Complex Concepts 2 - Exam 1
What is #1 when caring for a Trauma patient? *** *SAFETY for yourself!*
- must have scene safety prior to treating patients
Trauma Nursing *** Interventions
- rapidly assess and intervene when life threatening situations arise (60s or less)
- keep the patient warm!!! (86 degrees or more) (cold blood will clot)
- avoid the trauma "Triad of Death": Hypothermia, Acidosis, Coagulopathy
- replace lost volume with fluids
- monitor V/S for shock (TREND!!), circulatory assessment
- monitor I&Os (helps estimate blood lost)
- reassess after intervention
- maintain C spine precautions
Reverse Triage *** AKA: Disaster triage; used only in mass casualty situations
- treats the less injured first and leaves the severely injured to possibly die
- allows for a greater number of patients to be treated by utilizing resources more effectively
- used to assess and categorize patients quickly; "immediate" has the potential for the greatest number
of patients
Black Triage Tag Color *** EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief should be provided
- agonal breathing, no spontaneous breathing even after repositioning airway
,EX: obvious non-survivable injury, respiratory arrest, cardiac arrest, airway repositioning does NOT work
and does not reestablish the airway
Red Triage Tag Color *** IMMEDIATE, highest priority patients
- victim can be helped by immediate intervention and transport
- requires medical attention within minutes for survival (up to 60 mins)
- includes compromises to patient's ABC
- RR >30, absent radial pulse or cap refill >2, doesn't obey commands, no spontaneous breathing air way
repositioned then we hear spontaneous breaths
EX: airway/breathing issues, uncontrolled/severe bleeding, severe burns, SHOCK, open chest/abdominal
wounds
Yellow Triage Tag Color *** DELAYED
- victim's transport can be delayed, need to go to hospital
- not able to walk but spontaneous breathing, RR <30, radial pulse present or cap refill <2, obeys
commands
- includes serious and potentially life-threatening injuries, but status not expected to deteriorate
significantly over several hours
EX: burns with no airway problems, major/multiple bone or joint injuries, back injuries with or without
spinal cord injuries, breathing and mental status are intact but cannot walk or move
Green Triage Tag Color *** MINOR
- victim with relatively minor injuries, able to walk, doesnt need hopsital
- status unlikely to deteriorate over days
- may be able to assist in own care: "Walking Wounded"
EX: minor fractures, minor soft tissue injuries
Disaster Triage Process *** *First:* call out, "If you can walk, come to the sound of my voice"
,- anyone who walks to you is tagged *Walking Wounded (green)*
*Second: START TRIAGE*
1. Breathing
- more than 30 RR = shock - *tag immediate (red)*
- less than 30 RR = move to step 2
- no respirations after 2 chin tilt attempts = *deceased (black)* - turn the patient to the LEFT SIDE
(position of comfort) and move on
2. Circulation
- more than 2 sec capillary refill = *tag immediate (red)*
- less than 2 sec capillary refill = move to step 3
- bleeding - control bleeding with pressure bandages
3. Mental Status
- give *"squeeze my hand"* command (some kind of task)
- no response = shock - *tag immediate (red)*
- follows command but is unable to walk - *tag delayed (yellow)*
Primary Survey *** a rapid assessment of life-threatening conditions
- completed systematically
- standard precautions (gloves, gowns, eye protection, face masks, shoe covers) must be worn to
prevent contamination w/ bodily fluids
Includes: *A, B, C, D, E*
Airway (A) & Cervical Spine *** Ventilation!! the most important step in the primary survey; includes the
cervical spine (3,4,5 keeps diaphragm alive) (controls everything); if a patent airway is not established,
brain injury and death will occur as a result of hypoxia w/in 3-5 mins; spontaneous breathing > airway
intact > move air in and out; GCS less than 8 > intubate (can't swallow/cough, lose gag reflex),
supplemental O2 until intubation
, 1. If patient is awake/responsive = airway is fine/intact → Put on non rebreather- Non rebreather is OK
for patients who are breathing normally
- if there's an obstruction (blood, vomit, swelling): clear with suction or use finger-sweep method then
reassess
2. Patient is unresponsive without suspicions of trauma: - Perform a head-tilt chin-lift - Do not do this if
patient has a c-spine injury (open the airway)
3. if client is unresponsive with suspicion of trauma, open the airway with a modified jaw thrust
maneuver
- airway can be maintained with an oropharyngeal (no gag reflex) or nasopharyngeal airway
- no NG tube if there's head/facial trauma, no OPA with a pt who has gag reflex
4. Suspect c- spine Injury: Immediately stabilize the neck with c-collar
Breathing (B) *** can only be assessed after a patent airway has been achieved, can pt use oxygen we
are supplementing
Monitor for: Lung sounds, chest rise and fall, RR and depth, O2 sat, JVD, chest trauma, trach position,
altered LOC
- watch for rising unequally: Paradoxical Flail Chest: an emergency in which fluid/air enters the lungs, 3+
fractured ribs, & upon inhale, chest leans to the side; fixed w/ a chest tube
- top chest tube = pneumothorax → removes air (air rises to the top) (sounds like nothing, air not
moving) > causes trachial deviation
- bottom chest tube = hemothorax → drains fluid (blood settles down)
- needle decompression: relieve pressure (2/3rd intercostal at mid clavicular line), temporary solution
for pneumothorax
- treat the cause!!
What is #1 when caring for a Trauma patient? *** *SAFETY for yourself!*
- must have scene safety prior to treating patients
Trauma Nursing *** Interventions
- rapidly assess and intervene when life threatening situations arise (60s or less)
- keep the patient warm!!! (86 degrees or more) (cold blood will clot)
- avoid the trauma "Triad of Death": Hypothermia, Acidosis, Coagulopathy
- replace lost volume with fluids
- monitor V/S for shock (TREND!!), circulatory assessment
- monitor I&Os (helps estimate blood lost)
- reassess after intervention
- maintain C spine precautions
Reverse Triage *** AKA: Disaster triage; used only in mass casualty situations
- treats the less injured first and leaves the severely injured to possibly die
- allows for a greater number of patients to be treated by utilizing resources more effectively
- used to assess and categorize patients quickly; "immediate" has the potential for the greatest number
of patients
Black Triage Tag Color *** EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief should be provided
- agonal breathing, no spontaneous breathing even after repositioning airway
,EX: obvious non-survivable injury, respiratory arrest, cardiac arrest, airway repositioning does NOT work
and does not reestablish the airway
Red Triage Tag Color *** IMMEDIATE, highest priority patients
- victim can be helped by immediate intervention and transport
- requires medical attention within minutes for survival (up to 60 mins)
- includes compromises to patient's ABC
- RR >30, absent radial pulse or cap refill >2, doesn't obey commands, no spontaneous breathing air way
repositioned then we hear spontaneous breaths
EX: airway/breathing issues, uncontrolled/severe bleeding, severe burns, SHOCK, open chest/abdominal
wounds
Yellow Triage Tag Color *** DELAYED
- victim's transport can be delayed, need to go to hospital
- not able to walk but spontaneous breathing, RR <30, radial pulse present or cap refill <2, obeys
commands
- includes serious and potentially life-threatening injuries, but status not expected to deteriorate
significantly over several hours
EX: burns with no airway problems, major/multiple bone or joint injuries, back injuries with or without
spinal cord injuries, breathing and mental status are intact but cannot walk or move
Green Triage Tag Color *** MINOR
- victim with relatively minor injuries, able to walk, doesnt need hopsital
- status unlikely to deteriorate over days
- may be able to assist in own care: "Walking Wounded"
EX: minor fractures, minor soft tissue injuries
Disaster Triage Process *** *First:* call out, "If you can walk, come to the sound of my voice"
,- anyone who walks to you is tagged *Walking Wounded (green)*
*Second: START TRIAGE*
1. Breathing
- more than 30 RR = shock - *tag immediate (red)*
- less than 30 RR = move to step 2
- no respirations after 2 chin tilt attempts = *deceased (black)* - turn the patient to the LEFT SIDE
(position of comfort) and move on
2. Circulation
- more than 2 sec capillary refill = *tag immediate (red)*
- less than 2 sec capillary refill = move to step 3
- bleeding - control bleeding with pressure bandages
3. Mental Status
- give *"squeeze my hand"* command (some kind of task)
- no response = shock - *tag immediate (red)*
- follows command but is unable to walk - *tag delayed (yellow)*
Primary Survey *** a rapid assessment of life-threatening conditions
- completed systematically
- standard precautions (gloves, gowns, eye protection, face masks, shoe covers) must be worn to
prevent contamination w/ bodily fluids
Includes: *A, B, C, D, E*
Airway (A) & Cervical Spine *** Ventilation!! the most important step in the primary survey; includes the
cervical spine (3,4,5 keeps diaphragm alive) (controls everything); if a patent airway is not established,
brain injury and death will occur as a result of hypoxia w/in 3-5 mins; spontaneous breathing > airway
intact > move air in and out; GCS less than 8 > intubate (can't swallow/cough, lose gag reflex),
supplemental O2 until intubation
, 1. If patient is awake/responsive = airway is fine/intact → Put on non rebreather- Non rebreather is OK
for patients who are breathing normally
- if there's an obstruction (blood, vomit, swelling): clear with suction or use finger-sweep method then
reassess
2. Patient is unresponsive without suspicions of trauma: - Perform a head-tilt chin-lift - Do not do this if
patient has a c-spine injury (open the airway)
3. if client is unresponsive with suspicion of trauma, open the airway with a modified jaw thrust
maneuver
- airway can be maintained with an oropharyngeal (no gag reflex) or nasopharyngeal airway
- no NG tube if there's head/facial trauma, no OPA with a pt who has gag reflex
4. Suspect c- spine Injury: Immediately stabilize the neck with c-collar
Breathing (B) *** can only be assessed after a patent airway has been achieved, can pt use oxygen we
are supplementing
Monitor for: Lung sounds, chest rise and fall, RR and depth, O2 sat, JVD, chest trauma, trach position,
altered LOC
- watch for rising unequally: Paradoxical Flail Chest: an emergency in which fluid/air enters the lungs, 3+
fractured ribs, & upon inhale, chest leans to the side; fixed w/ a chest tube
- top chest tube = pneumothorax → removes air (air rises to the top) (sounds like nothing, air not
moving) > causes trachial deviation
- bottom chest tube = hemothorax → drains fluid (blood settles down)
- needle decompression: relieve pressure (2/3rd intercostal at mid clavicular line), temporary solution
for pneumothorax
- treat the cause!!
