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NURS 361 - Advanced Acute Care Nursing Practice I Final > Trauma Assessment > Flashcards

Trauma Assessment Flashcards

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1
Q

What kinds of injuries are seen in trauma patients?

A

Blunt trauma (Falls/MVC)
Penetrating trauma (gunshot/stabbings)
Thermal trauma
Burn trauma
Blast trauma

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2
Q

What is the motor vehicle impact sequence?

A
  • Vehicle collides with object
  • Occupants continue to move in direction of travel until they collide with the interior of vehicle
  • Internal structures collide within body cavity
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3
Q

What questions might you ask related to a motor vehicle collision trauma to better understand the mechanism of injury?

A

How fast was the car going?
What did they hit and how?
Were they ejected?
Where was the damage on the car?
Did the car rollover?
What were they driving? Size of vehicle, pedestrian

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4
Q

What are the steps involved in the initial assessment of a trauma event?

A
  • Preparation/ triage
  • Primary Survey (A,B,C,D,E,F)
  • Reevaluation (transfer needed?)
  • Secondary Survey
  • Reevaluation and post resuscitation
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5
Q

What steps occur in the preparation/triage phase of caring for a trauma patient?

A

Notification of trauma patient/prepare the trauma room (decide roles for nursing team)
Donning personal protective equipment
Triage (MOI/Vital signs)
- Physical derangements
- Obvious or suspected injuries hemodynamically stable
- High energy transfer

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6
Q

What is CTAS?

A

Canadian Triage and Acuity Scale. Assess and determine severity of presenting problem.

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7
Q

What is level 1 in CTAS?

A

Resuscitation

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8
Q

What is level 2 in CTAS?

A

Emergent

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9
Q

What is level 3 in CTAS?

A

urgent

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10
Q

What is level 4 in CTAS?

A

Less urgent

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11
Q

What is level 5 in CTAS?

A

non-urgent

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12
Q

Within the CTAS, what levels will the majority of trauma patients be at?

A

At levels 1 &2

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13
Q

Time to see level 1 (resuscitation) patient?

A

see patient immediately

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14
Q

Time to see level 2 (emergent) patient?

A

within 15 minutes

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15
Q

Time to see level 3 (urgent) patient?

A

within 30 minutes

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16
Q

Time to see level 4 (less urgent) patient?

A

within 60 minutes

17
Q

Time to see level 5 (non-urgent) patient?

A

within 120 minutes

18
Q

What is involved in the primary survey of the trauma patient?

A

Across the room observation
Alertness
Airway
Breathing and ventilation
Circulation and control hemorrhage
Disability (neurological status)
Exposure and environmental control

(A, B, C, D. E)

19
Q

What is a simple approach to assessing alertness?

A

AVPU

A: alert and oriented
V: responds verbally
P: pain (responds to)
U: unresponsive

20
Q

How do you inspect the airway in a trauma patient?

A
  • Inspect, auscultate, and palpate
  • Loose teeth, foreign objects, blood, edema, inhalation injury
  • Are they maintaining their own airway?
  • Do we need to suction the airway?
  • Do we need an OPA or a NPA?
  • Do we need a definitive airway like a endotracheal tube?
21
Q

What do you assess regarding breathing in a trauma patient?

A

Spontaneous breathing?
Symmetrical rise and fall of the chest?
Skin colour (are they cyanotic?)
Auscultate and palpate
Do we need to place oxygen on? Titrate and monitor ( we don’t want to hyper - oxygenate if it is not needed)
Are they working to breathe?
Life threatening injuries:
- Open pneumothorax
- Tension pneumothorax
- Flail chest
- Hemothorax

22
Q

What do you assess regarding circulation in a trauma patient?

A
  • Uncontrolled bleeding
  • Pale skin/cyanosis/ pink
  • Auscultate heart sounds
  • Palpate pulses/ central and peripheral
  • Pressure on bleeding wounds
  • Pelvic binder
  • Two large IVs- in case you need to get a lot of fluid/blood in
23
Q

What do you assess regarding disability (neurological status) in a trauma patient?

A

Glasgow coma scale
Perrl (pupils equal, round, reactive to light)
Glucose level
Move all four extremity

24
Q

What is involved in ‘Exposure’ in a trauma patient?

A
  • Remove all clothing/coverings
  • Avoid hypothermia
  • Complete head to toe exam
  • You want to get the clothes off so you don’t miss any injuries
    Once you look at them, warm blankets, dry gown etc.
    Roll patient, maintain cspine
25
Q

What does the ‘F’ represent in the A,B,C,D,E,F of the trauma patient?

A

Full set of vitals and family presence

26
Q

What is the importace of vital sign completion and monitoring in the trauma patient?

A

Monitor vital signs to determine effectiveness of the resuscitation
Trend vital signs frequently for changes in patient status

27
Q

How is the family involved in the trauma patient care response and who care for them?

A
  • Facilitate family presence as soon as a member of the trauma team is available
  • charge nurse typically cares for the family members
28
Q

What is involved in ‘Getting monitoring devices/Give comfort’ with the trauma patient?

A
  • Labs
  • Monitor cardiac rate and rhythm with telemetry
  • Nasogastric tube/orogastric tube
  • Oxygenation and etco2 monitoring
  • Pain assessment
29
Q

What is involved in the secondary assessment for the trauma patient?

A

History
Head to toe assessment
Inspect posterior surfaces
Just keep reevaluating
What are the additional tests that we need?
LABS, ABG, xray, CT Scans, Splints, wound care, tetatnus, pain medication, operating room?
Do we need to transfer the patient to another facility?

30
Q

Why is rapid evaluation of abdominal and pelvic trauma key?

A

Because of high potential for large-volume hemorrhage

31
Q

What does SAMPLE stand for r/t assessment?

A

S: Signs and symptoms
A: Allergies
M: Medications
P: Pertinent past history
L: Last intake and output
E: Events leading up to injury

32
Q

What does ABCDEFGHI represent for trauma assessment?

A

Airway
Breathing
Circulation
Disability
Expose and examine
Full set of vitals and family
Give comfort measures
Head-to-toe and history
Inspect posterior surface

33
Q

What are considered life threatening respiratory injuries in a trauma patient?

A
  • Open pneumothorax
  • Tension pneumothorax
  • Flail chest
  • Hemothorax

NURS 361 - Advanced Acute Care Nursing Practice I Final (13 decks)

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