Presented by: Dave Jay S. Manriquez, BSN.RN.

Traumatic brain injury, often referred to as TBI, is most often an acute event similar to other injuries. In other aspects, TBI is very different, since our brain defines who we are, the consequences of a brain injury can affect all aspects of our lives, including our personality. Brain injuries do not heal like other injuries. Recovery is a functional recovery, based on mechanisms that remain uncertain. Symptoms may appear right away or may not be present days or weeks after the injuryThe most important consideration in any head injury is whether or not the brain is injured. Even seemingly minor injury can cause significant brain damage secondary to obstructed blood flow and decreased tissue perfusion. Because the cerebral cells need an uninterrupted blood supply, irreversible brain damage and cell death occur when blood supply is interrupted for even a few minutes.One of the consequences of brain injury is that the person often does not realize that a brain injury has occurred.

Brain Injury StatisticsAnnual number of people who experience a traumatic brain injury:

1. 4 million annually in the United States

Deaths: 50,000

Hospitalization: 235,000

Among children ages 0 to 14 years

Deaths: 26, 850

Hospitalizations: 37,000Number of Americans living with a traumatic brain injury: Approximately 5.3 million

Groups at risk: Males are about twice as likely as females to sustain a TBI. The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.

Adults age 75 years or older have the highest rates of TBI-related hospitalization and death.

Certain military duties (e.g., paratrooper) increase the risk of sustaining a TBI.

African Americans have the highest death rate from TBI.

The leading causes of TBI : Falls (28%); Motor vehicle-traffic crashes (20%)

Struck by/against events (19%) Assaults (11%).

Most people are unaware of the scope of TBI or its overwhelming nature. TBI is a common injury and may be missed initially when the medical team is focused on saving the individual's life.  TBI is classified into two categories: mild and severe.A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes. These injuries are commonly overlooked.  Even though this type of TBI is called "mild", the effect on the family and the injured person can be devastating.  Severe brain injury is associated with loss of consciousness for more than 30 minutes and memory loss after the injury or penetrating skull injury longer than 24 hours. The deficits range from impairment of higher level cognitive functions to comatose states. The effects of TBI can be profound. Individuals with severe injuries can be left in long-term unresponsive states. For many people with severe TBI, long-term rehabilitation is often necessary to maximize function and independence.  Even with mild TBI, change in brain function can have a dramatic impact on family, job, social and community interaction.

SYMPTOMS OF TRAUMATIC BRAIN INJURY

There are a few different systems that medical practitioners use to diagnose the symptoms of

Traumatic Brain Injury.  This section discusses the Glasgow Coma Scale.  The Glasgow Coma Scale is based on a 15 point scale for estimating and categorizing the outcomes of brain injury on the basis of overall social capability or dependence on others.

The test measures the motor response, verbal response and eye opening response with these values:I. Motor Response6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No responseII. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No soundsIII. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening

This number helps medical practitioners categorize the four possible levels for survival, with a lower number indicating a more severe injury and a poorer prognosis:

Mild (13-15): See notes on the signs and symptoms below.Moderate Disability (9-12):

Loss of consciousness greater than 30 minutes Physical or cognitive impairments which may or may resolve Benefit from Rehabilitation

Severe Disability (3-8): Coma: unconscious state.  No meaningful response, no voluntary activitiesVegetative State (Less Than 3):

Sleep wake cycles Aruosal, but no interaction with environment No localized response to pain

Persistent Vegetative State: Vegetative state lasting longer than one monthBrain Death: No brain function Specific criteria needed for making this diagnosis

There are a few different systems that medical practitioners use to diagnose the symptoms of Traumatic Brain Injury.  The Ranchos Los Amigos Scale measures the levels of awareness, cognition, behavior and interaction with the environment.

Ranchos Los Amigos Scale

Level I: No ResponseLevel II: Generalized ResponseLevel III: Localized ResponseLevel IV: Confused-agitatedLevel V: Confused-inappropriateLevel VI: Confused-appropriateLevel VII: Automatic-appropriateLevel VIII: Purposeful-appropriate

A traumatic brain injury (TBI) can be classified as mild if loss of consciousness and/or confusion and disorientation is shorter than 30 minutes.

Mild Traumatic Brain Injury is: Most prevalent TBI ; Often missed at time of initial injury 15% of people with mild TBI have symptoms that last one year or more. Defined as the result of the forceful motion of the head or impact causing a brief change

in mental status (confusion, disorientation or loss of memory) or loss of consciousness for less than 30 minutes.

Post injury symptoms are often referred to as post concussive syndrome.

Common Symptoms of Mild TBI Fatigue Headaches Visual disturbances Memory loss Poor attention/concentration Sleep disturbances Dizziness/loss of balance Irritability-emotional disturbances Feelings of depression Seizures

Other Symptoms Associated with Mild TBI Nausea Loss of smell Sensitivity to light and sounds Mood changes Getting lost or confused Slowness in thinking

The person looks normal and often moves normal in spite of not feeling or thinking normal.  This makes the diagnosis easy to miss.  Family and friends often notice changes in behavior before

the injured person realizes there is a problem.  Frustration at work or when performing household tasks may bring the person to seek medical care.

Brain injuries can range in scope from mild to severe.  Traumatic brain injuries (TBI) result in permanent neurobiological damage that can produce lifelong deficits to varying degrees.  Moderate to severe brain injuries typically refer to injuries that have the following characteristics:

Moderate brain injury is defined as a brain injury resulting in a loss of consciousness from 20 minutes to 6 hours and a Glasgow Coma Scale of 9 to 12

Severe brain injury is defined as a brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8

Cognitive deficits including difficulties with: Attention Concentration Distractibility Memory Speed of Processing Confusion Perseveration Impulsiveness Language Processing "Executive functions"

Speech and Language not understanding the spoken word (receptive aphasia) difficulty speaking and being understood (expressive aphasia) slurred speech speaking very fast or very slow problems reading problems writing

Sensory difficulties with interpretation of touch, temperature, movement, limb position and

fine discriminationVision

partial or total loss of vision weakness of eye muscles and double vision (diplopia) blurred vision problems judging distance involuntary eye movements (nystagmus) intolerance of light (photophobia)

Hearing decrease or loss of hearing ringing in the ears (tinnitus) increased sensitivity to sounds

Smell and Taste loss or diminished sense of smell (anosmia) and taste

Seizures the convulsions associated with epilepsy that can be several types and can involve

disruption in  consciousness, sensory perception, or motor movementsPhysical Changes

Physical paralysis/spasticity Chronic pain Control of bowel and bladder Sleep disorders Loss of stamina Appetite changes Regulation of body temperature Menstrual difficulties

Social-Emotional Dependent behaviors Emotional ability Lack of motivation Irritability Aggression Depression Disinhibition Denial/lack of awareness

Diagnostic Tests X-rays, CT scans and MRI's of brain are pictures of the inside of the head. The picture

will show if there is bleeding and/or swelling, skull fractures and where the damage has been done.

Often, Cervical Spine and other spinal films may be completed. When someone is involved in trauma, the neck and back may also be injured.

EEG: this test shows the presence of brain waves, their intensity and frequency. It is also used to determine if the patient is having seizures.

TREATMENTS FOR TBIInitial treatment: The nursing staff's responsibility is to assess, monitor and interpret vital physiologic or body functions, notify the physician of changes, repeat assessments at regular intervals and provide information for the family. The patient will be monitored for signs of infection and pain.

Rehabilitative Center Treatment :

The Rehabilitation Nurse assists patients with brain injury and chronic illness in attaining maximum optimal health, and adapting to an altered lifestyle.  The Rehabilitation Nurse provides care for the patient on the nursing unit.  The focus of nursing care is on:

Health maintenance Nutrition

Potential for aspiration

Impaired skin integrity

Bowel and bladder incontinence

Impaired physical mobility

Impaired or limited ability to take care of self

Ineffective airway

Sleep pattern disturbance

Chronic pain

Impaired cognition

Impaired verbal communication and comprehension

Sexual dysfunction

Acute Treatment:

Acute treatment of a Traumatic Brain Injury (TBI) is aimed at minimizing secondary injury and life support.

Mechanical ventilation supports breathing and helps keep the pressure down in the head.  A device may be placed surgically in the brain cavity to monitor and help control intracranial pressure.

Medications to sedate and put the individual in a drug-induced coma may be used to minimize agitation and secondary injury.  Seizure prevention medications may be given early in the course and later if the individual has seizures.  Behavioral issues also can be treated with medications.  Medications for attention problems and aggressive behavior are often tried.Medications may be used for:

Attention and concentration- amantadine and methylphenidate, bromocriptine and antidepressants.

Aggressive behavior- carbamamazapine and amitriptyline

Surgical Treatment:

In closed head injury, surgery does not correct the problem.  A bolt or ICP (intracranial pressure) monitoring device may be placed in the skull to monitor pressure in the brain cavity.   If there was bleeding in the skull cavity, this may be surgically removed or drained. Bleeding vessels or tissue may need to be repaired.  In severe cases, if there is extensive swelling and damaged brain tissue, a portion may be surgically removed to make room for the living brain tissue.

The overall goal of all surgical treatment is to prevent secondary injury by helping to maintain blood flow and oxygen to the brain and minimize swelling and pressure.

Supportive Care:TBI patients are monitored with equipment for breathing, heart rhythm, blood pressure, pulse and intracranial pressure.

MAINTAINING THE AIRWAY

Keep unconscious patient in a position that facilitates drainage of oral secretion Establish effective suctioning procedures Guard against aspiration and respiratory insufficiency Monitor for pulmonary complications

SEIZURE PRECAUTION

Dilantin is the usual medication administered through the IV to prevent seizures. A tetanus shot also may be given.

MAINTAIN HYDRATION AND ADEQUATE NUTRITION

Fluid is administered through the IV for nutrition and liquid. The need for nutritional support using parenteral (IV) or enteral solutions (a tube placed in the stomach) is determined by a registered dietician and the doctor.

A urinary catheter is put in the bladder for urine collection. The individual is not aware of the need to use the bathroom.  

It is important to maintain the unconscious patient's blood pressure through IV fluid and medication.

MAINTAINING SKIN INTEGRITY The patient is turned and positioned in bed to prevent bedsores because most unconscious

people cannot move independently. The unconscious person may have a compression device wrapped around the legs that

resembles a plastic tub mat. This device prevents blood clots.  Daily injections are also given to prevent blood clots.

TREATMENT OF INCREASED ICP

Controlling body temperature (keeping the temperature low to normal) Elevating the head of the bed

Using controlled narcotic sedation to cause paralysis, keeping the person still and comfortable

Ensuring proper breathing

Administering medication including Mannitol

Hypertensive therapies

MONITORING FOR POTENTIAL COMPLICATIONS

I. Decreased Cerebral PerfusionII. Cerebral Edema and Perfusion

III. Impaired Oxygenation and Ventilation

IV. Post-Traumatic Seizures

Recovery

These are the indicators the medical team uses for prognosis: Duration of Coma. The shorter the coma, the better the prognosis. Post-traumatic amnesia. The shorter the amnesia, the better the prognosis. Age.  Patients over 60 or under age 2 have the worst prognosis, even if they suffer the

same injury as someone not in those age groups.

Suggested Videos:http://www.youtube.com/watch?v=FgtHvBF4t-Ehttp://www.brainandspinalcord.org/media-center/AlyssasStory-final2.html

In 1995, actor Christopher Reeve fell off a horse and severely damaged his spinal cord, leaving him paralyzed from the neck down. From then until his death in 2004, the silver screen Superman became the most famous face of spinal cord injury.

Spinal cord injuries cause myelopathy or damage to white matter or myelinated fiber tracts that carry signals to and from the brain. It also damages gray matter in the central part of the spine, causing segmental losses of interneurons and motorneurons.

Stages:

A. Stage of spinal shock sensation and motor power localized below the vertical height of the lesion are lost. This

stage lasts for 2 to 3 weeks in humans, and hours to days in other animals due to a lesser degree of encephalitis.B. Stage of recovery

after a period typically ranging from 2 to 3 weeks of injury, the nerves partially recover, and the return of segmental reflexes produce paraplegia-in-flexion.C. Stage of reflex failure

after a period of days the recovered reflexes again start to give way due to complete degeneration of nerve cells.

Spinal cord injury symptoms depend on two factors:

1) The location of the injury. In general, injuries that are higher in your spinal cord produce more paralysis. For example, a spinal cord injury at the neck level may cause paralysis in both arms and legs and make it impossible to breathe without a respirator, while a lower injury may affect only your legs and lower parts of your body.

a) Cervical injuriesCervical (neck) injuries usually result in full or partial tetraplegia (quadriplegia). Depending on the exact location of the injury, one with a spinal cord injury at the cervical level may retain some amount of function as detailed below, but are otherwise completely paralyzed.

C3 vertebrae and above : Typically lose diaphragm function and require a ventilator to breathe. C4 : May have some use of biceps and shoulders, but weaker C5 : May retain the use of shoulders and biceps, but not of the wrists or hands. C6 : Generally retain some wrist control, but no hand function. C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the

hand and fingers. C7 is generally the level for functional independence.

b) Thoracic injuriesInjuries at the thoracic level and below result in paraplegia. The hands, arms, head, and breathing are usually not affected.

T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.

T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good.

c) Lumbar and Sacral injuriesThe effects of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus.

2) The severity of the injury. Spinal cord injuries are classified as partial or complete, depending on how much of the cord width is damaged.

a) In a partial spinal cord injury, which may also be called an incomplete injury, the spinal cord is able to convey some messages to or from your brain. So people with partial spinal cord injury retain some sensation and possibly some motor function below the affected area.

b) A complete spinal cord injury is defined by total or near-total loss of motor function and sensation below the area of injury. However, even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord. It's a key distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not.

SYMPTOMS: Pain or an intense stinging sensation caused by damage to the nerve fibers in your spinal

cord Loss of movement Loss of sensation, including the ability to feel heat, cold and touch Loss of bowel or bladder control

Exaggerated reflex activities or spasms Changes in sexual function, sexual sensitivity and fertility Difficulty breathing, coughing or clearing secretions from your lungs

Emergency signs and symptoms Fading in and out of consciousness Extreme back pain or pressure in your neck, head or back Weakness, incoordination or paralysis in any part of your body Numbness, tingling or loss of sensation in your hands, fingers, feet or toes Loss of bladder or bowel control Difficulty with balance and walking Impaired breathing after injury An oddly positioned or twisted neck or back

Injury may be traumatic or nontraumatic

A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or compresses one or more of your vertebrae. It may also result from a gunshot or knife wound that penetrates and cuts your spinal cord. Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around your spinal cord.

Nontraumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine.

Common causes of spinal cord injury:

Motor vehicle accidents. Auto and motorcycle accidents are the leading cause of spinal cord injuries, accounting for almost 50 percent of new spinal cord injuries each year.

Acts of violence. About 15 percent of spinal cord injuries result from violent encounters, often involving gunshot and knife wounds.

Falls. Spinal cord injury after age 65 is most often caused by a fall. Overall, falls make up approximately 22 percent of spinal cord injuries.

Sports and recreation injuries. Athletic activities such as impact sports and diving in shallow water cause about 8 percent of spinal cord injuries.

Diseases. Cancer, infections, arthritis and inflammation of the spinal cord also cause spinal cord injuries each year.

Risk factorsAlthough a spinal cord injury is usually the result of an unexpected accident that can happen to anyone, some groups of people have a higher risk of sustaining a spinal cord injury. These include:

Men. Spinal cord injury affects a disproportionate amount of men. In fact, women account for only about 20 percent of spinal cord injuries in the United States.

Young adults and seniors. People are most often injured between ages 16 and 30. But there is another peak in people older than 60. Motor vehicle crashes are the leading cause of spinal cord injury for young people, while falls cause most injuries in older adults.

However, in some cities, acts of violence — such as gunshot wounds, stabbings and assaults — are a major cause of spinal cord injury.

People who are active in sports. Sports and recreational activities cause 8 percent of the 11,000 spinal cord injuries in the United States each year, although sports-related spinal cord injury is becoming less common. High-risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing.

People with predisposing conditions. A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis.

TESTS & DIAGNOSIS X-rays. Medical personnel typically order these tests on all trauma victims suspected of

having a spinal cord injury. X-rays can reveal vertebral problems, tumors, fractures or degenerative changes in your spine.

Computerized tomography (CT) scan. A CT scan may provide a better look at abnormalities seen on an X-ray.

Magnetic resonance imaging (MRI). This test is extremely helpful for looking at the spinal cord and identifying herniated disks, blood clots or other masses that may be compressing the spinal cord.

Myelography. Myelography allows your doctor to visualize your spinal nerves more clearly. This test is used when MRI isn't possible or when it may yield important additional information that isn't provided by other tests.

Diagnosis: Ineffective breathing patterns related to weakness or paralysis of abdominal and

intercostals muscles and inability to clear secretions Ineffective airway clearance related to weakness of intercostals muscles Impaired physical mobility related to motor and sensory impairment Disturbed sensory perception related to motor and sensory impairment Risk for impaired skin integrity related to immobility and sensory loss

Treatment:Early stages of treatment

Medications. Methylprednisolone (Medrol) is a treatment option for acute spinal cord injury. This corticosteroid seems to cause some recovery in people with a spinal cord injury if given within eight hours of injury. Methylprednisolone works by reducing damage to nerve cells and decreasing inflammation near the site of injury.

Immobilization. You may need traction to stabilize your spine and bring the spine into proper alignment during healing. Sometimes, traction is accomplished by placing metal braces, attached to weights or a body harness, into your skull to hold it in place. In some cases, a rigid neck collar also may work.

Surgery. Often, emergency surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity. Controversy exists regarding the best time to perform surgery. Some surgeons believe it

should be performed as soon as possible in most circumstances, while others believe it's safer to wait for several days before attempting any surgery. Research has not clearly proved which approach is better.

Ongoing care:

PROMOTING ADEQUATE BREATHING AND AIRWAY CLEARANCE Suctioning may be indicated, but caution in doing this because suctioning can stimulate

the vagus nerve, producing bradycardia, which can result in cardiac arrest Chest physical therapy and assisted coughing may be indicated when patient cannot

cough effectively Breathing exercises are supervised by the nurse to increase the strength and endurance of

the inspiratory muscles, particularly the diaphragm Ensure proper humidification and hydration to prevent secretions from becoming thick

and difficult to remove even with coughingIMPROVING MOBILITY

Proper alignment is maintained at all times Reposition frequently and is assisted out of bed as soon as the spinal column is stabilized Use various types of splints to prevent footdrop. Trochanter rolls help prevent external

rotation of the hip joints Range of motion exercises help preserve joint motion and stimulate circulation

MAINTAINING SKIN INTEGRITY Position is changed every 2 hours assists in the prevention of pressure ulcers and pooling

of blood and tissue fluid on dependent areas that could lead to blood clots Skin should be kept clean by washing with a mild soap, rinsed well and blotted dry Pressure-sensitive areas should be kept well lubricated and soft with lotion Patient should be well informed about the danger of pressure ulcers to encourage

understanding of the reason for preventive measuresIMPROVING URINARY AND BOWEL ELIMINATION

Intermittent catheterization is carried out to avoid overdistention of bladder and UTI Record fluid intake, voiding pattern, amounts of residual urine after catherterization,

characteristics of urine and any unusual sensations that may occur As soon as bowel sounds are heard upon auscultation, the patient is given a high-calorie,

high-protein, high-fiber diet with the amount of food gradually increased Administer prescribed stool softeners to counteract the effects of immobility and pain

medicationsPROVIDING COMFORT MEASURES

If pins, tongs and calipers are in place, the skull is assessed for infection, including drainage. Hair around the tongs is usually shaved to facilitate inspection

The back of the head is checked periodically for signs of pressure, with care taken not to move the neck

Patient in Halo Traction: areas around the pin sites are cleansed daily and observed for redness, drainage and pain, notify neurosurgeon if one of the pins becomes detached while another person stabilized the head in a neutral position, skin under the halo vest is inspected for excessive perspiration, redness and skin blistering, powder is not used under

the vest because it may contribute to pressure ulcers, the liner should be changed periodically to promote hygiene and good skin care

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Thrombophlebitis Immobilizarion and the associated venous stasis, as well as varying degrees of

autonomic disruption, contribute to the high risk and susceptibility for DVT Measures such as ROM exercises, thigh-high elastic compression stockings, adequate

hydration and anticoagulation medications (heparin and warfarin ) as prescribed are given

Orthostatic Hypotension Activity should be planned in advance and adequate time given for a slow progression

of position changes from recumbent to sitting and upright. Tilt tables frequently are helpful in assisting patients to make tgis transaction

Autonomic Dysreflexia Stimuli that may trigger this: distended bladder ( most common ); distention or

contraction of visceral organs, especially the bowel; or stimulation to the skinPROMOTING HOME CARE

The ultimate goal of the rehabilitation process is independence. The nurse becomes a support to both the patient and the family, assisting them to assume responsibility for increasing aspects of patient care and management.

Survivors of SCI face the changes associated with aging with a disability. Thus, teaching in the home and community focuses on health promotion and addresses the need to minimize risk factors.

NURSING BEDS

1. Clinitron Bed - The Clinitron Air Fluidized Bed combines air fluidized therapy and low air loss therapy on an articulating frame providing patients with relief from bed pressure sores, designed to prevent pressure ulcers and promote wound healing. The Clinitron II aides patients with advanced stage or multiple pressure ulcers, flaps, grafts, burns and other skin disorders.

2. Rotarest Bed – Indicated for the treatment and prevention of pulmonary complications as a result of immobility, thoracic or lumbar fracture. It is not to be used as a primary means of stabilizing cervical spine fractures, A halo and vest or internal fixation is required.

3. Stryker Frame - A frame that holds the patient and permits turning in various planes without

individual motion of parts, allowing staff to turn a patient easily. The patient is held firmly between the pieces of material as if part of a sandwich. The device may be rotated around the patient’s long axis. This permits turning the patient without his or her assistance.

4. Circle Electric Bed – an electrically powered apparatus, which can be used as a turning frame for vertical rotation

Tilt Bed5. Tilt Bed – Easy to maneuver, it offers adjustable positions including seated, reclining and

sleeping, plus all positions inbetween. The Tilt chair/bed also offers pressure relief, adjustable seat with infinite locking, adjustable leg rests, adjustable back and lockable castor wheels.

Resources:http://www.traumaticbraininjury.com/content/understandingtbi/effectsoftbi.html

http://www.brainandspinalcord.org/brain-injury/statistics.htmlhttp://www.cdc.gov/ncipc/factsheets/tbi.htmhttp://www.brainandspinalcord.org/brain-injury/statistics.htmlhttp://www.mayoclinic.com/health/spinal-cord-injury/DS00460http://en.wikipedia.org/wiki/Spinal_cord_injurySmeltzer,Suzzane. Medical-Surgical Nursing.1oth edition