described. Nurses' professional roles in clinical trial participation, such as helping the patient to identify open clinical trials and acting as clinical interpreter and patient advocate during the patient's participation in a trial, are detailed. Professional considerations that must be addressed by the nurse are reviewed and include ensuring that the trial has received approval from an Institutional Review Board for the participation of human subjects; that the responsibilities of participation are congruent with the nurse's personal values and workplace obligations; and that once engaged, the nurse can make the commitment to sustain participation in the trial. Most important, the nurse must keep the patient's needs and values uppermost in mind during the evaluation of potential clinical trials. Nurses have a critical role to play in the promotion of clinical trials, the recruitment of patients for clinical trial participation, the education of the patient and family, and the clinical care and support of patients throughout their participation in clinical trials.     

Chest trauma.

For any patient with obvious or suspected chest trauma, one must first assure an adequate airway and adequate ventilation. One should never hesitate to administer oxygen to a victim with a chest injury. The nurse should be concerned with adequate circulation--this may mean the administration of intravenous fluids, specifically volume expanders, via large-bore cannulae. Any obvious open chest wound should be sealed, and any fractures should be splinted. These patients should be rapidly transported to the nearest Emergency Department capable of handling this type of injury. The majority of patients who arrive in the Emergency Department following blunt or penetrating trauma should be considered to be in critical condition until proven otherwise. On presentation, it is essential to recognize those signs, symptoms, and laboratory values that identify the patient's condition as life-threatening. Simple recognition of these signs and symptoms and early appropriate intervention may alter an otherwise fatal outcome.     

Reduction and management of perioperative anxiety

Patient anxiety is a normal part of the surgical patient's 'career' and would be anticipated by nurses in a variety of settings. Anxiety causes a number of undesirable effects which may place the patient at greater perioperative risk. Factors that mitigate against the nurse being able to devote adequate time to this important aspect of patient care will not disappear overnight and arguably, without quality psychological care, patients are being placed at greater risk. This article considers the issue of perioperative anxiety with the aim to revise the concept and highlight the serious implications of giving it a lesser priority within patient care. Alternative strategies should be sought that might also help patients take back some control over their own challenging situations. Practitioners must acknowledge that there is a need to investigate their current practice and that they have a responsibility to address patient anxiety effectively.     

Role of the nurse in the multidisciplinary team approach to care of liver transplant patients

Nursing plays an important contributory role in the multidisciplinary team approach to patient care. The nurse who is responsible for the care of liver transplant patients requires special preparation to meet the patient's needs during the critical phases of the liver transplant process. In the hospital setting, a primary nursing-care delivery system enhances the nurse's role in supporting the goal of patient recovery. Primary nursing places the accountability and responsibility for planning, administering, and evaluating the care of the liver transplant patient with the primary nurse. The transplant nurse acts as a key link in the communication network within the multidisciplinary team, and effective communication is essential in the care of the liver transplant patient. For achievement of a life-style of independence after transplantation, the patient is assisted by the nurse, who provides instruction in such areas as diet, medications, monitoring of vital signs, and record keeping. Although the nurse is only one member contributing to the care of liver transplant patients, the nurse's role in the success of treatment is vital.