Hospital protocols

When an oncoming car crossed the median strip it crashed into James who was riding his motorcycle, inflicting upon him serious pelvic injuries. His pelvis was broken and his bladder was ruptured. On admittance to the emergency department via an ambulance, James went to the operating theatre (OT) for surgery and was sent from the OT to the high dependency unit (HDU) for a higher level of nursing care than he may have received if he had been sent to another ward.

When he was admitted to HDU he had a central venous (CV) line, an arterial line, drain’s, external fixation devices and an indwelling catheter protruding from his body, all designed to assist his body to heal but these aids also provided a portal of infection into the body. Infection is a high source of mortality and morbidity in intensive care settings and much of the care James received was aimed at avoiding this. Pain management was also a high priority for James as pain can have a negative impact on the healing process.

This assignment will look at the high acuity needs of James and why he was initially nursed in the HDU instead of on an orthopedic or genitourinary ward. The nursing care James received will also be investigated and compared with nursing literature. The need to keep James pain free will be discussed as well as the high requirement to keep him free of infection. Legal requirements govern many of the daily tasks a nurse must perform. Some of these legal requirements and an evaluation of how they were performed will be investigated in this assignment. Sudden calamities can effect the structure of a family. Nursing staff can play an important role in assisting families to cope with these events and how they did this for James’s wife and family will be looked at.

It is important to mention that confidentiality will be maintained throughout this report. The actual name of the person will be changed, and any identifying information will be changed or omitted from this report. Informed consent was obtained from James in order to complete this report. According to the Department of Health (1991), informed consent can help give people control over their lives, promote trust and partnership between all parties concerned, and encourage individuals to accept responsibility for their health. The writer explained that this report was a requisite for the completion of the paper and it would involve an interview with James about his medical condition as well as allowing the writer access to his notes. His wife signed the consent form for him, which is held by the writer.

According to Palmer, Giddens and Palmer (1996), trauma care is described as a sequence of events that begins with the prehospital care administered by the ambulance staff, the emergency care administered in the emergency room, the critical care which is administered by the specialist doctors and surgeons, intermediate care and rehabilitative care. Palmer, Giddens & Palmer, 1996, (p. 219) state death from traumatic injury has “a trimodal distribution”, with part one occurring within seconds or minutes after the injury when the person dies from injuries sustained before medical attention is administered.

The second peak of death will occur within a few hours of injury when the patients die in the emergency department from the injuries they received. These injuries are potentially reversible however and reflect an urgent need for medical attention within a specific time-frame – the golden hour. The third wave of deaths in trauma occurs in the days and weeks following the injury and many of these deaths are attributed to infection or sepsis.

Severe pelvic injuries are associated with a high mortality rate (Urden, Stacy & Lough, 2002). For this reason James was admitted to the HDU where the ratio of nurses to patients is one nurse to two patients, thereby ensuring that he received the more intensive nursing care he required. According to Coulter (2001), the severity of illness may correlate to the degree of the change in the patients health status as a result of their disease or trauma, reflecting the areas of major concern of nursing diagnoses and cares to be given.

James experienced a blunt trauma injury that ruptured his bladder, separated his symphysis pubis, also known as a “sprung pelvis” (Simon & Koenigsknecht, 1982), and damaged his hand. Simon and Koenigsknecht (1982) describe a sprung pelvis as being the most serious of pelvic dislocations because all of the joints of the pelvis are dislocated and the incidence of associated injuries with this type of fracture is very high. After renal injury, bladder injuries are the second most common injury to the genitourinary tract and are most commonly associated with blunt trauma and pelvic injury (Tintinalli, Ruiz, & Krome, 1996).

The bladder is sited deep within the bony pelvis, it is protected from all but the most severe injuries to the abdomen and pelvis. Thelan, Davie, Urden and Lough (1994), also state that the type of injury to the bladder not only depends upon the strength of the blunt force and its location but also on how much urine is in the bladder at the time of the insult to it. James’s ruptured bladder was diagnosed using cystographic examination and he required surgery to repair extraperitoneal and intraperitonal ruptures of his bladder.

Intraperitoneal bladder rupture is described as a burst injury arising after a blunt trauma insult to a full bladder that results in a laceration in the dome of the bladder. This results in the spillage of urine into the peritoneal cavity. Surgery is required to repair this type of injury (Tintinalli, Ruiz & Krome, 1996). When James underwent surgery 800 milliliters of urine was removed from his abdominal cavity and two Nelaton drains were inserted into either side of his bladder to continue to drain any excess fluid. These remained insitu for 10 days before they were removed, however they drained less than 100 milliliters of fluid from each side over the 10 day period.

Extraperitoneal bladder rupture is diagnosed using the cystogram. It does not usually require surgery and is treated with an indwelling urinary catheter to drain urine for 10 – 14 days. The cystogram is repeated to confirm healing before the withdrawal of the urinary catheter (Tininalli, Ruiz & Krome, 1996). James had an indwelling catheter (IDC) inserted whilst he was in the operating theatre. The output from this was measured hourly and the colour of the urine was also observed and documented. Initially the output and colour was observed to be that of frank blood but this improved over the period of 12 days until the output was straw coloured urine. During this period of time the IDC drained freely and did not require flushing.

The symphysis pubis was stabilised with external fixations. These were inserted to close the seven centimeter gap that had resulted from the impact. James had three surgeries to correct his symphysis pubis. In the third surgery his symphysis pubis was rejoined and fixed with plates, ensuring that it would stay together and heal properly. The external fixations remained insitu to provide further stabilisation and James was informed that he could expect these to remain in place for up to 12 weeks.

At the time of his first surgery James had a chest drain inserted into his right lung because he had fluid present in his thoracic cavity. Tests revealed the fluid to be urine. Surgeons denied any diaphragmatic ruptures or tears, however, an intensive care doctor suggested that there had been a tear, but they are very difficult to locate and it will heal without intervention (personal communication, Dr. Ward, 7-5-03). James also received five units of packed red blood cells on arrival in HDU after his surgery. His vital signs were monitored according to the hospital policy for patients receiving blood products and he experienced no adverse reactions.

Much of the nursing care received by James focused on keeping him free from infection. According to Thelan, et. al. (1994), infection is a major cause of mortality and morbidity for patients in intensive care settings and “of trauma patients who survive longer than three days, infection is a frequent cause of death” (p. 757). Fortunately for James, his protective leather clothing protected him from the cuts and grazes he may otherwise have received when he fell off his motorbike. This eliminated one of the avenues for infection to invade his body. The main portals of entry for infection to enter his body was via the intravenous lines, the drains, external fixations and the IDC as well as the large surgical wound made by the surgeons when they repaired his bladder. However, the urine spilled into the peritoneal cavity and up into the thoracic cavity also provided another source of potential infection.

Endogenous bacteria were released into the internal environment, via the urine, as a result of the intraperitoneal rupture. James was administered regular doses of a strong antibiotic medication (Mandol, 1 gram, twice daily), to counter any infection that may arise from his injuries. His CV and arterial lines were cleaned daily with chlorhexidine, a strong bacteria killing solution and then covered with a protective dressing, according to hospital protocols. The Nelaton drains and the external fixation sites were dressed daily using aseptic technique and sterile dressings to ensure they remained free from infection, as was his laparotomy wound which was in the shape of an inverted T and held together with staples. To ensure his status remained infection free, hourly baseline observations were performed and recorded on his hospital chart. Alterations in baseline observations may indicate infection is present in the body (Taylor, Lillis & LeMone, 2000).

With each shift change the nursing staff performed what was described as a “top to toe” examination of James. This involved physically inspecting all of the parts of his body they could see without turning him over and noting any changes – positive or negative. An inspection of his back and buttocks was performed each evening when James had his bed bath to ensure no pressure sores were developing. Each nurse who looked after James listened to his chest, noting the sounds they heard and they also listened to his bowel sounds and noted their findings in the nursing notes. His left hand which was in a back-slab cast was assessed daily for colour, warmth, sensation and movement to ensure correct healing. His dressings were assessed regularly for exudate and discharge and his position was changed regularly to lessen the risk of pressure sores developing.

According to Boggs and Wooldridge-King (1993), surgical dressings should be changed daily after the initial 24 hour period when they are left intact and not disturbed. All dressing changes were performed using an aseptic technique to limit the possibility of infection contaminating any of James’s wounds and the lack of infection was evidenced by his baseline vital signs remaining stable, no redness observed around the edges of his wounds and no pus forming.

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