PAPER EMERGENCY CRITICAL CARE

RESTRICTED VISITING POLICIES

EVIDENCE BASED PRACTICE: Putting More Sacred Cows Out To Pasture

GROUP 29

1. Cindiani Yulistia Rawing 00000016849

2. Cindy Claudia D 00000018014
3. Clara Cika Oktaviani 00000016879
4. Indria Wahyu Dadang W 00000017306
5. Intan Sucitra Sima 00000016886
6. Irwan Simarmata 00000018011
7. Irwanto 00000016864

FACULTY OF NURSING AND ALLIED HEALTH SCIENCE

PELITA HARAPAN UNIVERSITY

KARAWACI

2017
Case Emergency :

On October 20, 2017, Mrs.Ck 31-year-old came to the emergency department at Siloam Hospital
because of a traffic accident 1 hour before entering the hospital. The patient momentarily lost
consciousness at the time of the injury and then regained it. The patient now has lost consciousness
again, looking bruised around the eyes and behind the ears. found also otorrhea and rhinorrhea.
The nurses takes quick action knowing that these are signs and symptoms of brain injury. The
result of CT-Scan is epidural hematoma.

When the patient's family comes to the hospital, the family is prohibited from entering and is only
limited to one person for a while before others enter. Families are very angry and sad because the
hospital policy only exacerbates family worries on the patient's condition. Then, nurse educates
the family about the policy.

Physical Assessment:

• Inspection

In auricular hematoma there is usually a lump in the auricular front of the basin, swelling due to
blood clots, changes in the shape of the ear or deformity, the color change which usually appears
purple, reddish and lumps in the auricle (earlobes).

• Palpate

Assess for tenderness, lumps in the auricle (earlobes) and the presence of fluctuations or feel
supple.

Psychological Assessment:

In the literature keywords related to the physiological effects of the Trendelenburg position and its
use for the treatment of hypotension and shock, we resume the difficult limitations to draw
definitive conclusions on the physiological response to Trendelenburg's position. Alternatives to
Trendelenburg positions, such as passive leg elevators, may provide greater benefits for the
introduction of hypotension or fluid responsiveness predictions with minimal or undesirable
effects.34,35 Increase the patient's leg while keeping the horizontal head of the bed relative to the
patient's stem resulting in a 150- 300 mL to the top of the thorax. This shift increases the aortic
volume, may not activate the baroreceptors, and avoid the risk of gastric aspiration. In one study,
25 researchers reported the same cardiovascular and lung effects for leg increments as for
Trendelenburg positions in 18 heart surgery patients. Others have demonstrated that this maneuver
correlates with the response to fluid loading and is predictive of the need for the patient's cardiac
output, stroke volume variation, or positive blood pressure in foot-lifting maneuvers. The
evidence, regardless of this, does not indicate a suitable benefit in Trendelenburg's position for
patients with hypothetical hypotension and / or shock, and that position with impaired ventilation
and oxygenation and may have other adverse effects such as those just recently important. In the
psychological aspect is usually also found a high level of stress and can cause emotions, behavioral
changes, anxiety, irritability, and confusion.
 Patofisiologi :

Head Injury

Skull Fracture

Tearing of the meningeal

artery media

Epidural Hematoma Lack of Knowledge

Pressing the temporal Anxietas

lobes

Compression

Oculomotor Cerebral Contex

Dilatation Oxygen supply to the brain

Palpebral Ptosis

Loss of consciousness
Head Pain ICP

Acute Pain Body Compensation

Vasoconstriction Risk of Injury Risk of nutritional changes

Autoregulation Disorder

Hipoksia Ineffective Perfusion of

Cerebral Tissue
Nursing Management :

1. Surgical care
Although several recent reports have described succesful conservative management of
epidural hematoma, surgical evacuation constitutes definitive treatment of this condition.
Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of
bleeding sites, and inspection of the dura. The dura is then tented to the bone and,
occasionally, epidural drains are employed for as long as 24 hours
2. Diet
The hypermetabolic and catabolic phenomena associated with severe head injury
necessitate caloric supplementation. Initiate enteral feeding as sson as possible
3. Activity
Patients who are treated conservatively should undergo close observation and should avoid
strenuous activity inpatients should remain on bedrest during the initial phase; this can be
followed by a progressive increase in activity.

Emergency Treatment

1. Decompression with simple trepanation

2. Craniotomy for hematom evacuation

Medical Treatment

1. Repair or Mintain vital Functions

Try to keep the airway free, clean the mucus and blood that can block the flow of the breathing
, if need use naso/oropharingeal pipe and give oxygen too, infusion is installed primarily to open
an intravenous line , use a NaCl 0,9% liqud or dextore in saline.

2. Reduce cerebral edema

Several ways can be tried to reduce cerebral edema:

a. Hyperventilation.
Aims to lower paO2 blood vasodilation In addition to special oxygen is maintained can help
anaerobic metabolism, so it can reducing the possibility of acidosis. When it can be checked,
paO2> 100 mmHg and paCO2 between 2530 mmHg.

b. Hyperosmolary fluid.

Generally used Manitol 1015% fluid per infusion to "pull" water from the inner space into the
intra-vascular space for later issued through diuresis. To get that effect desired, mannitol should
be given in sufficient doses in a short period of time, generally given: 0.51 grams / kg body weight
in 1030 minutes.

c. Corticosteroids.

The use of corticosteroids has been disputed since some time ago. The recent opinions tend to be
states that corticosteroids are not / less beneficial in the case head injury. Its use is based on the
assumption that this drug stabilize the blood brain barrier. Parenteral doses that have been tried
also vary:Dexamethasone had been tried with a dose of up to 100 mg of bolus followed by 4 dd 4
mg. In addition, Methylprednisolon ever used with a dose of 6 dd 15 mg and Triamsinolon with a
dose of 6 dd 10 mg.

d. Barbiturates.

Used to anesthetize the patient so that brain metabolism can pressed as low as possible,
consequently oxygen demand will also decreased; because of low needs, the brain is relatively
more protected of the possibility of hypoxy-induced piercings, despite oxygen supply reduced.
This method can only be used with surveillance strict.

Indication :

The operation is performed when there:

Volume of hematoma > 30 ml EDH and SDH thickness greater than 5

mm and midline shift with GCS 8 or less
Patient's condition worsens
Local signs and increase of ICT >25
open skull fractures, and depressive skull
mmHg
fractures with depth >1 cm
Referensi:

Houser J. Evidence-based practice in Health Care. In: Houser J, Oman K. 2011 . EvidenceBased
Practice: An Implementation Guide for Healthcare Organization.Sudbury, MA: Jones-Bartlett
Learning, LLC; 2011:1-20.

Price, Sylvia Anderson. 2005. Patofiologi: Konsep Klinis Proses-Proses Penyakit, edisi 6.
Jakarta : EGC, 2005

Robertson C.S, Zager E. 2010. Clinical Evaluation of Portable Near-infrared Device for detection
of Traumatic Intracranial hematom, Journal of Neurotrauma.

Wilkins, Williams L. 2008. Contralateralb Acute Epidural Hematoma After Decompressive

Surgery of Acute Subdural Hematoma, Vol.65.

Makic, M. B. F., VonRueden, K. T., Rauen, C. A., & Chadwick, J. (2011). Evidence-based
practice habits: putting more sacred cows out to pasture. Critical Care Nurse, 31(2), 38-62.
Retrievedfrom
http://medcom.uiowa.edu/annsblog/wp-content/uploads/2011/04/EBP-Habits-Putting-Sacred-
Cows-out-to-Pasture-2011-April.pdf

Rauen, C. A., Chulay, M., Bridges, E., Vollman, K. M., & Arbour, R. (2008). Seven evidence-based
practice habits: putting some sacred cows out to pasture. Critical Care Nurse, 28(2), 98-123.
Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/21459864

Metheny N. 2011 . Restrcted visiting policies. Crit Care Nurse. 2011;31(2):96–97. Retrieved from

http://allnurses.com/general-nursing-discussion/tipping-sacred-cows-1085580.html