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 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
What are the clinical manifestations Lethal Trauma Triad?
Hypothermia
Coagulopathy
Acidosis
This type of trauma results from being exposed to others traumatic experience through their stories and caring for them.
Indirect or Secondary Trauma
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 does the Glasgow Coma Scale (GCS) assess?
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 3 skin components must be assessed?
Skin color.
Skin temperature.
Skin moisture.
What does the letter F stand for in the Trauma Nursing Process?
Full set of vitals and Family presence
What does the V component stand for in the AVPU scale?
V: Verbal – Patient responds to verbal stimuli.
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 the P component stand for in the AVPU scale?
P: Painful – Patient responds only to painful stimuli.
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
The scoring system used to assess the severity of traumatic injury that combines GCS, systolic blood pressure and respiratory rate.
The Revised Trauma Score or Trauma Score.
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 phrase used to help remember to evaluate the trauma patient after an intervention has been implemented?
"When you mess reassess."