Trauma Nursing Objectives and Triage
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Questions and Answers

What does the term "<C>" stand for in the context of the Primary Survey?

  • Compromised airway
  • Critical care
  • Catastrophic hemorrhage (correct)
  • Circulatory collapse

When assessing the airway during the primary Assessment, it is important to avoid hyperextension of the neck.

True (A)

During the assessment of Breathing, you should listen for dyspnea, cyanosis, and paradoxical/asymmetric chest wall movement.

True (A)

Which of the following assessments and interventions are considered part of the "Circulation" component of the primary assessment?

<p>All of the above (D)</p> Signup and view all the answers

What does the Glasgow Coma Scale assess when assessing the patient's "Disability" in the primary survey?

<p>All of the above (D)</p> Signup and view all the answers

During the "Exposure" component of the Primary survey, you should always remove impaled objects immediately to prevent further injury.

<p>False (B)</p> Signup and view all the answers

The "Full Set of Vitals and Family Presence" component of the primary survey encourages family members' presence during the initial assessment and resuscitation.

<p>True (A)</p> Signup and view all the answers

Which of the following are considered "comfort measures" in the context of the "Get Monitoring Devices & Give Comfort" stage of the primary survey?

<p>All of the above (D)</p> Signup and view all the answers

During the Secondary Survey, a pulseless extremity is considered a time-critical emergency requiring immediate attention and intervention.

<p>True (A)</p> Signup and view all the answers

When assessing the posterior surfaces of a patient during the Secondary Survey, it is essential to logroll the patient to prevent injury to the cervical spine.

<p>True (A)</p> Signup and view all the answers

Which of the following are crucial components of the "Just Keep Reevaluating" aspect of the Secondary Survey?

<p>All of the above (D)</p> Signup and view all the answers

EMTALA requires immediate medical attention and stabilization for patients who present to the Emergency Department regardless of their ability to pay for services.

<p>True (A)</p> Signup and view all the answers

A physician is required to stop and render aid to a person who is in an accident, regardless of whether it is safe or prudent to do so.

<p>False (B)</p> Signup and view all the answers

Which of the following conditions may lead to Pulseless Electrical Activity (PEA)?

<p>All of the above (D)</p> Signup and view all the answers

When a patient dies in the Emergency Department, it is essential to inform the family and friends about the situation, providing compassionate support and assistance during the difficult time.

<p>True (A)</p> Signup and view all the answers

What does the acronym ABCDEFG stand for in trauma assessment?

<p>Alertness, Breathing, Circulation, Disability, Exposure, Full Set of Vitals, Get Monitoring Devices, and Give Comfort (C)</p> Signup and view all the answers

<C> in <C>ABC stands for "catastrophic hemorrhage."

<p>True (A)</p> Signup and view all the answers

What is the primary method of opening an airway in trauma emergencies?

<p>Jaw-thrust maneuver</p> Signup and view all the answers

When is rapid-sequence intubation recommended for securing the airway?

<p>When the patient is unconscious and at risk of aspiration (C)</p> Signup and view all the answers

Which of the following is NOT a sign of a compromised airway?

<p>Strong pulse (C)</p> Signup and view all the answers

The Glasgow Coma Scale assesses the patient's ______, ______, and ______ response.

<p>eye, verbal, motor</p> Signup and view all the answers

When assessing a patient's circulation in trauma, it is crucial to check for signs of shock and capillary refill.

<p>True (A)</p> Signup and view all the answers

What type of fluid is generally used for aggressive fluid resuscitation in trauma patients?

<p>Normal saline or lactated Ringer's solution</p> Signup and view all the answers

What is the best approach to manage penetrating abdominal trauma in the early stages of care?

<p>Do not remove impaled objects, stabilize the patient, and prepare for surgical intervention (C)</p> Signup and view all the answers

Match the following terms related to the initial assessment of trauma patients with their corresponding actions or considerations:

<p>ABCDEFG = Alertness, Breathing, Circulation, Disability, Exposure, Full Set of Vitals, Get Monitoring Devices, and Give Comfort &lt;C&gt;ABC = Prioritize catastrophic hemorrhage control Jaw-thrust Maneuver = Safely open the airway without hyperextending the neck Rapid-sequence Intubation = Used for unconscious patients at risk of aspiration Glasgow Coma Scale = Assesses eye, verbal, and motor responses</p> Signup and view all the answers

Flashcards

Multiple Trauma Patient Assessment

Evaluating a patient with multiple injuries, focusing on immediate stabilization and treatment.

Hypovolemic Shock Treatment

Treating a trauma patient suffering from low blood volume.

Triage

Prioritization of patients based on the severity of their injuries.

ESI (Emergency Severity Index)

A method for categorizing trauma patients based on the severity of their condition.

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Primary Survey (ABCDEFG)

Initial rapid assessment focused on life-threatening conditions.

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Uncontrolled External Hemorrhage

Significant bleeding that needs immediate control.

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Airway Assessment

Evaluating a patient's ability to breathe.

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Airway Stabilization

Protecting the airway and cervical spine.

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Jaw-Thrust Maneuver

Technique to open the airway without hyperextending the neck.

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Breathing Assessment

Evaluating a patient's breathing quality and adequacy.

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Circulation Assessment

Evaluating heart rate, pulse, and skin condition to check for signs of shock.

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Disability Assessment

Evaluating the patient's mental status & neurological condition.

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Exposure Assessment

Assessing all body regions for injury—preserving evidence.

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Secondary Survey

Detailed assessment of body systems.

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SAMPLE History

Collecting patient history (Symptoms, Allergies, Medications, Past history, Last oral intake, Events).

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VIPP

Vital signs, Injuries sustained, Interventions and Pain level

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Glasgow Coma Scale

Assessment of responsiveness of a patient.

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FAST

Focused abdominal sonography for trauma.

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Logroll

Rolling patient to examine posterior surface.

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Ethical Considerations in Trauma Care

Addressing moral dilemmas in trauma situations, including care responsibilities.

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Pulseless Electrical Activity (PEA)

Electrical activity without a mechanical pulse.

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Death in Emergency Department

Caring for grieving family members, death protocols.

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Gerontological Considerations

Adjusting care to the unique needs of older adults with injuries.

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Trauma Nursing

A specialized area of nursing focusing on the care of patients experiencing traumatic injuries.

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Multiple Trauma Patient

A patient who has sustained injuries to multiple body systems. They require a comprehensive and coordinated approach to care.

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Hypovolemic Shock

A life-threatening condition that occurs when the body loses a significant amount of blood or fluids, leading to decreased blood volume and pressure.

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Emergency Severity Index (ESI)

A system used to classify patients according to their acuity and resource needs, guiding triage decisions.

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Cervical Spine Stabilization

Preventing movement of the neck to protect a potential spinal injury.

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Vital Signs (VIPP)

Continually monitoring vital signs, injury status, interventions, and pain levels to assess a patient's response to care.

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Glasgow Coma Scale (GCS)

A neurological assessment tool that evaluates a patient's level of consciousness, aiding in identifying brain injury severity.

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Focused Abdominal Sonography for Trauma (FAST)

An ultrasound examination used to detect internal bleeding in the abdomen.

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Death in the Emergency Department

Providing compassionate support to families experiencing loss, following protocols for death notification and handling.

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Gerontological Considerations in Trauma Care

Adjusting care to the unique needs of older adults who have experienced trauma, recognizing their vulnerability.

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Emergency Medical Treatment and Active Labor Act (EMTALA)

A federal law that requires hospitals to provide emergency medical care to all patients, regardless of their ability to pay.

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Good Samaritan Law

A law that protects individuals who provide aid in emergencies from legal liability, encouraging them to help.

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Trauma Codes

Emergency alerts used to signal the presence of a trauma patient, triggering rapid response teams to provide immediate care.

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Abuse and Assault

Trauma nursing may involve caring for victims of abuse or assault, requiring specialized skills and sensitivity.

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Hypoxia

Low oxygen levels in the blood, a common complication in trauma patients.

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Acidosis

Increased acidity in the blood, a potential complication of trauma due to tissue injury or shock.

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Hyperkalemia/Hypokalemia

Abnormal potassium levels in the blood, which can be caused by trauma and affect heart function.

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Hypothermia

Low body temperature, a common complication in trauma patients, especially those exposed to cold environments.

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Study Notes

The Primary Survey: A Life-Saving Approach

  • The "C" in the primary survey stands for Circulation.
  • Airway: Maintain a patent airway by positioning the patient’s head in a neutral position, tilting their chin up, and potentially using an airway adjunct. Avoid hyper-extending the neck, which can hinder breathing.
  • Breathing: Assess the patient's respiratory rate, effort, and sounds. Observe for signs of respiratory distress, including dyspnea (difficulty breathing), cyanosis (bluish discoloration of the skin), and paradoxical/asymmetric chest wall movement.
  • Circulation: Includes assessing the patient's pulse, blood pressure, and skin color. Other interventions include controlling external bleeding, starting IV fluids, and administering medications.
  • Disability: The Glasgow Coma Scale (GCS) assesses a patient's level of consciousness, evaluating their eye opening, verbal response, and motor response to provide a numerical score reflecting their neurological status.
  • Exposure: Remove clothing to allow for a comprehensive physical assessment and maintain patient warmth. However, impaled objects should never be removed, as they can worsen injury.
  • Full Set of Vitals and Family Presence: Encourage family members’ presence during the initial assessment and resuscitation, providing support and comfort.
  • Get Monitoring Devices & Give Comfort: This includes monitoring vital signs, managing pain, and providing emotional support to the patient. Examples of comfort measures include using blankets, providing a bedside fan, and offering reassurance.

The Secondary Survey: A Deeper Dive

  • A pulseless extremity is a time-critical emergency requiring immediate attention and intervention.
  • Logrolling is a technique used to assess the posterior surfaces of a patient during the secondary survey. This maneuver allows examination without moving the patient's cervical spine and risking further injury.
  • Just Keep Reevaluating: This involves the continual reassessment of the patient's condition throughout the primary and secondary surveys, including vital signs, pain levels, and the effectiveness of treatments.

Additional Considerations

  • EMTALA (Emergency Medical Treatment and Active Labor Act): Requires immediate medical attention and stabilization for patients who present to the Emergency Department, regardless of their ability to pay for services.
  • Duty to Act: A physician is generally not legally obligated to stop and render aid to a person who is in an accident. However, there are exceptions, for example, if the physician is the only person present.
  • Pulseless Electrical Activity (PEA): This occurs when there is electrical activity in the heart but no mechanical contraction, resulting in a lack of pulse. This can be caused by a range of factors, including hypoxia, hypovolemia, hyperkalemia, and cardiac tamponade.
  • End-of-life Care: When a patient dies in the Emergency Department, it is essential to inform the family and friends about the situation, providing compassionate support and assistance during the difficult time. Offer condolences, facilitate the grieving process, and provide resources for support.

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Trauma Nursing Student Version PDF

Description

This quiz covers essential knowledge for nursing professionals in trauma care, focusing on assessment, emergency stabilization techniques, and ethical considerations. It includes key concepts of triage, primary survey assessments, and the management of hypovolemic shock. Enhance your understanding of trauma nursing and improve patient care strategies.

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