Page 481 - ACCCN's Critical Care Nursing

458 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

TABLE 17.2 Nursing management of the neurologically impaired, immobilised, mechanically-ventilated patient

Nursing domain Nursing outcome Nursing interventions
Ventilation and ● Airway patent. ● Assess ventilation parameters: ensure ET patency and position.
oxygenation ● Arterial pH, PaO 2 , PbtO 2 , SaO 2 within ● Assess bilateral chest movement: listen for airway obstruction or
normal range. ET cuff leak; auscultate for air entry.
● PaCO 2 & ETCO 2 within normal range. ● Assess chest X-ray.
● Lungs clear to auscultation. ● Adequate sedation and ventilation to maintain PbtO 2 , ICP, CPP.
● No evidence of atelectasis or aspiration. ● Suction only as necessary: preoxygenate, avoid prolonged
● Chest X-ray clear of pathology. coughing; effective technique.
● Avoid ICP complications of PEEP.
● Position to avoid aspiration.
● Provide meticulous oral hygiene.
Mobility/safety ● Cerebral blood flow uncompromised. ● Haemodynamic stability maintained. Brain ischaemia and
● Minimal and transient changes in intracranial hypertension controlled.
PbtO 2 –ICP–CPP and return to desired ● Nursing interventions planned for minimal disturbance; efficient
parameters within 5 min of nursing intervention.
intervention. ● Pressure-relieving mattress: allows minimal position changes for
● Patient integument maintained and integument protection, with minimal CMRO 2 requirement,
infection free: skin, mucous membranes, sequential compression device for venous return.
cornea, wounds, invasive lines ● Hygiene maintained: assess integument, assess cornea, assess
● Complications of immobility prevented: mucous membranes.
DVT, pneumonia, muscle strength. ● Maintain infection control interventions with invasive devices
● Patient safety enabled, preventing and wounds.
nosocomial infection, secondary brain ● Administer preventive plan of treatment with vigilance and
injury, self-harm. prediction.
● Nutrition prescribed according to ● Enable communication with other health professionals.
patient need. ● Chemical and physical restraint applied per assessment and
● Healing defined and uneventful. prescription, within institutional policy.
Psychological/ ● Family and significant others informed ● Refer and coordinate information and service provision from
family and supported. other health professionals.
● Psychological wellbeing of patient in ● The provision of quality, informed and inclusive care to the
recovery patient provides family and significant others with the
● The patient will feel safe. confidence that the nurse advocates for the patient in their place.
● Ensure psychological assessment and administer prescribed
therapy for delirium and post traumatic stress.
● Nursing interventions planned to allow for rest and recovery.
● Administer coordinated rehabilitation strategies.

through the head and cervical spine. In reality, cervical ● Extension–rotation: Rotational injuries result from
trauma is produced by a combination of these mecha- forces that cause extreme twisting or lateral flexion of
nisms as listed below. the head and neck. Fracture or dislocation of vertebrae
may also occur. The spinal canal is narrower in the
● Hyperflexion: These injuries usually result from force- thoracic segment relative to the width of the cord, so
ful decelerations and are often seen in patients who when vertebral displacement occurs it is more likely
have sustained trauma from a head-on motor vehicle to damage the cord. Until the age of 10, the spine has
collision (MVC) or diving accident. The cervical increased physiological mobility due to lax ligaments,
region is most often involved, especially at the C5–C6 which affords some protection against acute SCI.
level. Elderly patients are at a higher risk due to osteophytes
● Vertical compression or axial loading: This typically and narrowing of the spinal canal.
occurs when a person lands on the feet or buttocks
after falling or jumping from a height. The vertebral
column is compressed, causing a fracture that result Classification of Spinal Cord Injuries
in damage to the spinal cord. SCIs can be broadly classified as complete or incom-
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● Hyperextension: This is the most common type of plete. The diagnosis of complete SCI cannot be made
injury. Hyperextension injuries can be caused by a until spinal cord shock resolves. If the bulbocaverno-
fall, a rear-end MVC, or hit on the head (e.g. during a sus reflex (BCR) is present (involuntary contraction of
boxing match). Hyperextension of the head and neck the rectal sphincter after squeezing the glans penis
may cause contusion and ischaemia of the spinal or clitoris or tugging on an indwelling urinary cathe-
cord without vertebral column damage. Whiplash ter) it indicates a complete injury. If, after the return
injuries are the result of hyperextension. Violent of the BCR, the patient has some sensation below the
hyperextension with fracture of the pedicles of C2 level of injury, he/she is considered to be sensory-
and forward movement of C2 on C3 produces the incomplete. If the BCR has returned and the patient
‘Hangman’s fracture’. has some motor function and sensation below the