Nursing outcome standards for polytrauma patients with traumatic brain injuries in the Mafikeng district

Moloko, Salaminah S (2001)

Thesis (MCUR)--University of stellenbosch, 2001.

Thesis

ENGLISH ABSTRACT: In trauma the priority is given to identifying the life-threatening injuries and immediately implementing treatment (Demetriades, 1993:3). Severe trauma resuscitation and assessment often have to be carried out simultaneously to detect and treat conditions that are rapidly fatal if not attended to immediately and according to priority. Urgent priorities in trauma management include maintaining a clear and patent airway to facilitate respiration and cervical spine protection by avoiding rough manipulation of the head and neck by supporting the neck with a neck immobiliser. Any external bleeding has to be controlled by applying direct pressure to the wound. Cardiovascular problems, for example shock or myocardial infarction, respiratory problems and hypoxia which are detrimental, particularly in the case of head injury, should be excluded. A detailed head-to-toe examination which includes the head, neck, chest, abdomen, back, musculo-skeletal system, rectum and vagina has to be performed. For the head-injured patient, correct any condition, which may complicate the existing head injury, for example hypoxia, shock, pneumothorax and fractures of long bones or pelvis. Implement the A (airway), B (breathing), C (circulation), D (disability, neurological and drugs) and E (environment) for structured management of the patient. Muller's, (1996) two-phase model was utilised to formulate and validate nursing outcome standards. In phase one literature was explored to develop provisional standards on polytrauma patients with traumatic brain injuries. In phase two the provisional standards were validated by experts (doctors and nurses) in critical care, trauma and emergency nursing including nurses and a doctor working in the casualty department of a provincial hospital in Mafikeng. Final standards were formulated and adapted accordingly. Standards for the management of a polytrauma patient with traumatic brain injuries included: A safe environment for patients, nurses and doctors Primary survey in casualty department which includes the maintenance of airway, breathing, circulation, disability/ neurological, drugs and exposure The secondary survey that includes the head to toe examination, definitive orthopaedic care and stabilisation before transfer to the intensive care unit A standard on all relevant equipment which might be needed in case the patient goes into cardiac arrest on the way to the intensive care unit, was also formulated. The standard on documentation included the primary and secondary survey in the casualty department, transport to the intensive care unit, activities and the condition of the patient. The final standards dealt with the accurate handing over of the patient to the intensive care personnel. The following recommendations were made: • Implement the outcome standard by means of a quality improvement programme through a top-down approach. • Provide training: Nurses and doctors have an obligation to render quality care, therefore they have the right to be trained in emergency procedures. • All registered nurses working in the casualty or emergency departmentsshould be trained in at least Basic Life Support (CPR), Advanced Cardiac Life Support (ACLS), Advanced Paediatric Life Support (APLS) and Advanced Trauma Life Support (ATLS) while waiting to be sent for the trauma-nursing course. • Improve infection control measures in the casualty department • Emergency drugs must always be available. • Improve the on-call system. • Formulate a policy on sharing of the equipment by both casualty and ICU staff. • Motivate for the necessary equipment. Implement procedures for debriefing of staff, the evaluation of actions during resuscitation and implement measures for psychological support of the family. • For further research, implement and test a training programme whereby nurses can formulate their own standards. • Evaluate whether the standards have improved the quality of trauma care, and develop standards for leu nursing of the brain injured patient and the rehabilitation of polytrauma patients with traumatic brain injuries The uniqueness of the study lies in the fact that no formal outcomes standard for trauma patients with traumatic brain injuries have been developed in any of the North West Provincial hospitals.

AFRIKAANSE OPSOMMING: Die identifisering van lewensbedreigende beserings en die onmiddellike implementering van behandeling, is in trauma 'n eerste prioriteit (Demetriades, 1993: 3). Resussitasie en die beraming van erge traumagevalle noodsaak in baie gevalle, gelyktydige hantering. Sou hierdie hantering nie gelyktydig en onmiddellik volgens prioriteit plaasvind nie, kan dit noodlottige gevolge inhou. Belangrike prioriteite in traumabehandeling sluit in, die instandhouding van 'n patente lugweg om asemhaling te onderhou asook die beskerming van die servikale rugmurgkolom, deur die ruwe manipulasie van die kop en nek te vermy deur die implementering van 'n nekimmobiliseerder. Kardiovaskulere probleme, byvoorbeeld skok of miokardiale infarksie, asook respiratoriese probleme wat lewensbedreigend vir die pasient met 'n hoofbeseering is, moet uitgesluit word. 'n Gedetailleerde van kop-tot-tone ondersoek, wat die kop, nek, borskas, abdomen, rug, muskulo-sketale stelsel, rektum en vagina insluit, moet uitgevoer word. In die pasient met hoofbeserings moet enige toestand byvoorbeeld frakture van die langbene of die pelvis, skok of 'n pneumothorax, eers behandel word. Implementeer die A (Iugweg - "airway"), B (asemhaling - "breathing"), C (sirkulasie -"circulation"), D (gestremdheid - "disability", neurologies- "neurological" en drogerye-"drugs") en E (omgewing - "environment") vir die gestruktureerde behandeling van die pasient. Die twee fase model van Muller (1996) is gebruik vir die formulering en validering van die verpleeguitkomsstandaarde. In fase een is die literatuur verken om die voorlopige standaarde vir polytrauma pasiente met traumatiese breinbeserings te ontwikkel. In fase twee is die voorlopige standaarde gevalideer deur kundiges (dokters en verpleegkundiges) in kritieke sorg, trauma en noodverpleging. Die verpleegkundiges en dokter wat werksaam is in die ongevalle-eenheid van 'n plaaslike provinsiale hospitaal in Mafikeng is ook ingesluit. Finale standaarde is geformuleer en dienooreenkomstig aanvaar. Die standaarde vir die politrauma pasient met traumatiese breinbeserings, sluit in: 'n Veilige omgewing vir pasiente, verpleegkundiges en dokters. Die prirnere beraming in ongevalle ten opsigte van instandhouding van die lugweg, asemhaling, sirkulasie, gestremdheid, drogerye en blootstelling. Die sekondere beraming: wat behels die kop-tot-tone ondersoek. Definitiewe ortopediese behandeling en stabilisering voor oorplasing na die intensiewe-sorg-eenheid. 'n Standaard met betrekking tot die nodige toerusting wat benodig mag word tydens 'n hart stilstand, oppad na die intensiewe-sorg-eenheid, is ook geformuleer. Die standaard ten opsigte van dokumentasie sluit die primere, en sekondere beraming, vervoer na die intensiewe-sorg-eenheid, aktiwiteite en toestand van die pasient, in. Die finale standaarde is gebaseer op die oorhandiging van die pasient aan die intensiewe-sorg-personeel. Die volgende aanbevelings word gemaak: • Implementeer die uitkomsstandaarde deur middel van 'n gehalteverbeteringsprogram deur gebruik te maak van 'n "top-down" benadering -, • Voorsien opleiding: Verpleegkundiges en dokters het 'n verpligting om gehaltesorg te lewer, hulle het dus 'n reg om onderrig te ontvang in noodprosedures, en verder het die pasient die req op gehalter noodbehandeling. • Aile geregistreerde verpleegkundiges wat in die ongevalle en die noodafdeling werk, behoort opgelei word in ten minste basiese lewensondersteuning (CPR), Gevorderde Trauma Lewens Ondersteuning (ACLS), Gevorderde Pediatriese lewensondersteuning (APLS) en Gevorderde Trauma lewensondersteuning (ATLS), terwyl gewag word om die trauma verpleegkundigekursus te deurloop. • Verbeter mteksiebeheermaatreels in ongevalle. • Noodmedikasie moet ten aile tye beskikbaar wees. • Verbeter die op-roepstelsel ("on cali"). • Formuleer 'n beleid oor die gesamentlike gebruik van toerusting deur beide ongevalle- en intensiewe-sorg-eenheid-personeel. • Motiveer vir die nodige toerusting. • Implementeer prosedures om personeel to te laat vir ontlonting (debriefing), die evaluering van aksies tydens die resusitasie prosedure en implementeer metodes vir die sielkundige ondersteuning van die familie. • Ten opsigte van verdere narvorsing behoort 'n opleidingsprogram qeunplernenteer en getoets te word met betrekking tot verpleegkundiges wat hulle eie standaarde will formuleer. • Evalueer of die standaarde die gehalte van traumasorg verbeter het en ontwikkel standaarde vir intensierwe-sorg-verpleging van die breinbeseerde pasient asook die rehabilitasie van politrauma pasiente met traumatise breinbeesering. Die unieke bydra van die studie word gevind in die feit dat daar nog geen gerformaliseerde uitkomstandaarde vir traumapasiente met breinbeseerings in enige van die Noord Wes Provinsie se hospitale ontwikkel is nie.

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