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Introduction The number of vehicles has grown from a mere 306,000 in 1951 to 58,863,000 by 2002 (Ministry of Road Transport and Highways, Transport Research Wing 2001 02). An examination of years of potential life lost indicates that injuries are the second most common cause of death after 5 years of age in India (Mohan and Anderson 2000). As per the report of 2001, 2,710,019 accidental deaths, 108,506 suicidal deaths and 44,394 violence-related deaths were reported in India. There has been an increase in accidental deaths from 122,221 to 188,003, from 40,245 to 78,450 for suicidal deaths and from 22,727 to 39,174 for violence-related deaths between 1981 and 1991. The injury mortality rate was 40/100,000 population during 2000. The number of deaths due to accidents increased by 47% during the period 19902000; 93% were due to unnatural causes and 7% (17,366) due to natural causes. The mortality rate among different age groups was: 8.2% (<14 years), 62% (1544 years), 20% (4559 years) and 9.2% (>60 years). Seventythree per cent of total deaths occurred among men, with a ratio of 3:1 between men and women.

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Definition Trauma unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen. Unintentional injuries are the leading causes of death in people between the ages of 1 and 34 years. In the 35- to 44-year age bracket, unintentional injury is second only to cancer as a leading cause of death. Traumatology is the branch of surgery which deals with trauma patients and their injuries Polytrauma Physical injuries or insults occurring simultaneously in several parts of body Crush Injuries Crush injuries occur when a person is caught between objects, run over by a moving vehicle, or compressed by machinery.

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Mechanism of injury The mechanism of injury may indicate the need for additional diagnostic workup and reassessment. The mechanism of injury is related to the type of injuring force and the subsequent tissue response. Injury occurs when the force deforms tissues beyond their failure limits. Wounds vary depending on the injuring agent. The effect of injury also depends on personal and environmental factors, such as the persons age and sex, the presence or absence of underlying disease process, and the geographic region. Force may or may not be penetrating. The injury delivered from force depends on the energy delivered and the area of contact. In penetrating injury, the concentration of force is to a small area. In blunt or nonpenetrating injury, the energy is distributed over a large area. The predominant feature affecting the impact is speed, or acceleration: FORCE = MASS X ACCELERATION

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Types of trauma 1. Blunt Injury Mechanisms of blunt injury include MVCs, falls, assaults, and contact sports. Multiple injuries are common with blunt trauma, and these injuries are often more life-threatening than penetrating injuries because the extent of the injury is less obvious and the diagnosis can be more difficult. Blunt injury is caused by a combination of forces. These forces include acceleration, deceleration, shearing, crushing, and compressive resistance: Acceleration is an increase in the velocity (or speed) of a moving object. Deceleration, on the other hand, is a decrease in the velocity of a moving object. Shearing occurs across a plane when structures slip relative to each other. Crushing occurs when continuous pressure is applied to a body part. Compressive resistance is the ability of an object or structure to resist squeezing forces or inward pressure. In blunt trauma it is the direct impact that causes the greatest injury. Injury occurs when there is direct contact between the body surface and the injuring agent. Indirect forces are transmitted internally with dissipation of energy to the internal structure. The extent of injury from an indirect force depends on transference of energy from an object to

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the body. Injury occurs as a result of energy released and the tendency for the tissues to be displaced on impact.3 Accelerationdeceleration injuries are the most common causes of blunt trauma. 2. Penetrating Injury Penetrating trauma refers to an injury produced by foreign objects penetrating the tissue. The severity of the injury is related to the structures damaged. The mechanism of injury is caused by the energy created and dissipated by the penetrating object into the surrounding areas.3 The amount of tissue damaged by a bullet is determined by the amount of energy that transfers into the tissue along with the amount of time it takes for the transfer to occur. The surface area over which the transfer is distributed also contributes to tissue damage. Velocity determines the extent of cavitation and tissue damage. Low-velocity missiles localize the injury to a small radius from the center of the tract and have little disruptive effect. They cause little cavitation and blast effect, essentially only pushing the tissue aside. It is important to obtain a brief description of the mechanism of gunshot injuries, including the weapon, the ammunition, and ballistics. This essential information is used to guide the assessment of patients who sustain injuries from these weapons. All trauma patients must be undressed and inspected for entrance and exit wounds during the assessment process.

3. Stab Wounds and Impalements A stab wound or impalement is a low-velocity injury. The main injury determinants are length, width, and trajectory of the penetrating object and the presence of vital organs in the area of the wound. Although the injuries tend to be localized, deep organs and multiple body cavities can be penetrated. 4. Surface trauma Surface trauma includes any injury that does not break the skin (closed wound) and any open wound in which the skin surface is broken. Types of closed wounds include contusions (bruising) and hematomas (collection of blood under the skin). Types of open wounds include abrasions, lacerations, avulsions, amputations, and punctures. Abrasions are a scratching of the epidermal and dermal layers of the skin. They bleed very little but can be extremely painful because of inflamed nerve endings.. Puncture wounds result from sharp, narrow objects such as knives, nails, or high-velocity bullets. They can often be deceptive because the entrance wound may be small with little or no bleeding. It is difficult to estimate the extent of damage to underlying organs as a result. Puncture wounds usually do not bleed profusely unless they are located in the chest or abdomen. Lacerations are open wounds resulting from snagging or tearing of tissue. Skin tissue may be

partly or completely torn away. They vary in depth and may be irregular in shape. Lacerations can cause significant bleeding if blood vessels or arteries are involved. Avulsions involve a full-thickness skin loss in which wound edges cannot be approximated. This type of injury is often seen in machine operators, or in lawn mower and power tool accidents. An amputation is a partial or complete severing of a body part. In cases of complete amputation, the arteries usually spasm and retract into the tissue, resulting in less bleeding than does a partial amputation, in which the lacerated arteries continue to bleed. If the patient has sustained an amputation, bleeding is controlled with direct pressure and elevation. A tourniquet is applied only as a last resort. If a tourniquet is necessary, it should be made of wide material such as a blood pressure cuff, which is less damaging to nerves and blood vessels. A dressing is applied to the amputated extremity, which is referred to as the stump. The stump is covered with sterile saline moistened gauze followed by dry gauze, which is held in place with an elastic bandage for pressure. Amputated parts are taken to the hospital with the patient for possible reattachment. At the hospital, the amputated part is rinsed with saline solution, wrapped in sterile gauze, and placed in a sealed plastic bag, which is then placed in a mixture of ice and ice water.

5. Head Trauma Sharp blows to the head can cause shifting of intracranial contents and lead to brain tissue contusion. The pathophysiology of head trauma can be divided into two phases. The first phase is the initial injury that occurs at the time of the accident and cannot be reversed. The second phase involves intracerebral bleeding and edema from the initial injury, which causes increased intracranial pressure (ICP). Management of head trauma is directed at the second phase and involves decreasing ICP. Early and late Signs and Symptoms of Increased Intracranial Pressure. Early Signs and Symptoms of Increased ICP Headache Nausea and vomiting Amnesia Altered level of consciousness Changes in speech Drowsiness Late Signs and Symptoms of Increased ICP Dilated nonreactive pupils Unresponsiveness Abnormal posturing Widening pulse pressure Decreased pulse rate Changes in respiratory pattern

6. Chest trauma Chest trauma can damage the heart and lungs and cause life threatening injuries, including pericardial tamponade, hemothorax, tension pneumothorax, and flail chest. Potentially lifethreatening injuries include pulmonary and myocardial contusion, aortic and tracheobronchial disruption, and diaphragmatic rupture. Chest trauma can result in laceration of lung tissue and cause a change in the negative intrapleural pressure. Air or blood leaking into the intrapleural space collapses the lung, resulting in a pneumothorax (air) or hemothorax (blood) and ineffective ventilation. In a tension pneumothorax, air is trapped in the pleural space during exhalation, resulting in increased pressure on the unaffected lung. The heart, great vessels, and trachea shift toward the unaffected side of the chest. As a result, blood flow to and from the heart is greatly reduced, causing a decrease in cardiac output. An uncorrected tension pneumothorax is fatal. Chest trauma can also injure the heart and great vessels and reduce the amount of circulating blood volume. The heart may be bruised (myocardial contusion) or may sustain direct trauma. Cardiac tamponade occurs when blood accumulates in the pericardial sac and increases pressure around the heart. The increased pericardial pressure prevents the heart chambers from filling and contracting effectively. A patient with cardiac tamponade exhibits hypotension, tachycardia, and neck vein distention and requires immediate

intervention to reduce the pressure in the pericardial sac and restore normal filling and contraction of the heart chambers. 7. Abdominal Trauma The organs of the abdomen are vulnerable to injury because there is limited bony protection. Injury to organs such as the spleen and liver, which have a rich blood supply, can result in rapid loss of blood volume and hypovolemic shock. Abdominal organs may be injured as a result of severe blunt or penetrating trauma. If hypotension is present, intraabdominal hemorrhage may exist. If the urinary bladder ruptures, urine leaks into the abdomen and blood may be detected at the urinary meatus or perineum. Penetrating trauma can cause lacerations to abdominal organs, resulting in rapid blood loss and hypovolemic shock. 8. Musculoskeletal Trauma Fractured bones can result in blood loss, compromised circulation, infection, and immobility. Unstable pelvic fractures can cause injury to the genitourinary system or disrupt the veins in the pelvis. Fractures of large bones such as the femur and tibia can cause significant blood loss. For example, a fractured femur can cause up to 1500 mL of blood loss and a fractured tibia or humerus can cause up to 750 mL of blood loss. Joint dislocations can cause neurovascular compromise by applying pressure to the nerves and blood vessels.

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PATHOPHYSIOLOGY

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Complications 1. COMPARTMENT SYNDROME Compartment syndrome occurs when the pressure within the fascia-enclosed muscle compartment is increased, causing blood flow to the muscles and nerves in the compartment to become compromised, thereby resulting in tissue ischemia.37 This ischemia then leads to tissue damage, which compromises nerve and muscle function. A prolonged elevation of compartmental pressure leads to death of the muscles and nerves involved. Intracompartmental pressures that exceed 30 to 40 mm Hg can cause muscle ischemia, and pressures greater than 55 to 65 mmHg cause irreversible muscle death. 2. DEEP VENOUS THROMBOSIS DVT is a significant risk for all trauma patients, especially those with musculoskeletal injuries. It is known as a common, life threatening complication of major Trauma. The danger of DVT is that it may progress to pulmonary embolus. The administration of low-dose heparin or low molecular-weight heparin and the use of intermittent pneumatic compression devices are recommended to prevent DVT. The pathophysiology of DVT, and later

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pulmonary embolus, is related to Virchows triad: Venous stasis from decreased blood flow, decreased muscular activity, and external pressure on the deep veins. Vascular damage or concomitant pathological state Hypercoagulability 3. FAT EMBOLISM SYNDROME Fat emboli are fat globules in the lung tissue and peripheral circulation after a long bone fracture or major trauma. Fat emboli may or may not cause systemic symptoms. Fat embolism syndrome is a serious (but rare) manifestation of fat emboli that involves progressive respiratory insufficiency, thrombocytopenia, and a decrease in mental status. It usually occurs within 72 hours of injury. Clinical indications of this syndrome include tachypnea, dyspnea, cyanosis, tachycardia, and fever. Nurses should be aware of the potential for fat embolism syndrome to develop and monitor the patient for hypoxemia with pulse oximetry. The patients neurological status is also monitored for signs of a decreasing mental status 4. 5. 6. 7. Shock Haemmorrhage Stroke Disseminated intravascular coagualopathy

Diagnostic evaluation 1. 2. 3. 4. 5. 6. 7. 8. History collection Physical examination Blood investigations X-ray Computed tomography MRI Ultrasonography

People with penetrating abdominal trauma may have signs of hypovolemic shock (insufficient blood in the circulatory system) and peritonitis (an inflammation of theperitoneum, the membrane that lines the abdominal cavity). Penetration may abolish or diminish bowel sounds due to bleeding, infection, and irritation, and injuries to arteries may cause bruits (a distinctive sound similar to heart murmurs) to be audible. Percussion of the abdomen may reveal hyperresonance (indicating air in the abdominal cavity) or dullness (indicating a buildup of blood). The abdomen may be distended or tender

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Management 1. Pre-hospital Management The trauma patient has a greater chance of a positive outcome if definitive care is initiated within 1 hour of injury. Care begins in the prehospital arena and is continued throughout the hospital stay. There are currently two theories about prehospital management of patients, the stay and play theory and the scoop and run theory.5 Proponents of the stay and play theory believe that time in the field can be well spent stabilizing the patients physiologic status, whereas proponents of the scoop and run theory believe that only life-threatening issues should be addressed in the field. Several studies demonstrated that the time taken to establish intravenous access was longer than the transport time to definitive care. This prolongation of transport was associated with an increase in patient mortality. Therefore, it was suggested that each emergency medical system (EMS) evaluate its approach to prehospital management, taking into account the transport time to definitive care. For example, in an urban area, the scoop and run theory may be appropriate because transport time to a definitive care setting is very short. In a rural area, however, the extra minutes that it may take to stabilize the patient may have a positive impact on the overall outcome because of the long transport time. The advanced trauma life support (ATLS) guidelines

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state that the emphasis for assessment and management in the prehospital phase should be placed on maintaining the airway, ensuring adequate ventilation, controlling external bleeding and preventing shock, maintaining spine immobilization, and transporting the patient immediately to the closest appropriate facility. The prehospital priority of maintaining adequate airway, breathing, and circulation (ABCs) may be difficult to attain owing to the mechanism of injury. It is imperative that cervical spine immobilization be maintained at all times during airway management and transport to definitive care. After assessing and managing the ABCs, the trauma patients neurological status is assessed, including level of consciousness and pupil size and reaction. Once this primary assessment is complete, a secondary assessment is done to determine any other injuries. The prehospital providers must consider the facility that will receive the patient. Transporting the patient to a level I facility allows definitive care to be initiated earlier in the process, thereby reducing patient mortality. Transport of the patient to a lesser facility for stabilization, followed by transport to the definitive care setting later on, is associated with higher patient mortality rates. 2. In-Hospital Management In-hospital patient management entails a rapid primary evaluation and resuscitation of vital functions, a more detailed secondary survey, and initiation of definitive care. According to the ACS,

adhering to this sequence allows for the efficient identification of life-threatening conditions. PRIMARY SURVEY During the primary survey, each priority of care is dealt with in order. The patients assessment does not continue to the next phase until each preceding priority is effectively managed. For example, if a patient does not have a patent airway, breathing and ventilation cannot be established. Therefore, it is during this initial phase that life-threatening injuries are identified and managed. So, if the patient does not have a patent airway, endotracheal intubation, chest tube insertion, and central line access may be initiated and intravenous fluid and blood products may be administered to maintain life-sustaining vital signs before moving on to the next phase of the evaluation. Assessing the patient for evidence of hypovolemia is essential. Blood loss can result from an external injury, associated with obvious bleeding, or from an internal injury, where bleeding may not be obvious. Any of these injuries can lead to inadequate tissue perfusion, which equals traumatic shock. It is necessary to first stop the bleeding with compression or surgery and then replace the lost intravascular volume. Some signs of hypovolemia include pallor, poor skin integrity, diaphoresis, tachycardia, and hypotension. Usually, trauma patients arrive at the trauma center with a large-bore intravenous line already in place, with intravenous fluid running in rapidly.

During the resuscitation period, an electrocardiogram (ECG) is done. The patient is placed on a monitor with pulse-oximetry and endtidal carbon dioxide monitoring. A Foley catheter and a nasogastric or orogastric tube are placed, and bloodwork is sent to the laboratory for evaluation. Bloodwork analysis includes evaluation of electrolytes, hemoglobin and hematocrit, blood type and crossmatch, and arterial blood gases (ABGs), if the patient is expected to have a high level of injury. The patient is also assessed for hypothermia. The trauma patient is often subjected to environmental factors, which, along with his or her altered physiological state and possible wet clothing, predispose the patient to hypothermia. Measures taken by health care professionals, such as the infusion of room-temperature intravenous fluids or exposure of the patients body to inspect for injuries, can exacerbate hypothermia. Warm fluids and blankets are used whenever possible to increase body temperature or maintain normothermia.

SECONDARY SURVEY Once the primary survey is completed, a more detailed secondary survey is initiated. This survey begins at the head and works down to the patients feet. Nonlife-threatening injuries are revealed during this survey. During this time, a plan is developed and the appropriate diagnostic tests (e.g., x-rays, ultrasound studies, computed tomography [CT] scans, angiographic studies) are ordered for the patient. This is also the time when a more detailed patient history can be obtained, as well as important information regarding the mechanism of injury. The nurse asks the field providers for information regarding the incident because the patient may not be able to speak or may not remember the event. Family and friends might be helpful in providing additional information about the patient. 1. FLUID RESUSCITATION Most trauma patients have a fluid volume deficit that must be corrected. The goals of fluid resuscitation are to maintain physiological support of circulation and oxygen transport while avoiding physiological and hemostatic deficiencies. It is essential to have adequate intravascular volume and oxygen-carrying

capacity to transport needed nutrients to the tissues. To guide fluid resuscitation, the nurse uses the patients physical assessment and hemodynamic parameters. Crystalloids Typically, crystalloids are used in the trauma patient. Crystalloids contain water and other electrolytes that are premixed into the fluid. These electrolytes may include sodium, potassium, and chloride. Crystalloids can be further broken down by their tonicity. The tonicity is based on the amount of sodium in the solution. Crystalloids can be classified as isotonic, hypotonic, and hypertonic. Hypertonic saline has been shown to enable a more rapid restoration of cardiac function with a smaller volume of fluid. It is supplied either in a 3%, 7.5%, or 23.4% sodium chloride (NaCl) solution. As little as 4 mL/kg, if given rapidly, may have the same hemodynamic effect as several liters of isotonic crystalloid. Hypertonic saline has the effect of shifting water into the plasma. This water comes from the red blood cells, interstitial space, and tissue. The result is a rapid increase in blood volume, which supports and improves hemodynamics. Hypertonic saline increases the mean arterial pressure and cardiac output, which then leads to peripheral vasodilation. The peripheral vasodilation allows for an increase in total splanchnic, renal, coronary, and mesenteric blood flow. The initial management of trauma patients often requires the rapid infusion of 2 L of

isotonic crystalloid as rapidly as possible, while trying to obtain a normal heart rate and blood pressure. However, research has shown that the infusion of crystalloids in patients with hypotension can cause more harm by displacing a hemostatic clot, only to cause more bleeding. The infusion of crystalloid also further dilutes the patients hemoglobin and can increase intraperitoneal blood loss. Colloids Colloids can also be given to resuscitate a trauma patient. Colloids, such as albumin, dextran, and hetastarch, create oncotic pressure, which encourages fluid retention and movement of fluid into the intravascular space. Proponents for colloid use have argued that less volume of fluid is necessary to achieve hemodynamic stability and the fluid is retained in the intravascular space longer. Despite possible advantages, there is no clear evidence that colloids are superior to crystalloids for resuscitation of the trauma patient. Potential complications, such as anaphylaxis and coagulopathy, have been reported with certain colloids. These potential adverse affects, together with higher costs, make colloid use less desirable than crystalloid use for resuscitation of trauma patients Blood Products Blood products are considered an excellent

resuscitation fluid. Red blood cells increase oxygen-carrying capacity and allow for volume expansion. Blood also stays in the intravascular space for longer periods of time compared with the other resuscitation fluids. Although there is some concern about bloodborne pathogens and transfusion reactions, it is essential to understand the advantages offered by blood transfusion. Blood should be transfused when patients are hemo-dynamically unstable or are showing signs of tissue hypoxia despite crystalloid infusion. Cross-matched blood is preferred but is not always possible if emergent transfusion prohibits type and crossmatching of the patients blood. Onegative blood is the preferred type of uncrossmatched blood, especially in women of childbearing age. O-positive blood may be used in male and postmenopausal female patients. If the patient requires large amounts of blood, transfusion of fresh frozen plasma and platelets is initiated. It is important to replace coagulation factors and platelets not contained in blood. In the event of massive blood transfusions, the risk of acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) is heightened. An extended period of hypotension increases the possibility of renal failure. Autotransfusion is another common modality used in the hemorrhaging trauma patient. Obviously, the nature of trauma prevents

patients from donating their own blood, as they could in an elective surgery. However, sometimes blood is salvaged from wounds, drains, and body cavities. Most often blood is saved from a chest tube underwater seal device. A cell saver is connected into the system and the blood from the wound collects there. Once full, the cell saver is disconnected from the underwater seal device and this blood is then transfused into the patient using a macroaggregate filter. Blood Substitutes Blood substitutes have been developed but have not been approved for use in all countries. These agents do not require crossmatching and do not carry the risk of bloodborne pathogen transmission. Blood substitutes have a long shelf life and are not immunosuppressive. They also have a lower viscosity then blood, which promotes flow and peripheral oxygen delivery.

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1. Ineffective tissue perfusion: cerebral, related to cerebral edema EXPECTED OUTCOME: The patient maintains adequate cerebral homeostasis without cerebral edema as evidenced by a GCS of 14 or greater. Give oxygen as ordered to maintain adequate oxygenation of brain tissues and prevent cellular damage from hypoxia at the cerebral level. If the patient has an altered level of consciousness or deteriorating respiratory effort, anticipate and assist with endotracheal intubation as needed to provide respiratory support to patient. Elevate the head of the patients bed 15 to 30 degrees, if possible, to reduce ICP. Maintain the patients head position at midline to ensure unobstructed venous drainage to help reduce ICP. Maintain intravenous access for fluids to maintain hemodynamic stability and access for medications. Monitor mannitol IV, an osmotic diuretic, as ordered to decrease cerebral edema. If the patient is agitated, calm the patient as agitation increases ICP.

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2. Ineffective breathing pattern related to neck injury or unstable chest wall segment or lung collapse EXPECTED OUTCOME: The patient maintains effective respiratory rate and experiences improved gas exchange in the lungs. If the cervical spinal cord has been traumatized, the effectiveness of breathing may be altered. If signs of respiratory distress are present, use the jaw thrust or chin lift maneuver, along with suction and airway adjuncts as needed to maintain patency of the airway. Maintain cervical collar and backboard to prevent further injury. Give oxygen as ordered to improve tissue oxygenation. Advanced adjunct airway equipment, including an endotracheal tube, must be readily available. Administer supplemental oxygen as ordered to promote tissue oxygenation. Maintain chest tube drainage system if inserted to help expand lung. 3. Ineffective airway clearance related to neck injury EXPECTED OUTCOME: The patient will maintain clear lung sounds. Suction the oropharynx and nasopharynx to clear secretions and prevent aspiration of secretions into the airway.

If the patient vomits, log roll the patient onto side to prevent aspiration of emesis. Use suction as needed.

4. Impaired physical mobility related to neck injury EXPECTED OUTCOME: Patient will maintain normal movement of extremities for patient. Maintain neck immobility during initial treatment of a patient with head or neck trauma to prevent serious injury until trauma damage is identified. 5. Decreased cardiac output related to compression of heart and great vessels EXPECTED OUTCOME: The patient will maintain vital signs within baseline limits. Report unstable vital signs to physician as patient may need immediate surgical intervention in the operating room. Explain diagnostic testing to patients with stable vital signs if radiographic studies are ordered to determine the extent of cardiac or pulmonary injury. Monitor patients vital signs and oxygen saturation continuously to detect signs of shock. 6. Deficient fluid volume related to hemorrhage or abdominal organ injury EXPECTED OUTCOME: Patient will maintain vital signs within baseline limits.

Monitor for signs of shock to detect hypovolemic shock. Maintain IV fluids as ordered per 18- or 16gauge IV cannulas to restore circulating volume. Assist with peritoneal lavage if performed to detect intra-abdominal hemorrhage. Maintain nasogastric tube if ordered to decompress the stomach. Cover abdominal wounds with a sterile dressing to prevent infection. If abdominal organs are exposed, cover with sterile saline-soaked dressings to prevent tissue necrosis. Assist with blood and blood products administration as ordered per agency policy to maintain circulating volume and improve tissue oxygenation.

7. Impaired physical mobility related to bone injury EXPECTED OUTCOME: Patient will maintain movement of extremities normal for patient. Remove all jewelry before applying a splint as the extremity may swell after injury. Maintain extremity in splint in the position found unless the distal circulation is severely compromised and keep immobilized if there is severe pain or deformity. Splinting promotes comfort and prevents further damage to surrounding tissue by preventing movement of broken bone ends.

Immobilize the joints above and below the affected area using a folded towel or a pillow until the patient is evaluated by a physician. Monitor skin color, temperature, distal pulses, capillary refill, movement, and sensation of the extremity after splint application to detect abnormalities.

8. Acute pain related to tissue trauma EXPECTED OUTCOME: The patient will experience relief after measures are provided to relieve pain as evidenced by verbal and nonverbal expressions of pain relief. Apply ice, elevate, and immobilize the affected area to decrease swelling and relieve pain. Provide analgesics as ordered to relieve pain. 9. Impaired skin integrity related to trauma EXPECTED OUTCOME: The patient will demonstrate healing of impaired tissue. Apply direct pressure to open wounds to control bleeding. Irrigate open wounds with sterile saline solution to thoroughly remove dirt and debris and clean exposed tissue to prevent infection. 10. Risk for infection related to tissue trauma EXPECTED OUTCOME: The patients wounds will remain free of infection.

With open wounds, give tetanus immunization as ordered if it has been more than 5 years since one was last given to prevent infection. Give antibiotics as ordered to prevent infection.

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Summary Till now we have seen about the definition, types, mechanism of injury, pathophysiology of trauma, diagnostic evaluation and medical and nursing management of patient with polytrauma.

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Conclusion A stitch in time saves nine, and it is better to be prepared rather than unknown. Trauma can be controlled but not all, controllable can be prevented by appropriate human behavior. During trauma help should be implanted as soon as possible to avoid further casualities.

Assignment solve the 10 multiple choice questions, 10 marks

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BIBLIOGRAPHY:1. Lewis, Heitkemper & Dirksen (2000) Medical Surgical Nursing Assessment and Management of Clinical Problem (7th ed) Mosby, pg no. 2552-66. 2. Black J.M. Hawk, J.H. (2005) Medical Surgical Nursing Clinical Management for Positive Outcomes. (7th ed) Elsevier, pg no. 2441-54. 3. Brunner S. B., Suddarth D.S. The Lippincott Manual of Nursing practice J.B.Lippincott. Philadelphia, pg no. 32051-59 4. Understanding medical surgical nursing, F A Davis 6th edition, elsieiver publication pg. no. 210-224. 5. www.trauma..org/systemtrauma.html

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