TNCC Notes for Written Exam: Definitions and Explanations, Exams of Nursing

Download TNCC Notes for Written Exam: Definitions and Explanations and more Exams Nursing in PDF only on Docsity! TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED Define central or transtentorial herniation. - ansA downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Define Hemothorax. - ansAccumulation of blood in the pleural space. Define Minor Head Trauma. - ansGCS 13-15 Define Moderate Head Trauma - ansPostresuscitative state with GCS 9-13. Define Pneumothorax. - ansResults when an injury to lung leads to accumulation of air in pleural space w/subsequent loss of negative intrapleural pressure. Partial or total collapse of lung may ensue. An open pneumothorax results from wound through chest wall. Air enters pleural space both through the wound and trachea. Define Severe Head Trauma. - ansPostresuscitative state with GCS score of 8 or less. Define tension pneumothorax. - ansLife-threatening injury. Air enters pleural space on inspiration, but air cannot escape on expiration. Rising intrathoracic pressure collapses lung on side of injury causing a mediastinal shift that compresses the heart, great vessels, trachea and uninjured lung. Venous return impeded, cardiac output falls, hypotension results. Immediate decompression should be performed. Treatment should not be delayed. Define uncal herniation. - ansThe 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. Disruptions of the bony structures of the skull can result in what? - ansDisplaced 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 Explain adrenal gland response. - ansWhen adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED 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 Cardiogenic Shock. - ansSyndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: - MI - Blunt cardiac injury - Mitral valve insufficiency - dysrhythmias - Cardiac Failure Explain Distributive Shock. - ansResults from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. Explain Hepatic Response. - ansLiver 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. TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Unilateral fixed and dilated pupil may indicate oculomotor nerve compression as a result of ICP + herniation syndrome - Bilateral fixed and pinpoint pupils = pontine lesion or drugs - Mildly dilated pupil w/sluggish response may early sign of herniation syndrome - Widely dilated pupil occasionally occurs w/direct trauma to globe of eye - Assess for consensual response - Assess redness, eye watering, blepharospasm - Assess extraocular movement, except when an open globe injury is known or suspected. - Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle - Perform visual acuity exam - Use Snellen or handheld chart. Check uninjured eye first - Assess for blurred or double vision with injured eye and then with both eyes open - Inspect for rhinorrhea or otorrhea - If drng present, may indicate CSF leak - Observe for impaled objects - Assess occlusion of mandible and maxilla - Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx - Observe for uncontrolled bleeding PALPATION - Palpate periorbital area, face and neck for: - Tenderness - Edema - Step-off de How would you assess a pt with a cranial injury? - ans(Initial assessment) INSPECTION: - Assess airway - RR, pattern and effort - Assess pupil size and response to light - 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 TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Blood behind tympanic membrane TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - 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 How would you assess a pt with a thoracic injury? - ans(Initial assessment) Obtain Hx. PHYSICAL: Inspection: - Observe chest wall - Assess breathing effort and RR - Symmetry - Inspect jugular veins (Distended = increased intrathoracic pressure as result of tension pneumothorax or pericardial tamponade. Flat = external jugular veins may reflect hypovolemia) - Inspect upper abdominal region for injury Percussion: - Percuss the chest (Dullness = hemothorax, Hyperresonance = pneumothorax) TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Hypertension in UE's - Decreased quality (amplitude) of femoral pulses compared to UE pulses - Loud systolic murmur in parascapular region - Chest pain - Chest wall ecchymosis - Widened mediastinum on chest xray - Paraplegia What are factors that contribute to ineffective ventilation? - ans- 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 are intracerebral hematoma's and its S/S? - ansOccur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S: - Progressive and often rapid decline in LOC - H/A - Signs of increasing ICP - Pupil abnormalities - Contralateral hemiplegia What are neck injury S/S? - ans- Dyspnea - Hemoptysis (coughing up blood) - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - Penetrating wounds or impaled objects - Pulsatile or expanding hematoma - Loss of normal anatomic prominence of the laryngeal region - Bruits - Active external bleeding - Neurologic deficit, such as aphasia or hemiplegia - Cranial nerve deficits - Facial sensory or motor nerve deficits - Dysphonia (hoarseness) TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Dysphagia (difficulty swallowing) What are S/S of a rib fracture? - ans- Dyspnea - Localized pain on movement, palpation, or inspiration - Pt assumes position intended to splint chest wall to reduce pain - Chest wall ecchymosis or sternal contusion - Bony crepitus or deformity What are S/S of a ruptured diaphragm? - ans(Anything below the nipple line and should be evaluated for potential diaphragmatic injury). - Dyspnea or orthopnea - Dysphagia - Abdominal pain - Sharp epigastric or chest pain radiating to left shoulder (Kehr's sign) - Bowel sounds heard in lower middle chest - Decreased breath sounds on injured side What are s/s of chemical burns to the eye? - ansChemical injuries require immediate intervention if it is to be preserved. S/S: - Pain - Corneal Opacification - Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - ans- Marked visual impairments - Extrusion of intraocular contents - Flattened or shallow anterior chamber - Subconjunctival hemorrhage, hyphema - Decreased intraocular pressure - Restriction of extraocular movements What are S/S with blunt cardiac injury? - ans"Cardiac contusion" or "concussion." Common with MVC or falls from heights. - ECG (sinus tach, PVC's, AV blocks) - Chest pain - Chest wall ecchymosis What are S/S with tracheobronchial injury? - ansBlunt trauma. "Clothesline-type" injuries. - Dyspnea, tachypnea - Hoarseness - Hemoptysis TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Subcutaneous emphysema in neck, face, or suprasternal area - Decreased or absent breath sounds - S/S of airway obstruction What are signs of a serious eye injury? - ans- Visual disturbances - Pain - Redness and ecchymosis of the eye - Periorbital ecchymosis - Increased intraocular pressure What are signs of ineffective breathing? - ans- 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. What are signs of ineffective circulation? - ans- Tachycardia - AMS - Uncontrolled external bleeding - Pale, cool, moist skin - Distended or abnormally flattened external jugular veins - Distant heart sounds What are the early signs and symptoms of increased ICP? - ans- Headache - N/V - Amnesia regarding events around the injury - Altered LOC - Restlessness, drowsiness, changes in speech, or loss of judgement What are the interventions for Disability? - ans- If assessment indicates a decreased LOC, conduct further investigation during secondary focused assessments - If pt is not alert or verbal, continue to monitor for any compromise to ABC's - If pt demonstrates signs of herniation or neurologic deterioration, consider hyperventilation. What are the interventions for Effective/Ineffective Circulation? - ans- Control any uncontrolled external bleeding by: - Applying direct pressure over bleeding site - Elevating bleeding extremity TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - 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 are the S/S of a basilar skull fx? - ans- H/A - Altered LOC - Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic membrane (hemotympanum) - Facial nerve (VII) palsy - CSF rhinorrhea or otorrhea What are the S/S of a depressed skull fx? - ans- H/A - Possible decreased LOC - Possible open fx - Palpable depression of skull over the fx site What are the S/S of a linear skull fx? - ans- H/A - Possible decreased LOC What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea - Tachycardia - Hyerresonance (increased echo produced by percussion over the lung field) on the injured side - Decreased or absent breath sounds on the injured side - Chest pain - Open, sucking wound on inspiration (open pneumothorax) What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress - Markedly diminished or absent breath sounds on affected side - hypotension - Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood loss present TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Tracheal deviation - shift toward uninjured side (LATE sign) - Cyanosis (LATE sign) What are the S/S of flail chest? - ans- Dyspnea - Chest wall pain - Paradoxical chest wall movement - the flail segment moves in during inspiration and out during expiration. What are the S/S of Hemothorax? - ans- Dyspnea, tachypnea - Chest pain - Signs of shock - Decreased breath sounds on injured side - Dullness to percussion on the injured side What are the S/S of orbital fracture (orbital blowout fracture)? - ans- Diplopia (double vision) - Loss of vision - Altered extraocular eye movements - Enophthalmos (displacement of the eye backward into the socket) - Subconjunctival hemorrhage or ecchymosis of the eyelid - Infraorbital pain or loss of sensation - Orbital bony deformity What are the S/S of pericardial tamponade? - ansA collection of blood in pericardial sac. As blood accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling. - Hyotension - Tachycardia or PEA - Dyspnea - Cyanosis - Beck's Triad (hypotension, distended neck veins + muffled heart sounds) - Progressive decreased voltage of conduction complexes on ECG What are the S/S of pulmonary contusion? - ans- Dyspnea - Ineffective cough - Hemoptysis - Hypoxia - Chest pain - Chest wall contusion or abrasions What are the signs and symptoms of postconcussive syndrome? - ans- Persistent H/A - Dizziness - Nausea TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Memory impairment - Attention deficit - Irritability - Insomnia - Impaired judgement - Loss of libido - Anxiety - Depression What are the two types of herniation that occurs with ICP? - ans1. Uncal herniation 2. Central or transtentorial herniation What are you looking for when auscultating lung sounds? - ansAbsence of BS: - Pneumothorax - Hemothorax - Airway Obstruction Diminished BS: - Splinting or shallow BS may be a result of pain What are you looking for when palpating the chest wall, clavicles and neck? - ans- 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 are you looking for when percussing the chest? - ansDullness: - hemothorax Hyperresonan ce - Pneumothorax What could a flail chest be associated with? - ans- Ineffective ventilation - Pulmonary contusion - Lacerated lung parenchyma What happens to a ruptured diaphragm? - ansPotentially life-threatening, results from forces that penetrate the body. Left hemidiaphragm is more susceptible to injury because the right side is protected by the liver. - Herniation of abdominal contents - Respiratory compromise b/c impaired lung capacity + displacement of normal tissue. - Mediastinal structures may shift to opposite side of injury TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED What is assessed and intervened for Expose/Environmental Controls? - ans- Remove clothing - Ensure appropriate decontamination if exposed to hazardous material - Keep pt warm - Keep clothing for evidence What is assessed under the Mnemonic "H"? - ansHISTORY / 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"? - ansINSPECT 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 is Cushing's phenomenon or Cushing's Reflex? - ansTriad of progressive HTN, bradycardia and diminished respiratory effort. What is diffuse axonal injury and its signs and symptoms? - ans(DAI) is widespread, rather than localized, through the brain. Diffuse shearing, tearing and compressive stresses from rotational or accerleration/deceleration forces resulting in microscopic damage primarily to axons within the brain. S/S: - Immediate unconsciousness - mild DAI, coma = 6-24 hrs - 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 TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED What is hyphema and its S/S? - ansAccumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S: - Blood in anterior chamber - Deep, aching pain - Mild to severe diminished visual acuity - Increased intraocular pressure What is kinematics? - ansA 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 kinetic energy (KE)? - ansKE equals 1/2 the mass (M) multiplied by the velocity squared. What is LeFort I fracture and its S/S? - ansTransverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S: - Slight swelling of maxillary area - Possible lip lac's or fractured teeth - Independent movement of the maxilla from rest of face - Malocclusion What is LeFort II fracture and its S/S? - ansPyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S: - Massive facial edema - Nasal swelling w/obvious fx of nasal bones - Malocclusion - CSF rhinorrhea What is LeFort III fracture and its S/S? - ansComplete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S: - Massive facial edema - Mobility and depression of zygomatic bones - Ecchymosis - Anesthesia of the cheek TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST BANK|100% COMPLETE Pass VERIFIED - Diplopia - Open bite or malocclusion - CSF rhinorrhea What is Needle Cricothyrotomy - ansPercutaneous transtracheal ventilation. (temporary) Complications include: - inadequate ventilation causing hypoxia - hematoma formation - esophageal perforation - aspiration - thyroid perforation - subcutaneous emphysema What is Newton's First Law? - ansA body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is Newton's Second Law? - ansForce equals mass multiplied by acceleration of deceleration. What is renal response? - ansRenal 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. What is Surgical Cricothyrotomy? - ansMaking 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.