Head Trauma / Head Injury The disruption of abnormal brain function due to trauma related injury resulting in compromised

neurologic function. Classification: GCS of 13-15 with loss of consciousness for 0-15 minutes. Moderate with GCS of 9-12 with loss of consciousness for up to 6 hours Severe with GCS of 3-8 with loss of consciousness greater than 6 hours. Types: Concussion Hematoma Contusion Skull fracture Signs and Symptoms: Disturbance to consciousness Restlessness Confusion to coma Respiratory irregularities Headache Cognitive deficits Vertigo Puppillary abnormalities Agitation Sudden onset of neurological deficit Nursing Management: Monitor for increase signs of ICP Observe for CSF leakage Maintain patent airway Monitor serial electrolytes, urine serum osmolality Monitor CVP and Swanz-Ganz measurements to guide in fluid replacement Administer IV hyperalimentation as prescribed Nursing Diagnosis Administer medications as prescribed o Osmotic diuretics o Antibiotics o Antacids o H2 receptors Pad side rails and monitor the patient for seizures Provide emotional support

 Abdominal Trauma Abdominal injuries account for a large percentage of trauma related injuries and deaths. Damage to a hollow organ can result to peritonitis leading to shock within few hours, and damage to a solid organ can result to lethal hemorrhage. Types: Penetrating Abdominal Injury

Usually the result of gunshot wounds or stab wounds. The mechanism that caused the penetrating abdominal trauma may cross the diaphragm and enter the chest. Blunt Abdominal Injury

Usually cause by motor vehicle accidents or falls. Trauma to the abdomen is frequently associated with extra abdominal injuries, that is, chest, head, and extremity injuries and severe concomitant trauma to multiple intraperitoneal organs. Causes more delayed complications, especially if there is injury to liver, spleen or blood vessels, which can lead to substantial blood loss into the peritoneal cavity. Nursing Management: Assess for MIVT(Mechanism, Injuries, V/S, Treatment) o Inspect the abdomen for obvious signs of injury Evaluate the signs and symptoms of hemorrhage Note for abdominal tenderness Ask about Kehrs sign Look for obvious abdominal distention Auscultate for bowel sounds Look for chest injuries which accompany intra abdominal injuries Assess for Cullens sign Continually assess for V/S, urinary output, CVP readings, hct values, and neurologic status, serum amylase, abdominal CT scan and X-rays. Assist in doing DPL(diagnostic peritoneal lavage) Nursing Diagnosis

Keep the patient quiet and on the stretcher because movement may fragment or dislodge a clot in a large vessel and produce massive hemorrhage Cut the clothing away from the wound Keep patient on NPO Insert two large bore cannula Assist in the insertion of NGT Administer medications as prescribed o Tetanus prophylaxis(ATS, TT) o Vasopressors e.g. Dopamine, Dobutamine, Norepinephrine, Aramine o Broad spectrum antibiotics

 Dental Trauma Fractures of maxillofacial bones or mandible may occur as the result of industrial, athletics, vehicular accidents, violent acts and falls. Maybe displaced and non-displaced usually closed and includes soft tissue injury. Signs and Symptoms Malocclusion, Asymmetry abnormal mobility Crepitus Pain or tenderness Diagnostic evaluations:

Tissue injury o Swelling o Echymoses o Bleeding

X-Ray and CT Scan Nursing Management Maintenance of adequate respiratory functioning may include oxygen support, endotracheal intubation or tracheostomy Control bleeding Reduction of fracture Immobilization Maintenance of adequate Nutritional intake with liquid or soft diet Pain control to promote comfort Monitor V/S to note early sign of complications Placed patient to a 35-45 degree position Provide reassurance and privacy as requested Nursing Diagnosis

 Near Drowning Is the term used when recovery, at least temporarily, occurs following submersion injury. Nursing Management Pre-hospital Treatment o Rescue breathing o Subdiaphragmatic Abdominal thrusts( Heimlich Maneuver) o Chest compressions o Associated Hypothermia In-hospital Treatment o Care must focused on pulmonary insufficiency o Eliminate hypoxia, acidosis and pulmonary edema o IV fluids is started to overcome hypotension o IFC is inserted to monitor urinary output o ECG to monitor heart beats and detect arrhythmias and treat them accordingly o Monitor the patient for hypothermia Nursing Diagnosis

 Poisoning A poison is a certain substance (liquid, solid, or gas) that when introduced to the body or skin surface, produce adverse effects in the body or even death. Ingested poisons can produce immediate and delayed effects. Immediate injury can cause when the poison is caustic to the body tissues that is a strong acid or a strong alkali. Ingested poisoning maybe accidental or intentional. Factors that influence the action of poison Amount of poison State of poison Route of administration the condition of the stomach Subsequent Assessment: Assess airway Identify the poison Observe any deviations from normal Obtain blood and urine test for toxicological screening Monitor neurologic status Monitor for fluid and electrolyte imbalance Signs and Symptoms Burns or stains around the mouth, pain on the mouth, throat and on swallowing Unusual breath odors, body odors, or odors on the patients clothing or at the scene. Abnormal breathing and circulation Nausea, Vomiting, Diarrhea, and severe abdominal pain Emergency Nursing Care Maintain an open airway Keep the airway clear and proper positioning If advising the patient thru telephone, have the patient to drink 1 or 2 glasses of water or milk Induce vomiting (syrup of ipecac) by giving the patient 30ml and 15cc for children.

Age of the patient State of health Diagnosis of poisoning

Sweating, excessive saliva formation or foaming of the mouth Dilated and constricted pupils Signs of shock Varying level of consciousness Convulsions - coma

Give activated charcoal after vomiting has stopped. (charcoal should not be mixed to the syrup of ipecac) Perform gastric lavage if vomiting cannot be induced Treat for shock if necessary For strong acids (toilet bowl cleaners or phenol) never induce vomiting, give milk of magnesia, egg white to neutralize and

dilute the acid. Start an IV with D5W at a

rate to KVO.

General Nursing Interventions Initiate large bore IV access Administer oxygen as required Monitor and treat shock Prevent aspiration of gastric contents by positioning, use of oropharyngeal airway and suctioning Assist the insertion of IFC to monitor renal function Monitor and treat complications such as hypotension, coma, cardiac dysrhythmias and seizures Assist in the insertion of NGT Administer activated charcoals, syrup of ipecac, specific antedote as prescribed If the client is unconscious, place patient in left lateral position with the head approximately 15 degrees downward Save samples of lavage products for laboratory tests Nursing Diagnosis

 Foreign Body Airway Obstruction Any presence of foreign body that could obstruct the airway. General Management 1.) Stand around the patient, wrap around the waists and proceed as follows. Make first of one hand, placing the thumb side of the fist against the fist against the patients abdomen in the midline, slightly above the navel and well below the umbilicus. Press your fists into the patients abdomen with a quick upward thrust. Each new thrust should be separate and distinct maneuver. 2.) Heimlich maneuver with unconscious patient lying down. Position patient supine with face up Kneel astride the patients high facing head Place the heel of one hand against the patients abdomen, the midline slightly above the navel and well below the tip of the xiphoid process., place the second hand directly on top of the fists Press into the abdomen with a quick upward thrust. 3.) Finger Sweep Open mouth by grasping both tongue and the other lower jaw between the thumb and fingers of the other hand down along the inside of the cheek and deeply into the throat to the base of the tongue. Use a hooking action to dislodge the forign body and maneuver it into the mouth for removal. Nursing Diagnosis

Trauma related to chemicals and radiation 1.) Electrical Injuries Are caused by lightning, arcing, and direct contact with electrical current. It is common in children and adolescents because sometimes they play a lot, and they touch things out of curiosity. Nursing Management Assess carefully for the MIVT/AMPLE (Allergies, Medications, Past Illness, Last meal, Events or environment) o Current strength of the electrical source o Path through the body o Current type o Duration of contact Assess and manage for the cellular response, system response and pain response as a result of the electrical contact. 2.) Inhalation Injuries Is the inhalation of toxic gas that could create system response. May occur in the upper airway (supraglottic), in few minutes to hours after inhalation or may involve lower airway and can cause ARDS and pulmonary edema. Signs and Symptoms Fatigue Vomiting Irritability Syncope Cardiac Dysrythmias Hypertension Ataxia Coma Nursing Management Assess carefully for the MIVT/AMPLE Perform physical assessment using the primary survey Give high flow oxygen Assess lung capacity by using incentive spirometer Assess for ABGs Prepare the patient for tracheostomy insertion if necessary A chest X-Ray is performed as a baseline Nursing Diagnosis

 Bites (Insects, Snake, Animal) 1.) Insect Stings Are injected poisons that can produce either local or systemic reactions. Signs and Symptoms Pain, erythema and edema at the site of injury Mild to severe and life threatening reactions Nursing Management Apply ice packs at the site to relieve pain Elevate extremity with large edematous, local reaction Administer oral antihistamine for local reactions Clean the wound thoroughly with soap and water Administer tetanus prophylaxis as ordered. 2.) Snake Bites(Envonamation) Injection of venom poisons that can cause neurotoxicity and hemotooxicity. Signs and Symptoms Local reactions o Burning pain, swelling, and numbness at the site o Hemorrhagic blisters, affected extremity may become edematous. Nursing Management Keep the patient calm and at rest, and the affected extremity is immobilized Administer oxygen Start IV line Administer vassopressors for the treatment of shock Monitor bleeding and administer blood products for coagulopathy. Nursing Diagnosis

 Burns Destruction of layers of the skin by thermal, chemical, and electrical agents. Degree of burns is assessed immediately upon arrival of the patient to the hospital. 1) First Degree (superficial partial thickness)

It involves epidermis, area is red or pink characterized by moderate pain and it heals spontaneously. 2) Second Degree (partial thickness)

It involves epidermis and dermis to the basal cells. Severe pain is noted, regeneration may occur in one month and scarring may occur. 3) Third Degree (full thickness)

It involves the epidermis, dermis, and subcutaneous tissue and may extend to the muscle in severe burns. White, gray or black in appearance, painless, edema of surrounding tissues, eschar formation, grafting is needed due to total destruction of dermal elements. 4) Fourth Degree It involves the muscle and bone. Increased destruction of RBCs Burn Classification According to % of body area destroyed Critical burns

30% or more of the body has sustained 2nd degree burn, and 10% has sustained 3rd degree burn, further complicated by fractures, respiratory involvement and smoke inhalation. Moderate Burns

Less than 10% of the body has sustained a 3rd degree burn and 15% to 30% has sustained a 2nd degree burn. Minor Burns

Less than 15% of the body has sustained a 2nd degree burn, and less than 2% has sustained a 3rd degree burn.

Burn Classification According to Cause Thermal Burns Flame burns, scalding with hot liquids or radiation Chemical Burns Strong acids or strong alkali solutions Electrical Burns Most serious type of burn Nursing Management Pour cold water in brief duration if seen within 10minutes of inury Burned area is covered with a sterile dressing o Patent airway is established o Provide 100% of O2 if burn occurred in an enclosed area provide fluid replacement therapy. CVP line is usually inserted. o Observe for Lab. Values o Maintain adequate UO o Relieve pain with narcotics; it should be given in small doses frequently. o Keep in NPO for the 1st 24hours Avoid heavy sedation to prevent respiratory complications Nursing Diagnosis