ELDER TIP Leg amputation can be a life-threatening procedure, especially in patients older than age 60 with peripheral vascular disease. Such patients suffer significant morbidity with above-the-knee amputations because of associated poor health, disease, or malnutrition; complications such as sepsis; and the physiologic insult of amputation.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Dysarthria:
Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient displays dysarthria, ask him about associated difficulty swallowing. Then determine respiratory rate and depth. Measure vital capacity with a Wright respirometer if available. Assess blood pressure and heart rate. Tachycardia, slightly increased blood pressure, and shortness of breath are usually early signs of respiratory muscle weakness.
Ensure a patent airway. Place the patient in Fowler’s position and suction him if necessary. Administer oxygen and keep emergency resuscitation equipment nearby. Anticipate intubation and mechanical ventilation in progressive respiratory muscle weakness. Withhold oral fluids in the patient with associated dysphagia.
If dysarthria isn’t accompanied by respiratory muscle weakness and dysphagia, continue to assess for other neurologic deficits. Compare muscle strength and tone in the limbs, and evaluate tactile sensation. Ask the patient about numbness or tingling. Test deep tendon reflexes (DTRs), and note gait ataxia. Assess cerebellar function by observing rapid alternating movement, which should be smooth and coordinated. Next, test visual fields and ask about double vision. Check for signs of facial weakness such as ptosis. Finally, determine level of consciousness (LOC) and mental status.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Headache:
Treatment
(Handbook of Diseases)
Depending on the type of headache, treatment interventions range from relaxation techniques, massage, and biofeedback to pharmacologic agents. Tricyclic antidepressants, beta-adrenergic blockers, and anticonvulsants may be prescribed for headache prevention; nonsteroidal anti-inflammatory drugs (NSAIDs), combination NSAIDs with caffeine, ergotamines, and dopamine antagonists may be used for abortive measures. Narcotic agents are generally avoided or may be limited to twice weekly.
Abortive therapy using the synthetic form of serotonin (sumatriptan) is available in an oral form and as a nasal spray and can easily be carried for immediate use.
Other measures include identification and elimination of causative factors, stressors, or stimuli that might trigger an attack such as in the migraine-type headache. Diet history and examination of lifestyle patterns may help identify causative agents.
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Source: Handbook of Diseases, 2003
Chest injuries, blunt:
Treatment
(Handbook of Diseases)
Clinical tip Blunt chest injuries call for immediate physical assessment, control of bleeding, maintenance of a patent airway, adequate ventilation, and fluid and electrolyte balance.
❑ Check all pulses and level of consciousness. Also, evaluate color and temperature of skin, depth of respiration, use of accessory muscles, and length of inhalation compared with exhalation.
❑ Check pulse oximetry values for adequate oxygenation.
❑ Observe tracheal position. Look for jugular vein distention and paradoxical chest motion. Listen to heart and breath sounds carefully; palpate for subcutaneous emphysema (crepitation) and a lack of structural integrity in the ribs.
❑ Obtain a history of the injury. Unless severe dyspnea is present, ask the patient to locate the pain, and ask if he’s having trouble breathing. Obtain an order for laboratory studies (arterial blood gas analysis, cardiac enzyme levels, complete blood count, and typing and crossmatching).
❑ For simple rib fractures, give a mild analgesic, encourage bed rest, and apply heat. To prevent atelectasis, instruct the patient on incentive spirometry and deep breathing, coughing, and splinting. Don’t strap or tape his chest.
❑ For more severe fractures, intercostal nerve blocks may be needed. Obtain X-rays before and after the nerve blocks to rule out pneumothorax.
❑ If the patient has excessive bleeding or hemopneumothorax, intubate him. Chest tubes may be inserted to treat hemothorax and to assess the need for thoracotomy. To prevent atelectasis, turn the patient frequently and encourage coughing and deep breathing.
❑ If the patient has pneumothorax, he may need a chest tube placed anteriorly to the midaxillary line at the fifth intercostal space, to aspirate as much air as possible from the pleural cavity and to reexpand the lungs. Insert chest tubes attached to water-seal drainage and suction.
❑ If the patient has flail chest, place him in semi-Fowler’s position. Reexpansion of the lung is the first definitive care measure. Administer oxygen at a high flow rate under positive pressure. Suction the patient frequently, as completely as possible. Carefully observe the patient for signs of tension pneumothorax.
❑ The patient with flail chest will also need I.V. therapy started. Use lactated Ringer’s solution or normal saline solution. Beware of both excessive and insufficient fluid resuscitation.
❑ For hemothorax, treat shock with I.V. infusions of lactated Ringer’s solution or normal saline solution. Administer packed red blood cells for blood losses greater than 1,500 ml or circulating blood volume losses exceeding 30%. Autotransfusion is an option. Administer oxygen.
❑ The patient with hemothorax will also need insertion of chest tubes in the fifth or sixth intercostal space anterior to the midaxillary line to remove blood. Monitor and document vital signs and blood loss. Watch for falling blood pressure, rising pulse rate, and hemorrhage —all require thoracotomy to stop bleeding.
❑ For pulmonary contusions, give limited amounts of colloids (for example, salt-poor albumin, whole blood, or plasma) to replace volume and maintain oncotic pressure. Administer an analgesic, a diuretic and, if necessary, a corticosteroid, as needed. Monitor arterial blood gas values to ensure adequate ventilation; provide oxygen therapy, mechanical ventilation, and chest tube care.
❑ For suspected cardiac damage, close intensive care or telemetry may detect arrhythmias and prevent cardiogenic shock. Impose bed rest in semi-Fowler’s position (unless the patient requires shock position); as needed, administer oxygen, an analgesic, and other supportive drugs to control heart failure or supraventricular arrhythmia.
❑ Watch for cardiac tamponade, which calls for pericardiocentesis. Essentially, provide the same care as for a patient who has suffered myocardial infarction.
❑ If the patient has myocardial rupture, septal perforation, or another cardiac laceration, immediate surgical repair is mandatory; less severe ventricular wounds require use of a digital or balloon catheter; atrial wounds require a clamp or balloon catheter.
❑ For the few patients with aortic rupture or laceration who reach the facility alive, immediate surgery is mandatory, using synthetic grafts or anastomosis to repair the damage. Give large volumes of I.V. fluids (lactated Ringer’s or normal saline solution) and whole blood, along with oxygen at very high flow rates; then transport the patient promptly to the operating room.
❑ If the patient has tension pneumothorax, insertion of a spinal or 14G to 16G needle into the second intercostal space at the midclavicular line is necessary to release pressure in the chest. After that, insert a chest tube to normalize pressure and reexpand the lung. Administer oxygen under positive pressure, along with I.V. fluids.
❑ For a diaphragmatic rupture, insert a nasogastric tube to temporarily decompress the stomach, and prepare the patient for surgical repair.
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Source: Handbook of Diseases, 2003
Amputation, traumatic:
Treatment
(Handbook of Diseases)
Because the greatest immediate threat after traumatic amputation is blood loss and hypovolemic shock, emergency treatment consists of local measures to control bleeding, fluid replacement with normal saline solution and colloids, and blood replacement as needed.
Reimplantation remains controversial, but it’s becoming more common and successful because of advances in microsurgery. If reconstruction or reimplantation is possible, surgical intervention attempts to preserve usable joints. When arm or leg amputations are done, the surgeon creates a stump to be fitted with a prosthesis. A rigid dressing permits early prosthesis fitting and rehabilitation.
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Source: Handbook of Diseases, 2003
Abdominal injuries:
Treatment
(Handbook of Diseases)
Abdominal injuries require emergency treatment to control hemorrhage and prevent hypovolemic shock, by infusion of I.V. fluids and blood components. Some abdominal injuries require surgical repair after stabilization, whereas others require immediate surgery. Blunt trauma to the spleen or liver may be treated with nonoperative management and close monitoring. Analgesics and antibiotics increase patient comfort and prevent infection. Most patients require hospitalization; if they’re asymptomatic, they may require observation for only 6 to 24 hours.
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Source: Handbook of Diseases, 2003
Battle's sign:
Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Assess the patient’s neurologic function frequently. Keep him in a supine position to decrease pressure on dural tears and to minimize CSF leakage. Avoid nasogastric intubation and nasopharyngeal suction, which may cause cerebral infection. Also, caution the patient against blowing his nose, which may worsen a dural tear.
The patient may need skull X-rays and a CT scan to help confirm a basilar skull fracture and to evaluate the severity of the head injury. Typically, a basilar skull fracture and associated dural tears heal spontaneously within several days to weeks. However, if the patient has a large dural tear, a craniotomy may be necessary to repair the tear with a graft patch. If the injury was due to abuse, notify the appropriate authority in the facility.
Patient teaching
Explain all procedures and tests. Inform the patient with a basilar skull fracture that he’ll require bed rest for several days to weeks. Explain the need to avoid placing pressure on the brain tissue, and advise him on proper positioning. Also tell him to refrain from blowing his nose.
If the injury was due to an accidental fall, advise the patient’s family to assess the household for safety hazards and remove precipitating factors such as throw rugs.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Dysarthria:
Nursing considerations
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Encourage the patient with dysarthria to speak slowly so that he can be understood. Give him time to express himself, and encourage him to use gestures. Dysarthria usually requires consultation with a speech pathologist.
Patient teaching
Instruct the patient and his family about communication techniques. Encourage the patient to express his feelings. Provide guidelines on foods or liquids that should be avoided due to risk for aspiration. Refer the patient to a speech therapist.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Battle's sign:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Explain activity restrictions and the need for bed rest to the patient. Provide emotional support to the patient and his family. Caution the patient against blowing his nose, which may worsen a dural tear.
Before discharge, instruct the patient’s family or caregiver to watch closely for changes in mental status, LOC, or respirations. Tell them to give the patient acetaminophen if he experiences headaches.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysarthria:
Emergency Actions
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient displays dysarthria, ask him about associated difficulty swallowing. Then determine his respiratory rate and depth, and measure vital capacity. Assess blood pressure and heart rate. Usually, tachycardia, slightly increased blood pressure, and shortness of breath are early signs of respiratory muscle weakness.
Ensure a patent airway. Place the patient in Fowler’s position and suction him if necessary. Administer oxygen, and keep emergency resuscitation equipment nearby. Anticipate intubation and mechanical ventilation in progressive respiratory muscle weakness. Withhold oral fluids in the patient with associated dysphagia.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
Patient counseling
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Teach the patient and his family or caregiver how to recognize signs of reduced LOC and seizures. Discuss ways to maintain a safe, quiet environment and reduce environmental stress, if indicated. Discuss the use of analgesics to ease the headache.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Battle's sign:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Expect a patient with a basilar skull fracture to be on bed rest for several days to weeks. (See Managing the patient with a basilar skull fracture.)
▪ Monitor his neurologic status closely.
▪ Anticipate that the patient may need skull X-rays and a computed tomography scan to help confirm basilar skull fracture and to evaluate the severity of head injury.
▪ Although a basilar skull fracture and associated dural tears typically heal spontaneously within several days to weeks, if the patient has a large dural tear, a craniotomy may be necessary to repair the tear with a graft patch.
Patient teaching
▪ Explain activities the patient should avoid, and emphasize the importance of bed rest.
▪ Explain to the patient and family the signs and symptoms to look for and report, such as changes in mental status, LOC, or breathing.
▪ Tell the patient to take acetaminophen for headaches.
▪ Explain what diagnostic tests the patient may need.
▪ Discuss surgery with the patient, if indicated, and answer his questions and concerns.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Dysarthria:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Consult with a speech pathologist, as needed.
▪ Administer medications and treatments as needed.
▪ Assess the patient's swallow and gag reflexes before feeding him.
▪ Give the patient time to express himself.
▪ Encourage the patient to express his feelings.
Patient teaching
▪ Encourage the patient with dysarthria to speak slowly so that he can be understood.
▪ Encourage him to use gestures to aid communication.
▪ Discuss different ways to communicate.
▪ Explain to the patient his diagnosis and the treatment plan.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Headache:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ Monitor the patient's vital signs and LOC.
▪ Watch for a change in the headache's severity or location.
▪ To help ease the headache, administer an analgesic, darken the patient's room, and minimize other stimuli.
▪ Prepare the patient for diagnostic tests, such as skull X-rays, a computed to-mography scan, lumbar puncture, or cerebral arteriography.
Patient teaching
▪ Explain all procedures and treatments to the patient.
▪ Discuss the signs of reduced LOC and seizures that the patient or his caregivers should report.
▪ Explain ways to maintain a safe, quiet environment and reduce environmental stress.
▪ Discuss the proper use of analgesics.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Brain Injury, Traumatic:
Brain Injury, Traumatic - TREATMENT
(The 5-Minute Pediatric Consult)
- Airway, breathing, circulation
- Pre-hospital stabilization: Avoid hypoxemia and hypotension (strong, possibly modifiable, independent predictors of outcome in TBI)
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Source: The 5-Minute Pediatric Consult, 2008
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