The bladder is sited deep within the bony pelvis, it is protected from all but the most severe injuries to the abdomen and pelvis. Thelan, Davie, Urden and Lough (1994), also state that the type of injury to the bladder not only depends upon the strength of the blunt force and its location but also on how much urine is in the bladder at the time of the insult to it. James’s ruptured bladder was diagnosed using cystographic examination and he required surgery to repair extraperitoneal and intraperitonal ruptures of his bladder.
Intraperitoneal bladder rupture is described as a burst injury arising after a blunt trauma insult to a full bladder that results in a laceration in the dome of the bladder. This results in the spillage of urine into the peritoneal cavity. Surgery is required to repair this type of injury (Tintinalli, Ruiz & Krome, 1996). When James underwent surgery 800 milliliters of urine was removed from his abdominal cavity and two Nelaton drains were inserted into either side of his bladder to continue to drain any excess fluid. These remained insitu for 10 days before they were removed, however they drained less than 100 milliliters of fluid from each side over the 10 day period.
Extraperitoneal bladder rupture is diagnosed using the cystogram. It does not usually require surgery and is treated with an indwelling urinary catheter to drain urine for 10 – 14 days. The cystogram is repeated to confirm healing before the withdrawal of the urinary catheter (Tininalli, Ruiz & Krome, 1996). James had an indwelling catheter (IDC) inserted whilst he was in the operating theatre. The output from this was measured hourly and the colour of the urine was also observed and documented. Initially the output and colour was observed to be that of frank blood but this improved over the period of 12 days until the output was straw coloured urine. During this period of time the IDC drained freely and did not require flushing.
The symphysis pubis was stabilised with external fixations. These were inserted to close the seven centimeter gap that had resulted from the impact. James had three surgeries to correct his symphysis pubis. In the third surgery his symphysis pubis was rejoined and fixed with plates, ensuring that it would stay together and heal properly. The external fixations remained insitu to provide further stabilisation and James was informed that he could expect these to remain in place for up to 12 weeks.
At the time of his first surgery James had a chest drain inserted into his right lung because he had fluid present in his thoracic cavity. Tests revealed the fluid to be urine. Surgeons denied any diaphragmatic ruptures or tears, however, an intensive care doctor suggested that there had been a tear, but they are very difficult to locate and it will heal without intervention (personal communication, Dr. Ward, 7-5-03). James also received five units of packed red blood cells on arrival in HDU after his surgery. His vital signs were monitored according to the hospital policy for patients receiving blood products and he experienced no adverse reactions.
Much of the nursing care received by James focused on keeping him free from infection. According to Thelan, et. al. (1994), infection is a major cause of mortality and morbidity for patients in intensive care settings and “of trauma patients who survive longer than three days, infection is a frequent cause of death” (p. 757). Fortunately for James, his protective leather clothing protected him from the cuts and grazes he may otherwise have received when he fell off his motorbike. This eliminated one of the avenues for infection to invade his body. The main portals of entry for infection to enter his body was via the intravenous lines, the drains, external fixations and the IDC as well as the large surgical wound made by the surgeons when they repaired his bladder. However, the urine spilled into the peritoneal cavity and up into the thoracic cavity also provided another source of potential infection.
Endogenous bacteria were released into the internal environment, via the urine, as a result of the intraperitoneal rupture. James was administered regular doses of a strong antibiotic medication (Mandol, 1 gram, twice daily), to counter any infection that may arise from his injuries. His CV and arterial lines were cleaned daily with chlorhexidine, a strong bacteria killing solution and then covered with a protective dressing, according to hospital protocols. The Nelaton drains and the external fixation sites were dressed daily using aseptic technique and sterile dressings to ensure they remained free from infection, as was his laparotomy wound which was in the shape of an inverted T and held together with staples. To ensure his status remained infection free, hourly baseline observations were performed and recorded on his hospital chart. Alterations in baseline observations may indicate infection is present in the body (Taylor, Lillis & LeMone, 2000).
With each shift change the nursing staff performed what was described as a “top to toe” examination of James. This involved physically inspecting all of the parts of his body they could see without turning him over and noting any changes – positive or negative. An inspection of his back and buttocks was performed each evening when James had his bed bath to ensure no pressure sores were developing. Each nurse who looked after James listened to his chest, noting the sounds they heard and they also listened to his bowel sounds and noted their findings in the nursing notes. His left hand which was in a back-slab cast was assessed daily for colour, warmth, sensation and movement to ensure correct healing. His dressings were assessed regularly for exudate and discharge and his position was changed regularly to lessen the risk of pressure sores developing.
According to Boggs and Wooldridge-King (1993), surgical dressings should be changed daily after the initial 24 hour period when they are left intact and not disturbed. All dressing changes were performed using an aseptic technique to limit the possibility of infection contaminating any of James’s wounds and the lack of infection was evidenced by his baseline vital signs remaining stable, no redness observed around the edges of his wounds and no pus forming.
James was encouraged to perform regular deep breathing exercises and educated on the use of the incentive spirometer. Incentive spirometry is used to increase the depth of inspiration in a patient who may not be taking adequate inspirations by themselves (Boggs & Wooldridge-King, 1993). A chest drain placed into the fifth intercostal space as well as post-operative pain could all contribute to a decrease in the depth of inspiration James was able to take. Normal respiration will move any fluid that is accumulating in the lungs of a healthy individual, whereas fluid that is pooling in the lungs of an individual with inadequate respirations may be another avenue for bacteria to colonise leading to infection (Kidd & Wagner, 2001).
James was educated on the correct way to use the incentive spirometer and initially needed reminding and encouraging to utilise it, however after a few days he needed no reminding and used it far more frequently than the suggested three inhalations, three times per day. It is important to encourage patient’s to participate in their self-care activities and treatment regimes in accordance to their level of progress and activity tolerance. According to Thelan, et. al. (1994), patient’s who take an active role in their own treatment regimes are less likely to feel like helpless or powerless victims. They go on to say that this greater sense of control over their illness will guide them more swiftly towards becoming as independent as possible.
Pelvic injuries and fractures are associated with high levels of pain (Thelan, et. al., 1994). Macintyre and Ready (1996) go on to say that it was often thought that whilst pain was not considered good for the patient, it was thought to do no harm. It is now recognised that this belief is incorrect and that the patient can indeed have harmful physiological and psychological effects if severe acute pain is undertreated (Macintyre & Ready, 1996). Macintyre and Ready (1996) state that the following conditions may result from undertreated pain. It may exaggerate existing pulmonary dysfunction leading to further pulmonary complications; cardiovascular effects include an increase in sympathetic nervous system activity leading to increases in heart rate and the workload of the heart which could result in myocardial ischemia due to a decrease in oxygen supply. People in severe pain often reduce their movements which increases their risk of developing deep vein thrombosis and pulmonary emboli, pain can lead to significant delays in gastric emptying and a reduction in gut motility as well as urine retention, and activation of the stress response is noted after surgery or trauma which results in the body releasing hormones. This hormone release may trigger a cascade of responses which leads to compromised wound healing as well as an impairment of the body’s immune reactions, which increases susceptibility to infection. Undertreated pain also causes patient anxiety, fear and sleeplessness.
James had been seriously injured and it was important that his health was not further compromised by allowing severe acute pain to delay healing so he was given regular analgesia for his pain control. He was also attached to a patient controlled analgesia (PCA) machine that delivered a controlled dose of analgesia whenever James required it. Macintyre and Ready (1996) state that the patient is more likely to maintain a reasonably constant blood concentration of analgesia which is more likely to be kept within the “analgesia corridor” (p. 76) for each patient.
The PCA enabled James to administer a dose of analgesic medication to himself when he was beginning to feel uncomfortable rather than wait until he experienced strong pain, request pain medication from the nurse, wait until it arrived and then wait longer until it worked. It gives patients a sense of control over their treatment, which as noted earlier assists them to recover and prevents feelings of hopelessness and powerlessness.
James was encouraged to utilise his PCA machine when any essential cares were being performed for him (such as bed baths) that may require him to move thus causing him pain and discomfort. The nursing staff were very prompt with the administration of the oral pain medication for James and they always evaluated the effectiveness of it within 30 minutes of administering it.
The administration of medications is governed by the Medicines Act of 1981 and the Medicines Regulations of 1984, (Galbraith, Bullock and Manias, 2001). The legislation guides and controls the manner by which nurses conduct their practice of administering medicinal drugs. The nurses in the HDU were very aware of these regulations and appeared to act very correctly regarding their professional responsibilities concerning medications.
When handling medications the nursing staff was extremely rigorous in upholding the five rights of medicine administration. Any medications that were added to fluids for intravenous administration were checked by two nurses, the empty containers were again checked by two nurses to ensure no errors had been made, before being administered to the patient. All bags of fluid and syringes containing added medications were labeled with a bright yellow sticker that stated what medications had been added, the date and time it had been added and then signed by the person who had added the medication. Any undated syringes with medications in them, that had been partially used and left on the patient’s trolley for later use, were discarded by the nurses coming on at the change of shift. It was explained to the writer that although this may seem to be wasteful and expensive, nurses were not prepared to compromise the health of their patients by administering a medication that they had not prepared and did not know how long it had been on the patient’s trolley for.
Other nursing considerations and interventions included regular position changes, oxygen administration, impaired physical mobility, neurovascular compromise, risk for development of compartment syndrome, fat embolism syndrome, sleep deprivation, altered tissue perfusion and high risk for fluid volume deficit. James received the nursing care he needed to ensure that these problems or potential problems were eliminated or managed effectively.
Hudak, Gallo and Morton (1998), say that calamities alter a family’s sense of equilibrium, creating challenges that the family must respond to. The patient’s responsibilities must be assumed by other family members and the social role of the patient is altered or missing. The family’s reaction to the event is also dependent upon the nature of the event (Hudak, Gallo & Morton, 1998). According to Kidd and Wagner (2001), both the patient and their families want to be educated about their condition and the hospital. This was achieved for James’s wife and family by educating them on his condition including the drains and external fixations protruding from James’s body. James’s wife was involved in decision making about his care - she signed all of his consent forms for surgery. Nursing staff advised her when doctors involved in James’s care, were available to discuss his progress with her.
James did not reside locally and his family and friends had to drive from another town to visit him. His wife, children and friends were frequent visitors, which James seemed to enjoy. However, frequent visitors, combined with regular nursing interventions and doctors visits, interfered with the amount of sleep James was able to get during the day, despite the fact that at times he seemed extremely tired. Visitors were limited to two people at a time and some of the nursing interventions were assessed by the nurses as being safe to leave until James awoke, thus ensuring that he was able to sleep undisturbed for periods during the day. James did not identify any specific cultural or spiritual needs, he was visited by the hospital chaplain on her rounds but he did not express a need to see her again.
According to Clochesy, Breu, Cardin, Whittaker and Rudy (1996), standards of practice “define the minimum level of care provided by a given profession that is considered adequate” (p. 25). The standards of care provided to James is determined by the Nursing Council of New Zealand (NCNZ), and at all times the nursing staff in the HDU upheld these standards. They acted in a manner that complied with legal requirements, upheld high ethical standards towards the patient and their colleagues, maintained high standards of practice, respected the rights of the patient and his family and inspired confidence and public trust in the profession of nursing.
One person driving on the wrong side of the road had a huge impact on James’s life. Serious pelvic injuries saw him in surgery three times for repairs. He will return home to live for approximately three months with external fixations protruding from his body, which will make life rather awkward for him. The nursing care he received in HDU is comparable with the latest and most up to date healthcare practices. James’s wife was included in discussions about her husband’s condition and care and this enabled her to learn about his injuries, which empowered her and helped her to cope. At all times nursing staff acted professionally and according to their legal requirements, upholding James’s ethical and cultural requirements. The nursing care James received in HDU was excellent.
References
Boggs, R. L. & Wooldridge-King, M. (1993). American association of
critical care nurses: procedure manual for critical care (3rd ed.).
Philidelphia: W. B. Saunders.
Clochsey, J. M., Breu, C., Cardin, S., Whittaker, A. A., & Rudy, E. B.
(1996). Critical care nursing (2nd. Ed.). Philadelphia:
W. B. Saunders.
Coulter, M. A. (2001). Intensive and critical care nursing. (Vol 17),
pages 183 – 185. Severity of Illness – An Important Concept For
Critical Care Nursing?
Department of Health. (1991). Principles and guidelines for informed
choice and consent. Wellington: Department of Health.
Galbraith, A., Bullock, S., & Manias, E. (2001). Fundamentals of
Pharmacology, (3rd ed.). Australia: Prentice Hall Health.
Hudak, C. M., Gallo, B. M., & Morton, P. G. (1998). Critical care nursing:
A holistic approach (7th ed.). Philadelphia: Lippincott.
Kidd, P. S., & Wagner, K. D. (2001). High acuity nursing (3rd. ed.).
New Jersey: Prentice Hall.
Macintyre, P. E., & Ready, L. B. (1996). Acute pain management – a
practical guide. London: W. B. Saunders.
Nursing Council of New Zealand (1994). Code of conduct for nurses and
Midwives. Wellington: Nursing Council of New Zealand.
Palmer, S., Giddens, J., & Palmer, D. (1996). Infection control.
Texas: Skidmore-Roth Publishing Inc.
Simon, R. R., & Koenigskencht, S. J. (1982). Orthopedics in emergency
medicine. New York: Appleton-Century-Crofts.
Taylor, C., Lillis, C., & LeMone, P. (2000). Fundamentals of nursing.
Philadelphia: Lippincott.
Thelan, L. A., Davie, J. K., Urden, L. D., & Lough, M. E. (1994). Critical
care nursing – diagnosis and management. (2nd ed.)
St Louis: Mosby.
Tintinalli, J. E., Ruiz, E., & Krone, R. L. (1996). Emergency medicine – a
comprehensive study guide. United States of America: McGraw Hill.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2002). Thelan’s critical care
nursing – diagnosis and management. (4th ed.) St Louis: Mosby.
