NURSING CARE PERTAINING TO THE CRUSH INJURY … · NURSING CARE PERTAINING TO THE CRUSH INJURY PATIENT 4 including further pelvic hemorrhage, persistent hypotension, cardiac arrest,

NURSING CARE PERTAINING TO THE CRUSH INJURY PATIENT 1

Aspects of Nursing Care Pertaining to the Crush Injury Patient: A Case Study

John B. Ward

UIN: 00818931

Old Dominion University

Submitted in partial fulfillment of the requirements in the course NURS 451: Adult Health Nursing III

in the School of Nursing Old Dominion University

NORFOLK, VIRGINIA

October 7th, 2012


Aspects of Nursing Care Pertaining to the Crush Injury Patient: A Case Study

This case study examines nursing aspects related to the care of the patient suffering from health

issues associated with a traumatic crush-injury. The patient discussed in this case study was severely

injured during a recent traumatic event during which he was knocked down and driven over by a

construction backhoe that was operating on a produce farm adjacent to where he was waiting for a bus.

Patient Overview

The patient, addressed as “L.L.” in this case study, is an 83-year-old male, currently residing as a

patient in the Intensive Care Unit at Sentara Virginia Beach General Hospital following a recent traumatic

injury received when he was knocked down and run over by a construction backhoe. Prior to his injury

and subsequent hospitalization, L.L. was a healthier-than-average elderly gentleman, with few reported

health issues. According to his friends and family, L.L. was still very active and in very good physical

and mental health, despite his older age. L.L was a regular volunteer at Sentara Virginia Beach General

Hospital, where he served as a visitor’s guide. With the exception of taking a bus to and from work, he

walked just about everywhere else he went. According to his best friend, it was not uncommon for him to

walk several miles a day. Unfortunately, on September 14th, 2012, after leaving the hospital following a

day of volunteering, L.L. was struck by a backhoe operating on a nearby produce farm adjacent to where

he waited for the bus. According to reports, L.L. was knocked to the ground and subsequently run over by

by the backhoe. L.L. was subsequently transported to the Sentara Virginia Beach General Hospital

Emergency Department via ambulance. Upon arrival to the Emergency Department, records indicate that

L.L. was alert and oriented, having complaints of pain in his chest and pelvic region. He was reported to

be persistently hypotensive during his time in the Emergency Department. Initial X-rays and CT scans

revealed that L.L. suffered multi-comminuted displaced bilateral pelvic fractures with involvement of his

right acetabulum, a multi-comminuted fracture of the sacrum, laceration of his right iliac artery and a

large pelvic hematoma, a cortical sternal fracture, a left clavicular fracture, minor bilateral

pneumothoraces, and a small, right lung pleural effusion. L.L.’s traumatic injury also caused significant

damage to his genitals, as well as significant damage to his integument in multiple places across his arms,


chest, abdomen, back, and buttocks. At some point shortly after being admitted to the hospital, the

patient’s health deteriorated, and he briefly arrested during a rapid sequence induction and subsequent

intubation attempt. He was resuscitated with CPR and just one round of ACLS drugs. After being

stabilized in the Intensive Care Unit, L.L. was taken to the Operating Room in order to address his pelvic

stabilization and bleeding issues. An external pelvic fixator was placed in order to stabilize the L.L.’s

pelvis, and a gel-foam slurry embolization angiography was performed to control hemorrhage from

multiple sites of damage along L.L.’s right iliac artery. Central line access was established, and a

suprapubic urinary catheter was also placed due to injuries received to his penis and urinary tract. During

his initial treatment, the L.L. received a total of 17 units of blood and 15 units of plasma, platelets, and

other clotting factors. Post-operatively, L.L was returned to the Intensive Care Unit, sedated, and on

mechanical ventilation. He continued to struggle with persistent hypotension, needing several additional

units of blood and plasma throughout the course of several days. In addition to the significant injuries

received from the initial injury, L.L. acquired a number of secondary health issues, including acute renal

failure, rhabdomyolysis, metabolic acidosis, and hypernatremia. He remained in critical condition on

mechanical ventilation throughout the course of the week during which I cared for him.

Scope of Paper

The purpose of this case study is to examine the nursing aspects related to the care of a patient

suffering from health issues associated with traumatic crush injuries. In doing so, this case study will

attempt to addresses the implications of crush-related injuries and their subsequent health consequences,

with specific attention given to traumatic pelvic injuries, trauma-related hemorrhage, hypovolemic shock,

and risk of infection. Crush syndrome will also be addressed.

Medical Diagnosis

Diagnosis for ICU Admission

The patient discussed in this case study was initially diagnosed with having traumatic injury, with

the charted diagnosis specifically citing pelvic fractures and a pelvic hematoma. Soon after his admission

to the hospital, the patient developed additional ongoing health issues secondary to his initial injury,


including further pelvic hemorrhage, persistent hypotension, cardiac arrest, rhabdomyolysis, metabolic

acidosis, acute renal failure, and hypernatremia.

Pathophysiology

The patient discussed in this case study was the victim of a traumatic crush injury that left him

with a fractured, unstable pelvis, fractures of the sacrum, clavicle, and sternum, lacerations of his right

iliac artery and subsequent hemorrhage, bilateral pnuemothoraces, and a variety of genitourinary and

integumentary issues.

Crush injuries are sustained as the result of compressive forces being applied to the body and its’

tissues (Bledsoe, Porter, & Richard, 2003, p. 927). Crush injuries can vary significantly in their degree of

severity. Crush injuries can range from minor injuries involving a crushed finger, to more severe crush

injuries involving entire limbs or even a patient’s torso. More severe crush injuries can pose significant

risks for the patients who receive them due to the often significant mechanism of injury and the inability

to directly observe internal injuries sustained during the crush event. The patient’s skin may remain intact

or appear normal upon initial visual inspection, thus making it difficult to determine the degree of injury

or to prevent internal hemorrhage from being discovered or controlled (Bledsoe et al., 2003, p. 928).

It is important to note the difference between a crush injury and “crush syndrome”. Experiencing

a traumatic crush injury does not necessarily imply that crush syndrome will occur. The systemic health

issues associated with true crush syndrome, including rhabdomolysis and the subsequent toxin release

into the bloodstream, often do not occur until body parts are entrapped for greater than 4 hours (Bledsoe

et al., 2003, p. 928). In true crush syndrome, toxic remnants of necrotic muscle, including myoglobin,

potassium, phosphate, and lactic acid accumulate in the bloodstream and build up to levels that become

harmful, and potentially deadly to the patient (Bledsoe et al., 2003, p. 928)

In the course of L.L’s traumatic event, his pelvis was fractured in several places, leading to

serious bleeding complications. The human pelvis is a large ring-shaped skeletal structure that serves to

connect the spine with the bones of the lower extremities. The pelvis houses the bladder, part of the

urinary tract, the nerves stemming from the lower extremities, and some of the body’s major blood


vessels, including the iliac arteries and veins (Urden, Stacy, & Lough, 2010, p. 969). The pelvis, itself,

also has a rich blood supply (Bledsoe et al., 2003, p. 1010). Fractures of the pelvis can occur in varying

degrees. Less severe fractures, such as non-comminuted fractures of the iliac crest, typically do not affect

pelvic stability. More significant pelvic fractures often involve multiple fractures or affect the stability of

the entire pelvis (Bledsoe et al., 2003, p. 1010). Fractures that affect the stability of the pelvis can cause

significant injury to the contents contained within the pelvis. Perhaps of most importance, injury to the

great vessels that travel through the pelvis and its’ openings can result in severe, rapid, life-threatening

hemorrhage (Urden et al., 2010, p. 969). Hemorrhage from the pelvic vasculature can result in the

accumulation of up two liters of blood in the pelvic and retroperitoneal spaces (Bledsoe et al., 2003, p.

928). Pelvic ring fractures are especially dangerous. The force necessary to fracture the pelvic ring must

be significant, and as a result, multiple fractures and internal injuries likely occur with such injuries

(Bledsoe et al., 2003, p. 928). Pelvic fractures can also can significant injury to the bladder, prostate, and

urethra, as well as the rectum and anus.

Hemorrhage posed the most significant risk to L.L’s health. Significant hemorrhage can result in

hypovolemic shock, as well as a significant decrease in the number of oxygen-carrying red blood cells

and necessary clotting factors contained within human blood. Hypovolemic shock occurs when the

circulating fluid volume within the intravascular space becomes depleted beyond what is necessary for the

cardiovascular system to function appropriately (Urden et al., 2010, p. 9680). Hypovolemic shock can

occur for a variety of reasons, including dehydration and bleeding. Severe hemorrhage can lead to a rapid

decline in health in a matter of minutes if left uncontrolled. A decrease in circulating blood volume leads

to a decrease in preload, and a consequent decrease in cardiac output (Urden et al., 2010, p. 981). In the

case of severe hemorrhage, oxygen-carrying red blood cells and clotting factors are also lost,

compounding the severity of the problem.

Related Signs and Symptoms

In the case of L.L., his crush injury was brief, likely only lasting for a few seconds. L.L’s injuries

were significant, and throughout his stay in the ICU, he did display several signs and symptoms that were


suggestive of crush syndrome and rhabdomyolysis, including a CPK > 2600 IU/L and an elevated lactic

acid level of 4.4 mmol/L. However, L.L. did not display the full range of symptoms that are often

observed with true crush syndrome, such as elevated levels of potassium and phosphate within the blood,

or the dark, tea-colored urine that is usually suggestive of extremely high myoglobin levels circulating in

the bloodstream. L.L.’s electrolyte levels were all within normal ranges at the time of assessment. His

urine was fairly clear and yellow. His CK-MB level was also elevated at 21.3 ng/mL though the cause of

this value is likely the result of damage to his myocardium during cardiac arrest and subsequent chest

compressions during CPR. Complicating matters, L.L. had a variety of different trauma-related issues,

such as severe hemorrhage, persistent hypotension, and cardiac arrest, that likely skewed assessment data.

If nothing else, these complications make it difficult to accurately pinpoint the source of abnormal

assessment findings and the degree of crush syndrome that may be directly attributed to L.L.’s crush

injury. It is likely that L.L. experienced some degree of crush syndrome, though it is likely that L.L.’s

abnormal findings were attributed to both his crush injury and to the secondary health issues mentioned

above. However, it is impossible to determine which factors contributed more to these findings.

Regarding his pelvic injuries, X-rays and CT scans revealed that L.L. suffered multi-comminuted

displaced bilateral pelvic fractures with involvement of his right acetabulum, and a multi-comminuted

fracture of the sacrum. These are severe pelvic fractures that pose significant risks to the patient. Fractures

such as these create pelvic instability, putting the patient at increased risk for damaging the organs and

vessels contained within the pelvic region. In addition, multi-comminuted displaced fractures result in

freely moving bone fragments that expose the patient to an increased danger of lacerating the major

vessels within the pelvic area. Both significant arterial and venous hemorrhage were noted within L.L.’s

pelvis. L.L. suffered several lacerations to his right iliac artery as a result of his crush injury. He suffered

a significant amount of blood loss and required gel-foam slurry embolization as a result. An external

fixator also had to be applied in order to stabilize L.L.’s freely-moving pelvis.

Bleeding was the biggest threat L.L.’s health in the first few days following his traumatic injury.

Lacerations to his iliac artery and the subsequent blood loss caused L.L to be persistently hypotensive and


tachycardic while in the ED. He often continued to be hypotensive while in the ICU despite

administration of multiple vasopressors. In the first 48 hours following his injury, L.L. required in excess

of 17 units of blood and 15 units of plasma and platelets as a result of his pelvic hemorrhage. Even after

these transfusions, L.L.’s labs remained decreased. At the time of assessment, L.L.’s RBC level was 2.75

mill/mm3, his Hgb level was 9.2 g/dL, his Hct was 26.8%, and his platelet count was 53/mm3. These

decreased values are indicative of a significant bleeding issue within in the body. Without a significant

blood transfusion, L.L. would likely have died in the first 24-48 hours after arriving to the hospital.

L.L.’s traumatic injury also caused significant damage to his genitourinary system, as well as

significant damage to his integument in multiple places across his arms, chest, abdomen, back, and

buttocks.

Nursing Diagnoses

The following entries are NANDA-approved nursing diagnoses for five different health priorities

for the patient discussed in this case study. Projected outcomes, interventions, and evaluations related to

the patients’ progress are also provided for the two leading health dangers facing the patient. Health

issues were prioritized according to their degree and immediacy of potential danger or discomfort to the

patient, with additional guidance from reputable nursing theory. Faye Abdellah’s “Patient-Centered

Approaches Theory” provided assistance when determining priority patient health issues. Abdellah’s

theory advocates that a nurse solve patient health problems using their knowledge of common nursing

problems – ones that have been derived from medical diagnoses (Johnson & Webber, 2010, p. 131). Her

list of 21 common nursing problems place a priority on maintaining oxygen supply to body tissues,

maintaining fluid and electrolyte balance, recognizing the physiologic responses of the body to disease

conditions, maintaining hygiene and physical comfort, maintaining good body mechanics, maintaining

sensory functions, and facilitating the maintenance of effective verbal and nonverbal communications

(Johnson & Webber, 2010, p. 132). These areas of nursing care address L.L.’s most pressing injuries and

subsequent illnesses, as well as his general state of physical and mental health.


Diagnosis #1

The patient is at continued risk for deficient fluid volume, as evidenced by a recent traumatic

crush injury, severe pelvic hemorrhage, persistent hypovolemia, fluid shift and swelling of injured tissues,

increased serum sodium level, and decreased blood count values.

Outcome #1

An important desired outcome for this patient regarding deficient fluid volume would be that he

would consistently maintain a systolic blood pressure of 90 mmHg or higher, or a mean arterial pressure

of 60 mmHg or higher, in the absence of further bleeding, and without fluid or vasopressor support,

within seven days following interventions to mitigate hemorrhage.

Assuming that no other major health issues arise, this outcome is appropriate for the nursing

diagnosis and it is reasonable to assume that this outcome could be reached if further hemorrhage can be

mitigated, and if initial blood loss is adequately restored via fluid resuscitation and blood transfusion.

Intervention #1

Interventions with Rationale

Hypovolemic shock, more specifically - hemorrhagic shock, is the greatest and most immediate

danger to this patient, as failure to correct this issue would surely result in rapid deterioration in health,

and possibly death. Failure to maintain normal blood pressure would, in turn, place the patient at risk for

developing inadequate tissue perfusion to the heart, brain, and other major organs of the body. The goals

of managing any type of shock are to maintain tissue oxygenation, increase vascular volume to normal

parameters, and provide support for compensatory mechanisms greater (Ignatavicius & Workman, 2010,

p. 836). These goals can be accomplished with oxygen therapy, fluid and blood replacement, and

pharmacological intervention. In the case of hemorrhagic shock, hemorrhage must controlled as soon as

possible, if not first. L.L.’s healthcare team has resorted to using all of these methods at some point in his

treatment to manage his bleeding and subsequent hypovolemia. Collaborative efforts between physician,

nursing, and respiratory care staff were required to mitigate these issues.


Primary physician intervention for this patient consisted of stabilization of the pelvis and

embolization angiography of the iliac vasculature in order to mitigate bleeding, prevent further

hemorrhagic shock, and to prevent further injury to pelvic contents. Without surgical intervention by

physician staff, the patient’s health would most likely not have improved, even in the face of aggressive

nursing interventions.

Respiratory care and oxygenation was managed with mechanical ventilation by the respiratory

therapy team once the patient was intubated. It must be noted that oxygenation is not necessarily effective

if hemodynamic status is compromised. The patient must have adequate fluid and be adequately perfused

in order for the patient to reap the benefits of good respiratory care.

Primary nursing interventions consisted of correcting the hypovolemia that resulted from the

patient’s blood loss. This involved administering fluids and blood products to the patient. When

hypovolemia is present, administration of crystalloids and colloids is the primary recommendation for

volume replacement (Ignatavicius & Workman, 2010, p. 837). Large volumes of crystalloid fluids were

administered for purposes of volume expansion and to maintain electrolyte balance, while albumin, a

protein-containing colloid, was administered in order to help restore and maintain colloid osmotic

pressure within the vasculature. Blood, plasma, and clotting factors were administered to the patient in

order to return his blood components back to normal ranges, thus increasing his oxygen-carrying capacity

and restoring the osmotic pressure within his vasculature. L.L. received over 17 units of blood and 15

units of plasma, platelets, and other clotting factors over the first two days that he was in the hospital.

Despite receiving this large volume of fluid and blood products, L.L. continued to have

difficulties maintaining his blood pressure. When hypovolemia is severe or occurs abruptly, patients often

do not respond to fluid volume replacement and pharmacological intervention becomes necessary to

maintain blood pressure (Ignatavicius & Workman, 2010, p. 837). In order to improve oxygenation and

tissue perfusion, pharmacological agents must then be used to increase cardiac output and increase mean

arterial blood pressure. Vasoconstricting drugs are used to increase venous return by constricting blood

vessels and decreasing venous pooling of blood (Ignatavicius & Workman, 2010, p. 838). Norepinephrine


and phenylephrine were administered to L.L. for these purposes. By the second day during which I cared

for this patient, only one vasopressor - norepinephrine, was still being used to maintain his blood

pressure. Vasopressin was also administered to L.L. in order to increase fluid retention and increase blood

pressure. Other vasopressor medications, such as dopamine and epinephrine, can be used to accomplish

these goals, however, they often carry more negative side effects for the patient.

Critical Thinking

Results of a 2011 study presented in the Journal of Trauma: Injury, Infection, and Critical Care

suggest that adhering to “hypotensive resuscitation strategies” when treating trauma patients with

hemorrhagic shock in postoperative periods results in lower mortality rates (Morrison et al., 2011). The

study suggests that reducing the volume of infusion of fluids and blood products to maintain a MAP of 50

mmHg, rather than 65 mmHg, results in a decreased chance of developing coagulopathy and an improved

chance of postoperative survivability (Morrison et al., 2011).

The results of this study could potentially be directly applicable to L.L.’s situation and his

management of fluids and blood products by nursing and physician staff. It is unknown what L.L.’s

desired MAP was following his initial admission and subsequent surgical interventions, however, it is

documented that L.L. received a significant volume of fluids and blood products in the time following

admission and surgical intervention. It is certainly possible that this volume of fluids and blood products

was necessary for L.L’s survival. However, this study provides evidence that excessive or unnecessary

fluid and blood product administration by healthcare staff can be just as detrimental to patient health as

not administering fluids or blood products in the first place. Nurses must keep this in mind when

managing fluid and blood product infusions for all patients, but especially for trauma patients

experiencing hemorrhagic shock.

SOP/Clinical Path

Collaborative efforts by physician, nursing, and respiratory care staff, such as those used during

the process of continuing care for L.L, are part of the “Collegiality” and “Collaboration” Standards of

Practice for Acute and Critical Care Nursing. These standards require that the nurse communicate with


the healthcare team, contribute information regarding patient care and their health condition to the team,

and to formulate a plan of care with the team that is designed to improve the patient’s health. By adhering

to these standards of care, it is anticipated that more focused and well-rounded care will be provided for

the patient. In the case of L.L., and as described in the above paragraphs, a multi-faceted approach from

different members of the healthcare team proved to be vital to his survival. L.L. had several different

significant injuries and subsequent illnesses that required care from a variety of angles. L.L’s

hypovolemic shock required management via surgical intervention performed by physicians, respiratory

care provided by the respiratory care staff, and fluid and pharmacological therapy provided by nursing

staff. By working as a team, the physician, nursing, and respiratory care staff helped L.L. overcome some

significant hurdles early on in the course of his illness, ensuring his immediate survival.

Patient/Family Teaching

Given that the patient will likely remain rather immobile, intermittently sedated, and on

mechanical ventilation for the coming days to the next few weeks, the patients’ family would receive the

greatest benefit from a teaching experience at this time. However, at this point in the patient’s care, family

involvement in direct physical care is rather limited. That being said, the patient’s family still knows the

patient better than any of the healthcare staff do, and they are present in the patient’s room nearly as

much, if not more, than some of the nursing staff. In addition, they appear to be regularly interested in the

patient’s condition and any changes that he may exhibit. Perhaps the patient’s family could receive basic

education regarding hemodynamic status and the patient’s hemodynamic instability issues. This might

allow the family to more closely monitor for changes in patient’s hemodynamic status when nursing staff

is not present in the room. This could potentially allow for signs of deterioration to be caught sooner, and

for interventions to be initiated before the patient’s health becomes compromised. It would also help

family members know what to expect if the patient’s hemodynamic status does deteriorate, and it would

allow them to process what they might witness.

Cultural Considerations


The most significant cultural consideration pertaining to L.L.’s continued risk for deficient fluid

volume and hemorrhagic shock is related to his age. Given their natural, age-related deteriorations in

general health, elderly populations are more prone to becoming injured, and they are more likely to be

more severely hurt or killed when injured. According to Urden, Stacy, and Lough (2010), older adult

victims of trauma have higher mortality rates, even when the injuries they receive are less severe than

those that would affect younger adults (p. 974). Urden et al. attributes higher complication and mortality

rates among populations over 40-years-old because of their preexisting medical conditions, decreased

physiologic reserves, and decreased abilities to compensate for severe injuries (p. 974). Urden et al. adds

that older adults who survive traumatic injury are often forced to face changes in their “pre-injury

functional status”, citing that even relatively minor trauma can be “the event that changes the lifestyle of

an older person from one of relative independence to one that requires prolonged rehabilitation or skilled

nursing care” (p. 974). Urden et al. also adds that treating older adult trauma patients experiencing

hypovolemic shock is significantly more complex because they have limited abilities to increase their

heart rate in response to blood loss (p. 974). Tachycardia is one of the earliest signs of bleeding, however,

it is often masked in older patients, making early identification of shock difficult or impossible (Urden et

al., p. 974). Urden et al. suggests that better outcomes are achieved with “early, appropriate, aggressive

trauma care”, in conjunction with early hemodynamic monitoring, in older trauma patients (p. 974).

Evaluation #1

Progress Towards Outcomes

It is desired that L.L. maintain a systolic blood pressure of 90 mmHg and a MAP of 60, in the

absence of further bleeding and without fluid or vasopressor support, within 7 days following

interventions to mitigate hemorrhage. L.L. made significant progress towards achieving this outcome over

the two days between shifts when I card for him. L.L. had required 17 units of blood and 15 units of

plasma, platelets, and other clotting factors, and several liters of fluid during his first two to three days in

the hospital. In addition, he initially required three different vasopressors to maintain his blood pressure.

By L.L’s fifth day following his injury, L.L., was no longer receiving regular transfusions, and he was


maintaining his blood pressure with only one vasopressor – norepinephrine. His blood pressure on this

day was 104/52, with average MAP of 64 mmHg. He showed no signs of further significant bleeding, and

he appeared to be showing some improvement in cardiovascular health. Unfortunately, L.L. received a

significant multi-system trauma when he was run over by the backhoe. Given his age and weakened state

of health, and the number of significant injuries that he sustained during his injury, it is unclear if L.L.

will meet his objectives or make significant improvements in the coming days and weeks, if at all. L.L. is

still facing a tremendous uphill battle, and until all aspects of his injuries and illnesses can be addressed,

he will continue to struggle to maintain his current level of health.

Additional/Alternative Plan

Given the severity of his injury and illness, it is very likely that L.L. will continue to have

significant health issues for a prolonged period of time, if he even survives his initial health complications

over the next few days and weeks. It is likely that his health will wax and wane over the coming days and

weeks, and that his care will need to be frequently tailored to suit his current situation at those times. If

the current plan for weaning fluids and vasopressors from L.L.’s regimen lead to an inability for L.L. to

maintain his blood pressure and fluid volume, then fluid and additional vasopressor administration will

need to be re-established, preferably beginning with fluids, if tolerable. If signs of bleeding or other

hematological abnormalities reappear, then additional administration of blood products and clotting

factors may need to be considered. Unfortunately, given the severity and nature of his illness, L.L. does

not have many alternative options aside from reverting back to the aggressive treatment regimen that he

received when he was first admitted to the hospital.

Diagnosis #2

The patient is at significantly increased risk for developing infection, as evidenced by recent

traumatic crush injury, invasive correctional surgery, having multiple open wounds and tissue injuries,

placement of an external fixator, prolonged immobility, use of long-term mechanical ventilation, central

line access, insertion of an indwelling suprapubic catheter, inability to provide for self-care needs, and

malnutrition related to difficulty with tube feeding.


Outcome #2

An important desired outcome for this patient regarding infection would be that the patient

remain free of infection for the duration of his stay in the ICU, as evidenced by having a normothermic

body temperature between 36.5-37.5oC (98-100oF), a white blood cell count between 4.0-11.0 K/uL, a

chest X-ray free of signs of infection, and failure to produce growth with blood, urine, respiratory,

cerebrospinal fluid, and wound cultures. In a healthier patient, many other factors would be considered for

evaluation when attempting to identify and treat infection, including heart rate, respiratory rate, blood

pressure, skin appearance, urine output, serum lactate levels, and mental status, however, L.L.’s

multifaceted illness would make it difficult to pinpoint the origin of abnormal values related to these signs

and symptoms.

At the time of assessment, all of the targeted values mentioned in the previous paragraph were

within normal ranges for L.L. This outcome is appropriate for the nursing diagnosis and it provides a

positive goal for patient health. However, given the number of multifaceted injuries, severity of illness,

and risks for infection that this patient has experienced over the past several days, it may not be

reasonable to assume that this outcome could be achieved or maintained for the duration of the patient’s

stay in the ICU. That being said, remaining free of infection should still be a goal for treatment while the

patient remains in the ICU.

Intervention #2

Interventions with Rationale

Although not an immediate threat, septic shock poses a very significant risk for L.L. given the

extent of his injuries, corrective surgeries, and the general severity of his illness. Compounding his risk

for developing infection, L.L. is essentially lying supine in bed, on mechanical ventilation with

intermittent sedation, housed in an external pelvic fixator, with little to no ability to move or perform self-

care. There are a seemingly infinite number of pathways for opportunistic pathogens to enter L.L.’s body

and wreak havoc on his immune system and weakened body.


Limiting further exposure to pathogens is the first goal of preventing L.L. from acquiring an

infection and becoming septic. Good hygiene practices, including frequent hand washing and use of

aseptic techniques, area a must. That applies to nurses, physicians, family members, and other healthcare

staff. Preventing L.L. from being exposed to infection is a collaborative effort for anyone and everyone

who comes into contact with L.L. Research has demonstrated that hand hygiene is the single most

effective way to limit the transmission of pathogens (Urden et al., 2010, p. 617). Alcohol-based hand-

cleansers are acceptable for decontamination when hands are not visibly soiled, however, soap and water

must be used when hand are visibly soiled, or when dealing with potential contamination by blood or

bodily fluids (Urden et al., 2010, p. 617). Gloves should be worn and sterile techniques should be adhered

to whenever possible. Oral hygiene and suctioning of oral and tracheal secretions should be performed

regularly, especially for patients on mechanical ventilation, such as L.L. Equipment should be

decontaminated between use, and efforts should be made to use disposable equipment whenever possible.

Special attention should be given to vent care, foley care, and central line care, as they are common

breeding grounds for infection.

Identifying patients who are at-risk of acquiring an infection, and identifying patients who

actually acquire an infection, are extremely important steps when attempting to combat pathogens in the

hospital setting. Early identification of infection allows for earlier treatment, and potentially, a better

outcome. Early identification of sepsis has been documented to decrease patient mortality (Urden et al.,

2010, p. 996). Many hospitals now promote the use of care “bundles” that guide physician and nursing

staff on treatment plans for patients at-risk of acquiring an infection, and those who have recently show

signs or symptoms of having an acquired infection. Once these patients have been identified, appropriate

interventions, such as prophylactic antibiotic use, can then be initiated.

Clearly, L.L. was at high risk for developing an infection and becoming septic. Blood, urine, and

respiratory cultures were obtained from L.L. and tested in the lab for signs of abnormal pathogen growth.

He was also closely monitored for changes in general health, vitals signs, and lab values. At the time of

assessment, L.L. had a normal body temperature, white blood cell count, and urine output, and all cultures


that were obtained tested “negative” or “minimal growth”. His chest x-ray only showed sings of injury-

related processes. However, L.L. was still proactively administered vancomycin, a broad-spectrum anti-

biotic that targets gram-positive bacteria that are resistant to penicillin, such as MRSA, and ciprofloxacin,

a fluroroquinolone antibiotic that targets urinary tract infections, with the hope that he won’t develop

these classes of infection. Chlorohexidine mouthwash was also administered in order to help prevent

ventilator-acquired pneumonia. These prophylactic regimens are intended to improve L.L.’s health

outcome.

Critical Thinking

Results from a 2011 study presented in the Dimensions of Critical Care Nursing highlight the

successfulness of bundle-like protocols and checklists when used to guide sepsis treatment. In this study,

a pre-determined, evidence-based “empiric antimicrobial guide” was used to determine the course of

sepsis treatment (Hutchison et al., 2011). This guide provided first and second-line antimicrobial

treatment choices based on the suspected source of sepsis – healthcare-associated pathogens, community-

associated pathogens, or neutropenic patient conditions. Results of this study determined that the use of

the empiric antimicrobial to guide sepsis treatment decisions resulted in a reduced length of hospital stay

for the patient, an earlier “time to first antibiotic” for the patient, and lower hospital costs (Hutchison et

al., 2011). This supports the growing practice of using treatment bundles to guide nursing interventions

that are now used by many hospitals.

A 2010 study presented in the Journal of Trauma Nursing addressed a similar issue. For this

study, a “multidisciplinary daily quality checklist” was used in a trauma ICU setting in order to determine

the degree of provider compliance to protocols designed to prevent infection (Chua et al., 2010). These

results were then applied to the success or failure of infection prevention protocols themselves in order to

determine if provider compliance was the reason that infection prevention protocols were successful or

unsuccessful. Results of this study indicated that nurses and pharmacies had improved rates of

compliance with infection prevention protocols when a daily quality checklist was implemented, while

physician and respiratory care staff had lower compliance rates (Chua et al., 2010). Overall results


indicated that central line infections, urinary tract infections, and ventilator-associated pneumonia

decreased following implementation of a daily quality checklist (Chua et al., 2010). These results provide

additional evidence to support the inclusion of protocols bundles to prevent infection.

SOP/Clinical Path

Once again, the Collegiality and Collaboration Standards of Practice for Acute and Critical Care

Nursing are most applicable to the care that is needed for L.L regarding infection control. Preventing the

transmission of infection is both an individual and team effort. Each person who comes into contact with

L.L., including physicians, nurses, respiratory therapists, and family members, must assume the

responsibility associated with infection-prevention actions. Each person who comes into contact with L.L

must be vigilant in their attempts to keep him free from infection. In addition, healthcare staff must work

together to plan for potential complications associated with infection, and they must work together to

identify signs of infection if, and when, they do occur.

Patient/Family Teaching

The focus of teaching related to infection should be directed towards L.L.’s family, in order to

limit exposure of pathogens to him. The family should be educated on the numerous risks for infection

that L.L. is currently facing. They should be educated on the common routes of infection transmission,

and on ways to reduce the transmission of pathogens via these routes. Just as with the healthcare

providers caring for L.L., family members should be instructed to wash hands frequently, and before each

contact with the patient. They may need to wear gloves when touching the patient. Close contact, and

transmission of bodily fluids, such as might occur with kissing, may need to be limited. Family members

should limit the number of outside items brought into the ICU, as they could potentially introduce

pathogens into the patient’s room.

Cultural Considerations

The most significant cultural consideration pertaining to L.L.’s risk for infection is, again, related

to his age. As humans grow older, several physiologic changes occur within the body, one of which is a

decrease in immune function. As older adults continue to age, their antibody and lymphocyte production


and their fever response all begin to decrease (Ignatavicius & Workman, 2010, p. 442). These changes

make older adults significantly more susceptible to pathogens and infection development. Given that L.L.

is 83 years old, it is likely that these changes have already taken place in his body. These changes, in

conjunction with his recent injuries and health issues, immobility, and need for mechanical ventilation, all

contribute to L.L.’s increased risk for developing an infection and becoming septic.

Progress Towards Outcomes

At the time of assessment, L.L. had a normal body temperature, a normal white blood cell count,

and adequate urine output. All of the cultures that were obtained tested “negative” or at “minimal

growth”, and his chest x-ray only showed sings of injury-related processes. L.L. did have other

concerning vitals and labs, such as hypotension and increased lactic acid levels, however, it was unclear if

these symptoms were related to his injuries, or possibly to an infection. Given that some of the critical

values mentioned above were negative or within normal limits, it would seem likely that these abnormal

results could be attributed to his injuries and subsequent bleeding, and not to an infection process.

However, given the extent of his injuries and severity of illness, it may not be reasonable to assume that

this outcome will be maintained for the duration of the patient’s time in the ICU. Most likely, infection

will take hold sooner, rather than later, and it will do so at a fairly quick pace. For this reason, an alternate

course of action will need to be initiated.

Additional/Alternative Plan

If L.L. does begin to show signs of infection development, rapid and aggressive treatment will

need to be initiated. Cultures will need to be taken again in order to look for and identify any new

pathogens brooding on or in L.L.’s body. The goal is to identify the pathogen causing the infection and

administer the proper medication to combat the pathogen and its’ spread. Once cultures are identified,

appropriate antibiotics, antivirals, or antifungals will need to be administered. Aggressive fluid therapy

with crystalloids may be needed if signs of septic shock appear. Vasopressors may need to be used if fluid

resuscitation is unsuccessful.

Diagnosis #3


The patient is at risk for continued impaired mobility, as evidenced by drug-induced cognitive

and perceptual impairment, an inability to move purposefully within the environment or perform self-care

needs, extensive musculoskeletal injury, mechanical restriction of movement, limited range of motion,

and prolonged immobility.

Diagnosis #4

The patient is at risk for continued feelings of pain and discomfort, as evidenced by extensive

musculoskeletal injuries received during recent traumatic crush event, subsequent surgery to correct

injuries, multiple open tissue injuries, significant injury to his genitourinary anatomy, use of mechanical

ventilation, and prolonged immobility.

Diagnosis #5

The patient is at risk for continued feelings of powerlessness, as evidenced by having limited

mobility, diminished patient-initiated actions, an inability to effectively communicate his feelings and

desires, having reliance on others for activities of daily living, and having little to no control over his

current health situation and plan of care.

Conclusion

The purpose of this case study was to examine several nursing aspects related to the care of a

patient suffering from injuries and other health issues associated with a traumatic crush event. This case

study attempted to addresses the implications of crush-related injuries and their subsequent health

consequences as they pertain to nursing care. Specifically, it attempted to emphasize the importance of

managing trauma-related hyppovolemia aggressively, and it attempted to improve awareness and

adherence to infection prevention measures. It also addressed other physical and psychosocial issues of

the crush-injury patient, including impaired mobility issues, feelings of pain and discomfort, and feelings

of powerlessness. L.L., the patient discussed throughout this case study, is still facing a variety of “health

hurdles”, and he clearly has a long road ahead of him. Perhaps, if knowledge gained from this case study

could be applied to future nursing care, L.L. and patients with similar health issues could have the benefit

of experiencing improvements in their level of health and wellness.


References

Bledsoe, B., Porter, R., & Richard, C. (2003). Essentials of paramedic care. New Jersey: Pearson

Education, Inc.

Chua, C., Wisniewski, T., Ramos, A., Schlepp, M., Fildes, J., & Kuhls, D. (2010). Multidisciplinary

trauma intensive care unit checklist: Impact on infection rates. Journal Of Trauma Nursing,

17(3), 163-166. doi:10.1097/JTN.0b013e3181fb38a6

Hutchison, R. W., Govathoti, D., Fehlis, K., Qi, Z., Cottrell, J. H., Franklin, N., & Montgomery, M.

(2011). Improving severe sepsis outcomes: Cost and time to first antibiotic dose. Dimensions Of

Critical Care Nursing, 30(5), 277-282. doi:10.1097/DCC.0b013e318227756d

Ignatavicius, D. & Workman, L. (2010). Medical surgical nursing: Critical thinking for collaborative

care. (6thed.). St Louis: Elsevier Mosby

Johnson, B.M., & Webber, P.B. (2010). An introduction to theory and reasoning in nursing. (3rd ed.).

China: Lippincott, Williams, & Wilkins.

Morrison, C., Carrick, M., Norman, M., Scott, B., Welsh, F., Tsai, P., & ... Mattox, K. (2011).

Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative

coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized

controlled trial. Journal Of Trauma, 70(3), 652-663. doi:10.1097/TA.0b013e31820e77ea

Urden, L.D., Stacy, K.M., & Lough, M.E. (2010). Critical care nursing: Diagnosis and management.

(6thed.). St. Louis: Elsevier Mosby


The Honor Pledge: “I pledge to support the Honor System of Old Dominion

University. I will refrain from any form of academic dishonesty or deception,

such as cheating or plagiarism. I am aware that as a member of the academic

community it is my responsibility to turn in all suspected violators of the

Honor Code. I will report to hearing if summoned.”

Signature: John Ward Date: 10.7.12


NURS 451 Client Case Study Grading Criteria

Student: __________________________ Score: __________ Grading Criteria Points Faculty Comments Points

Awarded Introduction Pt. Overview Scope of paper

2 1

Medical Diagnosis Dx for ICU adm. Patho Related S/S

2 4 4

Nursing Diagnosis 5 NANDA (1+ psych/soc) Priority with theorist support

5

10

Outcomes for top 2 NDX Appropriate for NDX Attainable within timeframe

#1 #2 2.5 2.5 2.5 2.5

Interventions for top 2 NDX Interventions with rationale SOP /Clinical Path Patient/family teaching Critical Thinking Cultural Considerations

#1 #2 6 6 2 2 2 2 2 2

3

Evaluation Progress toward outcomes Additional/alternative plan

#1 #2 5 5 1 1

Conclusion Review of learning

3


Grading Criteria Points Faculty Comments Points

Awarded Sources 5+ sources 3+ primary nursing research Study results reviewed/applied Study poorly reviewed/applied Research omitted

1

3 3 3 1 1 1 0 0 0

APA Format (Cover page, headings, margins, type size) Format conforms to APA Format Format includes 1-3 APA errors Format includes 4-6 APA errors Format includes >6 errors

3 2 1 0

APA- References/Reference Page Conform to APA Format Include 1-3 APA errors Include 4-6 APA errors Include >6 APA errors Do not conform to APA format

4 3 2 1 0

Writing Style (Grammar, spelling, punctuation, language) Logical, organized, without errors Logical, organized minor errors (<5) Lacks logic/organization OR major spelling/grammar/errors (>5) Lacks logic / organization AND major spelling / grammar / errors (>5)

3

2

1

0

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