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NSG 478 > Acute trauma > Flashcards

Acute trauma Flashcards

1
Q

The nurse in the emergency room has received report from EMS of an incoming patient who was the victim of a high-speed, roll-over motor vehicle accident and sustained multiple injuries. Which of the following should the nurse assess first?
A) Pedal pulses
B) Chest rise and fall
C) Blood pressure
D) Head and neck pain

A

B) Chest rise and fall
Always your abc

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2
Q

Nursing care and mgmt of trauma

A
  • Spinal immobilization until cleared
  • Accurate and thorough history as able
  • Determine mechanism of injury
  • Locate and document all wounds
  • Withhold oral fluids
  • Tetanus and antibiotic prophylaxis as ordered
  • Continuous monitoring and assessment
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3
Q

Mechanism of injury

A

Forces and energy that causes trauma
1. Falls
2. Blast
3. MVC
4. GSW
5. Pedestrian struck

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4
Q

Significant MOI

A
  • Ejection from vehicle
  • Death of someone in the same vehicle
  • Rollover motor vehicle accident
  • High speed collisions (40+mph)
  • Pedestrian struck
  • Falls from 20+ feet
  • Motorcycle accident with rider separation
  • Penetrating trauma to head, neck, torsos and proximal extremity
  • Significant blunt force trauma to head neck or torso
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5
Q

Motor vehicle accidents (MVA): Seat belts and air bags

A
  • Airbags without seatbelts only slightly reduce risk of fatality
  • Assessment of injury pattern will coincide with type of seatbelt (Skin will have an injury that is the same shape as the belt)
  • In 30+ mph MVA with an unbelted occupant slams into the internal compartment of the vehicle is the same impact as falling from a 3 story building
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6
Q

MVA: Over the dash

A
  • Upper torso injuries
  • Chest moves forward and hits the steering wheel and dash
    • Fractured Ribs
    • Flail chest
    • Contusions
    • Intra-abdominal injuries
  • Head hits windshield
    • Skull fractures
    • Brain injury
    • Neck injury
    • Lacerations
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7
Q

MVA: Under the dash

A
  • Lower torso injuries
  • Body slides under the steering wheel and dash
    • Hip dislocation and fracture
    • Femur fracture
    • Knee dislocation
    • Tibia/fibula fracture
    • Ankle injury , dislocation, fracture
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8
Q

MVA: Rear end collision

A
  • Accelerated forward motion (whiplash)
    • Neck injuries
    • Chest wall injuries
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9
Q

MVA: side impact injury (Tbone)

A
  • Lateral movement of the vehicle
    • Head and neck injuries
    • Chest injuries
    • Pelvic injuries
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10
Q

MVA: Roll over accidents

A
  • Number of injuries as well as severity of injuries is increased
  • Multiple impact points
  • Ejection from vehicle
  • UFO/Sun roof
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11
Q

Chest Trauma

A
  • Blunt trauma occurs more frequently than penetrating chest trama
  • Can be life threatening
    • hypoxemia
    • Hypovolemia
    • Cardiac failure
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12
Q

Chest trauma assessment: history

A
  • Time elapsed sience injury
  • Mechanism of injury
  • LOC
  • Specific Injuries
  • Estimated blood loss
  • Recent drug/alc use
  • any pre hospital care
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13
Q

Flail chest

A
  • More than 2 ribs fractured in at least 2 places each
  • Causes paradoxical movement
    • Inspiration causing the chest (lungs) to sink in
    • Expiration causing the chest (lung) to go out
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14
Q

Chest trauma assessment: Look

A
  • RR
  • depth of respirations
  • Equal chest wall expansion, paradoxical chest wall motion (Flail chest)
  • Look for bruising, seat belt or steering wheel injures, any penetrating wounds, foreign objects

Done first

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15
Q

Chest trauma assessment: Listen

A

Listen for normal and equal breath sounds on each side
Done second

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16
Q

Chest trauma assessment: Feel

A
  • Palpate for chest wall tenderness
  • Palpate for subQ emphysema (air bubbles under the skin)
  • Assess for tracheal alignment
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17
Q

Chest trauma mgmt: assess

A
  • Pain
  • Anxiety
  • Resp distress
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18
Q

Chest trauma mgmt: Treatment

A
  • Goal is to evacuate blood and air from pleural space
  • Chest Tube
  • Fill chest wound
  • O2
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19
Q

Tension pneumothorax

A
  • Trachea: Deviated (side of injury)
  • Chest expansion:Decreased
  • Breath sounds: Diminished or absent
  • Percussion: Hyper resonant
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20
Q

Simple Pneumothorax

A
  • Trachea: Midline
  • Chest expansion: Decreased
  • Breath sounds: May be diminished
  • Percussion:Usually normal may be hyper resonant
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21
Q

Hemothorax

A
  • Trachea: Midline
  • Chest expansion: Decreased
  • Breath sounds: Diminished if large, normal if small
  • Percussion: Dull
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22
Q

A patient is brought to the emergency room after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause?
Impact of a steering wheel
Fall to the ground from a ladder
Stabbing with a knife
Concrete debris from an explosion

A

Stabbing with a knife
Probably

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23
Q

Abdominal/pelvic trauma

A
  • History of injury
  • Inspection: Sharp or blunt? examine pelvis and perineum
  • Auscultate: Bowel sounds
  • Palpate: Tenderness, including rebound tenderness
    • Muscle rigidity
    • Pain
    • Distension
  • Labs and diagnostics
    • UA,CBC, preg, PT/INR
    • Pelvic X ray, ct
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24
Q

Abdominal/pelvic trauma: Blunt injury

A
  • Look at
    • the speed of impact
    • Location of wound
    • Intrusion of vehicle
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25
Q

Abdominal/pelvic trauma: Penetrating injury

A
  • Look at
    • Type of weapon
    • Distance
    • Speed
    • Location of wound
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26
Q

The nurse is admitting the patient with a penetrating abdominal injury from a knife wound. What should the nursing measures for a penetrating abdominal injury include: (Select all that apply)
1. Assessing for manifestations of hemorrhage
2. Covering any protruding viscera with sterile dressings soaked in normal saline solution
3. Looking for any associated chest injuries
4. Exploring the abdominal wound with a gloved finger
5. Irrigating the wound with normal saline

A
  1. Assessing for manifestations of hemorrhage
  2. Covering any protruding viscera with sterile dressings soaked in normal saline solution
  3. Looking for any associated chest injuries
  4. Irrigating the wound with normal saline
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27
Q

Musculoskeletal trauma: Fractures

A

ABC’s, including pulse in extremities

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28
Q

Musculoskeletal trauma: Pulseless extremity

A
  • Reposition
  • If ineffective, be quick and complete exam and then transfer to OR: ortho emergency
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29
Q

Musculoskeletal trauma:

A
  • Fractures
  • If pulseless, reposition
  • Life vs limb injuries
  • Compartment syndrome
30
Q

Musculoskeletal trauma: Life or limb, life

A
  • femur or pelvic fractures (lots of good arteries there)
  • Can die from associated blood loss of up to 2-3 liters
31
Q

Musculoskeletal trauma: Limb

A
  • Fractures associated with vascular dmg
  • open wounds or compartment syndrome
32
Q

Musculoskeletal trauma: Compartment syndrome

A
  • Extreme swelling to the point it impedes blood flow to the distal end of the extremity
  • Loss of pulse is a late sign
  • Disproportionately high pain
  • Pain on passive stretch of affected muscle
  • Palpable tenseness
  • Altered sensation
  • Delayed capillary refill
33
Q

Mgmt of compartment syndrome

A

fasciotomy: relieve the pressure by making an incision

34
Q

Musculoskeletal trauma mgmt:

A
  • Control the bleeding
  • Assess and recognize vascular compromise
  • Consider comparment syndrome
  • pain control
  • Reduce and immobilize fractures and dislocations
35
Q

Blast or explosion injuries:

A
  • Combination of mechanisms
    • Blunt and penetrating (Shrapnel)
  • Consider proximity, enclosed space, multiple fragments and secondary impacts (Throw or fall from height)
36
Q

Initial assessment of a pt

A
  • Priorities stay the same no matter the cause of injury
  • A: Airway and C spine protection
  • B: Breathing and ventilation
  • C: Circulation and bleeding control
  • D: Disability (Neurology)
  • E: Environment and exposures
37
Q

Initial assessment of a pt: Airway

A
  • Establish a patent airway
  • C spine stabilization
  • May need adjunctive therapy to maintain airway
38
Q

Initial assessment of a pt: Breathing and vent

A
  • Assess for adequate breathing and vent
  • RR
  • Chest movement
  • O2 sat
  • Mechanical vent
39
Q

Initial assessment of a pt: Circulation and bleeding control

A
  • Assess organ perfusion
  • LOC
  • Skin color and temp
  • Pulses: rate and character
  • Control bleeding
  • Restore volume
40
Q

Initial assessment of a pt: Disability

A
  • LOC
  • GCS
  • Motor and sensory to limbs

It is actually just neuro

41
Q

Initial assessment of a pt: Environment and exposure

A
  • Expose the pt
  • Look for wounds, rashes, contusions, injuries
  • Check temp
42
Q

Initial assessment of a pt: Neuro status

A
  • Baseline neuro status
  • GCS
  • Pupillary response
  • Observe for neuro deterioration
43
Q

GCS

A
  • Scale used to determine neuro function. assess LOC
  • Score ranges 3-15 with 15 being the best
  • Composed of 3 test (Motor, speech, eye)
  • Important to consider the individual scores as well as total score
  • Consider if the pt received narcotics or sedated
44
Q

GCS: Motor

A
  1. No response
  2. Decerb
  3. Decort
  4. Withdrawal from pain
  5. Localizes to pain
  6. Obeys commands
45
Q

GCS: Eye

A
  1. No response
  2. To pain
  3. To speech
  4. Spontaneously
46
Q

GCS: Speech

A
  1. None
  2. Incomprehensible (Grunting)
  3. Inappropriate
  4. Confused
  5. Orientated
47
Q

Pupillary response

A
  • Check for symmetry
  • Check size
  • Check reaction
  • Are pupils dilated
48
Q

When are eyes no longer considered symmetrical

A

Greater than 1mm between them

49
Q

Fixed pupils

A

No response to light

50
Q

Dilated pupils

A

> 4 mm

51
Q

What else goes on during the initial assessment

A
  • All happening at once
  • Initial assessment
  • Resuscitation
  • Prevent hypothermia
  • Blood work and diagnostics
  • Vitals
  • Urine output
52
Q

What labs are done during the initial assessment

A
  • ABG
  • CBC
  • PT/PTT/INR
  • Chemistries
  • Lactate
  • Pregnancy
  • Cardiac enzymes
  • X ray
  • CT
  • Ultrasound
53
Q

What after the initial assessment

A
  • Initial assessment is ongoing, continually assess your pt
  • Monitor for changes
  • Identify and treat deterioration
54
Q

Starting a secondary assessment

A
  • Complete history
  • Complete head to toe physical
  • Complete neuro assessment
  • Further diagnostic testing
  • Continuoius reevaluation
55
Q

Secondary assessment: History

A
  • Sample history
    • S+S
    • Allergies
    • Meds
    • past medical history
    • Last oral intake
    • Events leading up to the injury
56
Q

Secondary assessment: Detailed physical exam: Head and face

A
  • External exam
  • Scalp, palpation and examination
  • Exam nose, ears auditory canal
  • Visual exam
  • Facial deformities
57
Q

Secondary assessment: Detailed physical exam: Neck

A
  • Soft tissue injuries
  • Hematoma
  • Bruit
58
Q

Secondary assessment: Detailed physical exam: Chest

A
  • Inspect
  • Auscultate
  • Palpate
  • Percuss
59
Q

Secondary assessment: Detailed physical exam: Abdomen/pelvis

A
  • Inspect
  • Auscultate
  • Palpate
  • Percuss
  • X-rays
  • Pain on palpation
  • Pelvic instability
60
Q

Secondary assessment: Detailed physical exam: Genitalia

A
  • Blood
  • Lacerations
61
Q

Secondary assessment: Detailed physical exam:Perineum

A
  • Contusions
  • Abrasions
  • Lacerations
62
Q

Secondary assessment: Detailed physical exam: Extremities

A
  • Deformities
  • Lacerations
  • Pain
  • Perfusion
  • X-ray (Soft tissue injuries, missed fractures)
63
Q

Secondary assessment: Detailed physical exam: Neuro

A
  • Cranial nerves
  • GCS
  • Pupillary response
64
Q

Secondary assessment: Detailed physical exam: Back and spine

A
  • Palpation
  • Deformity
  • Tenderness
  • Swelling
  • Sensation
  • Urinary output
  • Immobilization
65
Q

Brain death criteria:Coma

A
  • No evidence of responsiveness
  • Absent eye movements or eye opening with noxious stimuli
66
Q

Brain death criteria

A
  • Coma
  • Absent brainstem reflexes
  • Apnea
67
Q

Brain death criteria: Absent brainstem reflexes

A
  • Absent pupillary response, ocular movement, corneal reflexes
  • Absence of facial movements, gag reflex
68
Q

Special considerations: Peds

A
  • Big Head
  • Soft head
  • Large tongue
  • Soft chest wall
  • Soft thinner muscular wall
  • Smaller blood volume
  • Age specific vitals

Kids compensate really well, deterioration is sudden

69
Q

Special considerations: Geriatric

A
  • Vision
  • Diminshed hearing
  • Respiratory vital capacity
  • Renal disease
  • Joint pain and degeneration
  • Peripheral neuropathy
  • Vascular disease (impaired blood flow to legs)
  • HD
  • High BP
  • Stroke
  • Diabetes
  • Meds (polypharm)
70
Q

When do you transfer pt

A
  • Multisystem or complex injuries
  • Patients with comorbidities
  • Pts with age extremes
  • Hospital does not have specialty care that patient requires
71
Q

what do you document

A
  • Description of all wounds
  • mechanism of injury
  • Time of events
  • Collection of any and all evidence, such as clothing

NSG 478 (23 decks)

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