Multiple Trauma book & ppt (chap 34) Flashcards
Define trauma.
Trauma is the result from an acute exposure to energy and occurs because of the body’s inability to tolerate excessive exposure to the energy source.
List the steps of the trauma nursing process.
PPE, listen to hospital providers report, ABCDE, FGHI
What does ABCDE stand for according to the primary survey?
A - airway B - breathing C - circulation D - disability E - exposure
What is purpose of airway management?
Done to maintain open airway and protect cervical spine, immobilize neck to prevent spinal cord contusion, laceration, compression, or transection
What are the causes of impaired airway.
Tongue falling into oropharynx, blood, vomitus, secretions, foreign objects in airway, fractures of facial bony structures, crushing injuries of laryngotracheal tree
What are the signs and symptoms of impaired airway?
No signs of breathing, no air felt or heard at nose or mouth, presence of foreign bodies in airway, abnormal chest movements, abdominal breathing, nasal flaring, stridor, hoarseness, snoring, gurgling, difficult or inability to speak, raspy or hoarse voice quality
What are the interventions to stabilize the airway?
Open airway (jaw thrust), suction, assess for/remove foreign bodies, neutral neck position, immobilize cervical spine either through positioning, hard cervical collar, or towel rolls across sides of head w/ tape
What are simple airways that a nurse can establish?
The simplest way to open airway is chin lift or modified jaw thrust. The nurse can also establish an oropharyngeal or nasopharyngeal airway
Who can use a oropharyngeal airway? What can it cause?
Only use in pts who are unconscious & can’t gag, can cause obstruction if improperly placed
Who can use a nasopharyngeal airway? Who cannot use?
Use in conscious pt who can gag, do not use if basilar facture suspected
When can endotracheal intubation be used? What are the different types of endotracheal intubation and when can they be used? What is the nursing process for this?
Used when previous methods are unsuccessful. Nasotracheal intubation can be used to reduce hyperextension of the neck. Orotracheal intubation is used when pt is apneic, cribriform palate fracture suspected, or with basilar skull fracture. Auscultate over epigastrium for gurgling sounds, auscultate for breath sounds to determine placement, repeat assessment of
When are surgical airways established what surgical airways can be established? What position is used to prevent airway collapse?
Used when unable to intubate trachea. Methods include: needle cricothyriodotomy, surgical cricothyriodotomy, tracheostomy. Position patient upright to prevent airway collapse.
How does the nurse evaluate breathing?
Evaluate by looking, listening, and feeling. PPV may be indicated but can cause gastric distention, prevent by using low volume/breaths. Evaluate ABGs, end tidal co2, arterial o2 saturation, and presence of pneumothorax.
What are the signs and symptoms of impaired breathing?
Rate, rhythm, depth of breathing abnormal, absent or diminished breath sounds, gurgling, crowing, gasping, cyanosis, use of accessory muscles, hypoxemia, hypercapnia
What are nursing interventions to stabilize breathing?
Apply o2 100%, inspect for signs of chest trauma, position on side after neck is stabilized, PPV (mouth-to-mouth, bag-valve mask, intubation, mechanical ventilation), rescue breathing if indicated
What is the trauma pt at risk for in regards to circulation? How do we assess circulation?
Trauma pt at risk for hypovolemic shock from acute blood loss. Assess circulation by: palpating pulses for strength, rate, rhythm, and symmetry of carotid, radial, femoral, and pedal pulses. Assess skin temp & capillary refill.
What are the signs and symptoms of impaired circulation?
Abnormal pulse, BP, weak or absent peripheral pulses, poor capillary refill, bleeding, pale/cool skin, uncontrolled bleeding, listen to heart tones.
What are nursing interventions to stabilize circulation?
Control bleeding, treat shock, CPR if indicated
What type of shock is common with a trauma pt? What is a major complication of this shock and what does it lead to?
Hypovolemic shock. Exsanguination is a major complication. . Pt can lose 50% of BV within minutes. Loss of 15% BV produces little symptoms, 30% loss results in tachycardia, tachypnea, and anxiety. >30% results in hypotension, marked tachycardia, and confusion. 40% loss is life threatening.
What does the D for in ABCDE stand for? How do we assess this?
Disability. Assess for neurologic disability by checking LOC, pupillary size and reaction. Assess LOC by using AVPU scale.
What does AVPU stand for?
A – alert
V – responds to verbal stimuli
P – responds to painful stimuli
U – unresponsive
What does the E stand for in ABCDE? How do we assess this and what is a complication?
Exposure. Completely undress the pt to begin the secondary survey. Be aware that pt is predisposed to hypothermia d/t exposure of cold
What does FGHI stand for according to the secondary survey?
F – full set of vitals including temp & include family if possible
G – get gadgets, give pain meds & labs
H – head to toe assessment
I – inspect the back
What systems do we survey in the head to toe component of the secondary survey?
Head, maxillofacial, cervical spine/neck, chest, abdomen, pelvis, perinum, genitalia, musculoskeletal, back, complete neurologic examination
What do we evaluate with the “head” in the head to toe component of the secondary survey?
Complete neuro assessment (GCS), reevaluate pupillary size and reactivity, inspect and palpate head for lacerations, fractures, contusions, hemotympanum, CSF leakage, edema
What do we evaluate with the “maxillofacial” in the head to toe component of the secondary survey?
Assess for facial fractures by inspection, palpation for open fractures, lacerations, and mobility or instability of facial structures
What do we evaluate with the “cervical spine/neck” in the head to toe component of the secondary survey?
Inspection and palpation of neck anteriorly and posteriorly for: pain, crepitus, bony step-offs, dislocation, neck vein distention, and tracheal deviation
What do we evaluate with the “chest” in the head to toe component of the secondary survey?
Inspect for paradoxical movement, flail segments, open chest wounds, and ecchymosis. Paplate for rib fractures, subcutaneous emphysema, respiratory excursion, and sternal fractures. Auscultate for quality, equality of breath sounds, and presence of adventitious sounds. Auscultate heart sounds for quality, extra sounds, murmurs, or pericardial friction rubs.
What do we evaluate with the “abdomen” in the head to toe component of the secondary survey?
Inspection and auscultations before palpation. Inspect for abrasions, contusions, lacerations, and distention. Auscultate for bowel sounds in four quadrants, bruits, and breath sound. Light and deep palpation for pain response, may indicate intraperitoneal bleeding, intervene as necessary.
What do we evaluate with the “pelvis, perineum, genitalia” in the head to toe component of the secondary survey?
Inspect pelvis for deformation and palpate for stability. Inspect perineum and genitalia for bleeding, hematoma, and lacerations. Rectal examination to evaluate wall inegrity, presence of blood, position of prostate, palpable pelvic fractures, and quality of sphincter tone.
What do we evaluate with the “musculoskeletal” in the head to toe component of the secondary survey?
Visual evaluation of extremities for contusions or deformities. Palpate extremities for tenderness, crepitation, or abnormal ROM. Evaluate all peripheral pulses, capillary refill, skin color, temp should be rechecked.
What do we evaluate with the “back” in the head to toe component of the secondary survey?
All pts should be log-rolled for visualization of posterior surfaces (be mindful of spinal immobilization). Inspect neck, back butt, and lower extremities.
What do we evaluate with the “complete neurologic examination” in the head to toe component of the secondary survey?
Motor and sensory function of extremities and reevaluate GCS and pupils. Any evidence of paralysis or paresis pt should be immobilized.
Define blunt trauma.
Any traumatic injury in which there is tissue deformation w/o interruption of skin integrity
Define penetrating trauma.
Injury that happens by transmission of energy to body tissue from a moving object that
Define shearing force.
A tearing injury that results when two structures or two parts of the same structure slide in opposite directions or at different speeds.
Name some examples of shearing force.
- C7-T1 injuries (mobile cervical to immobile thoracic)
- Aortic tears
- Splenic & renal injuries
- Liver, brain, heart injuries
Define acceleration.
An increase in the rate of velocity of a moving body or part of the body
Define deceleration.
A decrease in the rate of velocity of a moving body or part of the body
Define compression force.
Being pressed or squeezed together causing a reduction in volume or size
Name some examples of compression force.
Sudden deceleration causing heart and lungs to be compressed against chest causing reduction in size. Small bowel compressed between spine and steering wheel, eventually causing reduction in volume.
Name some examples of injury due to blunt trauma.
• Head injuries, spinal cord injuries, fractures, abdominal injuries
Name some examples of low energy missiles.
Knives, arrows, or any type of object that can be thrown from the hand (stick, metal rod)
Name some examples of medium energy missiles.
Handguns, certain types of rifles
Name some examples of high energy missiles.
Hunting rifles, shotguns
Name a very important nursing consideration when object is penetrated into skin.
DO NOT take out the penetrating object, leave it there and protect it from further movement until surgical interventions can be done. If you take out penetrating object person can bleed to death (exsaguination).
