TNCC WRITTEN EXAM 2022, Exams of Nursing

Download TNCC WRITTEN EXAM 2022 and more Exams Nursing in PDF only on Docsity!

24 Hour Burn Fluid Calculation - ANS Dosage x Kg x % - ml in first 24 hours

-More than 20% of their TBSA burned require:

*Adults: 2-4 ml of crystalloid solution x kg x %

*Peds: 3-4 ml of crystalloid solution x kg x %

*Infants: fluid with 5% dextrose at a maintenance rate in addition to the Peds rate protocol

(1/2 the amount should be infused in first 8 hours)

Define central or transtentorial herniation. - ANS A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium.

Define Hemothorax. - ANS Accumulation of blood in the pleural space.

Define Minor Head Trauma. - ANS GCS 13-

Define Moderate Head Trauma - ANS Postresuscitative state with GCS 9-13.

Define Pneumothorax. - ANS Results 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. - ANS Postresuscitative state with GCS score of 8 or less.

Define tension pneumothorax. - ANS Life-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. - ANS 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.

Disruptions of the bony structures of the skull can result in what? - ANS 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

Explain adrenal gland response. - ANS 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 Cardiogenic Shock. - ANS Syndrome that results from ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes: MI, Blunt cardiac injury, Mitral valve insufficiency, dysrhythmias, Cardiac Failure

Explain Distributive Shock. - ANS Results 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. - ANS 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 Hypovolemic Shock. - ANS 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.

Explain Irreversible Shock. - ANS Shock uncompensated or irreversible stages will cause compromises to most body systems.

• Inadequate venous return
• inadequate cardiac filling
• decreased coronary artery perfusion
• Membranes of lysosomes breakdown within cells and release digestive enzymes that cause intracellular damage.

Explain Obstructive Shock. - ANS Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself.

Some causes:

• Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).
• Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.
• Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock

Explain Pulmonary Response. - ANS Tachypnea happens for 2 reasons:

1. Maintain acid-base balance
2. Maintain increased supply of oxygen

• Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs to increase rate of ventilation. Increased RR is an attempt to correct acidosis + augments oxygen supply to maximize oxygen delivery to alveoli.

How do you confirm ET Tube/Alternative Airway Placement? - ANS - 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? - ANS Observe:

• mental status
• RR and pattern
• chest wall symmetry
• any injuries
• patient's skin color (cyanosis?)
• JVD or tracheal deviation? (Tension pneumothorax)

How would you assess a patient with ocular, maxillofacial and neck trauma? - ANS (Initial assessment)

HISTORY

• MOI?
• Acceleration/Deceleration?
• What was it caused by?
• Pt restrained? Airbags deployed? Etc.
• What are the pt's complaints?
• Pt normally wear glasses or contacts?
• Pt have hx of eye problems?
• Pt ever have eye surgery?
• Pt have visual or ocular changes associated with chronic illness?

PHYSICAL

INSPECTION:

• Inspect eye, orbits, face and neck
• Check for symmetry, edema, ecchymosis, ptosis, lacerations and hematomas
• Inspect globe for lacerations, large corneal abrasions, hyphema, and extrusion or prolapse of intraocular contents
• Determine whether lid lac's
• Assess pupil's (PERRL)
• 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 defects or depressions
• Subcutaneous emphysema (esophageal or tracheal tear)
• Palpate trachea above suprasternal notch
• Trach deviation = late indication of tension pneumothorax or massive hemothorax
• Assess sensory fx of perioribital areas, face and neck
• Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.
• Check position of trachea

DIAGNOSTIC STUDIES:

• Xrays, CT scans, MRI's
• Fluorescein staining
• Slit-lamp exam
• tonometry (measures intraocular pressure)
• Bronchoscopy or esophagoscopy

How would you assess a pt in hypovolemic shock? - ANS (Use Initial Assessment) and then:

Inspect:

• LOC
• Rate and quality of respirations
• External bleeding?
• Skin color and moisture
• Assess jugular veins and peripheral veins

Auscultate:

• BP
• Pulse pressure
• Breath sounds
• Heart sounds
• Bowel sounds

Percuss:

• Chest and abdomen

Palpate:

• Central pulse (carotid or femoral)
• Positive inotropic effect (force of contraction) may be evidence by a bounding central pulse

• Palpate peripheral pulses
• Palpate skin temp and moisture

Diagnostic Procedures:

• Xrays and other studies
• Labs

Planning and Implementation

• Oxygen
• IV's with warmed replacement fluids
• Control external bleeding with direct pressure
• Elevate LE's
• NGT
• Foley
• Monitor and pulse oximeter
• Monitor for development of coagulopathies
• Surgery?

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
• 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 mm Hg may cause increased cerebral vasodilation, increased CBF, increased ICP.
• Prolonged hyperventilation NOT RECOMMENDED.
• Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction, decreased CBF, decreased ICP. And ischemia secondary to severe vasoconstriction.
• Hyperoxygenate pt with 100% O2 via bag-mask
• Apply direct pressure to bleeding sites except depressed skull fractures
• Cannulate 2 large IV's
• Hypotension doubles pt's death rate (w/severe head trauma)
• Vasopressors used to maintain CPP.
• Insert OG or NGT. OG should be used with severe facial trauma.
• Position pt, elevate head to decrease ICP (but may also reduce CPP).
• Position head midline to facilitate venous drng. Rotate head to compress veins in neck and result in both venous engorgement and decreased drng from brain
• Prepare for ICP monitoring device
• Administer mannitol as prescribed.
• Mannitol, hyperosmolar, volume-depleting diuretic, decreases cerebral edema + ICP by pulling interstitial fluid into intravascular space for eventual excretion by kidneys.
• Administer anticonvulsant

• Sx should be avoided b/c increases cerebral metabolic rate + ICP. Indications for sz prophylaxis:
• Depressed skull fx
• Sz at time of injury
• Sz on arrival to ED
• Hx of sz's
• Penetrating brain injury
• Acute subdural/epidural hematoma
• Administer antipyretic med/Cooling blanket
• Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP
• Do not pack ears/nose if CSF leak suspected
• Admin tetanus prophylaxis
• Wound repair for facial/scalp Lac's
• Admin other meds
• Analgesics, sedatives, narcan, romazicon, etc.
• Admin antibiotics
• Pt's w/basilar skull fx need prophylaxis against meningitis
• Prepare pt for OR, hospital admin or transfer.

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)

Palpation:

• Palpate chest wall, clavicles and neck for:
• Tenderness
• Swelling or hematoma
• Subcutaneous emphysema
• Note presence of bony crepitus
• Palpate central and peripheral pulses and compare quality between:
• Right and left extremities
• Upper and lower extremities
• Palpate the trachea (above suprasternal notch. Trach shift may indicate late sign of tension pneumothorax or massive hemothorax)
• Palpate extremities for motor and sensory function (lower extremitiy paresis or paralysis may indicate aortic injury).

Auscultation:

• Auscultate compare BP in both UE's and LE's
• Auscultate breath sounds (decreased or absent breath = pneumo or hemothorax. Diminshed BS = splinting. Shallow = b/c of pain).
• Auscultate chest for presence of BS (diaphragmatic rupture)
• Auscultate Heart sounds (muffled = pericardial tamponade)
• Auscultate neck vessels for bruits (vascular injury)

Diagnostic Procedures:

• Xrays
• Arteriography
• Bronchoscopy and laryngoscopy
• CT's
• FAST
• Labs (cardiac enzymes)
• ECG, CVP

How would you care for a pt with an Abdominal Injury? - ANS (Initial assessment)

Obtain Hx.

PHYSICAL:

Inspection:

• Observe the lower chest for asymmetric chest wall movement.

-Observe the contour of the abdomen. Distention may indicate bleeding

-Inspect lower chest, abdomen, flanks, and back for seat belt abrasions or soft tissue injuries

-Inspect pelvic area for soft tissue bruising

Percussion:

• Percuss for hyperresonance or dullness. Hyperresonance indicates air, dullness indicates fluid.

Palpation:

• Palpate all four quadrants. Press and quickly release to determine presence of rebound tenderness.

-Palpate pelvis for bony instability, asymmetry, or pain.

-Palpate flanks for tenderness

-Palpate anal sphincter for presence or absence of tone

Auscultation:

-Auscultate the chest. If bowel sounds heard in chest may have diaphragmatic rupture with herniation of the stomach or small bowel

-Auscultate bowel sounds. Absence indicative of visceral injury.

Diagnostic Procedures:

• Xrays
• MRI
• IVP and DPL
• CT's
• FAST
• Labs (cardiac enzymes)

-Cystogram or urethrogram

-Angiography

ICP is a reflection of what three volumes? What happens when one increases? - ANS 1. Brain

2. CSF
3. 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 O2 in cerebral vessels. CO dilates cerebral blood vessels = increase blood volume and ICP.

Nsg Interventions for Compartment Syndrome - ANS -Elevate the limb to the level of the heart to promote venous outflow and prevent further swelling. Elevation above the heart may decrease perfusion to a compromised extremity

-Assist with measurement of fascial compartment pressure

-Prepare for fasciotomy to preven muscle or neurovascular damage

Nsg Interventions for Crush Injury - ANS -Administer intravenous isotonic crystalloid solution to increase urinary output and facilitate excretion of myoglobin

-Elevate the injured extremity above the level of the heart to reduce swelling and pain unless compartment syndrome is suspected. For compartment syndrome, maintain at level of the heart

-Gently clean open wounds

-Prepare the patient for surgical debridement, fasciotomy, or amputation

Nsg Interventions for Open Fracture - ANS -Irrigate any wound with sterile saline

-Cover open wounds with dry, sterile dressings.

-Administer antibiotics, as prescribed

-Inspect dressings frequently for continued bleeding

-Administer tetanus prophylaxis, as indicated

Nsg Interventions for Pelvic Fracture - ANS -Stabilize pelvis by wrapping in folded sheet

-Apply a pneumatic antishock garment to splint pelvic fractures

-Prepare for application of an external fixator

S/S of Esophageal Injury? - ANS -Subcutaneous emphysema

-Peritoneal irritation

-Pain radiating to the neck, chest, shoulders, or throughout the abdomen

-Gross blood in gastric aspirate

S/S of Gastric Injury? - ANS -Abdominal Pain

-Peritoneal irritation

-Evisceration of stomach

-Gross blood in gastric aspirate

S/S of Large and Small Bowel Injuries? - ANS -Peritoneal irritation manifested by abdominal wall muscle rigidity, spasm, involuntary guarding, rebound tenderness, or pain

-Evisceration of small bowel or stomach

-Hypovolemic Shock

-Gross blood from rectum

S/S of Renal Injuries? - ANS -Hematuria

-Flank or abdominal tenderness elicited during palpation

-Ecchymosis over flank may occur, but normally develops 6 to 12 hours after injury

Six Ps of compartment Syndrome - ANS Pain, Pallor, Pulses, Paresthesia, Paralysis, Pressure

Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ANS A tight-fitting nonrebreather mask at 12-15 lpm.

What are aortic injuries S/S? - ANS - Hypotension

• Decreased LOC
• 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? - ANS Occur 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)

• 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? - ANS Chemical 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 Hepatic Injuries? - ANS -Upper Right Quadrant Pain

-Abdominal Wall Muscle Rigidity, Spasm, Involuntary Guarding

-Rebound Tenderness

-Hypoactive or Absent Bowel Sounds

-Signs of hemorrhage or hypovolemic shock

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 of Splenic Injuries? - ANS -Signs of hemorrhage or hypovolemic shock

-Pain in the left shoulder (Kehr's sign) when lying supine or Trendelenburg

-Tenderness in the upper left quadrant

-Abdominal wall muscle rigidity, spasm, or involuntary guarding

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? - ANS Blunt trauma. "Clothesline-type" injuries.

• Dyspnea, tachypnea
• Hoarseness
• Hemoptysis
• 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 Effective/Ineffective Circulation? - ANS - 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
• Use blood administration tubing for possible administration of blood
• Use rapid infusion device based on protocol
• Use NS 0.9% in same tubing as blood product
• IV = surgical cut-down, central line, or both.
• Blood sample to determine ABO and Rh group
• IO in sternum, legs, arms or pelvis
• Administer blood products
• PASG (without interfering with fluid resuscitation)

What are the late observable signs of symptoms of increased ICP? - ANS - 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 are the late signs of breathing compromise? - ANS - Tracheal deviation

• JVD

What are the mandibular fracture S/S? - ANS - Malocclusion

• Inability to open the mouth (trismus)
• Pain, especially on movement
• Facial asymmetry and a palpable step-off deformity
• Edema or hematoma formation at the fracture site
• Blood behind, ruptured, tympanic membrane
• Anesthesia of the lower lip

What are the most common type of injury associated with chest trauma? - ANS blunt; MVC's. Penetrating; firarm injuries or stabbings

What are the nursing interventions for a patient with a maxillofacial or neck injury? - ANS - Administer oxygen

• For facial trauma, place pt in high-fowler's position if no spinal injury is present.
• Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
• Monitor for progressive airway assessment
• Prepare for intubation, PRN.
• Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
• Control external bleeding w/direct pressure
• Monitor for continued bleeding + expanding hematomas
• Apply cold compresses to face to minimize edema
• Assist w/repair of oral lac's, PRN
• Admin antibiotics
• Stabilize impaled objects
• Admin analgesic meds

What are the nursing interventions for a pt with an ocular injury? - ANS - Assess visual acuity & reassess

• Elevate HOB to minimize intraocular pressure
• Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise intraocular pressure

• Assist w/removal of foreign bodies as indicated; stabilize impaled objects
• Apply cool packs to decrease pain + periorbital swelling
• Admin medications
• Instill prescribed topical anesthetic drops for pain
• Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to prevent drying and ulceration
• Antibiotics topically or systemically
• Admin tetanus prophylactically
• Use an eye patch to affected eye
• Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
• Patch, shield or cover w/cool pack
• Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected eye. Use metal or plastic and do not put pressure on the globe.
• Provide psychosocial support
• Obtain an ophthalmology consultation
• Provide d/c instructions:
• Importance of protective eyewear
• No driving w/eye patch on
• Wear sunglasses to prevent tearing, aid photophobia
• Prepare for admission, OR or transfer

What are the Rapid Sequence Intubation Steps? - ANS 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 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
• 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