TNCC study guide 100% VERIFIED ANSWERS 2024/2025 CORRECT, Exams of Nursing

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TNCC study guide 100% VERIFIED ANSWERS 2024/2025 CORRECT MIST (Prehospital report) Mechanism of injury (MOI) Injuries sustained Signs and symptoms in the field Treatment in the field Across-the-room Observation First look at the pt If pt has uncontrolled hemorrhage reprioritize ABC to CAB Trauma Nursing Process (TNP) Assessment Outcomes/Planning Implementation Evaluation Operational Process Points Preparation and triage Primary Survey (ABCDE) w/ resuscitation adjuncts Reevaluation (consider it pt needs transfer) Secondary survey (HI) w/ reevaluation adjuncts Reevaluation and post resuscitation care Definitive care or transfer Primary Survey (ABCDE) Airway & Alertness w/ simultaneous cervical spinal stabilization Breathing and ventilation Circulation and Control of Hemorrhage Disability (neuro state) Exposure and Environmental Control Cervical spine stabilization for c-spine injury State need for second person to provide manual cervical spinal stabilization (two hands holding the pts head and neck) THEN demonstrate manual opening of airway using jaw- thrust maneuver Jaw-thrust maneuver If pt is anything less than A in AVPU airway maybe compromised Always use two people to assess for obstruction if suspected CSI AIRWAY: Inspect mouth for: Tongue obstruction Loose or missing teeth Foreign bodies (FB) Blood, emesis, secretions Edema Is there any snoring, gurgling, or stridor? Tip After each intervention, reassess pt Patent Airway Interventions Always be alert, can be compromised at anytime Look for possible risks that can lead to obstruction: P- the pt responds only to painful stimulation (consider airway adjunct) U- the pt is unresponsive (announce loudly to team, immediately check pulse, consider CAB) Glasgow Coma Scale (GCS) 1 being no response 1-4 score Eye opening: spontaneous, speech, pain, none 1-5 Verbal response: oriented, confused, inappropriate response, incomprehensible, none 1-6 motor response: obeys, localizes pain, w/d from pain, abnormal flexion (decorticate), abnormal extension (decerebrate), none Assess Pupils Shape, size, reactivity, and symmetry CT scan CT of head and c-spine if neuro compromise need to be ordered EXPOSURE Remove all clothing AND inspect for uncontrolled bleeding and injuries ENVIRONMENTAL: Warmth Blankets Warm lights Increase room temp Warmed fluids Warmed O2 Resuscitation Adjunts (FG) Full set of vitals & Family presence: BP, HR, RR, T Get resuscitation adjuncts FAMILY Remember importance of family presence Resuscitation adjuncts (LMNOP) Lab studies - ABG, lactic acid, blood type, crossmatch Monitor cardiac (EKG/ECG) Consider NG/OG Oxygenation and ventilation assessment (PaO2 & ETCO2) Pain assessment Nonpharmacologic Interventions Apply Ice Reposition pt Padding over bony prominences Consider analgesic meds Nonopioid: Tylenol, Motrin, Toradol Opioid: Morphine, fentanyl, dilaudid Reevaluation Look for findings from primary assessment that indicate: Uncontrolled internal hemorrhage Emergency surgical interventions Transport to higher level of care Reevaluation Adjuncts Additions Labs Rad scans Wound care Splints Traction device Tdap Admin meds Prep for transfer Secondary Survey (H) History Head-to-toe assessment HISTORY MIST Past medical hx Head-to-Toe Assessment Inspect and Palpate head and face Inspect and Palpate neck (removal and/or place c-collar_ Inspect and Palpate chest Auscultate breath AND heart sounds Inspect abd and flank Auscultate bowel sounds Palpate ALL four quadrants of abd Inspect pelvis and perineum Put pressure over iliac crests downward to check for instability Apply pressure to symphysis pubis to check for instability Inspect and Palpate all four extremities for neurovascular status and injury Log roll pt to look at posterior side Inspect and Palpate posterior Newtons 3 laws 1. an object in motion will stay in motion 2. force = mass x acceleration 3. for every action there is an equal and opposite reaction 5 forms of energy that exist 1. Mechanical- energy transfer from one object to another in form of motion 2. thermal-heat transfer from environment to host 3. chemical- heat energy trnsfer from active chemical substances such as chlorine, drain cleaner, acids 4. electrical- energy transfer from light socket 5. radiant- energy transfer from blast sound waves, nuclear, rays from the sn eternal forces in trauma 1. deceleartion- falls and collison = sudden stop 2. acceleration- sudden onset of motion- hit by a car 3. compression- hit stationary objects; bullets; blast forces internal forces of energy in trauma stress- internal force that resists external force solid organs good at pressure wave energy air organs better at shear forces 4 main types of traumatic injury 1. blunt trauma- falls; mvc; trauma 2. penetrating- stabing; GSW 3. Thermal 4. Blast Trauma- bomb deceleration vs acceleration forces -Deceleration: injury that occurs as pt slows down acceleration injury: injury that occurs as a result of other parts of the body stopping before the organs do (concussion; shearing of aorta) environment and pathophysiology when MOI is a fal -point of impact on the body -type of surface that is hit -tissues ability to resist injury (bone is less flexible) -pt pushed = more acceleration 3 impacts in a MVC 1. vehicle hits another object: occupant = acceleration 2. occupant collides with interior of vehicle: internal organs continue 3. internal structure collide with body 5 mechanisms of injury in a blast trauma Primary: blast injury; air-filled organs at risk to rupture secondary: fragment injuries; puncture wounds; lacerations tertiary: impacts with larger objectes propelled by the blast win causing blunt trauma quaternary: heat/flame/gas and smoke quinary: exposure to hazardous materials (radioactive) Haddon Matrix in prevention and reduction of injury places emphasis on countermeasures at preventing injury more than changing human behvior such as airbags, vehicle design and road blueprints why is there repeated emphasis on assessment for hemorrhage through the initial emphasis uncontrolled hemorrhage is teh majore causae of preventable death after injury Which tool can be used to rapidly assess the level of consciousness during the A - Airway and Alertness step? Why is it important to determine alertness along with airway? What are the components of this tool? A- alert *any below here may have compromised airway V- verbal stimuli P-painful stimuli U- unresponsive Which method of opening the airway is recommended for use in trauma? Jaw thrust maneuver w/ one provider stabilizing c-spine Assessment of airway Insect for tongue obstruction; loose/missing teeth; foreign objects; blood, vomit, secretion; Naopharyngeal and oropharyngeal should not be used with facial trauma or basilar skull fracture List, in order, the seven steps of verifying ETT placement. 1. CO2 detection device 2. symmetric rise and fall of chest 3 listen for presence of gurgling over epigastrium (at the same time as 2) 4. Listen for bilaterally breath sounds 5. secure ETT tube and note number at the lip for positioning 6. prepare for mechanical ventilation 7. note the patient's color and improvement 8. X-ray Identify and explain the circumstances in which the pulse oximetry reading may be unreliable and why. 1. poor peripheral perfusioncaused by vasoconstriction, hypotension, hypothermia 2. inflated BP cuff 3. Carbon monoxide poisoning 4. methemoglobinemia 5. severe dehydration Differentiate between qualitative and quantitative end-tidal carbon dioxide. Quantitative: one time numeric value of ETCO2 (capnography) Qualitative: colorimetric CO2 detector states presence/absence of CO2 Define hyperoxia and the pulse oximetry parameters used to monitor it. Hyperoxia refers to an excess supply of oxygen in the tissues. Better outcomes depend on prompt titration of oxygen as indicated by maintaining SpO2 between 94-98%. Discuss the steps of rapid sequence intubation. Preparation: gather supplies; patency of vascualr access; anticipate failed intubation PreO2: Pretreatment: Lidocane Opioids Atropine Defasciculating dose of neuromuscular blocking agents Paralysis: sedation then paralyze Protection and positioning: protect airway from aspiration and provide manual ventilation; monitor ventilatory status and O2 saturation Placement w/ proof Post intubation management: secure tube; x-ray Describe the etiology and pathophysiology of the four main classifications of shock. 1. Hypovolemic: decreased amount of cirulating blood volume 2. Obstructive: obstruction on vasculature or heart prevents tissue perfusion; tension pneumo & cardiac tamponade 3. Cariogenic shock: heart cannot pump effectively 4. Distributive shock: fluid in the wrong areas; neurogenic; anaphylactic; septic Define the components of cardiac output. Heart rate x stroke volume= CP Stroke volume impacted by preload, after load, contractility Compensated shock 1. anxiety, lethargy, confusion, and restless 2. systolic BP = normal 3. rising diastolic BP = narrowed pulse pressure 4. bounding & tachy pulse 5. increased resp. rate 6. decreased urinary output Decompensated shock 1. LOC deteriorates 2. systolic BP= normal or a little lower 3. narrowing pulse pressure 4. tachycardia >100bpm 5. weak and thready pulse 6. rapid and shallow resp. 7. cool, clammy, cyanotic skin 8. base excess not within nomral range of -2 to +2 9. serum lactate levels greater than 2-4 Irreversible shock 1. obtunded, stuporous, comatose 2. marked hypotension and HF 3. decreased and shallow respiratory rate 4. pale, cool, and clammy skin 5. kidney, liver, and other organ failure 6. severe acidosis, elevated lactic acid levels, worsening ABGs 7. coagulopathies w/ petechiae, purpura or bleeding 1. non-opioid & adjuvant 2. opioid for mild to moderate pain + (1) 3. oiioid for moderate to severe pain + (1) Differentiate between the four levels of procedural sedation and anesthesia. see chart on pg 100 Describe the responsibilities of the nurse during procedural sedation. -Assist with education and counseling -focused history -have necessary equipment: O2; suction; monitoring; resus equipment; resus medication; sedatives/analgesic/reversal -assure right people -TIME OUT - After: -manage pain and anxiety -monitor ital signs -perform teaching Define and list three types of primary brain injury. skull and craniofacial fractures intracranial lesions lacerations, tearing, shearing and bleeding into brain Discuss causes of secondary brain injury and give three examples. hypotension hypoxemia hypercarbia cerebral edema increased ICP Decreased CPP cerebral ischemia Describe the effect of hypercarbia on cerebral blood flow. What are benefits and risks of hypercarbia in the context of intracranial pressure and cerebral blood flow? CO2 causes vasodilation too much CO2 = increased ICP to little CO2= decreased cerebral perfusion Define the components of and use for the FOUR (Full Outline of UnResponsiveness) Score. Eye response Motor Response Brainstem reflexs Respirations Describe three tests for the presence of cerebral spinal fluid in otorrhea or rhinorrhea. 1. B2-Transferrin- fluid sent to lab 2. halo sign 3. glucose Mild TBI GCS score of 13-15 Brief LOC <30 min amnesia of less than 24hrs no cahnge on neuroimaging studies Moderate TBI GCS score of 9-12 wide variety of symptoms including altered LOC, confusion, amnesia, focal neurologic deficits may deteriorate to severe head injury over time Severe TBI GCS <8 significant alteation in consciousness abnormal pupillary response abnormal motor posturing Define second impact syndrome. pt suffers a second mild TBI before recovery from teh first second impact causes loss of auto regulation leading to cerebral edema Define and provide assessment findings for postconcussive syndrome may develop days or months following injury nausea dizziness and persistent headache memory and judgment impairment attention deficit insomnia and sleep disturbances loss of libido anxiety; irritability; depression; emoional lability -limit concomitant eye movement by patching unaffected eye -performing globe closure as soon as possible -antibiotics -systemic analgesics Differentiate the grades of traumatic hyphema. 1 blood occupying less than 1/3 anterior chamber 2. blood occupying 1/3 -1/2 anterior chamber 3. blood occupying 1/2 but less tan total filling of anterior chamber 4. blood occupying the entire anterior chamber Describe the treatment goal of treatment for chemical ocular burns. Irrigating the area until pH returns to normal (alkaline burns @ least 2L) determine baseline pH of the eye (normal is 7.0-7.3) administer antibiotics and cycloplegics tetracaine drops for pain visual acuity reassessment What is flail chest? A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum. Paradoxical chest movement where ribs come out on expiration Flail chest assessment findings dyspnea chest wall pain paradoxical movement of the chest Differentiate simple pneumothorax, open pneumothorax, tension pneumothorax, and hemothorax. simple pneumo: partial or complete lung collapse open pneumothorax: wound through chest wall. air enters pleural space through wound on inspiration tension: air can get in but cannot get out hemothorax: blood accumulates in the intrapleural space List interventions for a pulmonary contusion. O2 at 94-9*% minimize use of IV fluids possible intubaition and ventilator support List the components of the Beck triad as they relate to cardiac tamponade. hypotension distended neck veins muffled heart sounds Describe the insertion sites used for needle thoracentesis and chest tubes and explain why they are different needle decompression: 2nd or 5th intercostal space. 5th is an emerging trend chest tube: 5th intercostal space Describe the injury patterns for blunt abdominal trauma. Lacerations to the solid organs such as the liver, spleen, and kidneys rupture of air-filled hallow organs- stomach, bowels, uterus and bladder tearing or shearing from sudden deceleation or acceleration force causing extreme stress on fixed sites in the abdomen: bowels; ureters, urethra and esophagus; vessels in kidneys and livers fractures of pelvis from fall or MVC Differentiate Cullen sign, Grey Turner sign, and Kehr sign. Cullen sign: ecchymosis around the umbilicus or in Grey Turners: flank ecchymosis Kehr sign: referred pain in the shoulder Describe the process for assessing pelvic stability. gentle pressure over the iliac wins downard and medially reveals laxity or instability apply pressure only once Define an unstable pelvic fracture and list the presenting clinical findings. 2+ fractures of the pelvic ring that have outward rotaional displacement assessment: shortening of the leg; external rotation of the leg; blood at the urinary meatus or hematuria; pelvic instability/pain; unexplained hypotension or evidence of hypovolemic shock Incomplete: central cord syndrome (motor function less in upper extremities); perineal sensation; sphincter tone; voluntary great toe flexor function Complete: lose all motor and senory function below level of lesion What assessment findings differentiate neurogenic shock from hypovolemic shock? Neurogenic shock presents with impaired cardiac output with bradycardia and a normal/strong pulse Hypovolemic shock is characterized by tachycardia w/ weak peripheral pulse Describe the four types of thoracic vertebral fractures. 8. What criteria allow the trauma patient cervical spinal clearance using NEXUS? -no posterior midline cervical spine tenderness -no evidence of intoxication is present the pt has a normal level of alertness -no focal neurologic deficit is present -the pt does not have a painful distracting injury List the assessment findings, most common sites, and treatment for compartment syndrome. Which symptoms are considered early signs? Which is considered the hallmark sign? Which electrolyte is most important? Most common site: leg and forearm Pain-halmark sign; early Pressure -early Pallor-late Pulses- late sign Paresthesia: late Paralysis: late *Potassium is important What mechanism of injury is commonly associated with rhabdomyolysis? What organ is most often affected? Kidneys most at risk MOI: crush injuries Define residual limb. part of the body that remains after amputation Describe the care of an amputated part. -remove dirt and debris -keep amputated park cool by wrapping it in saline moistened sterile gauze and place ina sealed bag. Place bag on ice water. -Do not allow amputated part to freez -label bag with pt ID -Antibiotics Tetanus Abrasion vs abulsion partial or full thickness wounds that denues the skin (road rash) avulsion: full-thickness wounds. Edges are not well approximated Describe interventions for frostbite. rewarming over 15-30 minutes in 40-42 degree H20 administer pain meds avoid friction or rubbing Extract fluid from clear blisters. Leave hemorrhagic Splint affected extremities Give NSAID, aspirin, or tPA to limit thrombus formation Describe signs of burns to the airway that may indicate airway edema. hoarse boice carbonaceous sputum burns around mouth/nares stridor What burn injuries meet the criteria for admission to a burn center? -Partial thickness burns greater than 10% -burns on face, hands, feet, genitalia, peri, major joints -electrical burns -chemical burns -inhalation injury -burned children -burn injury to pt with special social, emotional, rehab intervention What complications are associated with electrical burns? -cardiac dysrhythmias -rhabdomyolysis - renal issues -fractures -seizures Restlessness crying fussiness agitation irritability older infant or toddler who does not express fear Describe the activities and associated factors related to low-energy trauma in the older adult. Falls most comon due to wet suraces, poor lighting, inadequate footwear,a nd cluttered pathways List common injuries from falls in the older adult population. Laceration TBI Fractures (hips) What condition is associated with a fall from which the older adult cannot rise? What complications result from this condition? Rhabdomyolysis causing: AKI hyperkalemia fluid shifting - hypovolemic shock fat embolism coagulopathies sepsis and MODS Review the age-related anatomic and physiologic change of the older adult in relation to the components of the initial assessment. pg 262 Describe the fluid resuscitation of an older adult patient related to fluid overload, when to administer red blood cells, and the use of anticoagulant medication. -smaller fluid boluses w. reassessment -auscultate lung sounds -early administartion of RBC to increase O2 carrying capacity -use pressure dressings and vitamin K to control bleeding Describe effects of common medications in relation to the older adult trauma patient. Beta-blocers can prevent increased herat rate Anticoagulants = bleeds Diabetes medss: alter LOC Analgesics: can alter balance and judgement Describe common patterns and severity of injuries in the bariatric trauma patient. Increased risk of complications once injured Which comorbid conditions factor into the risks of the bariatric trauma patient? And how? Diabetes sleep apnea decreased endurance GERD Describe the pathophysiologic changes of the systems of the bariatric patient and the effects on trauma resuscitation efforts. Starts on pg 273 Describe techniques to improve the intubation process for the bariatric trauma patient. -Use ramped position with elevated head -awake intubation using fiveroptic technology -use lean body wt for RSI doses -use reverse trendlenburg Discuss the use and insertion of nasogastric tubes in the bariatric patient. Recent hx of bariatric surgery = don't use blind placement of GN or OG tubes List the populations at higher risk for interpersonal violence. very young and very old pregnancy disabled Describe the types of abuse Physical Emotional Sexual Financial Spirital Neglect Signs of physical abuse bruises in various stages patterned scarring/burn marks dislocated joints bruising or swelling spiral, repeated, multiple, untreated fractures dental injuuries Nature of the injury- intensity/uncontrollability characteristics of the individual reaction or response (coping/defense mechanism) Describe interventions that can facilitate patient and family coping with trauma. RESPOND Reassure pt and family they are safe Establish rapport with the pt and family Support pt through initial aftermath; help contact family Plan of care; manage Pain Offer hope Never deliver news of death or disability alone to pt Determine the pt needs Describe interventions used for patients with language and communication needs. Determine the pt preferred language for communication ID family designated to receive important medical informatin if pt cannot speak for self speak slowlt and clearly to pt and familes; allow tiem for quetsions Use a professional interpreter List techniques used for preventing escalation. -One point-of-contact person for message -talk to families in private room -limit environmental stimuli -assess the need for personal space -sit and talk on the same level -avoid healthcare jargon -promote contacting other family members -assess need for spiritual support -multidisciplinary referrals for support -observe verbal and nonverbal cues Differentiate compassion fatigue, secondary traumatic stress (STS), and burnout in nurses. Combo of STS and burnout and can occur with repeated exposure to suffering STS-Intrusion, avoidance, arousal (pg 302) Burnout: emotional exhaustion; depersonalization from work; decreased sense of accomplishment Describe the methods used to build resilience. Make connections avoid seeing crises as insurmountable problems accept that change is part of living move toward your goals take decisive actions look for opportunities for self-discovery nurture a positive view of yourself keep things in perspective maintain a hopeful outlook take care of yourself Differentiate debriefings from defusings in critical incident stress management. Defusing: informal; occur within a few hours of event Debriefing: formal; 24-72 hrs following event Describe an ethical consideration related to trauma care. Describe the four phases of emergency management. Mitigation (prevention) Preparedness Response (triage) Recovery Define the components of the Incident Command Structure. Use common terminology Activate only what needs to be activated Expect communication difficulties One person is in charge People manage 3-7 subordinates Resource managment designated incident facilities (shelter, food bank, morgues) What is the goal of disaster triage? do the greatest good for the greatest number of potential survivors What components are considerations when designing a decontamination area? only basic live saving measures done in decon area triage area is downwind and downhill pt transport themselves increased blood loss and need for transfusion delayed recovery from anesthesia and increase in postop discomoft What injury is often associated with rib fracture? What intervention can limit the risk of pneumonia from this injury? Associated with pulomnary contusion and is a risk factor for developing pneumonia Aggressive pain managment can help What are the risk factors for acute respiratory distress syndrome? Aspiration pumonary contusion fat embolism pulmonary embolism near-drowning inhalation injury non-thoracic trauma massive transfuion O2 toxicity DIC Shock pneumonia *usually appears 24-48 hrs after injury What treatment strategies help lower the risk of ARDS? PEEP ventilation with lower tidal volume Optimal levels: 10-15 What interventions will help prevent ventilator acquired pneumonia? Elevate head of bed 45 degrees Early chlorhexidine oral care to decontaminate the mouth subglottic & endotracheal suctioning What are the effects of abdominal compartment syndrome by system? Abdominal effects: compress ab structures causing decreased perfusion and ischemia, acidosis, leaking capillaries, intestional swelling Cardiovascular: decrease venous return; and increased intrathroacic pressure; Respiratory: decreased lung expansion; respiratory acidosis; ARDS Neurologic: increast intrathroaci pressure = increased jugular vein pressure- decreased drainage = increasing ICP Describe the components of abdominal compartment syndrome. Sustained intra abdominal pressure above 20 or an abdominal perfusion pressure of less tahn 60 associated with organ dysfunction What interventions treat pulmonary embolus? Define the components of capnography. 1. numeric value: shows info about ventilation 2. Waveform: Respiratory cycle - change in waveform could mean bronchospasm, obstruction, V/Q mismatch 3. PETCO2 -PaCO2 gradient: change can mean hemodynamic instability or decreasing lung compliance