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Case Study - Need help prioritizing

Posted

Specializes in Cardiology. Has 1 years experience.

I have the hardest time prioritizing nursing interventions. This is the scenario and then my interventions are listed below. If someone could help me and then explain why one if more important than other that would be awesome!

SCENARIO:

MVC

Multiple lacerations to the face and chest

Bleeding from face and head - controlled

Possible severe head injury

Right pupil smaller than left pupil

Possible basilar skull fracture

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Possible development of haemothorax

Symmetrical rise and fall of chest with diminished left breath sounds

Possible intra-abdominal hemorrhage

Abdomen is hard and distended

Liver injury

Bruising on right upper quadrant

Deformity to left wrist and right ankle

INTERVENTIONS:

  • ABCs should be maintained at all times
  • Pt is at risk for elevated ICP; Minimize this by:
    • Maintaining C-spine
    • Securing an endotracheal tube
    • Elevate head of bed if possible after spine clearance

    [*]Assess and medicate for pan

    [*]Prevention of intracranial hypertension is key as well as maintaining adequate and stable cerebral perfusion pressure

    [*]Optimize cerebral hemodynamic and oxygenation

    [*]Assume hypovolemia as the cause for hypotension until proven otherwise

    • Expose the patient to view all body surfaces for evidence of injury
    • Cover with warm blankets and warm IV fluids to maintain temperature

    [*]FAST ultrasound at bedside

    [*]Gastric tubes and urinary catheter placement to decompress the stomach and bladder

    [*]Monitor for signs of hematemesis and hematuria

    • Monitor for signs of severe hemorrhage
      • Hypotension and flank, scrotal, and perianal edema and ecchymosis

    [*]Assess labs

    • Hypoglycemia
    • Alcohol
    • Other drugs

    [*]Diagnostic testing:

    • Skull x-ray - determines if there is a fracture
    • CT of brain - determines if hemorrhage has occurred
    • CT of abdomen - determines if hemorrhage has occurred

Am I missing any interventions?

<3nurseE>

Specializes in Cardiology. Has 1 years experience.

So sorry forgot to add the vitals

BP 104/70

HR 128

RR 14

O2 Sat 95% on NRB

Temp 97.9

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Is your scenario given to you?

SCENARIO:

MVC

Multiple lacerations to the face and chest

bleeding from face and head – controlled

Possible severe head injury

Right pupil smaller than left pupil

Possible basilar skull fracture

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Possible development of haemothorax

Symmetrical rise and fall of chest with diminished left breath sounds

Possible intra-abdominal hemorrhage

Abdomen is hard and distended

Liver injury

Bruising on right upper quadrant

Deformity to left wrist and right ankle

Wow....You graduate next month!! Congrats!

Who is saying that the injuries are possible you? or the given scenario? Are they assessment findings?

From what I see......You have a patient involved in a MVC....vitals are as follows......

BP 104/70

HR 128

RR 14

O2 Sat 95% on NRB

Temp 97.9

Assessment.....

Multiple lacerations to the face and chest

Bleeding from face and head – controlled

Right pupil smaller than left pupil

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Abdomen is hard and distended

Bruising on right upper quadrant

Deformity to left wrist and right ankle

Multiple lacerations to the face and chest
indicative of blunt force trauma
Right pupil smaller than left pupil

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Are indicative of a head injury.
Abdomen is hard and distended

Bruising on right upper quadrant

is indicative of liver laceration intra-abdominal bleeding
Deformity to left wrist and right ankle
fractured extremities

So....looking at these vitals and assessment what would concern you?

BP 104/70

HR 128

RR 14

O2 Sat 95% on NRB

Temp 97.9

Think ABC's and what will kill them first

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Is your scenario given to you? Wow....You graduate next month!! Congrats!

Who is saying that the injuries are possible you? or the given scenario? Are they assessment findings?

From what I see......You have a patient involved in a MVC....vitals are as follows......

BP 104/70

HR 128

RR 14

O2 Sat 95% on NRB

Temp 97.9

Assessment.....

Multiple lacerations to the face and chest

Bleeding from face and head – controlled

Right pupil smaller than left pupil

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Abdomen is hard and distended

Bruising on right upper quadrant

Deformity to left wrist and right ankle

indicative of blunt force trauma and are indicative of a head injury.is indicative of liver laceration intra-abdominal bleeding and fractured extremities

So....looking at these vitals and assessment what would concern you?Think ABC's and what will kill them first

INTERVENTIONS:

  • ABCs should be maintained at all times
  • Pt is at risk for elevated ICP; Minimize this by:
    • Maintaining C-spine
    • Securing an endotracheal tube
    • Elevate head of bed if possible after spine clearance

    [*]Assess and medicate for pan

    [*]Prevention of intracranial hypertension is key as well as maintaining adequate and stable cerebral perfusion pressure

    [*]Optimize cerebral hemodynamic and oxygenation

    [*]Assume hypovolemia as the cause for hypotension until proven otherwise

    • Expose the patient to view all body surfaces for evidence of injury
    • Cover with warm blankets and warm IV fluids to maintain temperature

    [*]FAST ultrasound at bedside

    [*]Gastric tubes and urinary catheter placement to decompress the stomach and bladder

    [*]Monitor for signs of hematemesis and hematuria

    • Monitor for signs of severe hemorrhage.. OR....distended firm abdomen, tachycardia?
      • Hypotension and flank, scrotal, and perianal edema and ecchymosis

    [*]Assess labs What about H&;H Type and cross for blood?

    • Hypoglycemia
    • Alcohol
    • Other drugs

    [*]Diagnostic testing: What about CXR, C-spine x-rays, and extremity xrays?

    • Skull x-ray – determines if there is a fracture The CT will show this
    • CT of brain – determines if hemorrhage has occurred
    • CT of abdomen – determines if hemorrhage has occurred

<3nurseE>

Specializes in Cardiology. Has 1 years experience.

Yeah the scenario is given to me - I just added the possible... stuff above it like the basial skull fracture ans so on!! Thanks for all your help! I just have the hardest time with this stuff!

and Yes i am so excited to graduate in 2 weeks!! YIPPIE

<3nurseE>

Specializes in Cardiology. Has 1 years experience.

I knew I was forgetting the type and cross - I think my brain just had so much going on cuz this scenario is a bit much.

So I know that ABCs is the first thing to look at but then what about the liver injury and the head injury - how do I prioritize these with their interventions? Like checking ICP but then I have to have diagnostics (when does that come into play)

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

You think of what benefits the patient the quickest......for example.....the patient can bleed to death while waiting to put the ICP in. Of course in real life it depends on what the scans show for if the bleed is bad enough they need to care for that right away after the bleeding in the abdomen is controlled...almost simultaneously.

So this patient still has a HR of 128 so I would be concerned about the firm/hard abdomen indicating internal bleeding. Now if the patient had a hard abdomen but a heart rate of 40....the brain will increase in priority...but you have to stop the bleeding in the abdomen quickly as well.

The insertion of an ICP in another invasive procedure and will be placed (usually) later in the process after the hematoma has been evacuated.....after the abdomen bleed has been slowed/stopped.

So....head to toe assessment. ABC

Can the patient maintain their airway? Can the airway be easily compromised?

the answer is No...they can't.....the airway is compromised by LOC/head injury, chest wall/lung injury, abdominal hemorrhage/critical blood loss.....intubate/ventilate (breathing)Symmetrical rise and fall of chest with diminished left breath sounds

Are the vitals stable?

Abdomen hard heart rate rapid, hypotensive......labs(including h/h type and cross, scans, rapid ultrasound, IV lines, foley, OGT....

But you scenario is giving you the answers......

Multiple lacerations to the face and chest

bleeding from face and head – controlled

Possible severe head injury

Right pupil smaller than left pupil

Possible basilar skull fracture

Bruising around left eye and temple

Bleeding and drainage from nose and ears

Possible development of haemothorax

Symmetrical rise and fall of chest with diminished left breath sounds

Possible intra-abdominal hemorrhage

Abdomen is hard and distended

Liver injury

Bruising on right upper quadrant

Deformity to left wrist and right ankle

everything is possible but the liver injury....start there.
Liver injury

Bruising on right upper quadrant

Possible intra-abdominal hemorrhage

Abdomen is hard and distended

Possible severe head injury

Right pupil smaller than left pupil

Possible basilar skull fracture

Bruising around left eye and temple

Bleeding and drainage from nose and ear

Possible development of haemothorax

Symmetrical rise and fall of chest with diminished left breath sounds

Deformity to left wrist and right ankle