Questions and Answers
Which of the following are non-pharmacological comfort measures? (Select all that apply)
What should be considered when applying ice to patients for comfort?
Hypothermia risk for major trauma and very small pediatric patients.
What should be considered when providing warmth?
Burn risk.
Which of the following can be identified when obtaining pertinent history? (Select all that apply)
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What should you ask yourself after completing all of your interventions and reassessments?
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What happens prior to patient arrival?
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What happens following patient arrival but before a decision to intubate has been made?
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Continue the TNP assuming the patient was intubated.
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Continue the TNP following assessments of ETT.
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Continue the TNP following assessments of circulation, neuro status, and removal of clothing to inspect for injury.
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Continue the TNP using the LMNOP mnemonic.
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Continue TNP after LMNOP.
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What interventions or diagnostics can you anticipate for this patient?
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What findings will you continue to reevaluate while the patient is in your care?
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What is a systematic process to guide your care of trauma patients?
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It is appropriate to consider transfer to a higher level of care before or during the A-E.
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Preparation and triage in TNP includes the activation of the trauma team, role assignment, preparation of the trauma room, and donning PPE.
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During the general impression, assessments and interventions identify life-threatening conditions and you should prioritize the life-saving interventions. Order of step completion is not important.
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What is assessed in GCS?
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The GCS is documented as non-testable if there is a factor, such as sedation or paralytics, interfering with communication.
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How do you first assess for pelvic instability? Then what do you do?
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You must assess pain using an __________.
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Study Notes
Trauma Nursing Process Overview
- Trauma Nursing Process (TNP) is a systematic approach for the care of trauma patients.
- Continuous assessment and intervention are critical throughout the process.
Patient Transfer Considerations
- After completing interventions, consider if the patient requires transfer for further care, surgery, or critical care.
Pre-Arrival Actions
- Activate the trauma team and prepare the trauma room.
- Don personal protective equipment (PPE).
Initial Patient Assessment
- Assess for uncontrolled external hemorrhage or unresponsiveness, adjusting priorities to C-ABC (Circulation, Airway, Breathing).
- Use AVPU (Alert, Verbal response, Pain response, Unresponsive) to assess consciousness.
- Ensure airway patency and effectiveness of breathing.
Post-Intubation Procedures
- Check endotracheal tube (ETT) placement and securement.
- Begin mechanical ventilation or continue assisted ventilation if intubated.
Continued TNP Actions
- Assess circulation and neurologic status with the Glasgow Coma Scale (GCS).
- Conduct a thorough inspection for injuries, including pupils and skin temperature.
LMNOP Mnemonic in TNP
- L: Conduct trauma panel labs.
- M: Monitor cardiac status and consider EKG.
- N: Consider the need for nasogastric (NG) or orogastric (OG) tube placement.
- O: Assess oxygen saturation and end-tidal capnography.
- P: Assess pain using appropriate scales.
Head-to-Toe Assessment
- Inspect and palpate extremities, abdomen, chest, and head for injuries.
- Reassess and document all injuries identified during the scenario.
Identifying Interventions and Diagnostics
- After gathering data, determine necessary interventions such as imaging, psychosocial support, and wound care.
Continuous Reevaluation
- Constantly reevaluate vital signs and all identified injuries to ensure effective interventions.
- Assess for any changes in patient condition or response to interventions.
Transfer of Care Considerations
- Identify the definitive care required and the potential need for transfer to a higher-level trauma center.
Allowing Family Presence
- Facilitate family presence if appropriate to support the patient emotionally.
Assessment of Urinary Output and Pelvic Stability
- Assess for urinary output management and check for pelvic instability before proceeding with interventions.
Double-Starred Criteria Importance
- Double-starred assessments and interventions (A-E) should be performed sequentially, as they are critical to patient care.
Single-Starred Criteria Flexibility
- Single-starred criteria are necessary but can be performed in any order and include assessments such as pain evaluation and posterior surface inspection.
Interventions for Life-Threatening Conditions
- Prioritize immediate interventions for identified injuries, reassessing the effectiveness continuously.
Importance of Team Communication
- Effective communication and role assignment among trauma team members are essential for successful TNP execution.
Non-Pharmacological Comfort Measures
- Implement comfort measures like verbal reassurance and distraction to support patient comfort before medication administration.
Patient Safety and Equipment Management
- Consider potential safety threats during preparation and ensure essential equipment is available and ready for use.
Pain Assessment and Management
- Assess pain thoroughly and consider non-pharmacological measures before ordering analgesics.
Note on Special Conditions
- Special care must be taken with pediatric and major trauma patients regarding warmth and ice application, balancing comfort with the risk of hypothermia or burns.
Documentation and History Collection
- Collect pertinent history through medical records, prehospital reports, and use the SAMPLE mnemonic (Signs/Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, Events leading to present illness/injury).
Final Steps
- After assessing the patient's condition and necessary interventions, ask if there is anything else to add, ensuring comprehensive patient care.
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Description
This quiz explores the comprehensive approach to the Trauma Nursing Process (TNP) for managing trauma patients. It covers essential aspects of patient assessment, transfer considerations, and post-intubation procedures crucial for effective trauma care. Test your knowledge on prioritizing actions for optimal patient outcomes.
