Complex 2 Exam 1 (shorter flash cards
same info)
What is #1 when caring for a Trauma patient? *** *SAFETY for yourself!*
- must have scene safety prior to treating patients
Trauma Nursing: Interventions *** - keep the pt warm!!! (86 degrees or more)
- avoid the trauma "Triad of Death": Hypothermia, Acidosis, Coagulopathy
- replace lost volume with fluids
- monitor V/S for shock (TREND!!)
- monitor I&Os (helps estimate blood lost)
Reverse Triage *** - AKA: Disaster triage, used only in mass casualty situations
- treats less injured first and leaves severely injured with lower priority, possibly leading to death
- allows for greater # pts to be treated by utilizing limited resources more effectively
- used to assess and categorize pts quickly
- "Immediate" has the potential for greatest # of pts to be treated and survive
Black Triage Tag Color With Examples *** - EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief should be provided
- EX: obvious non-survivable injury, respiratory arrest, cardiac arrest, airway repositioning does NOT
work and does not reestablish the airway
Red Triage Tag Color With Examples *** - IMMEDIATE
- victim can be helped by immediate intervention and transport
- requires medical attention within minutes for survival (up to 60 mins)
,- includes compromises to pts ABC
- EX: airway/breathing issues, uncontrolled/severe bleeding, severe burns, SHOCK, open
chest/abdominal wounds
Yellow Triage Tag Color With Examples *** - DELAYED
- victim's transport can be delayed
- 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 With Examples *** - MINOR
- victim with relatively minor injuries
- 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 *** 1. First step:
a. call out, "If you can walk, come to the sound of my voice"
- anyone who walks to you is tagged Walking Wounded (green)
2. Second Step: START TRIAGE
a. Breathing
- >30 RR = shock, tag immediate (red)
- <30 RR = move to next step
- no respirations after 2 chin tilt attempts = deceased (black), turn pt to LEFT SIDE (position of comfort)
and move on
b. Circulation
,- >2 sec cap refill = tag immediate (red)
- <2 sec cap refill = move to next step
- bleeding = control with pressure bandages
c. Mental Status
- give command: "squeeze my hand" (some kind of task)
- no response = shock, tag immediate (red)
- follows command but unable to walk = tag delayed (yellow)
Primary Survey: Basics *** - rapid assessment of life-threatening conditions
- completed systematically so life-threatening conditions are not missed
- standard precautions: gloves, gowns, eye protection, face masks, shoe covers, MUST be worn to
prevent contamination with bodily fluids
- Includes: ABCDEs, used as triage method to guide primary survey
ABCDE Principles *** - Airway/Cervical Spine
- Breathing
- Circulation
- Disability
- Exposure
Airway (A) / Cervical Spine *** - the most important step in primary survey
- includes the cervical spine, which controls everything
- if a patent airway is not established, further steps are useless
- as a result of hypoxia, brain injury and death will occur within 3-5 mins if airway NOT PATENT
, Airway (A) / Cervical Spine: Nursing Actions *** 1. Assess airway patency (if obstructed, speech might be
coarse/muffled)
2. If pt awake/responsive = airway open
- put on non-rebreather (Non-rebreather is OK for pts who are breathing normally)
3. if pts ability to maintain airway lost:
- inspect for blood, broken teeth, vomitus, or forgein materials causing obstruction
- clear with suction or use finger-sweep method then reassess
4. if pt is unresponsive without suspicions of trauma: - Perform a head-tilt/chin-lift maneuver
- Do not do this if pt has a c-spine injury
5. if pt unresponsive with suspicion of trauma:
- perform a modified jaw thrust maneuver to open airway
- airway can be maintained with an oropharyngeal (no gag reflex) or nasopharyngeal airway
- no NG tube if there is head/facial trauma
6. Suspect c-spine Injury: Immediately stabilize neck with C-collar
Breathing (B) *** 1. *can only be assessed after a patent airway has been achieved
2. Assessment: auscultate breath/lung sounds, chest rise and fall, RR and depth, O2 sat, JVD, chest
trauma identifications, trach position
- 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
- bottom chest tube = hemothorax → drains fluid
3. Nursing Actions: if pt not breathing/inadequately, manual ventilation with bag valve (BV) mask
performed with supplemental o2 or mouth-to-mask until BV mask obtained
Circulation (C) *** 1. nurses should assess HR, BP, peripheral pulses/cap refill, skin color, and UO for
adequate perfusion
same info)
What is #1 when caring for a Trauma patient? *** *SAFETY for yourself!*
- must have scene safety prior to treating patients
Trauma Nursing: Interventions *** - keep the pt warm!!! (86 degrees or more)
- avoid the trauma "Triad of Death": Hypothermia, Acidosis, Coagulopathy
- replace lost volume with fluids
- monitor V/S for shock (TREND!!)
- monitor I&Os (helps estimate blood lost)
Reverse Triage *** - AKA: Disaster triage, used only in mass casualty situations
- treats less injured first and leaves severely injured with lower priority, possibly leading to death
- allows for greater # pts to be treated by utilizing limited resources more effectively
- used to assess and categorize pts quickly
- "Immediate" has the potential for greatest # of pts to be treated and survive
Black Triage Tag Color With Examples *** - EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief should be provided
- EX: obvious non-survivable injury, respiratory arrest, cardiac arrest, airway repositioning does NOT
work and does not reestablish the airway
Red Triage Tag Color With Examples *** - IMMEDIATE
- victim can be helped by immediate intervention and transport
- requires medical attention within minutes for survival (up to 60 mins)
,- includes compromises to pts ABC
- EX: airway/breathing issues, uncontrolled/severe bleeding, severe burns, SHOCK, open
chest/abdominal wounds
Yellow Triage Tag Color With Examples *** - DELAYED
- victim's transport can be delayed
- 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 With Examples *** - MINOR
- victim with relatively minor injuries
- 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 *** 1. First step:
a. call out, "If you can walk, come to the sound of my voice"
- anyone who walks to you is tagged Walking Wounded (green)
2. Second Step: START TRIAGE
a. Breathing
- >30 RR = shock, tag immediate (red)
- <30 RR = move to next step
- no respirations after 2 chin tilt attempts = deceased (black), turn pt to LEFT SIDE (position of comfort)
and move on
b. Circulation
,- >2 sec cap refill = tag immediate (red)
- <2 sec cap refill = move to next step
- bleeding = control with pressure bandages
c. Mental Status
- give command: "squeeze my hand" (some kind of task)
- no response = shock, tag immediate (red)
- follows command but unable to walk = tag delayed (yellow)
Primary Survey: Basics *** - rapid assessment of life-threatening conditions
- completed systematically so life-threatening conditions are not missed
- standard precautions: gloves, gowns, eye protection, face masks, shoe covers, MUST be worn to
prevent contamination with bodily fluids
- Includes: ABCDEs, used as triage method to guide primary survey
ABCDE Principles *** - Airway/Cervical Spine
- Breathing
- Circulation
- Disability
- Exposure
Airway (A) / Cervical Spine *** - the most important step in primary survey
- includes the cervical spine, which controls everything
- if a patent airway is not established, further steps are useless
- as a result of hypoxia, brain injury and death will occur within 3-5 mins if airway NOT PATENT
, Airway (A) / Cervical Spine: Nursing Actions *** 1. Assess airway patency (if obstructed, speech might be
coarse/muffled)
2. If pt awake/responsive = airway open
- put on non-rebreather (Non-rebreather is OK for pts who are breathing normally)
3. if pts ability to maintain airway lost:
- inspect for blood, broken teeth, vomitus, or forgein materials causing obstruction
- clear with suction or use finger-sweep method then reassess
4. if pt is unresponsive without suspicions of trauma: - Perform a head-tilt/chin-lift maneuver
- Do not do this if pt has a c-spine injury
5. if pt unresponsive with suspicion of trauma:
- perform a modified jaw thrust maneuver to open airway
- airway can be maintained with an oropharyngeal (no gag reflex) or nasopharyngeal airway
- no NG tube if there is head/facial trauma
6. Suspect c-spine Injury: Immediately stabilize neck with C-collar
Breathing (B) *** 1. *can only be assessed after a patent airway has been achieved
2. Assessment: auscultate breath/lung sounds, chest rise and fall, RR and depth, O2 sat, JVD, chest
trauma identifications, trach position
- 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
- bottom chest tube = hemothorax → drains fluid
3. Nursing Actions: if pt not breathing/inadequately, manual ventilation with bag valve (BV) mask
performed with supplemental o2 or mouth-to-mask until BV mask obtained
Circulation (C) *** 1. nurses should assess HR, BP, peripheral pulses/cap refill, skin color, and UO for
adequate perfusion
