RNSG 2432- Mod_15 Notes Trauma Shock

RNSG 2432- Mod_15 Notes Trauma Shock -...

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NOTES Mod #15 Trauma/Shock   cmj Module #15: Nursing Care of the Individual Requiring Critical Care: Trauma, Shock,  Emergency and Critical Care Nursing  Trauma / Triage        (click here-two separate sites) A. Etiology/Pathophysiology etc 1. Definition : *Regarding Emergency Care: there may appear to be “chaos” in the ED,  however there is an inherent order in the timing and choice of interventions performed  throughout (and prior to…pre-hospital) a client’s stay in the ED….organizational flow of  events involves triage ( prioritization ), in-depth nursing assessment of the client,  diagnostic testing, formulation of diagnoses, outcome management, evaluation,  disposition, and documentation.   RNSG 2432 87
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2. Trauma:  Sudden accidents or purposeful acts leading to injury, disability or death a. Impact : initial physical injuries and long term effects; rehabilitation and psychosocial  effects on clients and family members b. Component s of Traumas 1) Host:  person or group at risk of injury 2) Mechanism : source of energy that causes trauma  *Most common: mechanical energy from motor vehicles in accidents 3) Intention: deliberate or unintentional 4) Environment : location and under what circumstances 88 RNSG 2432
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c. Types of trauma 1) Blunt:   no communication between damaged tissue and outside environment;  injuries internal. ..can be minor to lethal 2) Penetrating : actual tissue damage to body structures, obvious from outside;  result of foreign objects set in motion; affect internal organs; ex gun shot wounds,  stab wounds common 3) Often combination  of blunt and penetrating 4) Pathophysiology/manifestations determined by location and extent of injury B. Common Manifestation/Complications * Determined by location/extent of injury; psychosocial impact also What potential “problems” do these photos suggest? C. Therapeutic Interventions/Collaborative Care 1. Goals of Collaborative Care:  stabilization and appropriate intervention RNSG 2432 89
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90 RNSG 2432
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Pre-hospital Care a. Injury identification 1) Require  rapid comprehensive trauma assessment  (use different systems)  *Glasco Coma scale  is one aspect: See text p. 140 Table 6-2  Champion  Revised Trauma Scoring Scale *  modifications of this used in ER…estimates  chance of survival. ..higher the score, the better the chance.   (*know how to use  this) 2) Determines need for trauma center and rapid transport 3) *Airway, Breathing, Circulation 4) Level of consciousness 5) Spinal cord injuries with deficit 6) Any obvious injuries (penetrating injuries to abdomen, chest, pelvis, neck head) 7) Evaluate crush injuries 8) Major burns b. Critical interventions 1) Life support
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RNSG 2432- Mod_15 Notes Trauma Shock -...

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