This area focuses on the nursing care of patients with all types of tissue trauma. Tissue trauma includes such problems as burns, accidents, ulcers, inflammatory disease, and accidental poisoning, as well as surgical intervention.

A. Theoretical framework - basis for care

1. Types of tissue trauma

a. Physical/mechanical/degenerative (for example: soft tissue trauma, accidents, falls, hiatal hernia, pressure ulcers, traumatic amputation, bee stings, animal bites)

b. Thermal (for example: burns, frostbite)

c. Chemical (for example: medications, poisons, toxins, burns)

d. Inflammatory (for example: appendicitis, inflammatory bowel disease [Crohn's disease, ulcerative colitis], diverticulitis, cholecystitis, gastritis, gastric ulcers, lupus erythematosus)

Gastroenteritis

Gastritis

Ulcerative Colitis

Diverticulosis

Appendicitis

Peptic Ulcer disease

Bowel obstruction

Inflammatory bowel disease [Crohn's disease]

Pancreatitis

Esophagogastric varices

Hemorrhoids

Cholecystitis (gall bladder)

Acute hepatitis

Acute and Chronic Glomerulonephritis

Systemic Lupus erythematosus

Necrotizing enterocolitis

Nephrotic syndrome

Peritonitis

Stomatitis

Pyelonephritis

e. Surgical intervention (for example: appendectomy, tonsillectomy, hernia repair, reconstructive surgery, exploratory laparotomy, gastrectomy, ileostomy, cholecystectomy, laparoscopis surgery)

2. Clinical manifestations of tissue trauma

a. Altered vital signs (for example: elevated pulse, temperature alteration)

b. Altered neurological status (for example: confusion, lethargy)

c. Altered neurovascular status (for example: diminished peripheral pulses)

d. Altered digestive and elimination patterns (for example: urinary frequency, absence of bowel sounds, constipation)

e. Alterations in mobility (for example: gait disturbance, weakness)

f. Alterations in integument and mucous membrane (for example: edema, erythema, ulceration, hematoma)

g. Altered fluid and electrolyte balance (for example: metabolic alkalosis, metabolic acidosis, fluid volume deficit)

3. Factors influencing the patient's response to tissue trauma

a. Age and physiological factors (for example: physical activity patterns)

b. Psychological factors (for example: stress, body image)

c. Socioeconomic and cultural factors (for example: lifestyle, health practices, occupation, environmental conditions, substance abuse)

d. Nutritional status (for example: obesity, malnutrition)

e. Presence of other illness (for example: diabetes mellitus, cardiac disease, long-term steroid therapy)

f. Site of tissue trauma

g. Extent or severity of tissue involvement

4. Theoretical basis for interventions related to tissue trauma

a. Medications (for example: analgesics, antibiotics, chelating agents, nonsteroidal anti-inflammatory agents, corticosteroids, antidotes, narcotic antagonists, antacids, antihistamines, beta inhibitors, anticholinergics, antiflatulents, debriding agents, histamine blockers)

b. Preoperative care (for example: types of anesthesia, preoperative teaching, premedications)

c. Intraoperative care (for example: anesthesia, blood and fluid replacement, positioning)

d. Postoperative care (for example: comfort management, immediate assessment of the patient postoperatively, routine care, wound care, physical activity, diet)

e. Emergency interventions (for example: first aid measures, antidotes, splints)

f. Treatment modalities (i.e., burn treatments, pressure dressings, wet-to-dry dressings)

B. nursing care related to theoretical framework

1. Assessment - gather and synthesize data about the patient's health status in relation to the patient's functional health patterns

a. Gather assessment data

1) Obtain the patient's health history (for example: subjective symptoms, nutritional status, medications, recent injuries, past illnesses, health habits, family history, occupation)

2) Assess factors influencing the patient's response to tissue trauma (see IIA3)

3) Obtain objective data related to the patient's tissue trauma problem (for example: clinical manifestations, activity tolerance, altered vital signs, cardiopulmonary assessment, behavioral response, extent of tissue trauma)

4) Review laboratory and other diagnostic data (for example: central venous pressure readings, vital signs, endoscopic procedures, diagnostic imaging modalities, serum electrolytes, serum albumin, CBC, liver enzymes)

b. Synthesize assessment data (see IIBIa[1-4] above)

2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care

a. Identify actual or potential nursing diagnoses (for example: risk for infection related to break in skin integrity; altered peripheral tissue perfusion related to thrombus formation)

b. Set priorities (for example: based on Maslow's hierarchy of needs, based on the patient's developmental level)

c. Establish expected outcomes (patient-centered goals) for care (for example: patient will verbalize diminished pain, patient will comply with diet and fluid regimen)

3. Planning - formulate specific strategies to achieve the expected outcomes

a. Consider factors influencing the patient's response to tissue trauma (see IIA3) in planning patient care (for example: consider cultural dietary restrictions for the patient with Crohn's disease, plan pain management for the patient with a history of substance abuse)

b. Plan nursing measures on the basis of established priorities to help the patient achieve the expected outcomes (for example: monitor fluid and electrolyte balance for a patient with burns)

4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes

a. Use nursing measures to control the extent of tissue trauma (for example: provide skin care for the patient with an ileostomy, use surgical asepsis when changing a burn dressing)

b. Use nursing measures to minimize patient discomfort (for example: provide skin care to T-tube drainage site, provide diversional activities for the patient postoperatively)

c. Use nursing measures to promote fluid, electrolyte, and nutritional balance (for example: offer small, frequent feedings for the patient following a gastrectomy; monitor intake and output for the patient with burns, report alterations in the patient's condition)

d. Use nursing measures to assist the patient and/or significant others to cope (for example: refer the patient with an ileostomy to a self-help group, use therapeutic communication to encourage patient to verbalize feelings regarding changes in body image)

e. Use nursing measures specific to prescribed medications (for example: monitor the electrolyte status of the patient receiving potassium supplements, monitor vital signs prior to the administration of analgesics, monitor the elimination pattern of a patient receiving lactulose [Cephulac])

f. use nursing measures to provide information and instruction (for example: reinforce crutch walking for a patient with an amputation, provide preoperative and postoperative instructions, provide instruction regarding endoscopic procedures)

5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes

a. Assess and report the patient's response to nursing actions relative to the expected outcomes (for example: condition of the skin around a surgically created opening, patient verbalizes relief of pain following the administration of a narcotic analgesic, record body weight and urine output for the patient with burns, report alterations on the patient's condition)

b. Revise the patient's plan of care as necessary (for example: assess the effectiveness of the ostomy device, increase frequency of coughing and deep-breathing exercises for the patient postoperatively)