NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries

Student Name

Chamberlain University

NR-341 Complex Adult Health

Prof. Name

Date

WEEK 5: Complex NR 341 – Trauma and Emergency Nursing

Overview of Emergency Department Visits and Nursing Role

Each year, more than 130 million individuals in the United States seek care in emergency departments (Centers for Disease Control and Prevention [CDC], 2021). Out of these, around 16 million require hospital admission for continued treatment. Emergency nursing plays a pivotal role in the initial management of life-threatening injuries, with early recognition being crucial for successful outcomes. Unlike routine care, diagnosis may be secondary to stabilizing the patient’s condition. Nurses in emergency settings must exhibit flexibility, fast critical thinking, and composure amid unpredictable, high-stress scenarios. Their responsibilities span across all age groups and encompass various urgent conditions including environmental injuries (heat or cold exposure), submersion trauma, poisoning, and acts of violence.

Primary Survey: Initial Life-Saving Assessment

What are the components of the primary survey?

The primary survey is a rapid assessment designed to identify and address life-threatening issues immediately. The components are:

• Airway with cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability (neurologic status)
• Exposure and environmental control
• Facilitation of family presence
• Get resuscitation adjuncts

This survey must be prioritized when any indication of uncontrolled hemorrhage is present. In such cases, the sequence is reprioritized to C-A-B: Catastrophic bleeding first, followed by airway and breathing management.

Which adjunct measures should be initiated during primary survey?

Adjunctive assessments support the primary survey using the LMNOP mnemonic:

Mnemonic	Purpose
L – Laboratory tests	Blood and diagnostic evaluations
M – Monitor ECG	Heart rate and rhythm monitoring
N – Nasogastric tube	Stomach decompression (contraindicated in facial/skull trauma)
O – Oxygenation	Pulse oximetry and oxygen therapy
P – Pain	Assessment and appropriate pain management

Important Note: In patients with facial trauma and signs like periorbital bruising or dysconjugate gaze, nasogastric tube placement is contraindicated due to the risk of brain penetration. Use orogastric tubes instead, and inspect for CSF leakage from ears or nose.

Triage in Emergency Settings

What is triage and how is it conducted?

Triage involves rapid assessment and categorization of patients based on illness severity to ensure the most critical are treated first. The Emergency Severity Index (ESI), a five-level triage system, considers both the urgency of a condition and anticipated resource needs:

ESI Level	Description	Examples
ESI 1	Unstable, needs immediate life-saving intervention	Cardiac arrest, severe bleeding
ESI 2	High risk, should be seen within 10 minutes	Chest pain, unresponsive trauma
ESI 3	Stable but urgent, needs multiple resources	Abdominal pain, hip fracture
ESI 4	Stable, simple diagnostics needed	Minor laceration, urinary symptoms
ESI 5	Stable, requires minimal/no resources	Flu, minor burns

How is the ESI level assigned?

Evaluate in the following order:

1. Is the patient in immediate danger of death? (ESI 1)
2. Is the patient at high risk but not immediately dying? (ESI 2)
3. If not, how many resources will be needed?
   • One or more resources: ESI 3
   • One resource: ESI 4
   • No resources: ESI 5

Patients in ESI levels 3-5 must have normal vital signs to be categorized as such.

Airway, Breathing, and Circulation in Emergency Care

How should airway and breathing be managed in trauma patients?

Airway obstruction is a leading cause of early trauma death. Prompt recognition and intervention include:

• Jaw thrust maneuver
• Suctioning
• Oral/nasal airways
• Endotracheal intubation
• Emergency tracheotomy (if required)

Breathing complications often result from trauma-related injuries such as pneumothorax or rib fractures. Use 100% oxygen via non-rebreather mask and identify signs like dyspnea, asymmetric chest movement, and absent breath sounds.

What is the role of circulation assessment and management?

Ensuring adequate perfusion is critical:

• Assess pulse, skin color/temp, LOC, and capillary refill
• Insert two large-bore IVs
• Administer isotonic fluids (e.g., LR or NS)
• Provide O-negative blood if urgent transfusion is needed
• Consider IO or central access if peripheral access is not possible

Neurologic Status, Exposure, and Adjuncts

What does “D” for Disability mean in the primary survey?

Assess neurologic function using the Glasgow Coma Scale (GCS) and check pupillary responses. Note that the GCS is not accurate in patients who are intubated or aphasic.

How is environmental exposure managed?

• Remove clothing to assess injury
• Preserve forensic evidence if applicable
• Use warming techniques to prevent hypothermia

Secondary Survey: A Full Systematic Evaluation

What is the secondary survey and when is it initiated?

After all life-threatening conditions are addressed, a secondary survey begins. It includes:

• History using SAMPLE:
  • Symptoms
  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events leading up to illness/injury
• Head-to-toe assessment
• Inspection of posterior surfaces (logroll with spinal protection)

Temperature Management and Environmental Injuries

What is Targeted Temperature Management (TTM)?

TTM, formerly known as therapeutic hypothermia, is used post-cardiac arrest to reduce brain injury. The goal is to maintain a core temperature of 89.6º – 96.8ºF (32º – 36ºC) for at least 24 hours. Cooling methods include:

• Cold saline infusions
• Surface cooling devices
• Invasive core temperature monitoring

What are heat-related emergencies?

Condition	Description	Treatment
Heat cramps	Muscle cramps post-exercise	Rest, oral/IV hydration
Heat exhaustion	Prolonged exposure to heat; symptoms include nausea, hypotension, tachycardia	Cooling, electrolyte replacement
Heatstroke	Medical emergency; failure of thermoregulation, no sweating, high core temp	Rapid cooling, manage airway, seizure prevention

Control shivering, as it raises core temperature and increases oxygen demand.

What are cold-related emergencies?

Condition	Description	Management
Frostnip	Red, cold skin; resolves with warmth	Passive rewarming
Superficial frostbite	Waxy skin, tingling, blisters	Warm water immersion, pain control
Deep frostbite	White/blackened skin, tissue necrosis	Debridement, elevation, systemic support
Hypothermia	Core temp < 95°F (35°C)	Rewarming methods (passive, active external/internal), monitor dysrhythmias

Mild hypothermia: 93–95°F
Moderate: 86–93°F
Severe: <86°F (shivering stops, coma likely)

Submersion Injuries and Trauma Management

What are the effects of submersion injuries?

Drowning causes hypoxia due to fluid aspiration. Management includes:

• Correct hypoxia
• Treat fluid/electrolyte imbalance
• Rewarm if hypothermic
• Support pulmonary function

What should be avoided in patients with head trauma?

Avoid inserting a nasogastric tube in patients with signs of basilar skull fracture (e.g., raccoon eyes, dysconjugate gaze). Use orogastric instead.

Emergency Preparedness and Mass Casualty Incidents (MCI)

How is disaster triage conducted using colored tags?

Tag Color	Meaning	Example
Red	Immediate attention	Severe bleeding, airway obstruction
Yellow	Delayed treatment	Stable fractures, moderate wounds
Green	Minor injuries	Walking wounded
Black	Deceased or no chance of survival	No breathing/pulse

Triage uses the START algorithm:

• Can the patient walk? → Green
• Breathing >30/min? → Red
• Normal cap refill and follows commands? → Yellow

Comprehensive Trauma and Emergency Care Management

Initial Trauma Assessment and Immediate Nursing Priorities

A client presenting with extensive trauma following a fall requires intensive and continuous monitoring. Immediate assessment and interventions should follow the primary and secondary survey protocols. The primary survey identifies and stabilizes life-threatening conditions and prioritizes the ABCs (Airway, Breathing, Circulation), Disability (neurological status), Exposure, and Adjuncts like oxygenation and monitoring (Jevon, 2022). The secondary survey is a head-to-toe evaluation to detect other injuries.

The client in this scenario arrives on a backboard with cervical spine immobilization and shows an obvious left tibial deformity, indicative of a fracture. IV access with warmed normal saline has been initiated, and the patient receives 2L/min oxygen via nasal cannula.

Vital signs:

• BP: 89/68 mmHg
• HR: 125 bpm
• RR: 16/min
• SaO₂: 93%
• Temp: 94°F (34.4°C)

These indicate hypovolemia and early shock, warranting urgent fluid resuscitation and diagnostics.

Diagnostics and Interventions Anticipated

Upon stabilization, immediate diagnostics such as:

Diagnostic Tool	Purpose
FAST Ultrasound	Identifies internal bleeding or organ damage
Chest X-ray	Rules out thoracic injury, pneumothorax, hemothorax
CT Scan	Evaluates internal organ and brain injuries

Additionally, realignment and immobilization of the tibial fracture are necessary. Neurovascular checks are essential to detect early signs of compartment syndrome, which can be limb-threatening (Miller & Skinner, 2021).

Surgical Management and Postoperative Complication

The client underwent:

• Open Reduction and Internal Fixation (ORIF) of the left femur and tibia
• Closed reduction of the mandibular fracture, followed by jaw wiring

Shortly after surgery, the client develops acute respiratory distress and petechiae on the neck and chest—hallmarks of Fat Embolism Syndrome (FES).

Q: What complication is anticipated based on the symptoms of respiratory distress and petechiae?

A: Fat Embolism Syndrome (FES)
This syndrome occurs 24–48 hours post-injury, especially in long bone fractures, and presents with:

• Respiratory distress
• Hypoxemia
• Petechial rash (neck, chest, conjunctiva)
• Neurologic changes (confusion, restlessness)

Fat Embolism Syndrome: Prevention and Treatment

Prevention	Treatment
Early surgical fixation of fractures	High-flow oxygen or mechanical ventilation
Corticosteroids (e.g., methylprednisolone)	IV fluids (isotonic + albumin) to maintain volume
Minimal repositioning of fractured limb	IV heparin (controversial) to reduce microemboli

Continuous SpO₂ monitoring and respiratory assessments are vital in reducing hypoxic damage (Zhou et al., 2023).

Q: What is the nurse’s priority action for suspected compartment syndrome?

A: Immediate notification of the provider for a fasciotomy.
Compartment syndrome is a surgical emergency, characterized by:

• Increasing pain
• Numbness
• Delayed capillary refill
• Pallor
• Absent distal pulses

Elevating or icing the limb can worsen ischemia and must be avoided.

Autopsy Requirements After Sudden Death in Emergency Setting

Autopsies may be legally required or requested by families under the following situations:

Situation	Autopsy Indication
Death within 24 hours of hospital admission	Yes
Violent or suspicious death	Yes
Family request	Yes
Elderly age alone	No (not a determining factor)

Trauma by System: Mechanism and Consequences

Trauma is the leading cause of death in individuals aged 1–44 years in the U.S. (CDC, 2019). Understanding the mechanism of injury (MOI)—blunt or penetrating—helps predict associated damage.

NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries

Mechanism	Examples
Blunt	MVCs, falls, assaults, blast injuries
Penetrating	Stab wounds, gunshots, impalements

Traumatic Brain Injuries (TBI)

TBIs are categorized as:

• Concussion (mild)
• Contusion (bruising of brain tissue)
• Epidural/Subdural hematoma (bleeding between skull layers)

Clinical signs vary:

Surface Signs	CNS Signs	Respiratory Signs
Raccoon eyes	LOC changes	Cheyne-Stokes
Battle’s sign	Unequal pupils	Hypoxia
Skull fracture	CSF leaks	Pulmonary edema

Medical Management of TBI

• Maintain airway and oxygenation
• Intubation if GCS ≤ 8
• Stabilize spine, control bleeding
• Prevent secondary injury (hypoxia, hypotension)

Q: Place the following actions in priority for head injury management

Answer (in order of priority):

1. Maintain airway and breathing
2. Stabilize cervical spine
3. Establish IV access
4. Monitor neurological signs
5. Prepare for surgical intervention

Spinal Cord Injury (SCI) and Shock Syndromes

SCI can lead to:

Spinal Shock	Neurogenic Shock
Flaccid paralysis	Hypotension and bradycardia
Absent reflexes	Loss of sympathetic tone
Temporary (days to weeks)	Lasts 1–3 weeks, affects perfusion

Q: What are signs of spinal shock and how should care be planned?

• Flaccid paralysis
• Absent deep tendon reflexes
• Loss of bladder/bowel control
• Rehabilitation is not contraindicated if stable

Q: What condition is present if client has hypertension, bradycardia, and diaphoresis above T6?

A: Autonomic Dysreflexia (AD)
It is triggered by stimuli below the injury (e.g., full bladder).

Management:

• Sit upright immediately
• Remove triggering stimuli
• Notify provider

Eye Trauma: Causes, Signs, and Treatment

Eye trauma can result from blunt or penetrating injuries, burns, or chemical exposure.

Signs	Treatment
Pain, swelling, bruising	Eye irrigation, patching, elevation, analgesia
Visible foreign body	Stabilize object, avoid removal

Chest Trauma: Mechanism and Complications

Flail Chest & Pneumothorax

Flail Chest:
Paradoxical chest movement; support with oxygen and pain management.

Tension Pneumothorax:
Life-threatening condition requiring needle decompression followed by chest tube insertion.

Abdominal Trauma and Complications

Blunt or penetrating abdominal trauma can cause:

• Hemorrhage (solid organ rupture)
• Peritonitis (hollow organ rupture)
• Abdominal compartment syndrome

Key signs:

• Distended, rigid abdomen
• Cullen’s or Grey Turner’s signs (internal bleeding)
• Hypovolemic shock symptoms

Fracture Management and Complications

Fractures are classified by completeness, direction, and skin integrity. The clinical picture often includes:

• Severe pain
• Swelling and bruising
• Loss of function
• Crepitus

Complications:

Complication	Description
Compartment Syndrome	Pressure buildup in muscle compartments; requires fasciotomy
Fat Embolism Syndrome	Fat droplets enter circulation; leads to respiratory failure
Rhabdomyolysis	Muscle breakdown releases myoglobin causing acute kidney injury (AKI)

Risk Factors and Injury Overview

Risk of Impaired Skin Integrity and Other Complications

Clients with paraplegia face a significant risk for impaired skin integrity due to reduced mobility and pressure on vulnerable areas, predisposing them to pressure ulcers. Additionally, they are susceptible to constipation as a result of diminished gastrointestinal motility, and severe hypotension may occur secondary to neurogenic shock, which causes a significant drop in vascular tone and cardiac output.

Primary vs. Secondary Spinal Cord Injury

Question: What is the difference between primary and secondary spinal cord injury?

Answer: Primary spinal cord injury results directly from mechanical trauma to the cord, which may occur through blunt or penetrating mechanisms. Secondary injury, on the other hand, is the progressive pathophysiological response that follows the initial insult. This includes cellular edema, ischemia, inflammatory cascades, blood-brain barrier breakdown, and eventual demyelination and necrosis (Asselin, 2020). The true extent of damage often cannot be fully assessed until edema subsides.

Burn Injuries: Overview

Burns involve tissue injury caused by thermal, electrical, chemical, or radiation sources. According to Asselin (2020), approximately 450,000 individuals in the U.S. seek treatment for significant burn injuries annually.

Types of Burns

Classification by Source

Type of Burn	Description
Thermal	Caused by flames, hot liquids (scalds), flash burns, or contact with heat.
Chemical	Result from acids (e.g., hydrochloric), alkalis (e.g., cement), or organics (e.g., phenols).
Smoke & Inhalation	Occurs from inhaling toxic gases or hot air, leading to airway edema.
Electrical	Due to electrical current; damage severity depends on voltage and contact time.
Cold (Frostbite)	Involves tissue freezing and ischemia from cold exposure.

Burn Injury Assessment and Severity

Signs of Inhalation Injury

Question: What symptoms suggest a smoke inhalation injury?

Answer: Common signs include hoarseness, drooling, copious secretions, stridor, wheezing, and altered mental status. These findings indicate airway irritation or thermal injury. Additional concerns include carbon monoxide poisoning, identified by confusion and headache, and pulmonary edema, which may present with pink frothy sputum and crackles.

Burn Depths and Characteristics

Burn Depth	Tissue Involved	Appearance	Pain/Sensation	Healing Process
Superficial Partial	Epidermis only	Red, painful, intact sensation	Present	Spontaneous healing
Deep Partial	Epidermis + dermis	Pink to white, blistered	Present but diminished	Epithelial regeneration
Full Thickness	All skin layers, possible subcutaneous	Leathery, black, eschar, no sensation	Absent	Requires grafting

Burn Location and Risk Factors

Burn Location	Clinical Significance
Face/Neck/Chest	Airway compromise, possible inhalation injury
Hands/Feet/Eyes	Affects self-care and daily function
Ears/Nose/Buttocks	Increased risk for infection due to cartilage exposure or contamination
Perineum	Prone to infection due to urinary/fecal exposure
Circumferential burns	Risk of compartment syndrome and impaired perfusion

Calculating Burn Surface Area

Rule of Nines vs Lund-Browder Chart

Region	Rule of Nines (%)	Lund-Browder (example)
Head and Neck	9%	3.5% (face) + 1% (neck)
Each Arm (front/back)	4.5% (each side)	Varies by age
Each Leg	9% (front/back)	Varies by proportion
Anterior Trunk	18%	6.5% (sectional)
Genitalia	1%	1%

Emergency Burn Care: Initial Priorities

Question: What are the top priorities in emergency burn care?

Answer:

1. Remove the source of the burn.
2. Airway assessment (look for soot, singed nasal hair, hoarseness).
3. Breathing and ventilation checks.
4. Circulation—monitor pulses and elevate limbs to minimize edema.
5. Initiate fluid resuscitation based on TBSA.

Fluid Resuscitation: Parkland Formula

Weight (kg)	TBSA (%)	Formula (4 mL × kg × TBSA)	Total Volume (24 hrs)	First 8 hrs (ml/hr)	Next 16 hrs (ml/hr)
72	45	4 × 72 × 45 = 12,960 ml	12,960 ml	810 ml/hr	405 ml/hr
109.1	36	4 × 109.1 × 36 = 15,709 ml	15,709 ml	982 ml/hr	491 ml/hr

Phases of Burn Management

Phase 1: Emergent (First 72 Hours)

• Priority: Prevent shock, maintain perfusion, manage respiratory status.
• Monitor: MAP >65 mm Hg, HR <120 bpm, urine output >0.5–1 ml/kg/hr.
• Electrolytes: ↓ Sodium, ↓ Albumin, ↑ Potassium, ↑ Hematocrit.
• Fluid Replacement: Begin with Lactated Ringer’s, followed by colloids after 24 hours.

Phase 2: Acute (Wound Healing)

• Starts after diuresis and ends with wound closure.
• Goals: Wound care, infection control, pain management, and nutrition.
• Partial-thickness burns heal with proper care; full-thickness burns require grafting.
• Pain Relief: Multimodal therapy (opioids + adjuvant agents like gabapentin).
• Topicals: Silver sulfadiazine, mafenide acetate, and antimicrobial dressings.

Phase 3: Rehabilitation (Restorative)

• Begins as wounds close and the patient resumes self-care.
• Focus: Psychosocial adjustment, contracture prevention, and functional recovery.
• Common Complications: Hypertrophic scarring, joint contractures.

Nutritional Therapy

Parameter	Goal
Caloric Needs	↑50–100% above baseline
Protein Intake	High-protein, high-carbohydrate
Enteral Feedings	Begin within 24–48 hours of injury
Micronutrient Supplement	Iron, zinc, vitamins A, C, D
Glucose Monitoring	Essential to prevent delayed healing
Weight Management	<10% loss from pre-burn weight

Monitoring for Complications

Phase	Potential Complications
Emergent	Hypovolemic shock, respiratory failure, renal dysfunction
Acute	Infection, Curling’s ulcer, hyperglycemia, fluid shifts
Rehab	Psychological distress, contractures, hypertrophic scars

Psychological and Functional Recovery

Question: How should a nurse support a patient with body image disturbances post-burn?

Answer: Encourage open discussion of feelings and provide emotional support. Promote independence and participation in self-care to foster recovery and self-efficacy. Avoid offering false reassurances and always validate the client’s emotional experiences.

Prioritizing Patient Care

Question: In what order should burn patients be seen?

1. Facial burns with signs of inhalation injury (airway compromise).
2. Patients reporting severe pain.
3. Post-operative debridement patients needing assessment.
4. Clients who are refusing dressing changes (educational opportunity).

---

Anticipated Lab Values by Burn Phase

Lab Parameter	Emergent Phase	Acute Phase
Sodium	↓ 130 mEq/L	Normalized
Potassium	↑ 6.5 mEq/L	Normalized (3.8 mEq/L)
Albumin	↓ 2.8 g/L	Improving
Hematocrit	↑ due to hemoconcentration	Returns to 42%
Urine Spec. Grav	↑ 1.040	Normal 1.018

References

Asselin, M. E. (2020). Burn injuries and nursing management. In Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.

American Burn Association. (2023). Burn Incidence and Treatment in the United States. Retrieved from https://ameriburn.org

Centers for Disease Control and Prevention (CDC). (2019). Injury prevention and control: Data and statistics. https://www.cdc.gov/injury/index.html

Jevon, P. (2022). Emergency Care and First Aid for Nurses. Elsevier Health Sciences.

Miller, D., & Skinner, D. (2021). Trauma: A Comprehensive Emergency Medicine Approach. Springer

NR 341 Comprehensive Nursing Care for a Patient with Multiple Traumatic Injuries

Zhou, Y., Li, X., Wang, Z., & Huang, L. (2023). Fat embolism syndrome after fractures: Prevention, early recognition, and management. Journal of Trauma and Acute Care Surgery, 94(3), 512–518. https://doi.org/10.1097/TA.0000000000003962

Centers for Disease Control and Prevention. (2021). Emergency department visits. https://www.cdc.gov/nchs/fastats/emergency-department.htm

Centers for Disease Control and Prevention. (2020). Unintentional drowning. https://www.cdc.gov/drowning/facts/index.html