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TNCC Notes for Written Exam LATEST 2024-2025 LATEST A+.pdf, Exams of Nursing

Lancaster UniversityNursing

TNCC Notes for Written Exam LATEST 2024-2025 LATEST A+.pdf

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TNCC Notes for Written Exam LATEST
2024-2025 LATEST A+
TNCC Notes for Written Exam
What is kinematics? -
✅ A branch of mechanics (energy transfer) that refers to motion and does not
consider the concepts of force and mass of the object or body.
What is Newton's First Law? -
✅ A body at rest will remain at rest. A body in motion will remain in motion until
acted on by an outside force.
What is the Law of Conservation of Energy? -
✅ Energy can neither be created nor destroyed. It is only changed from one form to
another.
What is Newton's Second Law? -
✅ Force equals mass multiplied by acceleration of deceleration.
What is kinetic energy (KE)? -
✅ KE equals 1/2 the mass (M) multiplied by the velocity squared.
What is the Mnemonic for the Initial Assessment? -
✅ A = Airway with simultaneous cervical spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the patient warm)
What is the Mnemonic for the Secondary Assessment? -
✅ F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter,
and gastric tube)/Family presence
G = Give comfort measures (verbal reassurance, touch, and pharmacologic and
nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfaces
Where do you listen to auscultate breath sounds? -
✅ Auscultate the lungs bilaterally at the second intercostal space midclavicular line
and at the fifth intercostal space at the anterior axillary line.
What are the late signs of breathing compromise? -
✅ - Tracheal deviation
- JVD
What are signs of ineffective breathing? -
✅ - AMS
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Download TNCC Notes for Written Exam LATEST 2024-2025 LATEST A+.pdf and more Exams Nursing in PDF only on Docsity!

2024 - 2025 LATEST A+

TNCC Notes for Written Exam

What is kinematics? - ✅ A branch of mechanics (energy transfer) that refers to motion and does not consider the concepts of force and mass of the object or body. What is Newton's First Law? - ✅ A body at rest will remain at rest. A body in motion will remain in motion until acted on by an outside force. What is the Law of Conservation of Energy? - ✅ Energy can neither be created nor destroyed. It is only changed from one form to another. What is Newton's Second Law? - ✅ Force equals mass multiplied by acceleration of deceleration. What is kinetic energy (KE)? - ✅ KE equals 1/2 the mass (M) multiplied by the velocity squared. What is the Mnemonic for the Initial Assessment? - ✅ A = Airway with simultaneous cervical spine protection B = Breathing C = Circulation D = Disability (neurologic status) E = Expose/Environmental controls (remove clothing and keep the patient warm) What is the Mnemonic for the Secondary Assessment? - ✅ F = Full set of VS/Focused adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence G = Give comfort measures (verbal reassurance, touch, and pharmacologic and nonpharmacologic management of pain). H = Hx and Head-to-toe assessment I = Inspect posterior surfaces Where do you listen to auscultate breath sounds? - ✅ Auscultate the lungs bilaterally at the second intercostal space midclavicular line and at the fifth intercostal space at the anterior axillary line. What are the late signs of breathing compromise? - ✅ - Tracheal deviation

  • JVD What are signs of ineffective breathing? - ✅ - AMS

2024 - 2025 LATEST A+

  • Cyanosis, especially around the mouth
  • Asymmetric expansion of chest wall
  • Paradoxical movement of the chest wall during inspiration and expiration
  • Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
  • Sucking chest wounds
  • Absent or diminished breath sounds
  • Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
  • Anticipate definitive airway management to support ventilation. Upon initial assessment, what type of oxygen should be used for a pt breathing effectively? - ✅ A tight-fitting nonrebreather mask at 12-15 lpm. What intervention should be done if a pt presents with effective circulation? - ✅ - Insert 2 large caliber IV's
  • Administer warmed isotonic crystalloid solution at an appropriate rate What are signs of ineffective circulation? - ✅ - Tachycardia
  • AMS
  • Uncontrolled external bleeding
  • Pale, cool, moist skin
  • Distended or abnormally flattened external jugular veins
  • Distant heart sounds What are the interventions for Effective/Ineffective Circulation? - ✅ - Control any uncontrolled external bleeding by:
  • Applying direct pressure over bleeding site
  • Elevating bleeding extremity
  • Applying pressure over arterial pressure points
  • Using tourniquet (last resort).
  • Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
  • Use warmed solution
  • Use pressure bags to increase speed of IVF infusion
  • Use blood administration tubing for possible administration of blood
  • Use rapid infusion device based on protocol
  • Use NS 0.9% in same tubing as blood product
  • IV = surgical cut-down, central line, or both.
  • Blood sample to determine ABO and Rh group
  • IO in sternum, legs, arms or pelvis
  • Administer blood products
  • PASG (without interfering with fluid resuscitation) How do you assess Mnemonic "D"? - ✅ DISABILITY

2024 - 2025 LATEST A+

✅ INSPECT POSTERIOR SURFACES

  • While maintaining C-spine, logroll pt with assistance to inspect back, flanks, buttocks and posterior thighs.
  • Palpate vertebral column for deformity and areas of tenderness
  • Assess rectum for presence/absence of tone, presence of blood What she be done after the Secondary Assessment? - ✅ Reassess:
  • Primary survey,
  • VS
  • Pain
  • Any injuries What are factors that contribute to ineffective ventilation? - ✅ - AMS
  • LOC
  • Neurologic injury
  • Spinal Cord Injury
  • Intracranial Injury
  • Blunt trauma
  • Pain caused by rib fractures
  • Penetrating Trauma
  • Preexisting hx of respiratory diseases
  • Increased age What medications are used during intubation? - ✅ LOAD Mnemonic: L = Lidocaine O = Opioids A = Atropine D = Defasiculating agents What are the Rapid Sequence Intubation Steps? - ✅ PREPARATION:
  • 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.

2024 - 2025 LATEST A+

  • 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 is a Combitube? - ✅ A dual-lumen, dual-cuff airway that can be placed blindly into the esophagus to establish an airway. If inadvertently placed into trachea, it can be used as a temporary ET tube. There are only two sizes: small adult and larger adult. What is a Laryngeal Mask Airway? - ✅ Looks like an ET tube but is equipped with an inflatable, elliptical, silicone rubber collar at the distal end. It is designed to cover the supraglottic area. ILMA, does not require laryngoscopy and visualization of the chords. What is Needle Cricothyrotomy - ✅ Percutaneous transtracheal ventilation. (temporary) Complications include:
  • inadequate ventilation causing hypoxia
  • hematoma formation
  • esophageal perforation
  • aspiration
  • thyroid perforation
  • subcutaneous emphysema What is Surgical Cricothyrotomy? - ✅ Making an incision in cricothyroid membrane and placing a cuffed endo or trach tube into trachea. This is indicated when other methods of airway management have failed and pt cannot be adequately ventilated and oxygenated. Complications include:
  • Aspiration
  • Hemorrhage or hematoma formation or both
  • Lac to trachea or esophagus
  • Creation of a false passage
  • Laryngeal stenosis How do you confirm ET Tube/Alternative Airway Placement? - ✅ - Visualization of the chords
  • Using bronchoscope to confirm placement

2024 - 2025 LATEST A+

✅ Most common to affect a trauma pt cause by hypovolemia.. Hypovolemia, a decrease in amount of circulating blood volume, may result from significant loss of whole blood because of hemorrhage or from loss of semipermeable integrity of cellular membrane leading to leakage of plasma and protein from intravascular space to the interstitial space (as in a burn). Some causes:

  • Blood loss
  • Burns, etc. Explain Cardiogenic Shock. - ✅ Syndrome that results from ineffective perfusion caused by ineffective perfusion caused by inadequate contractility of cardiac muscle. Some causes:
  • MI
  • Blunt cardiac injury
  • Mitral valve insufficiency
  • dysrhythmias
  • Cardiac Failure Explain Obstructive Shock. - ✅ Results from inadequate circulating blood volume because of an obstruction or compression of great veins, aorta, pulmonary arteries, or heart itself. Some causes:
  • Cardiac tamponade (may compress the heart during diastole to such and extent that atria cannot adequately fill, leading to decreased stroke volume).
  • Tension pneumothorax may lead to inadequate stroke volume by displacing inferior vena cava and obstructing venous return to right atrium.
  • Air embolus may lead to obstruction of pulmonary artery and subsequent obstruction to right ventricular outflow during systole, with resulting obstructive shock Explain Distributive Shock. - ✅ Results from disruption in SNS control of the tone of blood vessels, which leads to vasodilation and maldistribution of blood volume and flow. (Neurogenic and Septic Shock). Neurogenic shock may result from injury to spinal cord in cervical or upper thoracic region. Spinal shock = areflexia and flaccidity associated with lower motor neuron involvement in complete cord injuries; reflexes return with resolution of spinal shock. Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatory mediators cause vasodilation, shunting of blood in microcirculation, and other perfusion abnormalities. What is vascular response? -

2024 - 2025 LATEST A+

✅ As blood volume decreases, peripheral blood vessels vasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors. Arterioles constrict to increase TPR and BP. What is renal response? - ✅ Renal ischemia activates release of renin. Kidneys do not receive adequate blood supply, renin is release into circulation. Renin causes angiotensinogen, normal plasma protein, to release angiotensin I. Angiotensin-converting enzyme from the lungs converts into angiotensin II. Angiotensin II causes:

  • Vasoconstriction of arterioles and some veins
  • Stimulation of sympathetic nervous system
  • Retention of water by kidneys
  • Stimulation of release of aldosterone from the adrenal cortex (sodium retention hormone) *Decreased urinary output = early sign renal hypoperfusion and an indicator that there's systemic hypoperfusion. Explain adrenal gland response. - ✅ When adrenal glands are stimulated by SNS, release of catecholamines (epinephrine and norepinephrine) from adrenal medulla will increase. Epi stimulates receptors in heart to increase force of cardiac contraction (positive inotropy) and increase HR (positive chronotropy) to improve cardiac output, BP and tissue perfusion. Shock stimulates hypothalamus to release corticotropin-releasing hormone that stimulates pituitary to release ACTH that stimulates adrenal gland to release cortisol. Effect of cortisol release is elevation in blood sugar and increased insulin resistance and gluconeogenesis, hepatic process to produce more sugar. Cortisol also causes renal retention of water and sodium, a compensatory mechanism to conserve body water. Explain Hepatic Response. - ✅ Liver can store excess glucose as glycogen. As shock progresses, glycogenolysis is activated by epi to break down glycogen into glucose.

2024 - 2025 LATEST A+

  • Oxygen
  • IV's with warmed replacement fluids
  • Control external bleeding with direct pressure
  • Elevate LE's
  • NGT
  • Foley
  • Monitor and pulse oximeter
  • Monitor for development of coagulopathies
  • Surgery? ICP is a reflection of what three volumes? What happens when one increases? - ✅ 1. Brain
  1. CSF
  2. Blood within the nonexpansible cranial vault As volume of one increases, the volume of another decreases to maintain ICP within normal range. As ICP rises, CPP decreases, leading to cerebral ischemia and potential for hypoxia and lethal secondary insult. Hypotensive pt w/marginally elevated ICP can be harmful. Slightly elevated BP could protect against brain ischemia in a pt with high ICP. Cerebral ischemia can lead to increased concentration of CO2 and decreased concentration of O2 in cerebral vessels. CO2 dilates cerebral blood vessels = increase blood volume and ICP. What are the early signs and symptoms of increased ICP? - ✅ - Headache
  • N/V
  • Amnesia regarding events around the injury
  • Altered LOC
  • Restlessness, drowsiness, changes in speech, or loss of judgement What are the late observable signs of symptoms of increased ICP? - ✅ - 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 is Cushing's phenomenon or Cushing's Reflex? - ✅ Triad of progressive HTN, bradycardia and diminished respiratory effort. What are the two types of herniation that occurs with ICP? -

2024 - 2025 LATEST A+

✅ 1. Uncal herniation

  1. Central or transtentorial herniation Why does herniation occur? What are the symptoms? - ✅ Because of uncontrolled increases in ICP. S/E's
    • Unilateral or bilateral pupillary dilation
    • AsyDimmetric pupillary reactivity
    • Abnormal motor posturing
    • Other evidence of neurologic deterioration Define uncal herniation. - ✅ The uncus (medial aspect of the temporal lobe) is displaced over the tentorium into the posterior fossa. This herniation is the more common of the two types of herniation syndromes. Define central or transtentorial herniation. - ✅ A downward movement of the cerebral hemispheres with herniation of the diencephalon and midbrain through the elongated gap of the tentorium. Disruptions of the bony structures of the skull can result in what? - ✅ Displaced or nondisplaced fx's causing CSF leakage b/c of lac to the dura mater, creating a passage for CSF. CSF leaks through the nose (rhinorrhea) or the ears (otorrhea). A potential entrance for invading bacteria. Also: meningitis or encephalitis or brain abscess Define Minor Head Trauma. - ✅ GCS 13- 15 Define Moderate Head Trauma - ✅Postresuscitative state with GCS 9-13. Define Severe Head Trauma. - ✅Postresuscitative state with GCS score of 8 or less. What is a concussion and its signs and symptoms? - ✅ A temporary change in neurologic function that may occur as a result of minor head trauma. S/S:
    • Transient LOC
    • H/A
    • Confusion and disorientation
    • Dizziness

2024 - 2025 LATEST A+

✅ Results when a collection of blood forms between the skull and the dura mater. Bleeding is arterial=blood accumulates rapidly:

  • Compression of underlying brain
  • rapid increase in ICP
  • Decreased CBF
  • Secondary brain injury
  • Usually requires surgical intervention S/S:
  • Transient LOC
  • Lucid period lasting a few minutes to several hours
  • Rapid deterioration in neurologic status
  • Severe H/A
  • Sleepiness
  • Dizziness
  • N/V
  • Hemiparesis or hemiplegia on opposite side of hematoma
  • Unilateral fixed and dilated pupil on same side of hematoma What is a subdural hematoma and its S/S? - ✅ A focal brain injury beneath the dura mater that results from acceleration/deceleration. Usually venous, and not necessarily from a fx. Formation may be acute or chronic. Acute pt's hematoma manifest 48 hrs post injury S/S:
  • Altered LOC or steady decline in LOC
  • S/S of increased ICP
  • Hemiparesis or hemiplegia on opposite side of hematoma
  • Unilateral fixed and dilated pupil on same side of hematoma Chronic pt's " " up to 2 wks post injury
  • H/A
  • Progressive decrease in LOC
  • Ataxia
  • Incontinence
  • Sz's What are intracerebral hematoma's and its S/S? - ✅ Occur deep within brain tissue, may be single or multiple and commonly associated with contusions (frontal & temporal lobes). They result in significant mass effect, leading to increased ICP and neurologic deterioration. S/S:
  • Progressive and often rapid decline in LOC
  • H/A
  • Signs of increasing ICP
  • Pupil abnormalities
  • Contralateral hemiplegia

2024 - 2025 LATEST A+

What are the S/S of a linear skull fx? - ✅ - H/A

  • Possible decreased LOC What are the S/S of a depressed skull fx? - ✅ - H/A
  • Possible decreased LOC
  • Possible open fx
  • Palpable depression of skull over the fx site What are the S/S of a basilar skull fx? - ✅ - 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 How would you assess a pt with a cranial injury? - ✅ (Initial assessment) INSPECTION:
  • Assess airway
  • RR, pattern and effort
  • Assess pupil size and response to light
  • Unilateral fixed and dilated pupil = oculomotor nerve compression from increased ICP + herniation syndrome
  • Bilateral fixed and pinpoint pupils indicate a pontine lesion or effects of opiates
  • Mildly dilated pupil w/sluggish response may be early sign of herniation syndrome
  • Widely dilated pupil occasionally occurs w/direct trauma to globe of eye
  • Determine if pt uses eye meds
  • Abnormal posturing?
  • Inspect craniofacial area for ecchymosis/contusions
  • Periorbital ecchymosis
  • Mastoid's process ecchymosis
  • Blood behind tympanic membrane
  • Inspect nose and ears for drainage
  • Drng present w/out blood, test drng w/chemical reagant strip. Presence of glucose indicated drng of CSF
  • If drng present and mixed with blood, test by placing drop of fluid on linen or gauze. If a light outer ring forms around dark inner ring, drng contains CSF
  • Assess extraocular eye movement (Tests cranial nerves, III, IV, VI)
  • Performing extraocular eye movements indicates functioning brainstem
  • Limitation indicates orbital rim fx w/entrapment or paralysis of either a cranial nerve or ocular muscle
  • Determine LOC with GCS PALPATION

2024 - 2025 LATEST A+

  • Hyperthermia may increase cerebral metabolic rate + ICP. Avoid causing shivering during cooling process; increases cerebral metabolic rate + may precipitate rise in ICP
  • Do not pack ears/nose if CSF leak suspected
  • Admin tetanus prophylaxis
  • Wound repair for facial/scalp Lac's
  • Admin other meds
  • Analgesics, sedatives, narcan, romazicon, etc.
  • Admin antibiotics
  • Pt's w/basilar skull fx need prophylaxis against meningitis
  • Prepare pt for OR, hospital admin or transfer. What are signs of a serious eye injury? - ✅ - Visual disturbances
  • Pain
  • Redness and ecchymosis of the eye
  • Periorbital ecchymosis
  • Increased intraocular pressure What is hyphema and its S/S? - ✅ Accumulation of blood, mainly RBC's that disperse and layer within the anterior chamber. A severe hymphema obscures entire anterior chamber + will diminish visual acuity severely or completely. Injuries are graded on amount of blood in chamber (Grades I-IV). S/S:
  • Blood in anterior chamber
  • Deep, aching pain
  • Mild to severe diminished visual acuity
  • Increased intraocular pressure What are s/s of chemical burns to the eye? - ✅ Chemical injuries require immediate intervention if it is to be preserved. S/S:
  • Pain
  • Corneal Opacification
  • Coexisting chemical burn and swelling of lids What are S/S of penetrating trauma/open or ruptured globe? - ✅ - Marked visual impairments
  • Extrusion of intraocular contents
  • Flattened or shallow anterior chamber
  • Subconjunctival hemorrhage, hyphema
  • Decreased intraocular pressure
  • Restriction of extraocular movements What are the S/S of orbital fracture (orbital blowout fracture)? - ✅ - Diplopia (double vision)

2024 - 2025 LATEST A+

  • 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 is LeFort I fracture and its S/S? - ✅ Transverse maxillary fx that occurs above level of teeth and results in separation of teeth from rest of maxilla. S/S:
  • Slight swelling of maxillary area
  • Possible lip lac's or fractured teeth
  • Independent movement of the maxilla from rest of face
  • Malocclusion What is LeFort II fracture and its S/S? - ✅ Pyramidal maxillary fx=middle facial area. Apex of fx transverses bridge of nose. Two lateral fx's of pyramid extend through the lacrimal bone of the face and ethmoid bone of skull into the median portion of both orbits. Base of the fx extends above level of the upper teeth into maxilla. CSF leak is possible. S/S:
  • Massive facial edema
  • Nasal swelling w/obvious fx of nasal bones
  • Malocclusion
  • CSF rhinorrhea What is LeFort III fracture and its S/S? - ✅ Complete craniofacial separation involving maxilla, zygoma and bones of cranial base. This fx is frequently associated w/leakage of CSF and fx mandible. S/S:
  • Massive facial edema
  • Mobility and depression of zygomatic bones
  • Ecchymosis
  • Anesthesia of the cheek
  • Diplopia
  • Open bite or malocclusion
  • CSF rhinorrhea What are the mandibular fracture S/S? - ✅ - 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

2024 - 2025 LATEST A+

  • Limitation range of ocular motion may indicate orbital rim fx w/entrapment or paralysis of cranial nerve or ocular muscle
  • Perform visual acuity exam
  • Use Snellen or handheld chart. Check uninjured eye first
  • Assess for blurred or double vision with injured eye and then with both eyes open
  • Inspect for rhinorrhea or otorrhea
  • If drng present, may indicate CSF leak
  • Observe for impaled objects
  • Assess occlusion of mandible and maxilla
  • Malocclusion or inability to open + close mouth is highly indicative of maxillary or mandibular fx
  • Observe for uncontrolled bleeding PALPATION
  • Palpate periorbital area, face and neck for:
  • Tenderness
  • Edema
  • Step-off defects or depressions
  • Subcutaneous emphysema (esophageal or tracheal tear)
  • Palpate trachea above suprasternal notch
  • Trach deviation = late indication of tension pneumothorax or massive hemothorax
  • Assess sensory fx of perioribital areas, face and neck
  • Facial fx's can impinge on infraorbital nerve, causing numbness of inferior eyelid, lateral nose, cheek, or upper lip on affected side.
  • Check position of trachea DIAGNOSTIC STUDIES:
  • Xrays, CT scans, MRI's
  • Fluorescein staining
  • Slit-lamp exam
  • tonometry (measures intraocular pressure)
  • Bronchoscopy or esophagoscopy What are the nursing interventions for a pt with an ocular injury? - ✅ - 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

2024 - 2025 LATEST A+

  • 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 nursing interventions for a patient with a maxillofacial or neck injury? - ✅ - 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 With any eye injury, what should the evaluation and ongoing assessments be? - ✅ - Reassessing visual acuity at reasonable intervals
  • Reassessing pain, including response to nonpharmacologic + pharmacologic interventions
  • Monitoring appearance, position, movements of globe and pupillary responses
  • Monitoring airway patency, respiratory effort and ABG's What are the most common type of injury associated with chest trauma? - ✅ blunt; MVC's. Penetrating; firarm injuries or stabbings What are S/S of a rib fracture? - ✅ - Dyspnea
  • Localized pain on movement, palpation, or inspiration
  • Pt assumes position intended to splint chest wall to reduce pain
  • Chest wall ecchymosis or sternal contusion
  • Bony crepitus or deformity What is a flail chest? - ✅ A fracture of two or more sites on two or more adjacent ribs, or when rib fractures produce a free-floating sternum.