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N332 final > trauma > Flashcards

trauma Flashcards

1
Q

Nursing assessments for a pts with traumatic injuries post resuscitation and/or critical care?

A 
HEAT TO TOE FRONT TO BACK
observe/look!
-are they breathing?
-any bleeding?
-is there guarding, rigidy?
auscultation
-bs in all 4 quads? hypo or hyper active?
-resp and cardiac sound like they should?
percussion
-hyper resonance--> air
-dullness--> fluid
palpation
-all 4 quads
-pelvis for stability
-anal sphincter for tone--> nerve damage, damage to lower GI tracht!!
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2
Q

diagnostics for pts with traumatic injuries?

A
  • x-ray–> some injuries may not be picked up the first time!!
  • labs- cbc, preg, coagulation, lactate, urinalysis, R&M, stool for occult blood
  • CT
  • FAST exam
  • angiography
  • urinalysis=myoglobin in the urine= rhabdo
  • cystogram= damage to heart or urinary system
  • STOOL for occult blood!!
  • ->if there throwing up fresh blood (upper GI)
  • -> stool, fresh blood–> lower GI!!, coffee grounds either direction=lower GI
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3
Q

what is FAST?

A

focused assessment for trauma, ultrasound in ER. 80-90% effective for picking up bleedings

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4
Q

nursing interventions for traumatic injury pt?

A
  • maintain pt airway
  • serial vital signs
  • IV input and blood volume
  • insert 2 large bore IVs (OR) one for fluid one for blood products… not just RBC, clotting factors, albumin etc.
  • I&o–> output can be one of the biggest factors for hemostability for trauma pt!
  • pain management–> addressing the cause of the pain!!!
  • foley catheter
  • antibiotics
  • psychosocial support
  • prepare for OR
  • NG as indicated
  • cover wounds
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5
Q

ibuprofen impact with trauma?

A

antiplatet effect!!! keep an eye on platelet count and clotting factors if administering this anti-inflammatory…

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6
Q

collaborative management for trauma?

A
  • PREVENTION!! we want to prevent them in the first place
  • IV therapy, critical care nurses, PT/RT, emerg doctors
  • rehab STARTS on admission
  • WHOLE focus of care= maximize patient function down the road… preventing complications
  • surgery
  • pharmacotherapy
  • -> abx
  • ->opiate analgesia
  • -> tetanus prophylaxis
  • -> gastric protection
  • -> anticoagulation
  • rehabilitation
  • psycho/social support
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7
Q

when do fatty embolisms occur?

A

12-72 hours!! usually.. could very well happen on your unit after transfer from emerg

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8
Q

neurological trauma=

A

direct injury to skull, brain, or spinal cord

  • -> brain= concussion/contusion/bleeds
  • SUBTLE CHANGES OVER TIME!!
  • we need a good solid baseline.. might be impacted by patients state
  • glascow goma scale-LOC!!
  • could be language barriers, hearing impairments, or cultural differences!! could impact ability to communicate
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9
Q

example of focal head injury

A

hit head–> subdural hematoma

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10
Q

example of diffuse head injury

A

concussion

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11
Q

assessing head trauma

A
  • changes in respiration–> RAPID look at what is happening!!
  • cervical integrity checked in ER
  • decreased LOC
  • GCS
  • papillary response
  • assessing cranial nerves
  • decreased pulse
  • increased systolic BP
  • widening PP
  • observe, palpate
  • changes in temperature
  • history of loss of consciousness or amenia
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12
Q

GCS less than 8?

A

major head injury!! comatose, likely need ventilation

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13
Q

when is mannitol administered?

A

if increased ICP but NOT if bleed suspected!!!

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14
Q

any injuries to mouth or head bleed….

A

PROFUSELY!!

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15
Q

why do we see increased systolic BP with head injuries?

A

increased ICP, body trys to maintain cerebral perfusion

-maintaining systolic over 100 is important for patient outcome!!

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16
Q

are blood products usually given to head trauma pts?

A

not usually!! risk of reaction to blood transfusion is greater than benefit
–> if they are also bleeding out somewhere as well you will see blood products being given!

17
Q

body goes into hypermetabolic state after injury, why do we monitor glucose after injury

A

make sure brain is getting glucose it needs

18
Q

with severe ICU patients injured we see which positions?

A

GCS 3 —> decorticate posturing, decerebrate posturing GCS 2!!
- in the process of dying

19
Q

primary brain injury usually results from?

A

mechanical damage caused by traumatic forces being applied. concussion.. laceration.. hemorrhage due to tearing of vessels.. burising, deforming of tissues…..

20
Q

secondary brain injury results from?

A

changes within the brain as a result of initial injury…

  • brain swells & increases intracranial volume
  • rigid cranium allows no room for expansion of contents so intracranial pressure increases
  • pressure on BV within the brain causes blood flow to the brain to slow
  • cerebral hypoxia and ischemia occur!!
  • intracranial pressure continues to rise… brain may herniate!!
  • cerebral bf ceases
21
Q

our huuuuge focus with primary brain injuries??

A

controlling intracranial pressure to avoid secondary injuries!!!

22
Q

what is shaken baby syndrome?

A

-very hard to deal with a child that wont stop screaming but education is sooo important!!
-infants have fontaneles that allow for swelling
–> posterior closes at 2-3 months, anterior closes between 12 and 18 months of age
-bulging fontanelle–> increased intracranial pressure–> HIGH PITCH SCREAM!!
ACT QUICKLY!!!

23
Q

over time in elderly, brain starts..

A

shrinking…. sometimes we think we are seeing depression or delirium but it is actually brain damage!!
any time you have elderly pt with fractured anything and you see a cut or bruise on face or neck, and then you see increased confusion or changed in LOC.. think UNDIAGNOSED CRANIAL BLEED!!

24
Q

elderly risk with cranial bleeds?

A

often on anticoagulants, heparin, warfarin!! really stop and think… do we have a brain injury with elderly pts and confusioN!!

25
Q

3 primary types of brain injuries?

A

intracranial lesions, contusions, lacerations

26
Q

non-displaced linear fractures?

A

cracked skull, may have negligible neurological deficits

27
Q

basilar skull fractures?

A

substantial force to skull, significant impact, not always detected on x-rays or CT scans. often looking at clinical findings for skull fractures

28
Q

base of skull fracture signs?

A
  • raccoon eyes
  • CSF rhinorrhea
  • CSF otorrhea
  • battle sign
  • haemotympanum
  • bump
29
Q

acute spinal cord injury?

A
  • can result from concussion, contusion, laceration, hemorrhage, or impaired blood supply to the cord
  • -> fracture of vertebral body
  • -> spinal shock
  • -> neurogenic shock
  • -> autonomic dysreflexia
  • -> cord syndromes (central, lateral, homers, anterior)
30
Q

stabilizers for spinal fractures?

A
  • jewett hyperextension brace
  • aspen collar
  • halo brace
31
Q

thoracic trauma?

A
  • 25% of MVC deaths are related to thoracic trauma

- second only to brain and spinal cord injuries as the l

N332 final (4 decks)

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