TNP Primary Survey
Name at least 4 things a nurse will inspect for when assessing airway patency of a trauma patient.
Obstructions such as: blood, vomitus, teeth, secretions, foreign objects, tongue obstructing.
Respiratory distress as evidenced by nasal flaring, open mouth breathing, stridor, snoring respirations, hoarse voice, crepitus in face or neck
What is the purpose of the head-to-toe assessment in trauma?
Any of the following are correct:
Identify and document all injuries.
Systematically assess each body part.
Prioritize injuries based on severity.
What condition do you suspect in a patient who was ejected from a vehicle if you note hypotension, a deviated trachea and significant respiratory distress with no air entry to the opposite lung of the tracheal deviation?
Tension Pneumothorax
What are the clinical manifestations Triad of Death? Bonus 100 points if you can identify a 4th component for the Diamond of Death
Hypothermia
Coagulopathy
Acidosis
What kind of trauma is a contraindication for an NG tube?
Skull fracture (basal skull)
Name at least 4 things a nurse will inspect for when assessing breathing effectiveness in the trauma patient.
Symmetry or paradoxical movement, accessory muscle use, respiratory rate/depth/effort, auscultation of lung sounds, trachea positioning (is it deviated or midline), crepitus, signs of pneumothorax (sucking chest wound), evidence of penetrating injury.
Why is it important to inspect posterior surfaces?
Any of the following are correct:
Identify hidden injuries (e.g., fractures, bruising).
Assess for any abnormal findings not visible from the front.
Ensure a complete assessment of the patient.
What three components make up the Glasgow Coma Scale (GCS)?
Eye opening
Verbal response
Motor response
Identify one way mechanism of injury can help in the care of a multisystem trauma patient.
Helps predict potential injuries.
Guides assessment and intervention strategies.
Assists in prioritizing care based on injury patterns.
Acknowledging that understanding a patient’s life experiences is key to potentially improving engagement and outcomes.
Trauma Informed Care
When conducting the circulatory assessment what are 3 key components to assess?
Skin color.
Skin temperature.
Skin moisture.
Also accept blood pressure, blood loss, cap refill
What kind of injury might you suspect if you see blood at the urethral meatus?
Bladder, pelvic, vaginal, urethral
Hypotension, BRADYCARDIA, warm skin, paralysis, priapism, altered loc,
What is the acronym used to describe the ultrasound exam that is done at bedside in the trauma patient?
FAST
= Focused Assessment by Sonography in Trauma
What complication should you monitor for in a patient with crush injuries due to the release of potassium into circulation?
Cardiac Dysrhythmias
When conducting the Disability (neurological) assessment in trauma name at least 2 things that must be evaluated.
Level of consciousness (AVPU & GCS)
Pupillary Reaction
Limb movement and sensation
Cranial Nerves
The G in the trauma nursing process stands for Get monitoring devices and Give comfort. Name at least 2 monitoring devices should be used.
Apply ECG leads, pulse oximeter, and BP cuff.
What does straw colored drainage indicate from the nose or ears?
CSF
What is the Protocol used as a standardized process for rapidly providing blood and blood components to trauma patients who are bleeding heavily?
Massive Transfusion Protocol
Normally when opening a patients airway the head tilt-chin lift is used. In trauma patients a better way to open the airway is?
Jaw Thrust
Name at least 2 things that will be done during the Exposure and Environmental Control step of the Trauma Nursing Process?
Expose the patient to identify injuries.
Prevent hypothermia (keep warm).
Assess for additional injuries or environmental factors.
Part of the Secondary Assessment in the Trauma Nursing Process is identified as L, M, N, O, P. Name one of the components that the letters stand for.
L = Labs
M = Monitor
N = Naso- or orogastric tube
O = wean Oxygen based on Oximetry; assess capnography
P = Pain assessment and pain management
What does SAMPLE stand for?
S: Signs and Symptoms
A: Allergies
M: Medications
P: Past medical history
L: Last oral intake
E: Events leading to the injury
When a trauma patient needs rapid vascular access but several attempts at IV access have failed what type of access should be initiated?
Intraosseous Access
What is the significance of pain to the left shoulder in a trauma patient with no obvious trauma to the area?
Kehr's sign - possible spleen injury or blood in abdominal cavity from rupture