Trauma Nurse Process

Question 1

Initial/Primary Assessment Includes

Answer 1

ABCD

Question 2

When should you consider the need for definitive care?

Answer 2

through every step technically, but especially after primary assessment

Question 3

Secondary Assessment

Answer 3

E-I

Question 4

3 PREPARATION STEPS

Answer 4

1. Activate trauma team, assign roles
2. Prepare room/equipment
3. Don PPE, safety

Question 5

THE PT HAS ARRIVED! What do first

Answer 5

General Impression
Uncontrolled bleeding, apnea/unresponsiveness
Reprioritize C-ABC

Question 6

A =

Answer 6

ALERTNESS + AIRWAY

Question 7

B =

Answer 7

BREATHING + VENTILATION

Question 8

C =

Answer 8

CIRCULATION + CONTROL BLEEDING

Question 9

D =

Answer 9

DISABILITY/NEURO

Question 10

E =

Answer 10

EXPOSURE/ENVIRONMENT

Question 11

F =

Answer 11

FULL SET OF VITALS + FAMILY PRESENCE

Question 12

G =

Answer 12

GIVE COMFORT + GET ADJUNCTS

Question 13

H =

Answer 13

HISTORY + HEAD-TO-TOE

Question 14

I =

Answer 14

IDENTIFY/INSPECT POSTERIOR SURFACES for injury

Question 15

J =

Answer 15

JUST KEEP REEVALUATING

Question 16

AVPU =

Answer 16

A = Alertness
V = Verbal
P = Pain
U = Unresponsiveness

Question 17

“LMNOP” is a part of which step?

Answer 17

G = GIVE & GET

Question 18

What else should you consider when assessing pain

Answer 18

An appropriate scale (1-10, CPOT)
Non-pharm AND pharm interventions

Question 19

ASSESSMENT OF A

Answer 19

AVPU
Alert?
Able to open mouth?
Patency/Pain?
Unresponsiveness?

Question 20

What should you be doing simultaneously during ALERTNESS + AIRWAY assessment?

Answer 20

Cervical Spine stabilization (simulate taking off and putting on c-collar)

Question 21

Name 4 ways to Assess the patency and protection of the airway

Answer 21

Breath sounds
Respirations (rate/depth/pattern/symmetry)
Spontaneous breaths
Tracheal deviation
SubQ emphysema
Wounds/deformities
Skin color

Question 22

ASSESSMENT OF B

Answer 22

1. OBSERVE: spontaneous breathing, tracheal deviation, symmetrical chest rise, skin color, wounds, depth/rate/pattern
2. AUSCULTATE: breath sounds
3. PALPATE: subq emphysema, deformities/wounds

Question 23

ASSESSMENT OF C

Answer 23

Pulses
Temp
Color
Moisture

Question 24

What other important thing should you assess during this C?

Answer 24

IV ACCESS!!!
Need for fluids/bolus
REASSESS!
(Can get labs at this step)

Question 25

ASSESSMENT OF D

Answer 25

GCS PUPILS* Glucose

Question 26

ASSESSMENT OF E

Answer 26

Remove clothing Inspect for injuries Warming measures

Question 27

Name 1 warming measure

Answer 27

Blankets Warmed IV fluids Increase room temp Warming lights

Question 28

ASSESSMENT OF F

Answer 28

1. VS (BP, pulse, SpO2, temp, respirations) 2. Contact family

Question 29

ASSESSMENT OF G

Answer 29

GET adjuncts (LMNOP) GIVE comfort

Question 30

LMNOP =

Answer 30

Labs Monitor HR/rhythm Naso-/orogastric tube Oximetry/capnography Pain

Question 31

What should you consider with "Give comfort"

Answer 31

Appropriate pain scale Nonpharm AND pharm pain interventions

Question 32

ASSESSMENT OF H

Answer 32

1. History 2. Head-to-toe

Question 33

ASSESSMENT OF I

Answer 33

1. Inspect Posterior surfaces 2. FAST

Question 34

When is "I" assessment deferred?

Answer 34

When imaging IS indicated?

Question 35

What should you do prior to J

Answer 35

Summarize identified injuries if haven't already during each step

Question 36

ASSESSMENT OF J

Answer 36

JUST KEEP REEVALUATING (VIPP)

Question 37

What's included in VIPP

Answer 37

Reeval... V = vitals I = injuries/interventions P = primary survey P = Pain

Question 38

Take it home--what do last

Answer 38

Determine Definitive care or transport