TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST
BANK|100% COMPLETE verified
What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil
- Unresponsiveness to verbal or painful stimuli
- Abnormal motor posturing patterns
- Widening pulse pressure
- Increased systolic blood pressure
- Changes in RR and pattern
- Bradycardia
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- Malocclusion
- Inability to open the mouth (trismus)
- Pain, especially on movement
- Facial asymmetry and a palpable step-off deformity
- Edema or hematoma formation at the fracture site
- Blood behind, ruptured, tympanic membrane
- Anesthesia of the lower lip
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise
intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
- Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to
prevent drying and ulceration
- Antibiotics topically or systemically
- Admin tetanus prophylactically
- Use an eye patch to affected eye
- Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
- Patch, shield or cover w/cool pack
,TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST
BANK|100% COMPLETE verified
- Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected
eye. Use metal or plastic and do not put pressure on the globe.
- Provide psychosocial support
- Obtain an ophthalmology consultation
- Provide d/c instructions:
- Importance of protective eyewear
- No driving w/eye patch on
- Wear sunglasses to prevent tearing, aid photophobia
- Prepare for admission, OR or transfer
What are the Rapid Sequence Intubation Steps? - ansPREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between
attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse oxtimetry
What are the S/S of a basilar skull fx? - ans- H/A
- Altered LOC
- Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic
membrane (hemotympanum)
- Facial nerve (VII) palsy
- CSF rhinorrhea or otorrhea
What are the S/S of a depressed skull fx? - ans- H/A
- Possible decreased LOC
- Possible open fx
- Palpable depression of skull over the fx site
What are the S/S of a linear skull fx? - ans- H/A
- Possible decreased LOC
What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
, TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST
BANK|100% COMPLETE verified
What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood
loss present
- Tracheal deviation - shift toward uninjured side (LATE sign)
- Cyanosis (LATE sign)
What are the S/S of flail chest? - ans- Dyspnea
- Chest wall pain
- Paradoxical chest wall movement - the flail segment moves in during inspiration and out during
expiration.
What are the S/S of Hemothorax? - ans- Dyspnea, tachypnea
- Chest pain
- Signs of shock
- Decreased breath sounds on injured side
- Dullness to percussion on the injured side
What are the S/S of orbital fracture (orbital blowout fracture)? - ans- Diplopia (double vision)
- Loss of vision
- Altered extraocular eye movements
- Enophthalmos (displacement of the eye backward into the socket)
- Subconjunctival hemorrhage or ecchymosis of the eyelid
- Infraorbital pain or loss of sensation
- Orbital bony deformity
What are the S/S of pericardial tamponade? - ansA collection of blood in pericardial sac. As blood
accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling.
- Hyotension
- Tachycardia or PEA
- Dyspnea
- Cyanosis
- Beck's Triad (hypotension, distended neck veins + muffled heart sounds)
- Progressive decreased voltage of conduction complexes on ECG
What are the S/S of pulmonary contusion? - ans- Dyspnea
- Ineffective cough
- Hemoptysis
- Hypoxia
- Chest pain
- Chest wall contusion or abrasions
What are the signs and symptoms of postconcussive syndrome? - ans- Persistent H/A
- Dizziness
- Nausea
- Memory impairment
- Attention deficit
- Irritability
- Insomnia
- Impaired judgement
- Loss of libido
BANK|100% COMPLETE verified
What are the late observable signs of symptoms of increased ICP? - ans- Dilated, nonreactive pupil
- Unresponsiveness to verbal or painful stimuli
- Abnormal motor posturing patterns
- Widening pulse pressure
- Increased systolic blood pressure
- Changes in RR and pattern
- Bradycardia
What are the late signs of breathing compromise? - ans- Tracheal deviation
- JVD
What are the mandibular fracture S/S? - ans- Malocclusion
- Inability to open the mouth (trismus)
- Pain, especially on movement
- Facial asymmetry and a palpable step-off deformity
- Edema or hematoma formation at the fracture site
- Blood behind, ruptured, tympanic membrane
- Anesthesia of the lower lip
What are the most common type of injury associated with chest trauma? - ansblunt; MVC's. Penetrating;
firarm injuries or stabbings
What are the nursing interventions for a patient with a maxillofacial or neck injury? - ans- Administer
oxygen
- For facial trauma, place pt in high-fowler's position if no spinal injury is present.
- Insert OG or NGT. OGT should be used if basilar skull fx or severe midface fx's are suspected
- Monitor for progressive airway assessment
- Prepare for intubation, PRN.
- Cannulate 2 large IV's, initiate isotonic crystalloid IV solution
- Control external bleeding w/direct pressure
- Monitor for continued bleeding + expanding hematomas
- Apply cold compresses to face to minimize edema
- Assist w/repair of oral lac's, PRN
- Admin antibiotics
- Stabilize impaled objects
- Admin analgesic meds
What are the nursing interventions for a pt with an ocular injury? - ans- Assess visual acuity & reassess
- Elevate HOB to minimize intraocular pressure
- Instruct pt not to bend forward, cough or perform Valsalva maneuver b/c these actions may raise
intraocular pressure
- Assist w/removal of foreign bodies as indicated; stabilize impaled objects
- Apply cool packs to decrease pain + periorbital swelling
- Admin medications
- Instill prescribed topical anesthetic drops for pain
- Instill NS drops or artificial tears to keep corneas moist. Cover eyelids w/sterile, moist saline dsg to
prevent drying and ulceration
- Antibiotics topically or systemically
- Admin tetanus prophylactically
- Use an eye patch to affected eye
- Patch or shield both eyes to reduce movement + photophobia in pt's w/retinal injuries
- Patch, shield or cover w/cool pack
,TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST
BANK|100% COMPLETE verified
- Do NOT patch injured eye of pt w/suspected open or ruptured globe or impaled object, patch unaffected
eye. Use metal or plastic and do not put pressure on the globe.
- Provide psychosocial support
- Obtain an ophthalmology consultation
- Provide d/c instructions:
- Importance of protective eyewear
- No driving w/eye patch on
- Wear sunglasses to prevent tearing, aid photophobia
- Prepare for admission, OR or transfer
What are the Rapid Sequence Intubation Steps? - ansPREPARATION:
- gather equipment, staffing, etc.
PREOXYGENATION:
- Use 100% O2 (prevent risk of aspiration).
PRETREATMENT:
- Decrease S/E's of intubation
PARALYSIS WITH INDUCTION:
- Pt has LOC, then administer neuromuscular blocking agent
PROTECTION AND POSITIONING:
- Apply pressure over cricoid cartilage (minimizes likelihood of vomiting and aspiration
PLACEMENT WITH PROOF
- Each attempt NOT to exceed 30 seconds, max of 3 attempts. Ventilate pt 30-60 seconds between
attempts.
- After intubation, inflate the cuff
- Confirm tube placement w/exhaled CO2 detector.
POSTINTUBATION MANAGEMENT:
- Secure ET tube
- Set ventilator settings
- Obtain Chest x-ray
- Continue to medicate
- Recheck VS and pulse oxtimetry
What are the S/S of a basilar skull fx? - ans- H/A
- Altered LOC
- Periorbital ecchymosis (raccoon eyes), mastoid ecchymosis (Battle's sign), or blood behind tympanic
membrane (hemotympanum)
- Facial nerve (VII) palsy
- CSF rhinorrhea or otorrhea
What are the S/S of a depressed skull fx? - ans- H/A
- Possible decreased LOC
- Possible open fx
- Palpable depression of skull over the fx site
What are the S/S of a linear skull fx? - ans- H/A
- Possible decreased LOC
What are the S/S of a pneumothorax? - ans- Dyspnea, tachypnea
- Tachycardia
- Hyerresonance (increased echo produced by percussion over the lung field) on the injured side
- Decreased or absent breath sounds on the injured side
- Chest pain
- Open, sucking wound on inspiration (open pneumothorax)
, TNCC NOTES FOR WRITTEN EXAM LATEST 2023-2024 |TEST
BANK|100% COMPLETE verified
What are the S/S of a tension pneumothorax? - ans- Severe respiratory distress
- Markedly diminished or absent breath sounds on affected side
- hypotension
- Distended neck, head and upper extremity veins-may not be clinically appreciated if significant blood
loss present
- Tracheal deviation - shift toward uninjured side (LATE sign)
- Cyanosis (LATE sign)
What are the S/S of flail chest? - ans- Dyspnea
- Chest wall pain
- Paradoxical chest wall movement - the flail segment moves in during inspiration and out during
expiration.
What are the S/S of Hemothorax? - ans- Dyspnea, tachypnea
- Chest pain
- Signs of shock
- Decreased breath sounds on injured side
- Dullness to percussion on the injured side
What are the S/S of orbital fracture (orbital blowout fracture)? - ans- Diplopia (double vision)
- Loss of vision
- Altered extraocular eye movements
- Enophthalmos (displacement of the eye backward into the socket)
- Subconjunctival hemorrhage or ecchymosis of the eyelid
- Infraorbital pain or loss of sensation
- Orbital bony deformity
What are the S/S of pericardial tamponade? - ansA collection of blood in pericardial sac. As blood
accumulates, it exerts pressure on the heart, inhibiting or compromising ventricular filling.
- Hyotension
- Tachycardia or PEA
- Dyspnea
- Cyanosis
- Beck's Triad (hypotension, distended neck veins + muffled heart sounds)
- Progressive decreased voltage of conduction complexes on ECG
What are the S/S of pulmonary contusion? - ans- Dyspnea
- Ineffective cough
- Hemoptysis
- Hypoxia
- Chest pain
- Chest wall contusion or abrasions
What are the signs and symptoms of postconcussive syndrome? - ans- Persistent H/A
- Dizziness
- Nausea
- Memory impairment
- Attention deficit
- Irritability
- Insomnia
- Impaired judgement
- Loss of libido
