Trauma Flashcards
(14 cards)
Describe the care of the trauma patient including priorities of care: airway, breathing, and circulation
Prioritize within ABCs: assessment findings and interventions/nursing management
A: Maintain open airway
Presence of foreign bodies?
Abnormal breathing sounds: stridor
If the patient is awake and responsive, the airway is patent
Give oxygen:
100% O2 via non-rebreather
Bag-valve-mask until advanced airway is established
Nursing assessment and management of airway:
When should the nurse be concerned for airway compromise? Give?
When should the nurse be concerned for c-spine misalignment?
If patient is unconsious
Give oxygen:
100% O2 via non-rebreather
Bag-valve-mask until advanced airway is established
When there is:
* Multisystem trauma
* Loss of consciousness
* Blunt injury above the clavicle
Breathing Interventions:
Prevent?
Watch for?
PREVENT HYPERVENTILATION!!
Watch for visible chest rise
Pneumothorax
What is it?
Caused by?
4 symptoms?
Treatment?
Air in pleural space
Caused by: Trauma:
Blunt = closed pneumothorax
Penetrating = open pneumothorax
- Acute dyspnea
- Ipsilateral chest pain
- Unilateral ↓ or absent breath sounds
- Hyper-resonance on percussion
Treatment: chest tube or self-limiting
Blunt: closed pneumothorax treatment?
Penetrating: open pneumothorax treatment?
chest tube
3 sided occlusive dressing then chest tube
Tension Pneumothorax
What is it?
Symptoms?
Treatment?
Air builds up so much that trachea moves
- Ipsilateral lung collapse
- Tracheal deviation to unaffected side
- Mediastinum shift
Treatment: needle decompression followed by chest tube
Hemothorax
What is it?
Massive hemothorax #?
Symptoms?
Treatment?
Blood in the pleural space
Massive hemothorax: >1500 mL blood in thoracic cavity
- Hypotension
- Unilateral ↓ breath sounds
- Dullness to percussion
Treatment: chest tube
Flail Chest
The fracture of 3 or more consecutive ribs, in 2 or more separate places
Paradoxical chest movements
Hypoxia
Treatment: non-rebreather and mechanical ventilation
Describe chest tube management
Keep all tubing?
Keep all connections?
Notify provider if drainage more than?
Should you clamp? why?
What is tidaling?
Keep all tubing and drainage system below patient’s chest including with ambulation
Keep all connections taped tightly
> 200 mL in first hour
Clamping the chest tube increases the risk of tension pneumothorax
Tidaling: movement of the fluid level with
respiration; EXPECTED
Chest tube disconnected from the Collection Device?
- Immediately clamp the tube
- Place end of chest tube in sterile water
- Swab chest tube and chamber with alcohol
- Reconnect
Chest tube dislodged from the Lung?
- Immediately apply pressure to insertion site
- Apply a sterile gauze or Vaseline gauze and dry dressing over insertion site
- Tighten the seal when patient exhales
- Notify provider to reinsert new chest tube
- Respiratory distress call a code
Nursing assessment and management of circulation:
Priority concerns? 2
Always assume?
HR?
BP?
Thready?
Poor?
What 2 other signs?
Nursing interventions? 3
Hypovolemia and Shock:
* Hypovolemic shock secondary to hemorrhage
* ALWAYS ASSUME HEMORRHAGIC SHOCK IF SEVERE BLEEDING!!
↑ Heart rate,
↓ Blood pressure,
Thready peripheral pulses,
Poor capillary refill > 2 seconds
Bleeding
Seat belt sign
- STOP THE BLEEDING!!!!!
- Place 2 large bore IVs
- Fluid resuscitation with IV fluids and blood products
SALT triage
Black tag?
Red tag?
Patient is dead
Adult not breathing after opening airway
Child not breathing after 2 rescue breaths
Patient is critically injured and require immediate intervention to sustain viability
May require more resources on arrival to hospital
Yellow tag?
Patients have serious medical problems; expected to survive until definitive care can be rendered; can wait for treatment
Ex. gunshot wounds but hemodynamically stable, major fractures, spinal cord injuries with acceptable vital signs
