Multiple Trauma book & ppt (chap 34) Flashcards
(115 cards)
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
