Rehabilitation nursing for an earthquake survivor with severe polytrauma: A case report and literature review

Chun?Yi XU, Fang TANG

Department of Orthopedic, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, Chengdu,China

ABSTRACT

The aim of this article is to summarize the experience of rehabilitation nursing of one case of severe polytrauma caused by earthquake.The key points of the rehabilitation nursing include body posture nursing, orthopedic rehabilitation nursing, pulmonary function rehabilitation nursing,bladder rehabilitation nursing, nutritional support, and psychological rehabilitation nursing.Through the comprehensive rehabilitation nursing interventions, satisfactory outcomes were obtained, and the patient was successfully recovered and discharged after 2 months.

Keywords: Earthquake, polytrauma, rehabilitation nursing

INTRODUCTION

Polytrauma refers to the presence of two or more separate injuries, at least one or more of which are life?threatening injuries.[1]Benefiting from advanced quality of care, the survival rate of patients with multiple traumas has increased,but meanwhile causing more patients with long?term disabilities.[2]In addition to physical suffering, these patients who have experienced natural disasters such as earthquakes,hurricanes, or wars also suffer from severe psychological stress and require a long process to rehabilitate themselves.[3]Early comprehensive rehabilitation nursing can help them restore function, prevent complications, and reintegrate into society as soon as possible.In this article, we reported a patient with severe earthquake?induced polytrauma transferred to our hospital on June 18, 2019.Through the treatment and comprehensive rehabilitation nursing care,the patient was successfully recovered and discharged after 2 months.

CASE PRESENTATION

The patient is a 56?year?old male survivor admitted to a local hospital with diagnoses of hemorrhagic shock and pelvic comminuted fracture after being hit by a concrete brick wall during the magnitude 6.0 earthquake occurring in Changning County, Yibin City, Sichuan Province, China, on June 17, 2019.Conservative treatments such as volume expansion, blood transfusion, hemostasis, tracheal intubation, and thoracic closed drainage were used to maintain the patient’s vital signs.However, due to the uncontrolled bleeding, the general condition of the patient gradually deteriorated.After the real?time 5G video consultation with our multidisciplinary expert team, air rescue was adopted to transfer the patient to our hospital on the evening of June 18, 2019, after more than 20 h of injury.

Arriving at our hospital with sedation status, tracheal intubation, ventilator?assisted ventilation, retention urinary tube, gastric tube, bilateral closed thoracic drainage tubes,hypothermia, heart rate 98 beats/min, and blood pressure 114/82 mm Hg maintained by norepinephrine, the patient was diagnosed as hemorrhagic shock, pelvic comminuted fracture,multiple organ failure, liver rupture, right hemothorax, lung contusion, and multiple rib fractures.After admission, the patient had surgeries of transcatheter arterial embolization,laparotomy, and liver repair.Forty?two hours later, when the patient’s condition was relatively stable, orthopedists did the surgery of pelvic ring multiple fracture reduction, channel screw internal fixation with robotic assisted.

The patient’s bilateral closed thoracic drainage tubes and ventilator were removed on June 23, 2019, with intermittent delirium, which was considered posttraumatic stress disorder (PTSD).The gastric tube was removed and an oral liquid diet was offered on June 26, 2019.After removing the urinary tube on July 5, 2019, the patient had dysuria and was given intermittent urinary catheterization until he completely recovered the spontaneous urination for 6 days.With comprehensive treatments and care, the patient could walk out of bed with a walker 6 weeks after admission.

REHABILITATION NURSING

Body posture nursing

The patient’s multiple pelvic ring fractures were instable type B, when moving or even turning over can result in stabbing of soft tissue at the fracture end, causing massive hemorrhage.Therefore, the pelvic bag was utilized to fix pelvis and turnover was not allowed before fracture surgery.An air cushion bed was used for circulating aerated dispersion pressure to prevent pressure sores.Before the pelvic operation, the patient adopted supine position with 15° abduction of both hips.Cushions were put under the knees and Achilles tendons to prevent muscle fatigue caused by overextension of the knee joints and avoid pressure ulcers on the heels and lateral ankles.[4]Seventy degrees semi?recumbent position was adopted to facilitate plasma drainage after the pelvic surgery, which also lowers the diaphragm and facilitates breathing.[5]

Orthopedic rehabilitation nursing

Initially, when the patient was delirious and could not cooperate with initiative exercise, passive movements were utilized to promote the blood circulation of limbs, avoid deep vein thrombosis, and prevent muscle atrophy and joint contracture.When the patient regained consciousness,instructed him to do exercises as follows.(1) Isometric exercise: the patient was taught to contract the muscles of limbs for the count of 10, then relax it, repeated this exercise 10 times every 3–4 h.[6](2) Ankle pump exercise: it comprises extending and flexing the ankle joint in supine position, 10 times every hour.It not only enhances the muscle strength but also improves the blood circulation of low limbs.[7](3) Straight leg raise exercise: it is an ideal exercise to get quadriceps strength back after surgery and often used to assess if the patient is ready to walk.When the patient’s major muscle force of legs recovered above Grade 3, he was instructed to lift his straight leg as high as he comfortably could (not ＞12 inches), hold for a 5–10 s, slowly lower the leg, then alternate the other leg.10–15 repetitions of each exercise, 4 times a day.[7,8]

Six weeks after surgery, the patient was able to get out of bed and walk slowly with a walker.Before that, he had been bedridden for a prolonged period; therefore, in order to prevent orthostatic hypotension, measures were taken as follows: before bed activity, first assisted the patient to sit up slowly, without dizziness and other discomforts, sat on the edge of the bed with legs down for half an hour, then stood with a walker for a few minutes before walking.After using the walker for 1 week, the patient switched to walking with a single crutch, and we taught him to go up and down stairs with crutch.The principles of physical activity were progression and not to cause pain and fatigue.

Pulmonary function rehabilitation nursing

In the early stage, the patient’s airway patency was mainly maintained by sputum sucking since he had a disturbance of consciousness and could not expectorate initiatively.Measures such as machine vibration and percussion on back were inapplicable for him due to the multiple rib fractures.

After weaning on June 23, 2019, nasal cannula oxygen therapy was offered, and the oxygen saturation remained around 96%.The patient was instructed to do diaphragmatic breathing exercise 3 times a day, 10–15 min each time.The specific methods are as follows: taking a supine or semi?recumbent position, put the hands on the navel, inhale through the nasal cavity, the rib cage lifts up, and the abdomen bulges slowly.At this time, the hands will feel upward.When exhaling, the abdominal muscles will contract and the hands will feel lowered.Diaphragmatic breathing can improve cardiopulmonary function through increasing intrathoracic lung volume, improving gas distribution at higher lung volumes, and decreasing the energy costs of ventilation.During the exhalation maneuver, the pursed?lip breathing technique also included, which is a breathing technique that consists of inhaling through the nose with the mouth closed and exhaling through tightly pursed lips slowly for 4–6 s.Pursed?lip breathing increases positive pressure generated within the airways and to buttress the small bronchioles,thereby preventing premature airway collapse.This technique can promote effective expiration and result in a reduced functional residual capacity.[9?11]

In order to reduce the chance of lung infections, huff coughing which is a technique helping move mucus from the lungs was taught to the patient: take in a deep breath and close the vocal cords in the glottis to shut off air flow from the lungs.Then, strain the chest and abdominal muscles so that a high expiration pressure in the lungs is built up, hold the breath for 3 s, and follow with 2–3 coughs.[12]

Bladder rehabilitation nursing

Urinary retention happened to the patient after removing the indwelling urinary catheter.We chose a more ideal approach of intermittent urinary catheterization to manage urinary retention, which mimics normal bladder function, allowing the bladder to fill and periodically to empty completely,thus minimizing the risk of infection and promoting bladder function recovery.[13]There are two ways of sterile and clean intermittent catheterization.Considering that the patient was in a critical condition, hemorrhagic shock and polytrauma had caused hypoimmunity.In order to prevent urinary system infection, sterile intermittent catheterization was adopted to manage the patient’s urinary retention.

The goal of an intermittent catheterization program is to empty the bladder at regular, consistent intervals, and maintain catheterization volumes at safe levels.[14]Drinking management and an appropriate catheterization schedule are necessary to maintain safe volumes.Fluid should be intake in a regular manner to avoid overfilling of the bladder and the daily fluid consumption should be controlled at 1500–2000 mL.The patient started on a catheterization schedule of every 4 h(6:00 am, 10:00 am, 2:00 pm, 6:00 pm, and 10:00 pm), and then the catheterization frequency was adjusted based on the pattern of urinary output.When the residual urine volume was ＜300 mL, the frequency was changed to every 6 h, and when the residual urine volume ＜200 mL, catheterization was performed every 8 h, and when the residual urine volume was ＜100 mL, the catheterization was stopped.[15?17]

Nutritional support

Nutritional support is an essential component of care for critically trauma patients.Twenty?four to forty?eight hours after trauma, a predictable hypermetabolic response occurs.The metabolic response to injury mobilizes amino acids and accelerates protein synthesis to support wound healing and the immunologic response to invading organisms.Stress hypermetabolism occurs after any major injury and is characterized by increases in metabolic rate and oxygen consumption.Energy requirements accelerate to promote immune function and tissue repair.The goal of nutritional care is to maintain host defenses and preserve lean body mass by supporting this hypermetabolism.[18,19]

The two routes of nutritional support are enteral nutrition(EN) and parenteral nutrition (PN).EN is the preferred route,while PN is adopted only when patients are unable to digest or absorb sufficient nutrition via the gastrointestinal tract.[20]Initially, the patient was under sedation and incapable of volitional intake, and the EN was administered via a feeding tube.The nutritional care plan was made by the nutrition support team which consists of dietitians, physicians, and nurses.Pump?assisted continuous feeding was adopted for the intake of EN liquid.Gastric residual volume (GRV) was measured every 4 h and the feeding rate was determined according to the GRV.The feeding tube was removed when the patient resumed oral nutrition and the nutrition care plan was adjusted based on the patient’s nutritional assessment.

Psychological rehabilitation nursing

Earthquakes are considered to be one of the most life?threating, devastating, and uncontrollable of the many different types of natural disaster.Earthquake survivors may face tremendous mental anguish due to bodily injury, fear,or property damage, which may cause psychological injury,including PTSD, anxiety disorders, panic, phobias, depression,and sleep disturbances.[21,22]

Initially, the patient experienced delirium, which was regarded as PTSD after the consultation from psychologists.PTSD is the most commonly present and most frequent psychopathology in the aftermath of natural disasters.[21]When the disaster survivors’ sense of safety and trust are shattered, they will feel unbalanced, disconnected or numb,and stuck with a constant sense of danger and painful memories.Trauma damages people’s ability to trust others and themselves, making them feel powerless and vulnerable.Overcoming the sense of helplessness and rebuild the sense of security are the key to overcoming PTSD.[23]The patient was encouraged to recall and process the emotions he felt during the earthquake in order to explore his thoughts and feelings about the trauma, conquer feelings of guilt and mistrust.When he wanted to talk, we volunteered our time to listen without judging, criticizing, or continually getting distracted.

The common symptoms of PTSD include emotional numbness,anger, and withdrawal; as a result, it can take a heavy toll on the family.The patient’s family members were informed of PTSD?related symptoms and treatment options, so that they could be better equipped to support the patient and keep things in perspective.Getting better from PTSD takes time,the family need to be patient with the pace of recovery and offer a sympathetic ear.Perceiving strong social support has been proved to be one major coping skill mechanism that can be utilized to minimize mental health symptoms.[24,25]

CONCLUSION

The polytrauma caused by the earthquake severely affects the patient’s physical and mental health, which may lead to permanent disability.Numerous complications of polytrauma are life?threating and can bring irreparable harms to patients and their families.The problem confronted by such patients is how to avoid physical and psychological disabilities.Therefore, it is vital to help patients recover from the trauma as soon as possible and improve their confidence in life and self?care ability.Early comprehensive rehabilitation nursing interventions can help patients to attain maximum physical and psychosocial functions and better reintegrate into society.

Declaration of patient consent

The authors certify that they have obtained appropriate patient consent.In the form, the patient has given his consent for his images and other clinical information to be reported in the journal.The patient understands that his name and initial will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.