SCOPE AND LIMITATION OF THE STUDY

This research focuses mainly on the patients specific condition, which is Pneumothorax and Traumatic Brain Injury secondary to Vehicular Accident. Comprised in the process of this study is to evaluate the condition of the patient before and upon admission, and after hospitalization, which we even focused more, to further evaluate what is the possible nursing and medical interventions would be applied to the patient in the entire course of therapies.

This study also focuses on the identification of all possible factors causing the disease, and to come up into better therapy of care.

This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Vehicular Accifent. This presentation also intends to help patient promote health and impose medical understanding to his support system of such condition through the application of the nursing skills. GENERAL OBJECTIVES OF THE STUDY This case presentation aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Vehicular Accident. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. SPECIFIC OBJECTIVES OF THE STUDY To To render nursing care and information to patient through the application of the nursing skills. SPECIFIC OBJECTIVES FOR THE PATIENT AND THE SUPPORT SYSTEM To raise the level of awareness of patient on health problems that he may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on his own.
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 To help patient in motivating him to continue the health care provided by the health workers. To raise the level of awareness of patient and his support system on health problems that the patient may encounter. To facilitate patient and his support system in taking necessary actions to solve and prevent the identified problems on their own that may arise during the process of rehabilitation. (Facilitate independent action) To help patient together with his SO in motivating them to continue the health care provided by the health workers. To render nursing care and information to patient and his family through the application of the nursing skills.

INCIDENCE REPORT

OVERVIEW OF THE STUDY

Motor Vehicular Accident, also known as traffic collision, occurs when a vehicle collide with a motor vehicle, pedestrian, animal, road debris, or another stationary obstruction, such as a tree or utility pole. It may result to injury, death and property damage. Motor vehicle accident injuries are as a direct result of the force of the impact and the biomechanics of injury. Most motor vehicle accidents are the typical hyperextension flexion injuries, or more commonly known as whiplash injuries. Motor vehicle accident injuries appear to be very challenging to most physicians as each mechanism of injury is slightly different.

Causes of MVA
Wherever there are motor vehicles and highways, there are accidents possibilities. These collisions can be caused by varying factors and can occur on any roadway. When people learn the various causes of motor vehicle accidents, they can become more aware of their driving habits and, thus, are more likely to avoid a collision. Driver Behavior The speeding, driving under the influence of alcohol or drugs, reckless driving (such as driving too fast for conditions), anger and aggressive driving, and inattention account for most motor vehicle accident.

Cell Phone Usage When you drive and talk on a cellular phone, your attention is divided between your driving and the party to whom youre speaking. Thus, you are more prone to hit, or be hit by, another vehicle.

Weather Vision is often impaired when a person drives through heavy rains or fog. A thin coating of ice can cause you to lose control of your vehicle. A snow accumulation on roads can not only make roads hard to negotiate but also can hide curbs, medians and signs. In all cases, accidents are more likely to occur.

Equipment Failure Through the most common cases of accidents directly caused by equipment failure involve loss of brakes, tire blowouts and steering or

suspension failure, the mere sound of a faulty piece of equipment can distract the driver and cause an accident. Roadway Hazards Intersections, merging lanes and curves or hills are permanent hazards that can contribute to accidents. Other hazards such as road construction, potholes, various debris in driving lanes, and vehicles parked on roadsides and traffic jams can also be factors in motor accidents. In many suburban and rural areas, animal such as dogs or cow can run into or block the road, causing motorists to swerve ad become more vulnerable to collision.

Risk Factors for Motor Vehicle Accident

Human Factors Visual and auditory acuity Decision-making ability Reaction speed Vehicular Factors Loss of Breaks Driver Impairment Alcohol blood alcohol level Physical impairment Poor eyesight and//or physical impairment with many jurisdictions setting simple sight test and for requiring appropriate to drive. Old age Requires drivers to test for reaction speed and eyesight after a certain age. Sleep Deprivation Sleep attack Fatigue Restlessness Drug Use OTC (Antihistamines, opioids, muscarinic antagonists Illegal Drugs Distractions Operating a mobile phone while driving Classical Music Considered to be calming yet too much could relax the driver to a condition of distraction. Roadway factors

Effect of Motor Vehicle Accident

Traumatic Brain Injury Cranial Nerve Damage Chest Trauma Fractures on the Extremities Neck Injury Spinal Cord Injury Other possible complications Spleenic Injury Hepatic Injury Pancreatic Injury Renal Injury

Blunt or Penetrating Trauma

I. TRAUMATIC BRAIN INJURY Traumatic Brain Injury (TBI) occurs as a result of an external force applied to the head and brain causing disruption of physiologic stability locally, at the point of injury, as well as globally with elevations in ICP (Intracranial Pressure) and potentially dramatic changes in blood flow within and to the brain. These changes may produce a diminished or altered state of consciousness. TBI may result in the impairment of cognitive abilities or physical functioning as well as a disturbance of behavior or emotional functioning. These impairments may be either temporary or permanent and may cause partial or total functioning disability or psychosocial maladjustment.

Primary Brain Injury Primary brain damage results from the physical stress (force) within the brain tissue caused by open or closed trauma. Open head injury occurs when there is a skull fracture or when the skull is pierced by a penetrating object. Closed head injury is the result of blunt trauma; the integrity of the skull is not violated. 3 Classifications of Brain Injury 1. Mild GSC score of 13 to 15 Loss of consciousness for 0 15 minutes 1. Moderate GSC score of 9 to 12 Period of loss of consciousness up to 6 hours Accompanied by other systemic injury Short critical care maybe needed for close monitoring. Difficulty with work, leaning and role function. 1. Severe GSC score of 3 to 8 Loss of consciousness for greater than 6 hours.

More serious and require management in critical care with ingoing monitoring of multiple physiologic parameters

a) Open Head Injury Fractures are: linear simple, clean break in which the impacted area of bone bends inwards and the area around it bends outward Linear fracture accounts for about 80% of all skull fractures. Depressed The bone is pressed inward into the brain tissue to at least the thickness of the skull. Open The scalp is lacerated, creating a direct opening to the brain tissue Comminuted Involves fragmentation of the bone open, and comminuted A unique fracture is a basilar skull fracture. It occurs at the base of the skull, usually extending into the anterior middle, or posterior fossa and results in cerebrospinal fluid (SCF) leakage from nose or ears. Of significance with this fracture is the is the potential development of hemorrhage caused by damage to the internal carotid artery; damage to cranial nerve (CN)I, II, VII, and VIII; and infection. Most penetrating injuries to the skull are caused by gunshot wounds (GSWs) and knife injuries. The degree of injury to brain tissue depends on the velocity, mass, shape, and direction of impact. Highvelocity injuries produce the greatest damage to brain tissue. As with any open head injury, the client with a penetrating injury is at high risk for infection from the object that pierced the skull and from other environmental contaminants. a) Closed Head Injury Closed head injuries are caused by blunt trauma and lead to: Mild concussion Diffuse axonal injury Contusion Laceration TYPES OF HEAD INJURY a) Concussion 7

 Close head injury characterized by loss of consciousness. Brief period of apnea. Mild concussion associated with subtle behavioral or cognitive changes, even if no obvious brain pathology exists. This condition, called POSTCONCUSSIVE SYNDROME, may last for more than a year. b) Epidural Hematoma c) Subdural Hematoma d) Subarachnoid Hemorrhage Type of Force One factor that must be considered in the dynamics of head injury. Acceleration injury caused by an external force contacting the head, suddenly placing the head in motion. Deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object.

Secondary Brain Injury Secondary responses to brain injury include any neurologic damage that occurs after the initial injury. Secondary injuries or responses increase the morbidity and mortality after head trauma. a) INCREASED INTRACRANIAL PRESSURE Cranial contents: Brain tissue Blood Cerebrospinal fluid (CSF) a) Hemorrhage b) Loss of Autoregulation c) Hydrocephalus An abnormal increase in CSF volume. Caused by impaired reabsorption of CSF at the arachnoid villi (from subarachnoid hemorrhage or meningitis) communicating hydrocephalus d) Brain Herniation In presence of increase ICP, brain tissue may shift and herniated downward.

II. CHEST WALL INJURY/ CHEST TRAUMA 8 Pulmonary Contusion

This condition most often follows injuries caused by rapid deceleration during vehicular accidents. Hemorrhage occurs between the alveoli. MANAGEMENT Treatment includes maintenance of ventilation and oxygenation. Central Venous Pressure (CVP) is monitored closely, and fluid intake is restricted as needed. Client in obvious respiratory distress may need mechanical ventilation with positive end-expiratory pressure (PEEP) to inflate the lungs.

Rib Fracture Most often result from direct blunt trauma to the chest. Direct force applied to the ribs fractures them and drives the bone ends into the thorax. Thus there is a risk for intrathoraxic injury, such as pulomary contusions or pneumothorax, which occurs most often if ribs one through four are fractures. MANAGEMENT Splinting reduces breathing depth and leads to inadequate clearance of pulmonary secretions. For uncomplicated rib fractures, treatment is nonspecific because the fractured ribs unite spontaneously. The main focus of management is to decrease pain so that adequate ventilation is maintained. Intercostal nerve block for severe pain. Potent analgesics that cause respiratory depression are avoided.

Flail Chest

Is the inward movement of the thorax during inspiration, with outward movement during expiration. It often occurs in high-speed vehicular crashes. It is more common in older clients. MANAGEMENT Humidified oxygen Pain management Promotion of lung expansion through deep breathing and positioning Secretion clearance by coughing and tracheal aspiration. MANAGEMENT Chest x-ray is used for diagnosis. Chest tubes may be needed to allow the air to escape and the lung to inflate.

Pneumothorax

Tension Pneumothorax MANAGEMENT A large-bore needle is inserted into the second intercostal space in the midclavicular line of the affected side as initial treatment. Then chest tube is placed into the fourth intercostal space, and the other end is attached to a water seal drainage system until the lung reinflates. Hemothorax Tracheobronchial Trauma

III. FRACTURE Trauma to the musculoskeletal system ranges from simple muscle strain to multiple bone fractures with severe soft-tissue damage. A fracture is a break or disruption in the continuity of a bone, Fractures can occur anywhere in the body and at all age. All fractures have the same basic pathophysiologic mechanism and nursing management, regardless of fracture type or location. STERNAL FRACURE Have anterior chest pain Overlying tenderness Ecchymosis Crepitus Swelling Chest wall deformity Area around the fracture may be bruised. RIB FRACTURE Severe pain Point tenderness Muscle spasm over the area of the fracture (can be aggravated by coughing, deep breathing, and movement). Area around the fracture may be bruised. CAUSES: 1. Direct or indirect trauma 2. Direct Blow or Cushing form 3. Twisting Force 4. Powerful muscle contraction highly develop muscle contact violently the muscle tear from bone sometimes pulling a small pieces of bone with it. 5. Fatigue and stress bone repeated after a repeated stress. 6. Bone weakness by disease or tumor or pathological fracture. When the bone is broken, adjacent structures are also affected, resulting in soft tissue edema, hemorrhage into the muscles and joints, joint dislocations, ruptured 10

tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by the fracture fragments. TYPES OF FRACTURE a) General Classification Complete break across the entire cross-section of the bone Incomplete break through only part of the cross-section of the bone Complicated when bone fragments penetrated an internal structure Close does not cause a break in the skin Open (Compound) cause a break in the skin Types of Open Fracture Grade I clean wound less than 1 cm Grade II larger wound without soft tissue damage Grade III highly contaminated a) Classification as to appearance Simple bone separated into two fragments only Comminuted bone is broken into 3 or more fragments Depressed broken bone fragments are driven inwards. Compressed bones collapsed under excessive pressure a) Classification according to direction of fracture line Transverse horizontal fracture line Linear/longitudinal vertical fracture line Oblique breaks runs in a slanting direction on the bone usually about 45 angle to bone shaft Spiral / torsion break line twist around the bone a) Classification according to cause Stress caused by too much activity to which bone is not accustomed Pathologic with pre-existing disease that predispose the bone to fracture Traumatic when it is a result of violence as in crushing injuries Avulsion a pulling away of a fragment of bone by a ligament or tendon or its attachment Epiphyseal fracture of epiphyseal Burst usually occurs in short bone resulting from a strong pressure leading to impaction of the disc

Fracture to a specific site Clavicle Common injury that results from a direct blow to the shoulder or a fall.

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Treatment goal: to align the shoulder in its normal position by means of closed reduction and immobilization Clavicular strap: may be used to pull the shoulder back, reducing and immobilizing the fracture. Nsg. Management: The nurse cautions the patient not to elevate the arm above shoulder level until the ends of the bone have united. Encourage the patient to exercise the elbow, wrist and fingers.

Elbow Distal result from motor vehicle crashes, falls on the elbow (in the extended or flexed position), or a direct blow. Nsg. Management: The goal of therapy is prompt reduction and stabilization of the distal humerus fracture, followed by controlled active motion after swelling has subsided and healing has begun. Wrist Fractures of the distal radius (colles fracture) are common and are usually the result of a fall on an open, dorsiflexed hand. This fracture is frequently seen in elderly women with osteoporotic bones and weak soft tissues. Nursing Management. Treatment usually consists of closed reduction and immobilization with a short arm cast. Hand Trauma to the hand often requires extensive reconstructive surgery. The object of treatment is always to regain maximum function of the hand. Nsg. Management. The finger is splinted for 3 to 4 weeks to relieve pain and to protect the finger from further trauma. Pelvis The sacrum, ilium, pubis and ischium bones from the pelvic bone, a fused stable, bony ring in adults. Falls, motor vehicle crashes, and crash injuries can cause pelvic fractures. Stable Pelvic Fractures Stable fractures of the pelvis include fracture of a single pubic or ischial ramus, fracture of ipsilateral pubic and ischial rami, fracture of pelvic wing if ilium and fracture of the sacrum or coccyx. Unstable Pelvic Fractures May result in rotational instability (e.g the open book type, in which a separation occurs at the symphysis pubis with some sacral ligament disruption), vertical instability (e.g. the vertical shear type, with superior-inferior displacement) or a combination of both. Tibia and Fibula Results from a direct blow, falls with the foot in a flexed position, or a violent twisting motion.

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Medical Management: Most closed tibial fractures are treated with closed reduction and initial immobilization in a long leg walking cast or a patellar tendon-bearing cast.

Femoral Shaft Considerable force is required to break the shaft of the femur in adults. Most femoral fractures are seen in young adults who have been involved in a motor vehicle crash or who have fallen from a high place. Frequently, these patients have associated multiple traumas. The patient presents with an enlarged, deformed, painful thigh and cannot move the hip or the knee. Assessment and Diagnostic Findings Assessment includes checking the neuromuscular status of the extremity, especially circulatory perfusion of the lower leg and foot (popliteal, posterior tibial and pedal pulses and toe capillary refill time). A doppler ultrasound monitoring devices may be needed to assess these fractures. Knee effusion suggests ligament damage and possible instability of the knee joint. Medical Management Continued neuromuscular monitoring is needed. Internal fixation usually carried out within a few days after the injury. Internal fixation permits early mobilization. A thigh cuff orthosis may be used for external support. To preserve muscle strength, the patient is instructed to exercise the lower leg, foot, toes and hip on a regular basis. Physical therapy includes ROM and strengthening exercises, safe use ambulatory aids, and gait training. Compression plates and intramedullary nails may need to be removed after 12 or 18 months due to reaction or loosening. After plates are being removed, a thigh cuff orthosis is used for several months to provide support while bone remodeling occurs. Because of patient risks associated with anesthesia and surgery,middle shaft and distal (supracandylar) fracture may be managed with skeletal traction. An external fixator may be used if the patient has experienced an open fracture, has extensive soft tissue trauma, has lost bone, has an infection, or has hip and tibial fractures.

Fractures may also be described according to anatomic placement of fragments, particularly if they are displaced or non displaced. Injuries to the skeletal structure may vary from a simple linear fracture to a severe crushing injury. The type and location of the fracture and the extent of damage to surrounding structures determine the therapeutic management. Maximum functional recovery is the goal of management.

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The signs and symptoms of a fracture include unnatural alignment, swelling, muscle spasm, tenderness, pain and decreased mobility. The position of the bone segments is determined by the pull of attached muscles, gravity, and the direction and magnitude of the force that caused the fracture. BONE HEALING PROCESS I. II. III. IV. V. VI. Hematoma Formation Hematoma to granulation tissue Callus Formation Osteoblastic Proliferation Bone Remodeling Bone Healing Complete

COMPLICATIONS a) b) c) d) e) f) g) h) ETIOLOGY The Primary cause of a fracture is trauma from a motor vehicular accident or fall and is spread over all socioeconomic groups. The trauma experienced may be a direct blow to the bone or an indirect force from muscle contractions or pulling forces on the bone, Precipitating Factors Sports Vigorous exercise Traumatic Accident Predisposing Factors Osteoporosis Osteomalacia Other bone diseases IV. NECK TRAUMA ETIOLOGY Knife 14 Acute Compartment Syndrome (ACS) Shock Fat Embolism Venous Thromboembolism Infection Ischemic Necrosis Fracture Blisters Delayed Union, Malunion, and nonunion

Gunshot Traumatic Accident

ASSESSMENT The priority in caring a client with neck trauma is assessment for a patent airway. After airway is assured, then assess for manifestations of bleeding or impending shock. Perform a baseline neurologic assessment for mental status, sensory level, and motor function. A carotid angiogram may be performed to rule out vascular injuries. Esophagus injury may occur with neck trauma. Assess for chest pain and tenderness, oral bleeding, and crepitus. A barium or meglumine diatrizoate (Gastrogafin) swallow may be needed to rule out an esophageal perforation injury. V. SPINAL CORD INJRY Effects: Paralysis Loss of reflexes Loss of sensory and motor function Management: Respiratory function is the first priority Immobilize in a flat, firm surface Cervical collar if cervical injury is suspected. Transport client as a unit Do not attempt to realign the body part Traction, cast, surgery VI. Other possible complications a) SPLEENIC INJURY The spleen is the most vascular organs of the body and contains approximately 1 unit (400-500mL) of blood at given time. Like the liver, the spleen is protected by the rib cage and its position is maintained by several ligaments, making deceleration injury common. Shock, hypotension, tachycardia, tachypnea, or pallor. Left upper abdominal or flank tenderness and guarding and peritoneal irritation. Thrombocytopenia Treatment:

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 Treatment of blood loss and shock is the key when treating injury to the spleen High-flow oxygen and fluids. a) HEPATIC INJURY Liver is the largest intra-abdominal solid organ. Although the liver is the second most commonly injured organ in abdominal trauma, liver damage is the most common cause of death after abdominal injury. Occurs most easily among children. Blood loss- shock, hypotension, tachycardia, tachypnea, or pallor Treatment: Treatment of injury to the liver is based on the level of blood loss and shock. Supplemental oxygen. Fluid replacement a) PANCREATIC INJURY Often accompanied by duodenal or biliary duct injury. High-energy forces are most commonly produced by penetrating trauma. Vague upper and midabdominal pain that radiates into the back. After several hours, generalized peritoneal irritation (Pancreatitis) Decrease glucose production for energy production. Treatment: Repeated abdominal examinations are the key to discover the patients worsening condition before vital signs change.

a) RENAL INJURY Commonly seen with falls and automobile collisions, where there is fracture of the 11th -12th rib or flank tenderness. Hematuria, pain (abdomen), flank on inspiration, costovertebral angle (CVA) tenderness. Flank discoloration. Treatment: Treat shock of presentmechanical ventilation. Supplemental oxygen, fluids,

PNEUMOTHORAX

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Is the accumulation of air in the intrapleural space. This may occur spontaneously or traumatically. May occur as a result of direct chest trauma by blunt (motor vehicular accident, fall or assault with blunt object) or penetrating forces (knife, gunshot or other missiles). However, it can also occur spontaneously in otherwise healthy people, particularly thin, young males. A lung may collapse

TYPES OF PNEUMOTHORAX

PRIMARY SPONTANEOUS PNUEMOTHORAX This usually occurs in otherwise healthy people with no history of chest trauma. It is most common in tall, thin men --- many of them smokers --- between 20 and 40 years of age. Is thought to develop when a small air blister (bleb) on the lung ruptures. Blebs are caused by a weakness in the lung tissue. SECONDARY SPONTANEOUS PNEUMOTHOTAX This develops in people who already have a lung disorder, especially emphysema, which progressively damages the lungs. Tuberculosis, pneumonia, cystic fibrosis and lung cancer TENSION PNEUMOTHORAX Occurs when a laceration of the pleura allows air into the pleural space but does not allow air to exit. Is a life-threatening problem. Clinical Manifestations Dyspnea Tachypnea Decreased or absent breath sounds on the affected side Tracheal deviation to the unaffected side Emergency Treatment Rapid needle decompression of the tension pneumothorax is required, using a large-bore needle (greater than 16 gauge) inserted in the second intercostals space, mid-clavicular line on the affected side. HEMOTHORAX Is a collection of blood in the intrapleural space. Blunt or penetrating injury to the chest wall may cause local vessels, such as the internal mammary arteries or intercostals arteries, to rupture. Large Hemothorax collection of greater than 1.5L of blood in the pleural space. Clinical Manifestations Chest wall percussion of the chest elicits a dull sound Shock from blood loss:

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 Decreased blood pressure Tachycardia Pale, cool or clammy skin Poor capillary refill Neck Vein Distention Emergency Treatment Insertion of a chest drain into the 5th-6th intercostals space, midaxillary line on the affected side for drainage of the blood and then fluid resuscitation is given for any signs of shock. PULMONARY CONTUSION This condition most often follows injuries caused by rapid deceleration during vehicular accidents. Bruising of lung tissue and often results from blunt trauma such as a rapid compression/decompression injury. Hemorrhagic and resulting edematous effects of the bruising may be mild or severe. Hemorrhage occurs between the alveoli. Clinical Manifestations Hemoptysis Tachycardia Tachypnea Dull chest pain Lacalized over the site of the contusion If contusion is severe, may progress to type hypercapnoeic hypoxic respiratory failure Emergency Treatment Oxygenation and ventilation with supplemental oxygen, analgesia and non-invasive (NIV) strategies, such as continuous positive airways pressure (CPAP) or biphasic positive pressure (BiPAP). Severe pulmonary contusion may require supportive invasive mechanical ventilation. RIB FRACTURES Most commonly caused by blunt trauma. May potentially rupture the intercostals arteries. Clinical Manifestations Chest wall pain (which worsen with deep breathing or coughing) Localized tenderness, Shallow, rapid respirations Tachycardia and possible low blood pressure. Emergency Treatment Intercostals nerve block Oral analgesia Incentive spirometry

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Extensive rib fracture (Flail chest): requires invasive supportive therapy such as Mechanical Ventilation and sedations.

ETIOLOGY
Idiopathic Blunt Chest Trauma Penetrating trauma to neck or trunk Airway disease Chronic Obstruction Pulmonary Disease (COPD) Asthma Cystic Fibrosis Infections: Necrotizing bacterial pneumonia TB Fungal pneumonia Pneumocystic crisis Connective Tissue Disease Pulmonary Infarction Iatrogenic Central line placement Other vascular access procedures

RISK FACTORS
Sex Men are far more likely to have a pneumothorax than women (though women can develop a rare form of pneumothoraxCATAMENIAL PNEUMOTHORAX) related to the menstrual cycle. Smoking Leading risk factor for primary spontaneous pneumothorax. The risk increases with the length of time and the number of cigarettes smoked. Lung Disease Having another lung disease, especially emphysema, makes a collapsed lung more likely. History of Pneumothorax Usually one to two years of first episode. Especially true if the first pneumothorax was small and healed on its own. Trauma Direct Indirect Blunt

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CLINICAL MANIFESTATIONS
Severity of symptoms depends on the size of the injury and amount of lung tissue left intact. Symptoms include: a. Pleuritic pain (a sharp pain occurring during inhalation) b. Increased respiratory rate c. Dyspnea d. Visible asymmetry of the chest, which results from rib fracture e. Hyperresonant lung sounds f. Decreased breath sound over the area of pneumothorax g. Trachea deviating to the injure side h. Neck vein distention (resulting from greater amount of pressure in the thorax) i. Palpable subcutaneous emphysema (as air leaves the chest cavity and remains in the subcutaneous space) j. Shifting of mediastinal structures to unaffected side of the chest (caused by large pneumothorax) k. Hypoxemia (seen on ABG) and clinical signs of shock, such as low blood pressure and tachycardia (caused by large pneumothorax) l. Feeling of tightness on chest In tension pneumothorax, the onset of symptoms is sudden and painful.

COMPLICATIONS
Complications of a tension pneumothorax are more serious and include: Low blood oxygen levels (hypoxemia) Respiratory Failure Cardiac Arrest Shock FLAIL CHEST Frequently a complication of blunt chest trauma from a steering wheel injury Occurs when 3 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments. As a result, the chest wall loses stability, causing respiratory impairment and usually severe respiratory distress. CARDIAC TAMPONADE Is the compression of the heart resulting from fluid or blood within the pericardial sac. It usually is caused by blunt or penetrating trauma to the chest. SUBCUTANEOUS EMPHYSEMA

MANAGEMENT
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The management of pneumothorax centers on Airway patency and lung reexpansion Evacuating air from the pleural space and preventing recurrence. Relieving pain Avoiding excessive activity Treating any associated injuries Surgical Fixation is rarely necessary unless fragments are grossly displaced and bone is potential for further injury. MANAGEMENT OPTION for Pneumothorax CONSERVATIVE (Pneumothorax of 15% or less) Observation Monitor condition with series of x-rays until air is completely absorbed and lungs has re-expanded. Needle aspiration Catheter drainage of pneumothorax Tube Thoracostomy INTERMEDIATE (Pneumothorax of greater than 15%) Tube Thoracostomy with instillation of sclerosing agent. Medical Thoracoscopy with. INVASIVE (air leak persists greater than 4 days) VATS blebectomy, pleurectomy, pleural abrasion. Minithoracostomy blebectomy, pleurectomy, sclerosing agent.

pleural

abrasion,

Chest Tube Thoracostomy (CTT) inserted by the physician into the pleural space to drain fluid and air and allow the lung to reexpand. To drain fluid and air, the tube is placed in the midaxillary line at approximately the fifth intercostals space. To drain the air alone, the tube is placed in the anterior chest at the midclavicular line and the fourth intercostals space. PARTS: a. Underwater seal drainage device prevent the negative pressure within the pleural space from pulling more air in through the chest tube itself. b. Drainage Chamber allows for removal of any fluid or blood within the pleural space. c. Suction removal of air and fluid from the pleural space. Pharmacologic Management Narcotic analgesic (Morphine Sulfate or Meperidine (Demerol) To control Pleuritic Pain Diet 21

A well-balanced diet with sufficient amounts of protein is encouraged for healing. The client with other injuries and conditions may require TPN or enteral feedings. Activity Presence of CTT does not call for restricting the client for activity. If hypoxia results from compromised breathing, activity restrictions are necessary. Presence of other injury or condition may also necessitate activity restriction. Activity is encouraged after client is adequately oxygenated and stable to promote expansion of the lungs.

NURSING INTERVENTIONS (PNEUMOTHORAX)

Monitor vital signs, checking for signs of shock (e.g., low blood pressure and tachycardia) Observe the patients respiratory rate (rate and depth); breathing pattern changes may indicate a worsening condition. Position the patient in a Semi-Fowlers position Monitor oxymetry (ABG) Administer oxygen if necessary Administer analgesics as prescribed For a patient with chest tubes: Maintain sterile dressing at chest tube insertion site. Maintain patency and integrity of the closed chest drainage system and suction as ordered. Evaluate amount of fluid and breath sounds to determine progress of closed chest drainage. Assess for sign and symptoms of wound infection. Assess for fear and anxiety and institute appropriate measures for alleviation and relief.

TRAUMATIC BRAIN INJURY (HEAD INJURY)

Is a traumatic insult to the head that may result in injury to soft tissue, bony structures, or the brain. Motor vehicle collision is the most common mechanism of injury, with more than two thirds of people involved to motor vehicle collisions experiencing some form of head injury.

A. CAUSED OF TBI Automobile accidents Fights Falls Sporting injuries. 22

Open Head Injury: Bullet or knife wounds.

A. MECHANISM OF INJURY a. Open Head injury Results from bullet wounds, etc Largely focal damage Penetration of the skull Effects can be just as serious as closed brain a. Closed Head Injury Resulting from a slip and fall, motor vehicle crashes, etc Focal Damage and diffuse damage to axons Effects tend to be broad (diffuse) No penetration to the skull b. Deceleration Injuries (Diffuse Axonal injury) Brain is slammed back and forth inside the skull. It is alternately compressed and stretched because of the gelatinous consistency. Severe injury: Massive axonal and neuron death. c. Chemical/Toxic Also known as metabolic disorders This occurs when harmful chemical damage the neurons Chemical and toxins can include insecticides, solvents, carbon monoxide poisoning, lead poisoning, etc d. Hypoxia (lack of oxygen) If the blood flow is depleted of oxygen, then irreversible brain injury can occur from anoxia (no oxygen) or hypoxia. It may take only a few minutes for this to occur This condition may be caused by heart attacks, respiratory failure drops in blood pressure and a low oxygen environment. This type of brain injury can result in severe cognitive and memory deficits. a. Infections The brain and surrounding membranes are very prone to infections if the special blood-brain protective system is reached. Viruses and bacteria can cause serious and life-threatening diseases of the brain (encephalitis) and meninges (meningitis). a. Stroke If blood flow is blocked through a cerebral vascular accident (stroke), cell death in the area deprived of blood will result If there is bleeding in or over the brain (hemorrhage or hematoma) because of a tear in an artery or vein, loss of blood flow and injury to the brain tissue by the blood will also result in brain damage.

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B. MILD TBI Loss of consciousness and/or confusion and disorientation shorter than 30 minutes. Headache, difficulty thinking, memory problems, attention deficits, mood swings, and frustration. Result of forceful motion of the head or impact causing a brief change in mental status Post injury symptoms are often referred to as post concussive syndrome Glasgow Coma Scale of 13 to 15 Concussion Minor head trauma Minor TBI Minor brain injury Minor head injury

Common Symptoms of Mild TBI Fatigue Headache Visual disturbances Memory loss Poor attention/concentration Sleep disturbances Dizziness/loss of balance Irritability-emotional disturbances Feelings of depression Seizures Other symptoms Nausea Loss of smell Sensitivity to light and sounds Mood changes Getting loss or confused Slowness in thinking A. SEVER TBI TBI results in permanent neurological damage that can produce lifelong deficits to varying degrees. Brain injury resulting in a loss of consciousness of greater than 6 hours Glasgow Coma Scale of 3 to 8. Cognitive deficits including difficulties with: Attention Concentration Distractibility Memory 24

Speed of processing Confusion Perseveration Impulsiveness Language Processing Executive Functions

Speech and language Not understanding the spoken word (receptive aphasia) Difficulty speaking and being understood (expressive aphasia) Slurred speech Speaking very fast or very slow Problems reading Problems writing Sensory Difficulties with interpretation of touch, temperature, movement, limb position and fine discrimination Perceptual The integration or patterning psychologically meaningful data of sensory impressions into

Vision Partial or total loss of vision Weakness or eye muscles and double vision (diplopia) Blurred vision Problems judging distance Involuntary eye movement (nystagmus) Intolerance of light (photophobia) Hearing Decrease of loss of hearing Ringing in the ears (tinnitus) Increased sensitivity to sounds Smell Loss or diminished sense of smell (anosmia) Taste Loss or diminished sense of taste Seizures The convulsions associated with epilepsy that can be several types and can involve disruption in consciousness, sensory perception, or motor movements. Physical Changes 25

Physical paralysis/spasticity Chronic pain Control of bowel and bladder Sleep disorders Loss of stamina Appetite changes Regulation of body temperature Menstrual difficulties

Social-Emotional Dependent behaviors Emotional ability Lack of motivation Irritability Aggression Depression Disinhibition Denial/lack of awareness A. 2 GENERAL TYPES OF TRAUMATIC BRAIN INJURY a. Open Head Injury The dura mater and cranial contents are penetrated and brain tissue is open to the environment allowing the environmental pathogens have direct access to the brain. a. Closed Head Injury The most common type Usually associated with blunt trauma May result to skull fracture, focal brain injuries, or diffuse brain injuries. Complicated by Increased ICF. SOFT TISSUE INJURIES Bleeding from the scalp can contribute to hypovolemia, especially one with multiple injuries. Scalp lacerations usually result from direct blows to the head; they often indicate deeper, more severe injuries. Because the skin is pulled tight around the scalp, wounds are often stretched open, allowing bleeding to occur unimpeded. MANAGEMENT Direct pressure to either side of the wound, not directly above the wound. SKULL FRACTURES 4 types of skull fractures a. Linear 26

b. Depressed c. Basilar d. Open Complication of skull fracture: a. Intracranial Hemorrhage b. Cerebral Damage c. Cranial nerve damage A. INTRACRANIAL PRESSURE The Pressure within the cranial vault. Normal ICP ranges from 0-15 mmHg. Increased Intracranial Pressure Increase of intracranial pressure with increased in cranial blood, CSF, or tissue. Also called as Intracranial hypertension. Causes delicate neurons and capillaries in the brain to become compressed leading to hypoxia, neuronal injury and death, inflammation, and swelling and ultimately progressive deterioration of brain function. Cause Death. Early Manifestations: Change in the LOC Pupillary changes-fixed, slowed response Headache Vomiting Slowing of speech

Late Manifestation Cushing Triad: widening of pulse pressure, bradycardia, hypertension Hypothermia Abnormal Posturing Projectile Vomiting Cheyne stokes breathing Ataxic Breathing Decorticate Decerebrate Loss of brain stem reflexes.

CAUSE OF INCREASED ICP 27

Increase blood flow to the brain or that block blood flow out of the brain Anything that significantly increases CSF production or block CSF outflow. Any increase in tissue mass (growing brain tumor)

The Stages of Increased ICP Stage I. If there is increased volume in one compartment, but normal intracranial pressure because of compensation. Usually involves a decreased CSF production or increased CSF reabsorption, followed by increased arterial constriction to decrease blood flow into the brain. Drowsiness and slight confusion. Stage II. If the volume continues to increase despite early compensatory mechanism, intracranial pressure begins to increase significantly. Occur with progression of a tumor or continual bleeding from a severed artery in an attempt to reduce pressure by reducing blood flow. Decreased level of consciousness Alterations in breathing pattern Pupillary changes Stage III. Cerebral arteries undergo reflex dilation, with the goal of increasing brain oxygen delivery. As blood volume increases, intracranial pressure increases further, thereby worsening the situation. Stage of Decompensation Cerebral blood flow slows Consciousness and reflexes are usually lost. Stage IV. Swelling and pressure in one compartment of the brain become very high, herniation (bulging) into another compartment occurs. Herniation increases pressure in other compartment, and eventually the whole brain becomes involved. Cerebral Responses to Increased ICP 1. Monroe Kellie Hypothesis

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Because of limited space in the skull, an increase in any of these 3 components will result to a change in the volume of the others

2. Autoregulation Ability of brain to control or change diameter of blood vessels to automatically maintain constant cerebral blood flow. The mechanism impaired in cases of sustained increase in ICP. 3. Cushings Reflex Vasomotor center triggers an increase in arterial pressure in an effort to overcome increased ICP. Produces the CUSHINGs TRIAD: increase BP or widening or pulse pressure, bradycardia and bradypnea. Treatment of Increased Intracranial Pressure Effective monitoring of Intracranial Pressure (ICP) Osmotic Diuretics (Mannitol) To reduce blood volume Steroids To decrease inflammation *Hyperventilation is contraindicated Nursing Management for Increased ICP Maintain patent airway Elevate the head of the bed 15-30 degrees to promote venous drainage Assist in administering 100% oxygen or controlled hyperventilation to reduce the CO2 blood levels constricts blood vessels, reduces enema Administer prescribed medication: Mannitol Corticosteroid Anticonvulsants

A. Classification of Traumatic Brain Injury Diffuse Brain Injury Any injury that affects the entire brain Includes: Cerebral concussion and diffuse axonal injury. CEREBRAL CONCUSSION Occurs when the brain is ______ around in the skull.

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Usually caused by rapid acceleration-deceleration forces. (coup-contrecoup) motor vehicle collisions or falls. SIGNS of CONCUSSION Confusion Disorientation to confusion for several minutes. Retrograde Amnesia a loss of memory relating to events that occurred before the injury. Anterograde (posttraumatic) Amnesia) a loss of memory relating to events that occurred after the injury

DIFFUSE AXONAL INJURY More severe diffuse brain injury Often associated with a poor prognosis Involves stretching, shearing or tearing of nerve fibers with subsequent axonal damage. Focal Brain Injury Is a specific, grossly observable brain injury (can be seen on CT scan) Includes: Cerebral Contusions and Intracranial Hemorrhage Cerebral Contusion Brain tissue is bruised and damaged in a local area Associated with physical damage in the brain, greater neurologic deficits (prolonged confusion or loss of consciousness). Most Commonly affected by a cerebral contusion is the frontal lobe Swelling A. INTRACRANIAL HEMORRHAGE Bleeding can occur between the skull and dura mater, beneath the dura mater but outside the brain, within the parenchyma (tissue) of the brain itself (intracerebral space), or into the CSF (subarachnoid space) Epidural Hematoma (extradural) Accumulation of blood between the skull and dura mater. Usually the result of a blow to the head that produces a linear fracture of the thin temporal bone. Death may follow Subdural Hematoma 30

Accumulation of blood beneath the dura mater but outside the brain. Usually occurs after falls or injuries involving strong deceleration forces. More common than epidural Fluctuating level of consciousness Slurred speech

Intracranial hematoma Involves bleeding within brain tissue (parenchyma). Occur following penetrating injury on the head or because of rapid deceleration forces. May be associated with DAI. Subarachnoid Hemorrhage Bleeding occurs on the subarachnoid space, where the CSF circulates. Causes: Trauma or rupture of an aneurysm pr anteriovenous malformation (AVM). Severe Headache (Thunder Clap headache) INTRACRANIAL PRESSURE

RISK FACTORS
a. Alcohol/Drugs b. Age c. Previous Medical Conditions

MANAGEMENT (TRAUMATIC BRAIN INJURY)

EMERGENCY MANAGEMENT Airway Management Positioning Side- lying position (projectile Vomiting) Suction to clear secretion Ventilation/hyperventilation No during the first 20 hours after the injury Continually assess the ventilator status of head trauma to ensure adequate oxygenation and ventilation. Ventilate a brain-injured patient at a rate of 10-12 bpm Fluid Administration One large-bore IV with normal saline or Lactated Ringers or Hartmanns solution. 31

Be cautious when administering dextrose-containing solution (D5W) Thermoregulation NON-SURGICAL MANAGEMENT Preventing or detecting increased ICP Promoting fluid and electrolyte balance Monitoring the effects of treatments and medications Fever defense mechanism in the presence of trauma or indication of inflammatory response. Cooling Management Hypothermia blanket Sponge bath Positioning Keep the head of the bed elevated at least 30 degrees or as recommended by the health care provider Log roll during turning to avoid hip flexion Mechanical Ventilation Done to maintain a partial pressure of arterial carbon dioxide (PaCo2) of about 35 mmHg. One major goal is to prevent hypercarbia. Arterial oxygen levels are maintained between 80 and 100 mmHg. ABG values are monitored twice a day. Chest Physiotherapy Hyperventilation Done carefully with 100% oxygen when patient is intubated. Lidocaine given IV or endotracheally Used to suppress cough reflex (which would increase ICP) PHARMACOLOGIC MANAGEMENT Mannitol (Osmotic Diuretic) Used to treat cerebral edema Management for increased ICP Furosemide (Loop Diuretic) Often used as adjunctive therapy to reduce the incidence of rebound from Mannitol and also enhances its therapeutic action. Opioids (Morphine Sulfate, Fentanyl Citrate) Naloxone (Narcan) Sedatives Lorazapam (Ativan), Midazolam (Versed) Neuromuscular Blocking Agents (NMBAs) Vecuronium Bromide Cisatracurium (Nimbex) 32

Used when client experienced agitation or if increased activity is causing ICP elevations. Must never be used without aggressive sedation/analgesia Not used routinely

Antiepileptic Drugs Phenytoin (Dilantin) Anticonvulsants Used to prevent seizure activity that may occur within 7 days following injury. (early onset seizure) Acetaminophen (Tylenol, Ace-tabs) Aspirin (Acetylsalicylic acid [ASA], Ancasal)
To reduce fever

Barbiturate Coma Given when ICP cannot be controlled by other means Penobarbital Sodium (Nembutal, Novopentobarb) Sodium Thiopental FLUID AND ELECTROLYTE MANAGEMENT Fluid management may be titrated to optimize volume resuscitation but minimize brain swelling and ICP elevation. Fluid management is also influenced by the response to diuretic therapy and elevation of laboratory values. Specific osmolarity (below 310 to 320 mOsm) Check urine specific gravity every 1 to 4 hours Monitor serum and urine concentration and electrolyte frequently. NUTRITION MANAGEMENT If theres improvement to level of consciousness , long-term nutritional support via enteral feeding is usually instituted. Small-lumen nasogastric or nasoduodenal tube or a percutaneous endoscopic gastrostomy (PEG) tube is used for continuous or intermittent feeding. Small-bore tubes decrease the risk for aspiration in a client who is at risk. Client should be weighed daily Monitor serum albumin and prealbumin levels to assess adequacy of protein. SURGICAL MANAGEMENT Insertion of Intracranial Pressure Monitoring device To evaluate the clients ICP more closely. All are devices are inserted through a burr hole that is placed in the skull using a twist drill. Intraventricular Catheter (IVC) A small tube inserted into the anterior horn of the lateral ventricle of the nondominant cerebral hemisphere. 33

 Advantage: CSF can be drained to decrease ICP Subarachnoid screw or bolt Hollow device placed into the subarachnoid space for direct pressure measurement. Disadvantage: CSF cannot be drained to treat ICP Less invasive Used to lower the risk for infection Epidural Catheter Transducer that is placed between the skull and the dura leaving the dura intact. Sudbural Catheter Placed under the dura mater Major advantage: decrease risk for infection from an open dural space. Fiberoptic Transducer-tipped Pressure Sensor Commonly used device for ICP monitoring Craniotomy done to patient with ICP that cannot be controlled done to remove the ischemic tissue or tips of the temporal bone. Removal of nonvital brain tissue without further compromise to ICP. Done to remove epidural and subdural hematomas

DIAGNOSTIC AND LABORATORY EXAMINATIONS

PNEUMOTHORAX Arterial Blood Gas Oxygen saturation Use in evaluating hypoxia and hypercarbia and respiratory acidosis Chest X-ray IMAGING: Chest radiography To radiologically confirm and localize tension pneumothorax. Patient unable to tolerate upright chest radiography can be taken in decubitus position with the suspected side up: Absence lung markings distal or peripheral to the visceral pleural line Displacement of mediastinum or anterior junction line Deep sulcus ____. CT scan More sensitive than chest radiography in the evaluation of small pneumothoraces and pneumomediastinum Allows further evaluation of underlying pulmonary disease or injury. Ultrasonography Rapid at bedside

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 ECG

Used in the diagnosis of pneumothorax which includes absence of lung sliding, absence of corner-tail artifact, and presence of lung point. M____ confirms pneumothorax with syncope lines above and below pleural line. Often necessary to rule out cardiac etiologies of chest pain. Nonspecific changes include T wave inversion, left axis deviation, and decreased R wave amplitude.

TRAUMATIC BRAIN INJURY Computed Tomography Scan To identify the extent and scope of injury to the brain. Can identify the presence of lesions that requires surgical intervention, such as epidural or subdural hematoma. MRI and CT scan (cervical spine and skull) Done to rule out fractures and discolorations. Chest X-ray Done to identify fractured ribs or other chest injuries. Flat plate of the abdomen, Abdominal ultrasound, or abdominal CT scan Assist in the diagnosis of abdominal bleeding or bowel laceration. MRI Useful in diagnosis of diffuse axonal injury, but not recommended for client with ICP monitoring devices or other invasive monitoring device.

Doppler flow studies Measure the integrity of the cerebral vessels Cerebral blood flow studies To measure the cerebral perfusion Glasgow Coma Scale Easy method of describing mental status and abnormally detection. Tests 3 areas: eye opening, verbal responses and motor responses. EYE OPENING 4 = Spontaneous 3 = To voice (when told to) 2 = To pain 1 = No response

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VERBAL RESPONSE 5 = Normal/oriented 4 = Disoriented/confused 3 = Words, but incoherent/inappropriate 2 = Incomprehensible/ mumbled words 1 = none MOTOR RESPONSE 6 = Normal obeys command 5 = Localizes pain 4 = Withdraws to pain (Flexion) 3 = Decorticate Posture 2 = Decerebrate Posture 1 = None (flaccid) Levels of Consciousness Deep Coma 3 5 Coma 68 Lethargic 9 11 Stuporous 12 14 Normal 15 Coma a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years) Persistent vegetative state a condition in which the patient is described as wakeful but devoid of conscious content and without cognitive or affective mental function. Brain death irreversible loss of all functions of the entire brain, including the brain stem.

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