Trauma Assessment and Management, Exams of Nursing

Download Trauma Assessment and Management and more Exams Nursing in PDF only on Docsity! Trauma Nursing Core Course Exam-TNCC- Questions and Answers (Verified 2024) .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSWER-Baroreceptors: 1. A- airway and Alertness with simultaneous cervical spinal stabilization 2. B- breathing and Ventilation 3. circulation and control of hemorrhage 4. D - disability (neurologic status) 5. F - full set of vitals and Family presence 6. G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ANSWER-ABCDEFGHI 1. Apnea 2. GCS 8 or less 3. Maxillary fractures 4. Evidence of inhalation injury (facial burns) 5. Laryngeal or tracheal injury or neck hematoma 6. High risk of aspiration and patients inability to protect the airway 7. Compromised or ineffective ventilation - ANSWER-Following conditions might require a definitive airway 1. bony fractures and possible rib fractures, which may impact ventilation 2. palpate for crepitus 3. subcutaneous emphysema which may be a sign for a pneumothorax 4. soft tissue injury - ANSWER-Palpate the chest for 1. Check the presence of adequate rise and fall of the chest with assisted ventilation 2. Absence of gurgling on auscultation over the epigastrium 3. Bilateral breath sounds present on auscultation 4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ANSWER-If the pt has a definitive airway in what should you do? 1. Dyspnea 2. Tachycardia 3. Decreased or absent breath sounds on the injured side 4. CP - ANSWER-Simple Pneumo assessment: 1. equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ANSWER-Auscultate the chest for: 1. Get a CT 2. Consider ABG 's if decreased LOC 3. Consider glucose check - ANSWER-D Interventions 1. Hypotension 2. JVD 3. Muffled heart sounds - ANSWER-Becks Triad: 1. open the airway, use jaw thrust 2. insert an oral airway 3. assist ventilations with a bag mask 4. prepare for definitive airway - ANSWER-If breathing is absent.. 1. pain - hallmark sign, early sign 2. pressure - early sign 3. pallor, pules, paresthesia, paralysis - late sign - ANSWER-Six P's of compartment syndrome: 1. Preparation 2. Preoxygenation 3. Pretreatment 4. Paralysis and Induction 5. Protecting and positioning - v 6. Placement of proof - secure the tube 7. Post intubation - secure ETT Tube, get X-ray for placement - ANSWER-Steps of Rapid Sequence Intubation 1. Preparation and Triage 2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G) 3. Reevaluation (consideration of transfer) 4. Secondary Survey (HI) with reevaluation adjuncts 5. Reevaluation and post resuscitation care 6. Definitive care of transfer to an appropriate trauma nurse - ANSWER-Initial Assessment 1. Suction the airway 2, Use care to avoid stimulating the gag reflex 3. If the airway is obstructed by blood or vomitus secretions, use a rigid suction device Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ANSWER-Hemothorax: Circulation and Control of Hemorrhage Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ANSWER-C Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - ANSWER-Qualitative D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - ANSWER-DOPE Disability - Neurologic Status 1. Assess pupils for equality, shape, and reactivity (PERRL) 2. Assess GCS (eye opening, verbal response, and motor response) - ANSWER-D don't forget flanks!!! inspect of lacs, puncture wounds, contusions, auscultate then palpate: bowel sounds? any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt maybe do a fast scan? - ANSWER-Head to toe assessment: Abdomen Exposure and Environmental Control Remove all clothes and assess for any obvious injuries and uncontrolled bleeding - ANSWER-E Flail chest - ANSWER-Paradoxical chest wall movement from hemorrhage is leading cause. Hypovolemia is caused by decrease in the amount of circulating volume. Goal is to replace volume. - ANSWER-Hypovolemic Shock Full set of vitals and family presence - ANSWER-F Get Resuscitation Adjuncts L - Labs (maybe a lactic acid), a b g 's, blood type M - monitors N - naso or oro gastric tubes O Oxygen and ETC02 monitors P - pain assessment and management - ANSWER-G H,I - ANSWER-Secondary Survery History and Head to toe MIST - prehospital report MOI Injuries sustained S s/s in the field T treatment in the field if patients family present get a better hx on them - ANSWER-H IF clothing is needed for evidence preserve in paper bag. Maintain body temp - cover the pt, turn up heat in room, administer warm fluids - ANSWER-E Interventions: immobilize cervical spine, tenderness, tracheal deviation - ANSWER-Head to toe assessment: Neck and cervical spine in massive transfusion protocol... responsible for dissolving clots - ANSWER-TXA inspect for lacs, abrasions, asymmetry of facial expressions palate for depressions and tenderness look at ears for drainage - ANSWER-Head to toe assessment: Head and face inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD - ANSWER-I inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, auscilate lung sounds and heart sounds - ANSWER-Head to toe assessment: Chest jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ANSWER-While assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. labs, wound care, tetanus, administer meds, prepare for transfer - ANSWER-Secondary Reval Adjuncts Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - ANSWER-Cardiac Tamponade Intervention: occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ANSWER-Distributive Shock Pediatric Assessment Triangle 1. General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry 2. Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds 3. Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ANSWER-PAT