Trauma Pt. 1 Flashcards
(23 cards)
How to prioritize assessment?
ABCs
- airway
- breathing
- circulation
What are signs of airway compromise?
- Maxillofacial trauma (face or jaw injury)
- Neck trauma or hematoma
- Laryngeal trauma
- Risk for aspiration (bleeding and vomiting)
- Unconscious
When should the nurse suspect C-spine misalignment?
- injury to the head, neck, or spine
- multisystem trauma
- unconscious patient
What are nursing interventions for airway management?
- Remove Foreign Body
- Suction: blood, tooth, gravel, etc
- Supply Oxygen
- 100% O2 via non-rebreather
- Bag-valve-mask until advanced airway is established
- Intubate EARLY
- Re-evaluate frequently and ASSESS FIRST
- Maintain C-spine Alignment
airway patency does NOT ensure adequate ventilation
What indicates the nursing interventions are effective?
- patient can speak or breathe effectively
- clear breath sounds
- normal O₂ saturation
What are signs of breathing problems in trauma?
- presence of foreign bodies
- abnormal or ↓ breathing sounds
- cyanosis
- ↓ O₂ saturation
If the patient is awake and responsive, the airway is patent
What is pneumothorax?
air in pleural space → accumulation collapses the lung
can occur due to trauma or spontaneouly
What are clinical manifestations of pneumothorax?
- acute dyspnea
- ipsilateral chest pain (pain on the same side as the injury)
- ↓ or absent breath sounds
- hyper-resonance on percussion (louder, hollow sound due to too much air)
What is spontaneous pneumothorax?
air in pleural space without trauma
How to treat spontaneous pneomothorax?
- may resolve on its own
- if large, chest tube
What is traumatic pneumothorax?
air enters pleural space due to trauma
- Blunt → closed pneumothorax
- Penetrating → open pneumothorax
How to treat traumatic pneomuthorax?
- blunt trauma: chest wall is still intact
- chest tube
- penetrating trauma: chest wall is damaged
- occlusive dressing then chest tube
What is open pneumothorax?
air enters through a chest wound (“sucking chest wound”)
What is an additional clinical manifestation of open pneumothorax?
hypercapnia → respiratory acidosis
also has the other pneumothorax manifestations
How to treat open pneumothorax?
temporary 3-sided occlusive dressing → chest tube
sterile dressing that’s taped on 3 sides w 1 side open. allows air out during exhalation but doesn’t let air in during inhalation
What is tension pneumothorax?
air enters pleural space and can’t escape, increasing pressure
inhale → air enters pleural space → trapped → ↑ intrapleural pressure
How to treat tension pneumothorax?
needle decompression followed by chest tube
What is hemothorax?
blood in the pleural space
What are clinical manifestations of hemothorax?
- hypotension
- unilateral ↓ breath sounds
- dullness to percussion
How to treat hemothorax?
chest tube
What is flail chest?
2+ ribs fractured in 2+ places, causing chest wall instability
What are clinical manifestations of flail chest?
- paradoxical chest movements (opposite direction during breathing)
- hypoxia
How to treat flail chest?
- non-rebreather
- mechanical ventilation
