Download TNCC 9th Edition latest updated 2024 Graded A+.pdf and more Exams Nursing in PDF only on Docsity!
- ANSPrehospital shock index pg. 85 .. activation: .... are found in the carotid sinus and along the aortic arch, are sensitive to the degree of stretch in the arterial wall. When the receptors sense a decrease in stretch, they stimulate the sympathetic nervous system to release Epi, norepi, causing stimulation of cardiac activity and constriction of blood vessels, which causes a rise in heart rate and diastolic blood pressure - ANSBaroreceptors:
- A- airway and Alertness with simultaneous cervical spinal stabilization
- B- breathing and Ventilation
- circulation and control of hemorrhage
- D - disability (neurologic status)
- F - full set of vitals and Family presence
- G - Get resuscitation adjuncts L- Lab results (arterial gases, blood type and crossmatch) M- monitor for continuous cardiac rhythm and rate assessment N- naso or orogastric tube consideration O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal caron dioxide (ETC02) monitoring and capnopgraphy H- History and head to toe assessment I- Inspect posterior surfaces - ANSABCDEFGHI
- Apnea
- GCS 8 or less
- Maxillary fractures
- Evidence of inhalation injury (facial burns)
- Laryngeal or tracheal injury or neck hematoma
- High risk of aspiration and patients inability to protect the airway
- Compromised or ineffective ventilation - ANSFollowing conditions might require a definitive airway
- bony fractures and possible rib fractures, which may impact ventilation
- palpate for crepitus
- subcutaneous emphysema which may be a sign for a pneumothorax
- soft tissue injury - ANSPalpate the chest for
- Check the presence of adequate rise and fall of the chest with assisted ventilation
- Absence of gurgling on auscultation over the epigastrium
- Bilateral breath sounds present on auscultation
- Presence of carbon dioxide (CO2) verified by a CO2 device or monitor - ANSIf the pt has a definitive airway in what should you do?
- Dyspnea
- Tachycardia
- Decreased or absent breath sounds on the injured side
- CP - ANSSimple Pneumo assessment:
- equal breath sounds bilaterally at the second intercostal space midclavicular line and the bases for fifth intercostal space at the axillary line - ANSAuscultate the chest for:
- Get a CT
- Consider ABG 's if decreased LOC
- Consider glucose check - ANSD Interventions
- Hypotension
- JVD
- Muffled heart sounds - ANSBecks Triad:
- open the airway, use jaw thrust
- insert an oral airway
- assist ventilations with a bag mask
- prepare for definitive airway - ANSIf breathing is absent..
- pain - hallmark sign, early sign
- pressure - early sign
- pallor, pules, paresthesia, paralysis - late sign - ANSSix P's of compartment syndrome:
- Preparation
- Preoxygenation
- Pretreatment
- Paralysis and Induction
- Protecting and positioning - v
- Placement of proof - secure the tube
- Post intubation - secure ETT Tube, get X-ray for placement - ANSSteps of Rapid Sequence Intubation
- Preparation and Triage
- Primary Survery (ABCDE) with resuscitation adjuncts (F,G)
- Reevaluation (consideration of transfer)
- Secondary Survey (HI) with reevaluation adjuncts
- Reevaluation and post resuscitation care
- Definitive care of transfer to an appropriate trauma nurse - ANSInitial Assessment
- Suction the airway 2, Use care to avoid stimulating the gag reflex
- If the airway is obstructed by blood or vomitus secretions, use a rigid suction device
apply direct pressure to bleeding elevate extremity apply pressure over arterial sites Consider a pelvic binder for pelvic fractures consider a tourniquet cannulate two veins with large caliber IV - if unable to gain assess consider IO a. obtain labs, type and cross b. infuse warm isotonic fluids c. consider balanced resuscitation d. use rapid infusion device - ANSC Interventions: ask pt to pen his or her mouth - ANSWhile assessing airway the patient is alert and responds to verbal stimuli you should.. Before the arrival of the pt - ANSWhen should PPE be placed: brachial pulse - ANSUnder age of 1 where do you find a pulse Breathing: To assess breathing expose the chest:
- Inspect for a. spontaneous breathing b. symmetrical rise and fall c. depth, pattern, and rate of respiration d. signs of difficulty breathing such as accessory muscle use e. skin color (normal, pale, flushed, cyanotic) f. contusions, abrasions, deformities (flail chest) g. open pneumothoraces (sucking chest wounds) h. JVD i. signs of inhalation injury (singed nasal hairs, carbonaceous sputum) - ANSB can be caused by blunt trauma. air escapes from injured lung to pleural space and negative intrapleural pressure is lost causing partial or collapsed lung - ANSSimple Pneumothorax can result from penetrating wound through chest wall causing air to be trapped in to the intrapleural place. Might hear "sucking" Tx: nonporous dressing tapes on 3 sided, then Chest tube and would closure surgical repair. - ANSOpen Pneumo:
Capnography monitors numeric value, as well as continuous waveform, indicating real-time measurement and trending over time. - ANSQuantitative: Caused by blood in the intrapleural space/ May also occur from lac to live or spleen combined with injury to the diaphragm. Ensure two large bore IVS are placed. Prepare for thoracentesis and chest tube insertion. If open thoracotomy is done chest tube is deferred. - ANSHemothorax: Circulation and Control of Hemorrhage Inspect first for any uncontrolled bleeding Skin color palpate for central pulses - carotid and femoral - rate, rhythm, and strength Skin temp: cool, diaphoretic, or warm and dry - ANSC Colorimetric CO2 detectors provide info about the presence or absence of CO2. A chemically treated indicator strip changes color revealing the presence or absence of exhaled CO2 - ANSQualitative D displaced tube O obstructed or kinked P pneumothorax E equipment failure , such as becoming detached from the equipment or loss of capnopgrahy - ANSDOPE Disability - Neurologic Status
- Assess pupils for equality, shape, and reactivity (PERRL)
- Assess GCS (eye opening, verbal response, and motor response) - ANSD don't forget flanks!!! inspect of lacs, puncture wounds, contusions, auscultate then palpate: bowel sounds? any rigidity, guarding? begin with light palpation start to palpate with side that does not hurt
look at ears for drainage - ANSHead to toe assessment: Head and face inspect posterior surfaces blogroll with at least 3 people. maintain c spine take out backboard Rectal tone per MD - ANSI inspect, auscultate, palpate any spontaneous breathing, rate, depth, and degree of effort, use of accessory muscles lacs, contusions, auscilate lung sounds and heart sounds - ANSHead to toe assessment: Chest jaw thrust maneuver to open airway and assess for obstruction. If pt has a suspected csi, the jaw thrust procedure should be done by two providers. One provider can maintain c-spine and the other can perform the jaw thrust maneuver. - ANSWhile assessing airway pt is unable to open mouth, responds only to pain, or is unresponsive you should.. labs, wound care, tetanus, administer meds, prepare for transfer - ANSSecondary Reval Adjuncts Needle pericardiocentesis, but it is a temp solution. Requires surgical evaluation. (Ultrasound guided) - ANSCardiac Tamponade Intervention: occurs as a result of maldistribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. Ex: Anaphylactic - release of antihistamines Septic Shock - systemic release of bacterial endotoxins, resulting in increased vascular permeability and vasodilation. Neurogenic shock - spinal cord injury results of loss in sympathetic nervous system control of vascular tone. Goal: Volume replacement and vasoconstriction - ANSDistributive Shock Pediatric Assessment Triangle
- General appearance - muscle tone, interactiveness, consoloability, poor or gaze, speech or cry
- Work of breathing - inadequate or excessive, accessory muscle use, retractions, tripod position, abnormal upper airway sounds
- Circulation of the skin - color, mottling or central or peripheral cyanosis, diaphoresis - ANSPAT Pt is at hospital in the right amount of time, right care, right trauma facility, right resources - ANSSafe Care: Reevaluation and Consider the need to Transfer - ANSFinal step in primary survey reorganize care to C-ABC - ANSIf uncontrolled hemorrhage .. results from hypo perfusion to the tissue due to an obstruction in either vasculature or heart. Goal is to relieve obstruction and improve perfusion. Ex: tension pneumo or cardiac tamponade are two classic examples that may result from trauma. - ANSObstructive Shock Results from pump failure in the presence of adequate intravascular volume. There is a lack of cardiac output and end organ perfusion secondary to a decrease in myocardial contractility and/or valvular insufficiency. Ex: MI's or dysrhythmia are common causes - ANSCariogenic Shock Sample is part of history S symptoms associated with injury A allergies and tetanus status M meds currently on including anticoagulant therapy P past medical hx L last oral intake E Events and environment factors related to the injury - ANSSAMPLE stabilized vital signs, improved mental status, improved urine output - ANSWhat are indicators of increased perfusion? Stroke Volume X HR - ANSCardiac Output = the decrease coagulopathy .. you will you bleed more - ANSThe colder you are the more acidic you are.. tracheal deviation and jvd - ANSLate signs of tension pneumo:
Describe the characteristics of cardiogenic shock - ANSCardiogenic shock results from pump failure in the presence of adequate intravascular volume. Lack of cardiac output and an organ perfusion occurs secondary to a decrease in myocardial contractility and or valvular insufficiency. This can happen with blunt cardiac trauma or an MI. Symptoms can include low blood pressure increase heart rate and respiratory rate chest pain shortness of breath dysrhythmias increase troponin and pale cool moist skin Describe the characteristics of distributive shock. - ANSDistributive shock occurs as a result of Mel distribution of an adequate circulating blood volume with the loss of vascular tone or increased permeability. This can occur with spinal cord injuries, sepsis, or anaphylaxis. Symptoms include low blood pressure heart rate respiratory rate preload and afterload, spinal tenderness, difficulty breathing, warm pink and dry skin with a cool core temperature. Describe the characteristics of hypovolemic shock - ANSHypovolemia is caused by a decrease in the amount of circulating volume usually caused by massive bleeding, but also can be from vomiting and diarrhea. Characteristics include low blood pressure and preload, increase heart rate respiratory rate and afterload, with contractility unchanged. Signs include obvious bleeding, weak peripheral pulses, pale cool and moist skin, distended abdomen, pelvic fracture, or bruise swollen and deformed extremities especially long bones. Describe the characteristics of obstructive shock - ANSObstructive shock is it mechanical problem that results from hypoperfusion of the tissue due to an obstruction in either the vasculature or the heart resulting in decreased cardiac output. Some causes include a tension pneumothorax, cardiac tamponade, or venous air embolism on the right side of the heart during systole in the pulmonary artery.Signs include anxiety, muffled heart sounds, JVD, hypertension, chest pain, difficulty breathing, or pulses paradoxes. Describe the four types of spinal cord injury - ANSCentral cord injury results in greater weakness distally, anterior injury includes motor loss or weakness below the cord level of injury yet sensory is intact, Brown-Sequard (hemicord) is weak on one side with sensory deficit on opposite side, posterior cord syndrome although rare is when the patient is unable to use sense vibration in proprioception Describe the measurement of an NPA - ANSMeasure from the tip of the patient's nose to the tip of the patients earlobe. Differentiate between the three impacts of motor vehicle impact sequence. - ANSThe first impact occurs when the vehicle collided with another object. The second impact occurs after the initial impact when the occupant continues to move in the original direction of travel until they collide with the interior of the vehicle or meet
resistance. The third impact occurs when internal structures collide within the body cavity. Measurement of an OPA - ANSPlace the proximal end or flange of the airway adjunct at the corner of the mouth to the tip of the mandibular angle. Name the three ways to confirm ETT placement - ANSPlacement of a CO2 monitoring device, Assessing for equal chest rise and fall, and listening at the epigastrium and four lung fields for equal breath sounds. True or false: NPAs and OPAs are definitive airways. - ANSFalse. When placing one of these? One should consider the potential need for a definitive airway. What are contributing factors to injuries related to blunt traumas? - ANSThe point of impact on the patient's body, the type of surface that is hit, the tissues ability to resist (bone versus soft tissue, air-filled versus solid organs), and the trajectory of force. What are the early signs of increased Intracranial pressure - ANSheadache, vomiting, behavioral changes that begin with restlessness and may progress to confusion, drowsiness, or impaired judgment What are the four types of shock? - ANSHypovolemic, Cardiogenic, Obstructive, & Distributive What are the four types of trauma related injuries? - ANSBlunt, penetrating, thermal, or blast. What are the greatest risks for transport? - ANSLoss of airway patency, displaced obstructive tubes lines or catheters, dislodge splinting devices, need to replace or reinforce dressings, deterioration in patient status change in vital signs or level of consciousness, injury to the patient and/or team members What are the late signs of Increased intracranial pressure - ANSdilated, non-reactive pupil(s); abnormal motor posturing (flexion, extension, flaccidity); Cushing's triad, Unresponsive to per verbal and painful stimuli, bradycardia and decreased respiratory effort What are the seven patterns of pathway injuries related to motor vehicle accidents? - ANSUp and over, down and under, lateral, rotational, rear, roll over, and ejection. What are the signs and symptoms of decompensated shock? - ANSDecreased level of consciousness, hypertension, narrow pulse pressure, tachycardia with weak pulses, tachypnea, skin that is cool clammy and cyanotic, base access outside the normal range, and serum lactate levels greater than two to 4MMOL/L.
What causes the primary effects of blast traumas? - ANSThe direct blast effects. Types of injuries include last long, tympanic membrane rupture and middle ear damage, abdominal hemorrhage and perforation, global rupture, mild Trumatic brain injury. What causes the secondary effects of blast traumas? - ANSProjectiles propelled by the explosion. Injuries include penetrating or blunt injuries or I penetration. What causes the tertiary effects of blast traumas? - ANSResults from individuals being thrown by the blast wind. Injuries include hole or partial body translocation from being thrown against a hard service: blunt or penetrating trauma's, fractures, traumatic amputations. What is a trademark symptom of an epidural hematoma - ANSLoss of consciousness then awake and alert then loss of consciousness What is bending? - ANSLoading about an axis. Bending causes compression on the side the person is bending toward intention to the opposite side What is combined loading? - ANSAny combination of tension compression torsion bending and/or shear. What is compression? - ANSCrushing by squeezing together What is Cullen's sign and its significance? - ANSCullens sign is periumbilical bruising and is indicative of intraperitoneal bleeding What is shearing? - ANSDamage by tearing or bending by exerting faucet different parts in opposite directions at the same time. What is tension? - ANSstretching force by pulling at opposite ends What is the minimum permissive hypertension and a trauma patient? - ANSA systolic of greater than or equal to 90 MMHG What is the minimum permissive oxygenation level of a trauma patient? - ANSGreater than or equal to 94% What is the Munro-Kellie doctrine? - ANSWithin the skull 80% his brain, 10% is blood, and 10% is CSF. Any increase of any of the products results in increased intracranial pressure. What is the recommended fluid bolus for a trauma? - ANS500 ML's of warmed isotonic crystalloid. Ongoing fluid boluses of 500 ML's should be given judiciously with constant reassessments after administration.
What is the relationship between mass and velocity to kinetic energy? - ANSKinetic energy is equal to 1/2 the mass multiplied the square of its velocity therefore when mass is doubled so is the net energy, however, when velocity is doubled energy is quadrupled. What is the trauma triad of death? - ANShypothermia, acidosis, coagulopathy What is torsion? - ANSTorsion forces twist ends in opposite directions. When capnography measurement reads greater than 45MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ANSIncreasing the ventilation rate. Doing so would allow the patient to blow off retained CO2. When capnography measurement reads less than 35MMHG, the nurse should consider increasing or decreasing the ventilation rate? - ANSDecreasing the ventilation rate. By doing so, the nurse allows the patient to retain CO2. When would you use a nasopharyngeal airway versus an oral pharyngeal airway? - ANSNasopharyngeal airways is contraindicated in patients with facial trauma or a suspected basilar skull fracture. Oral pharyngeal airways is used in unresponsive patients unable to maintain their airway, without a gag reflex as a temporary measure to facilitate ventilation with a bag mask device or spontaneous ventilation until the patient can be intubated.
