NUR 445 EXAM 4
What is primary survey - answer Primary is Identifying life-threatening conditions and
institute management
o Identify life threatening conditions and institute management ABCDE
§ Airway
§ Breathing
§ Circulation
§ Disability -> LOC & GCS
§Exposure/Environment -Strip them
what is secondary survey - answer Secondary is at the hospital (FGHI)
o Focused assessment with solography for Trauma (FAST):
§ Ultrasound that looks for free fluid(blood) in the abdominal cavity, pericardium, or
pelvis
§ Insertion of foley to monitor I&Os
§ Insertion of gastric tube to empty stomach and prevent aspiration
§ Initial surgical stabilization
o Full Set of Vitals/focused adjuncts/family presence
o Give comfort measures
o History and Head-to-Toe
o Inspect posterior surfaces
o Remove-cut off all clothing
§ May be evidence so DO NOT TRASH CLOTHES
Chest Trauma is most often caused by - answerby motor vehicle collisions
treatment for chest trauma - answerABC'S
Morphine allows the patient to breathe effectively
EARLY S/S OF HYPOXEMIA - answerDyspnea, agitation and anxiety, then decreased
LOC
Priority interventions for suspected C-Spine or head injury - answerC-COLLAR
How would you assess the airway of a patient with suspected head/neck injury -
answer· Modified jaw thrust
· DO NOT REMOVE THE C-Collar
Nursing interventions do patients with blunt chest trauma (ABCD) - answer· Assess the
Airway maintaining C-Spine stabilization
· Assess breathing -> breath sounds, even chest rise (uneven chest rise, absent chest
sounds)
, o Chest tube for hemo/pneumo
o Chest pain
§ Splint, deep breath and cough, Incentive spirometer
· Circulation
o IV fluid resuscitation to maintain hemodynamic stability
o Hemothorax -> May need blood transfusion
· Disability -> level of consciousness (GCS scale)
Signs and symptoms of tension pneumothorax - answer· Tracheal deviation toward the
unaffected side and asymmetrical chest movement is a hallmark sign
· Positive pressure in the pleural cavity and affected lung collapses
· Pain
· SOB
· Trouble breathing
· assess subcutaneous emphysema ->crackling feeling under the skin
TREATMENT FOR BLUNT CHEST TRAUMA - answer· Chest tube
· Incentive spirometer -> every 1-2 hours to prevent atelectasis and assists in keeping
airway clear
S/S OF CARDIAC TAMPONADE - answer· Hypotension, muffled heart sounds, and
JVD -> Becks triad
What is the most common cause of death with 48 hours in trauma patients -
answerHemorrhage
What are the interventions for victims of snakebite - answer· Below heart -> functional
position
· No tunicate, ice, or alcohol to affected extremity
· Antivenom -> rapid treatment (most effective when given within 4-6 hours after
envenomation)
· Clean the wound and give tetanus prophylaxis is immunization is unknown or
outdated.
· Continuous cardiac monitoring -> hemodynamic monitoring
· IV access and IV monitoring
· Keep patient calm
Nursing interventions for hypothermia - answer· Prevention is the best treatment
· Treatments vary on the type
Treatment for mild hypothermia (89.6-95) - answero Passive external warming -> heater
(warm environment, remove wet clothes, dry the patient, cover with a warmed blanket,
and wrap the head.
treatment for moderate hypothermia (82.4-89.6) - answero Active external rewarming ->
heat packs, heated blankets, IV fluids etc.
What is primary survey - answer Primary is Identifying life-threatening conditions and
institute management
o Identify life threatening conditions and institute management ABCDE
§ Airway
§ Breathing
§ Circulation
§ Disability -> LOC & GCS
§Exposure/Environment -Strip them
what is secondary survey - answer Secondary is at the hospital (FGHI)
o Focused assessment with solography for Trauma (FAST):
§ Ultrasound that looks for free fluid(blood) in the abdominal cavity, pericardium, or
pelvis
§ Insertion of foley to monitor I&Os
§ Insertion of gastric tube to empty stomach and prevent aspiration
§ Initial surgical stabilization
o Full Set of Vitals/focused adjuncts/family presence
o Give comfort measures
o History and Head-to-Toe
o Inspect posterior surfaces
o Remove-cut off all clothing
§ May be evidence so DO NOT TRASH CLOTHES
Chest Trauma is most often caused by - answerby motor vehicle collisions
treatment for chest trauma - answerABC'S
Morphine allows the patient to breathe effectively
EARLY S/S OF HYPOXEMIA - answerDyspnea, agitation and anxiety, then decreased
LOC
Priority interventions for suspected C-Spine or head injury - answerC-COLLAR
How would you assess the airway of a patient with suspected head/neck injury -
answer· Modified jaw thrust
· DO NOT REMOVE THE C-Collar
Nursing interventions do patients with blunt chest trauma (ABCD) - answer· Assess the
Airway maintaining C-Spine stabilization
· Assess breathing -> breath sounds, even chest rise (uneven chest rise, absent chest
sounds)
, o Chest tube for hemo/pneumo
o Chest pain
§ Splint, deep breath and cough, Incentive spirometer
· Circulation
o IV fluid resuscitation to maintain hemodynamic stability
o Hemothorax -> May need blood transfusion
· Disability -> level of consciousness (GCS scale)
Signs and symptoms of tension pneumothorax - answer· Tracheal deviation toward the
unaffected side and asymmetrical chest movement is a hallmark sign
· Positive pressure in the pleural cavity and affected lung collapses
· Pain
· SOB
· Trouble breathing
· assess subcutaneous emphysema ->crackling feeling under the skin
TREATMENT FOR BLUNT CHEST TRAUMA - answer· Chest tube
· Incentive spirometer -> every 1-2 hours to prevent atelectasis and assists in keeping
airway clear
S/S OF CARDIAC TAMPONADE - answer· Hypotension, muffled heart sounds, and
JVD -> Becks triad
What is the most common cause of death with 48 hours in trauma patients -
answerHemorrhage
What are the interventions for victims of snakebite - answer· Below heart -> functional
position
· No tunicate, ice, or alcohol to affected extremity
· Antivenom -> rapid treatment (most effective when given within 4-6 hours after
envenomation)
· Clean the wound and give tetanus prophylaxis is immunization is unknown or
outdated.
· Continuous cardiac monitoring -> hemodynamic monitoring
· IV access and IV monitoring
· Keep patient calm
Nursing interventions for hypothermia - answer· Prevention is the best treatment
· Treatments vary on the type
Treatment for mild hypothermia (89.6-95) - answero Passive external warming -> heater
(warm environment, remove wet clothes, dry the patient, cover with a warmed blanket,
and wrap the head.
treatment for moderate hypothermia (82.4-89.6) - answero Active external rewarming ->
heat packs, heated blankets, IV fluids etc.
