Trauma Nursing Process TNP TNCC Exam

What should you ask yourself after completing all of your interventions and reassessments? - Correct Ans-Does this patient need to be transferred to another hospital, to surgery, or to critical care? What happens prior to patient arrival? 1-3 - Correct Ans-1. Activate trauma team 2. Prepare trauma room 3. Don PPE What happens following patient arrival but before a decision to intubate has been made? 4-8 may change based on C-ABC - Correct Ans-4. Assess for obvious uncontrolled external hemorrhage or unresponsiveness/apnea and the need to reprioritize to C-ABC 5**. Assess level of consciousness using AVPU 6. Open the airway 7**. Assess the patency and protection of the airway 8**. Assess breathing effectiveness Continue the TNP assuming the patient was intubated. 9-11 - Correct Ans-9**. If intubated, assess endotracheal tube placement 10. If intubated, assess ETT position and securement 11. If intubated, state the need to begin mechanical ventilation or continue assisted ventilation Continue the TNP following assessments of ETT. 12-15 **12, 13, and 15 are double-starred - Correct Ans-12**. Assess circulation 13**. Assess neurologic status using GCS 14. Assess pupils 15**. Remove all clothing AND inspect for obvious abnormalities or injuries Continue the TNP following assessments of circulation, neuro status, and removal of clothing to inspect for injury. 16-18 - Correct Ans-16. Provide warmth 17. Obtain a full set of vital signs and weight in kilograms (if not determined earlier) 18. Facilitate family presence Continue the TNP using the LMNOP mnemonic. 19-23 - Correct Ans-19. L - trauma panel labs 20. M - monitor (Cardiac, consider EKG) 21. N - consider need for NG/OG 22. O - assess O2 and end-tidal capnography 23**. P - assess pain using appropriate pain scale Continue TNP after LMNOP (so after pain has been assessed). 24-26 - Correct Ans-24. Non-pharmacological comfort measures 25. Consider analgesic med order 26. Obtain pertinent history Head-to-Toe 27-43 - Correct Ans-27. Inspect and palpate head for injuries 28. Inspect and palpate face for injuries 29. Inspect and palpate neck for injuries -- Demonstrate removal AND reapplication of cervical collar for assessment (if indicated). 30. Inspect and palpate chest for injuries 31. Auscultate breath sounds 32. Auscultate heart sounds 33. Inspect the abdomen for injuries 34. Auscultate bowel sounds 35. Palpate all four quadrants of the abdomen for injuries 36. Inspect and palpate the flanks for injuries 37. Inspect the pelvis for injuries 38. Apply gentle pressure over iliac crests downward and medially 39. Apply gentle pressure on the symphysis pubis (if iliac crests are stable) 40. Inspect the perineum for injuries 41. Consider GU - urinary output 42. Inspect and palpate all four extremities for neurovascular status and injuries 43. Inspect and palpate posterior surfaces -- NOT if the patient has suspected spinal or pelvic injuries After the head-to-toe, the learner should summarize injuries identified throughout the scenario and ask themselves: - Correct Ans-"What interventions or diagnostics can you anticipate for this patient?" Following the completion of head-to-toe assessment in TNP, you must do what? 44 - Correct Ans-44. Identify at least THREE interventions or diagnostics these may include the following: Antibiotics Consults Head CT for any alterations in mental status Imaging (other radiographs, CT, ultrasound, interventional radiology as indicated) Law enforcement Mandatory reporting Psychosocial support Social services Splinting Tetanus immunization Wound care After identifying potential interventions/diagnostics and completing your assessments and interventions, you should ask yourself what? - Correct Ans-"What findings will you continue to reevaluate while the patient is in your care?" "Just keep re-evaluating" Just Keep Reevaluating. 45-48 - Correct Ans-45. Reevaluate vital signs 46. Reevaluate all identified injuries and effectiveness of interventions 47. Reevaluate primary survey 48. Reevaluate pain What do you ask yourself after re-evaluations are done? 49-50 - Correct Ans-49. "What is the definitive care for this patient?" 50. Consider need for transfer to a trauma center or admission After all of the assessments, interventions, reassessments, etc. are done, what is the last thing to ask? - Correct Ans-"Is there anything you would like to add at this time?" When considering GU and how to monitor urinary output: - Correct Ans-- Assess for contraindications for an indwelling urinary catheter - External catheter - Weighing diapers (pediatrics and adults) How do you first assess for pelvic instability? Then what do you do? - Correct Ans-Apply gentle pressure over iliac crests downward and medially. If iliac crests are stable, then apply gentle pressure on the symphysis pubis. T/F: It is appropriate to consider transfer to a higher level of care before or during the A-E. - Correct Ans-True. Consider this throughout. What is a systematic process to guide your care of trauma patients? - Correct Ans-trauma nursing process What does it mean to have double-starred criteria? - Correct Ans-It means that this criteria MUST be done in order. For double-starred criteria, ___ and ___ must be completed prior to moving to the next step. - Correct Ans-assessments, interventions Double-starred criteria include letters ___-___. - Correct Ans-A-E What does it mean to have single-starred criteria? - Correct Ans-This means the criteria needs to be done, but the sequence is not critical. **A stands for ___ and ___. - Correct Ans-alertness, airway **B stands for ___ and ___. - Correct Ans-breathing, ventilation **C stands for ___. - Correct Ans-circulation **D stands for ___. - Correct Ans-disability **E stands for ___. - Correct Ans-exposure What are the 4 potential single-starred criteria? - Correct Ans-- reassessment of primary survey interventions - blood glucose if alterations in mental status noted in disability assessment - pain assessment using appropriate pain scale - inspection of posterior surfaces (unless CI) Why might inspection of posterior surfaces be contraindicated? - Correct Ans-May be contraindicated by suspected spine or pelvic injury You must assess pain using an ___________. - Correct Ans-appropriate pain scale What are the double-starred criteria? (hint: A-E) - Correct Ans-**Alertness and Airway **Breathing and Ventilation **Circulation **Disability **Exposure T/F: Preparation and triage in TNP includes the act