Trauma Nursing Core Course (TNCC)- 9th edition, Exams of Nursing

Download Trauma Nursing Core Course (TNCC)- 9th edition and more Exams Nursing in PDF only on Docsity! Trauma Nursing Core Course (TNCC)- 9th edition Why is alertness included in the airway assessment? - Including this helps evaluate the patient's ability to protect their own airway What pneumonic is used to assess a patient level of alertness? - A: Alert V: Responds to verbal stimuli P: Responds to pain U: Unresponsive Why is AVPU beneficial to use at the beginning of the initial patient assessment? - Will help determine appropriate airway intervention In a patient who is unable to open their mouth or unresponsive, how do we assess the airway? - Jaw- thrust maneuver is performed to open airway and mouth to assess for obstruction What inspecting the airway, what are we inspecting for? - Vocalization Tongue Obstruction Loose or missing teeth Foreign objects Fluids (blood, vomit, secretions) Edema Burns/ evidence of inhalation injury If an airway is patent, what is the goal? - Focusing efforts at maintaining and supporting a patent airway (Pt may be allowed to assume position that facilitates better air exchange so long as no CSI is suspected) Can an oropharyngeal airway be used in someone with a gag reflex? - No How do you assess breathing? - Expose the patient's chest and inspect for the following: Spontaneous breathing Symmetrical chest rise and fall Depth, pattern and rate of resps Work of breathing (accessory muscles, pursed lip, diaphragmatic breathing) Skin colour Contusions, abrasions, deformities Open pneumothorax JVD Signs of inhalation injuries Sign of inhalation injuries - Singed nasal hairs Carbonaceous sputum Hoarse voice How to assess for proper placement of a definitive airway (3 steps) - 1. Attach CO2 detector (assess for presence of CO2 after 5-6 breaths) 2. Adequate rise/fall of chest with assisted ventilation 3. Auscultate for gurgling over epigastrium and presence of bilateral breath sounds.