HESI Trauma Nursing Process MUST knows with QUESTIONS and APPROVED answers

Trauma Nursing Process MUST knows with QEUSTIONS and APPROVED answers Preparation and triage - ANSWER Activate trauma team, prep trauma room with rapid infuser and whatever else, need to don PPE Across-the-room observation - ANSWER Assess for obvious uncontrolled external hemorrhage (to reprioritize to CABC) Airway and Alertness with Simultaneous Spinal Cord Stabilization MUST hits - ANSWER 1) assess LOC using AVPU 2) State need for second person to provide manual c-spine stabilization AND demonstrate manual opening of airway using jaw thrust 3) Determine airway patency with: tongue obstructing, any loose or missing teeth, any foreign objects, blood vomitus or secretions, any oedema, snoring/gurgling/stridor (TEBLOOFS), bony deformity 4) Need for airway adjunct/definitive airway 5)ALWAYS reassess your intervention Airway TEBLooFS - ANSWER Tongue obstructing, edema, blood/vomitus/secretions, loose or missing teeth, foreign objects, snoring/gurgling/stridor respirations 7 Steps of RSI (will most likely be in airway...because chances are that even if an airway adjunct is effective, it is temporary, and b/c patient will not be able to maintain their airway independently, we will need to prepare for intubation) 7 P's...3 Pre's 3 assorted, and 1 post - ANSWER PREparation, PREoxygenation, PREtreatment, paralysis with induction, protection and positioning, placement with proof of successful intubation, POSTintubation management Techniques for determining breathing effectiveness (either happens during AIRWAY if definitive airway is placed, or during BREATHING/VENTILATION if no airway necessary) - ANSWER INSPECT, AUSCULTATE, PALPATE. SPONTANEOUS BREATHING, symmetrical chest rise and fall, depth/pattern/rate (DPR) of respirations, increased WOB, SKIN COLOR, open wounds or deformities, breath sounds present and equal, SQ emphysema, TRACHEAL DEVIATION AND JVD REMEMBER TO ENSURE YOUR PATIENT HAS AT A MINIMUM OF 15L NONREBREATHER AT FIRST FOR OXYGENATION MUST know points for ETT placement verification (there are 5) - ANSWER 1) CO2 detector device (ETCO2), 5) SKIN COLOR, 2) symmetry of chest rise and fall AND auscultates epigastrium, 3) auscultate for bilateral breath sounds, 4) after 5-6 breaths assess CO2 detector device for evidence of CO2 in exhaled air