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Nursing Assessment and Interventions for Cranial and Thoracic Injuries, Cheat Sheet of Nursing

Johns Hopkins University (JHU)Nursing

A comprehensive overview of nursing assessment and interventions for patients with cranial and thoracic injuries. It covers various aspects of patient assessment, including vital signs, neurological status, and physical examination. The document also outlines key interventions for managing these injuries, including pain management, airway management, and monitoring for complications. It is a valuable resource for nursing students and professionals seeking to enhance their knowledge and skills in caring for patients with these types of injuries.

Typology: Cheat Sheet

2024/2025

Available from 02/22/2025

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TNCC Notes for Written Exam 100+ Verified Questions and
Correct Answers 2025
What is kinematics? - correct answer>>A branch of mechanics (energy transfer) that
refers to motion and does not consider the concepts of force and mass of the object or
body.
What is Newton's First Law? - correct answer>>A body at rest will remain at rest. A body
in motion will remain in motion until acted on by an outside force.
What is the Law of Conservation of Energy? - correct answer>>Energy can neither be
created nor destroyed. It is only changed from one form to another.
What is Newton's Second Law? - correct answer>>Force equals mass multiplied by
acceleration of deceleration.
What is kinetic energy (KE)? - correct answer>>KE equals 1/2 the mass (M) multiplied by
the velocity squared.
What is the Mnemonic for the Initial Assessment? - correct answer>>A = Airway with
simultaneous cervical spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the patient warm)
What is the Mnemonic for the Secondary Assessment? - correct answer>>F = Full set of
VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric
tube)/Family presence
G = Give comfort measures (verbal reassurance, touch, and pharmacologic and
nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfaces
Where do you listen to auscultate breath sounds? - correct answer>>Auscultate the
lungs bilaterally at the second intercostal space midclavicular line and at the fifth
intercostal space at the anterior axillary line.
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Download Nursing Assessment and Interventions for Cranial and Thoracic Injuries and more Cheat Sheet Nursing in PDF only on Docsity!

TNCC Notes for Written Exam 100+ Verified Questions and

Correct Answers 2025

What is kinematics? - correct answer>>A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - correct answer>>A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - correct answer>>Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - correct answer>>Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - correct answer>>KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - correct answer>>A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - correct answer>>F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - correct answer>>Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line.

What are the late signs of breathing compromise? - correct answer>>- Tracheal deviation

  • JVD What are signs of ineffective breathing? - correct answer>>- AMS
  • Cyanosis, especially around the mouth
  • Asymmetric expansion of chest wall
  • Paradoxical movement of the chest wall during inspiration and expiration
  • Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
  • Sucking chest wounds
  • Absent or diminished breath sounds
  • Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated - Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - correct answer>>A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - correct answer>>- Insert 2 large caliber IV's
  • Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - correct answer>>- Tachycardia - AMS
  • Uncontrolled external bleeding
  • Pale, cool, moist skin
  • Distended or abnormally flattened external jugular veins
  • Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - correct answer>>- Control any uncontrolled external bleeding by:
  • Applying direct pressure over bleeding site
  • Elevating bleeding extremity
  • Applying pressure over arterial pressure points - Using tourniquet (last resort).
  • Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
  • Use warmed solution
  • Use pressure bags to increase speed of IVF infusion

What is the second thing assessed under the Secondary Assessment? - correct answer>>GIVE COMFORT MEASURES

  • Talking to pt
  • Pharmacologic/Nonpharmacologic pain management
  • Observe for physical signs of pain What is assessed under the Mnemonic "H"? - correct answer>>HISTORY / HEAD-TO-TOE ASSESSMENT
  • MIVT
  • M = Mechanism of injury
  • I = Injuries sustained
  • V = Vital Signs
  • T = Treatment
  • Pt generated information
  • PMH
  • Head-to-toe assessment What is assessed under the Mnemonic "I"? - correct answer>>INSPECT POSTERIOR SURFACES
  • While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
  • Palpate vertebral column for deformity and areas of tenderness
  • Assess rectum for presence/absence of tone, presence of blood What she be done after the Secondary Assessment? - correct answer>>Reassess:
  • Primary survey,
  • VS
  • Pain
  • Any injuries What are factors that contribute to ineffective ventilation? - correct answer>>- AMS - LOC
  • Neurologic injury
  • Spinal Cord Injury
  • Intracranial Injury
  • Blunt trauma
  • Pain caused by rib fractures
  • Penetrating Trauma
  • Preexisting hx of respiratory diseases
  • Increased age What medications are used during intubation? - correct answer>>LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - correct answer>>PREPARATION: - gather equipment, staffing, etc. PREOXYGENATION:
  • Use 100% O2 (prevent risk of aspiration). PRETREATMENT:
  • Decrease S/E's of intubation PARALYSIS WITH INDUCTION:
  • Pt has LOC, then administer neuromuscular blocking agent PROTECTION AND POSITIONING:
  • Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration PLACEMENT WITH PROOF
  • Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between attempts.
  • After intubation, inflate the cuff
  • Confirm tube placement w/exhaled CO2 detector. POSTINTUBATION MANAGEMENT:
  • Secure ET tube
  • Set ventilator settings
  • Obtain Chest x-ray
  • Continue to medicate
  • Recheck VS and pulse oxtimetry What is a Combitube? - correct answer>>A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult.

esophageal perforation

  • aspiration
  • thyroid perforation
  • subcutaneous emphysema What is Surgical Cricothyrotomy? - correct answer>>Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include:
  • Aspiration
  • Hemorrhage or hematoma formation or both
  • Lac to trachea or esophagus
  • Creation of a false passage
  • Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? - correct answer>>- Visualization of the chords
  • Using bronchoscope to confirm placement
  • Listening to breath sounds over the epigastrum and chest walls while ventilating the pt
  • CO2 detector
  • Esophageal detection device
  • Chest x-ray How do you inspect the chest for adequate ventilation? - correct answer>>Observe:
  • mental status
  • RR and pattern
  • chest wall symmetry
  • any injuries
  • patient's skin color (cyanosis?)
  • JVD or tracheal deviation? (Tension pneumothorax) What are you looking for when auscultating lung sounds? - correct answer>>Absence of BS:
  • Pneumothorax
  • Hemothorax
  • Airway Obstruction Diminished BS: Splinting or shallow BS may be a result of pain What are you looking for when percussing the chest? - correct answer>>Dullness:
  • hemothorax Hyperresonance
  • Pneumothorax What are you looking for when palpating the chest wall, clavicles and neck? - correct answer>>- Tenderness
  • Swelling
  • subcutaneous emphysema
  • step-off deformities = These may indicate: esophageal, pleural, tracheal or bronchial injuries. Palpate trachea above suprasternal notch. Tracheal deviation may indicate a tension pneumothorax or massive hemothorax. What is the DOPE mnemonic? - correct answer>>D - Displaced tube O - Obstruction: Check secretions or pt biting tube P - Pneumothorax: Condition may occur from original trauma or barotrauma from ventilator E - Equipment failure: pt may have become detached from equipment or there's a kink in the tubing Explain Hypovolemic Shock. - correct answer>>Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes:
  • Blood loss - Burns, etc.

What is vascular response? - correct answer>>As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - correct answer>>Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II.

Angiotensin II causes:

  • Vasoconstriction of arterioles and some veins
  • Stimulation of sympathetic nervous system
  • Retention of water by kidneys
  • Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - correct answer>>When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. - correct answer>>Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose. In a compensatory response to shock, hepatic vessels constrict to redirect blood flow to other vital areas. Explain Pulmonary Response. - correct answer>>Tachypnea happens for 2 reasons:
  1. Maintain acid-base balance

Foley

  • Monitor and pulse oximeter
  • Monitor for development of coagulopathies - Surgery? ICP is a reflection of what three volumes? What happens when one increases? - correct answer>>1. Brain
  1. CSF
  2. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - correct answer>>- Headache
  • N/V
  • Amnesia regarding events around the injury
  • Altered LOC
  • Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - correct answer>>- Dilated, nonreactive pupil
  • Unresponsiveness to verbal or painful stimuli
  • Abnormal motor posturing patterns
  • Widening pulse pressure
  • Increased systolic blood pressure
  • Changes in RR and pattern
  • Bradycardia

What is Cushing's phenomenon or Cushing's Reflex? - correct answer>>Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? - correct answer>>1. Uncal herniation

  1. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - correct answer>>Because of uncontrolled increases in ICP. S/E's
    • Unilateral or bilateral pupillary dilation
    • AsyDimmetric pupillary reactivity
    • Abnormal motor posturing
    • Other evidence of neurologic deterioration Define uncal herniation. - correct answer>>The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - correct answer>>A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - correct answer>>Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - correct answer>>GCS 13- 15 Define Moderate Head Trauma - correct answer>>Postresuscitative state with GCS 9-13.
  • severe DAI, coma = weeks/months or persistent vegetative state
  • Elevated ICP
  • Abnormal posturing
  • HTN
  • Hyperthermia
  • Excessive sweating because of autonomic dysfunction
  • Mild to severe memory impairment, cognitive, behavioral, and intellectual deficits What is a cerebral contusion and its S/S? - correct answer>>A common focal brain injury in which brain tissue is bruised and damaged in a local area. Mainly located in frontal

and temporal lobes. May cause hemorrhage, infarction, necrosis and edema. Max effects of bleeding & edema peak 18-36 post injury. S/S:

  • Alteration in LOC
  • Behavior, motor or speech deficits
  • Abnormal motor posturing
  • Signs of increased ICP What is an epidural hematoma and its S/S? - correct answer>>Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly:
  • Compression of underlying brain
  • rapid increase in ICP
  • Decreased CBF
  • Secondary brain injury
  • Usually requires surgical intervention S/S:
  • Transient LOC
  • Lucid period lasting a few minutes to several hours
  • Rapid deterioration in neurologic status
  • Severe H/A
  • Sleepiness
  • Dizziness
  • N/V
  • Hemiparesis or hemiplegia on opposite side of hematoma
  • Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - correct answer>>A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S:
  • Altered LOC or steady decline in LOC
  • S/S of increased ICP
  • Hemiparesis or hemiplegia on opposite side of hematoma
  • Unilateral fixed and dilated pupil on same side of hematoma
  • Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP
    • herniation syndrome
  • Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates
  • Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome Widely dilated pupil occasionally occurs w/direct trauma to globe of eye Determine if pt uses eye meds - Abnormal posturing?
  • Inspect craniofacial area for ecchymosis/contusions
  • Periorbital ecchymosis
  • Mastoid's process ecchymosis
  • Blood behind tympanic membrane
  • Inspect nose and ears for drainage
  • Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF
  • If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF - Assess extraocular eye movement (Tests cranial nerves, III, IV, VI)
  • Performing extraocular eye movements indicates functioning brainstem
  • Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle - Determine LOC with GCS PALPATION
  • Palpate cranial area for:
  • Point tenderness
  • Depressions or deformities
  • Hematomas
  • Assess all 4 extremities for:
  • Motor function, muscle strength and abnormal motor posturing
  • Sensory function DIAGNOSTIC PROCEDURES
  • Lab Studies PLANNING AND IMPLEMENTATION
  • (Initial assessment)
  • Clear airway (stimulation of gag reflex can produce transient increase in ICP or vomiting with subsequent aspiration.
  • Administer O2 via NRB
  • Assist with early ET intubation
  • Administer sedative/neuromuscular blocking agent
  • Consider hyperventilation
  • PaCO2 above 45 What are signs of a serious eye injury? - correct answer>>- Visual disturbances Pain Redness and ecchymosis of the eye