Because C7 is the lowest mobile and T1is the highest immobile part.
#1 affected organ with blunt force injuries.
ET tube is in esophagus
Symptoms of hypovolemic shock.
Scale used during primary survey to determine LOC.
V-response to Verbal stimuli
P-response to Painful stimuli
Ability to move air in and out of lungs
Gas exhange at the cellular level
O2 in - CO2 out
Reasons for ventilation
Acute ventilatory failure.
Acute ventilatory failure.
Can't move CO2 out
=acute respiratory acidosis
= increase CO2, decrease pH
Insufficient O2 in blood
Supplies for intubation
Pre-intubation duties and care
Call anesthesia and respiratory.
Confirm patients wishes with family.
Set up suction.
Oral care -- remove dentures.
Post-intubation duties and care
Secure ET tube.
Patient and family needs.
Used if patient will be intubated for a long period of time.
Improves patient comfort.
Negative pressure ventilation.
(-) pressure in lungs causes air to be sucked in.
Positive pressure ventilation
Air being pushed into lungs.
Delievers a preset Volume of air.
Pressure will vary.
Deliever preset Pressure.
Tidal Volume (TV)
Amount of air delievered to lungs with one breath in mL's
Precentage of O2 in inspired air.
Rate setting on vent.
# of breaths/min give to patient.
Can be patient or vent controlled.
Keeps alveoli inflated during expiration.
Will increase O2 to blood by keeping more surface area on copullary wills.
- Barotrauma, decreased CO2
Peak airway pressure
Pressure required to deliever volume of air.
Healthy lungs - 20 cm H2O
Goal - <40 cm H2O
Assist control ventilation
Guaranteed set # of breaths/min at set TV.
Any additional attempts to breathe, are assited at set TV
Advantages and disadvantages of Assist controlled ventilation.
Advantage - allows respiratory rest
Disadvantage - hyperventilation
guaranteed set # of breaths/min @ TV.
Any additional attempts ot breathe, are at TV that patient sets
Advantages and Disadvantages of S-IMV
Advantages - exercise of repiratiory muscles
Disadvantages - Potential for fatigue
No set rate or TV
Pt generated thier own, only a source of O2.
Used for weaning.
High pressure alarms
-secretions, coughing, kinked tube
Low pressure alarms
Pushing against little or no reisistance
Disconnection or leak
- check tubing, connections
Complications of mechanical intubation
CV - decreaed CO
Plumonary - O2 toxicity, VAP, barotrauma
GI - stress ulcer
What complications are possible when large amounts of NS is given to a patient with hypotension in hypovolemic shock?
Hyperchloremic acidosis d/t large amounts of chloride.
What question is important to ask prior to assessing a patient with a traumatic injury?
"What was the mechanism of injury?"
Name 3 predictable traumatic injuries that can occur from using both a lap belt and shoulder harness in a motor vehicle crash?
Chest wall contusion
Small bowel contusion
What triage classification would you as a nurse, give a patient with a temp of 100.5, productive cough, SaO2 of 93% on 3L of O2?
Non-life threathening; Urgent, serious health.
Name the principle phases of trauma care according to Advanced Trauma Life Support.
Resusciation (along with primary survey)
What nursing actions occur during "D" Phase of the primary survey?
Quick neuro assessment using the AVPU scale.
Where is the most common location for a coup-contrecoup shearing injury to occur?
Between C7 and T1
What type of blunt injury are pregnant women at greatest risk to incur?
Blunt abdominal trauma.
What type of complications could cause death during the 3rd peak or trimodal distribution of trauma-related deaths?
Systemic inflammatory response syndrome
Multiple organ dysfunction syndrome
Acute respiratory syndrome
What method of establishing an airway is contraindicated in traumatic injuries?
What type of airway is contraindicated if there is suspician of a cribriform plate fracture or basal skull fracture?
Name 3 methods used to confirm the adequacy of ventilation and oxygenation.
What diagnostic tool is used to diagnose the presence of slpeen or liver injuries in traumatic injuries?
What is the major complication of liver or spleen injuries?
-- Trend H&H
Name 2 metabloic phased to stress injury that occur when the body is attemping survival and recovery.
Ebb phase - 24-36hrs
Flow phase - after 36hrs
What shock state is present in traumatic injury when there is acute blood loss or fluid shifts?
Classic clinical manifestations of hypovolemic shock?
Paradoxical, uncoordinated respiratory movement.
Worrisome complications that can occur with flail chest.
How is flail chest treated?
Adequate pain medication
Stabilization of rib fractures
What triage classification would you give a patient with fracture ankle, alert, stable vital signs?
Fast track; Minor acute
Waht is the cause of cardiac tamponade?
Blunt or penetrating trauma causes pericardium to fill with blood restricting myocardial contractility.
What is the primary goal in "A" phase?
Maintain the patency of the airway and cervical spine immobilization.
What is a potential complication that can occur if a missle is removed from the body?
What airway is recommended for a conscious patient without suspicion of basal skull fracture or cribiform plate fracture?
What methods of establishing an airway are approved in traumatic injuries?
Modified jaw thrust
The temporary space that is created by displaced tissue from a penetrating missile.
Complications that can occur following rib fracture(s).
What ribs are at greatest rish to fracture?
What triage classification would you give a patient with a fall from a standing position, on Coumadin, hit his head and an altered LOC?
Emergent; Highest priority; Life-threatening.
What emergency surgical intervention is performed to locate hemorrhaging great vessels in hemorrhagic chest trauma?
Open resuscitative thoracotomy
Blunt force that involoves and increase in the velocity of a moving body or structure.
What criteria is used by a nurse to triage ETC patients?
Based of severity of injury or health problem.
Based on immediacy of the treatment.
What is the name for the collateral damage to the surrounding vessels, nerves, and organs of tissues from a penetrating missle?
How is the velocity of a missle related to the degree of tissue and organ damage?
The greater the velocity the greater the tissue and organ damage.
Upon initial contact in caring for a patient on a ventilator, what nursing actions should occur?
1. Ausculatate all lung fields for breath sounds.
2. Note demarcation line of the ET tube at the lip.
3. Confirm ventilator settings.
Blunt force that involoves being pressed or squeezed by force.
What does canopgraphy measure?
End Tital Volume (EtCO2)
Gives objective confirmation of ET tube placement.
EtCO2 <35 mm/Hg?
ET tube may be in the espohagus
Why is an elderly trauma patient have limited organ function when faced with a physiologic challenge?
Limited physiologic reserve.
What factors could delay or alter an accurate neuro evelaluation of a trauma patient during the primary survey?
Use and abuse of impairing substances.
Limited longitudinal stretch or stress upon a tissue or organ that can occur in a traumatic injury.
Monifestations of Tension and Open Pneumothorax
Abset breath sounds on the affected side
Decreased venous pressure
Increased intrathorasic pressure
Tension pneumothorax vs. Open pneumothorax
Tension - damage of the lung causing air to ecsape from the lung into the pleural cavity.
Open - penetration of the skin casing air from the atomosphereto enter the pleural cavity.
Treatment of tension vs. open pneumothorax
Tension - needle aspiration, chest tube
Open - occlusive dressing taped x3, chest tube, surgery prn.
-How to prevent?
->80% FiO2 for over 48hrs
-Can damage endothelium
-Increased PEEP and decreased FiO2
Interventions designed to prevent complications of mechanical ventilation.
-Prevention of stress ulcer
-Oral care Q4
Richmond Agitation Scale
-MD sets target score
-RM tries to match by adjusting sedation.
Complications of artifical airways
Vocal cord paralysis or damage
Nursing Diagnoses for mechanical ventilation
Ineffective Airway Clearance
Impaired Gas Exchange
---monitor CO2 and pH
Ineffective Breathing Pattern
---tachy, brady, dysynchrony, anxiety
Alteration in Cardiac Output
---d/t increased PEEP
Rapid Shallow Breathing Index (RSBI)
Used to assess a weaning trial.
RR / TV = RSBI
Monitor for stridor
Assess breath sounds
Cough and deep breathing
Your ventilated patient seems to be in distress. Her SaO2 is 84%, she is cyanotic and diaphoretic. What to do first?
Bag patient with 100% O2
-onset - 5min
-duration - 4-5hrs
-dosage - 2-4mg IV Q4
-onset - 15min
-duration - 4-5hrs
-dosage - 0.2-1mg IV Q2-3
Morphine vs Dilaudid
Dilaudid is 7x's stronger than Morphine
-dosage - 50mcg-100mcg
*useful for procedures
Opaite reversal agent
Will reverse all effects of opaites, including pain
-onset - Rapid
-duration - 4hrs
-dosage - weight based - 1-4mg
-onset - slow - 10-20min
-duration - 12hrs
Benzodiazepine reversal agent
Reversal agent for Benzo's
Reversal agent for opiates
White in color - dissolved in lipids
-onset - 2 min
-duration - 2-5min
-how to test?
Paralyzes skeletal muscles
Must sedate and analgesia
-Test with peripheral nerve stimulator
Assessment and non-verbal cues of pain
Compliance of vent.
Scale used for non-verbal pain assessment
Visual Analog Scale
0-10 face scale used for pain assessment
When is the spinal cord considered unstable?
When there is a lack of vertebral support
When there is a lock of ligament support
When there are 2+ damaged vertebral columns
Where is the beginning and end of the spinal cord?
Starts at foreamen magnum
Ends at L1 or L2
If the spinothalamic tract was injuried in an incomplete spinal injury, how might the patient present?
Unable to differentiate temp. below the level of injury
Altered and/or increased pain below the level of injury
What is the most common reason for a laminectomy?
Neural impingement stenosis
How are spinal cord injuries classified according to ASIA (American Spinal Injury Association)?
According to the level of vertebral injury.
If it is complete or incomplete
What type of spinal cord injury results in the absence of all motor and sensory function below the level of injury?
Complete spinal cord injury
What is the name of the spical cord injury id damage to the spical cord occurs between T2 anf L1?
What type of incomplete spinal cord injury results in spastic muscles and exaggerated tendon reflexes below the level of injury?
Upper motor neuron injury
What level of vertebral spinal cord injury results in loss of phrenic nerve innervations with the diaphragm?
Would a patient with complete coup-contrecoup shearing spinal cord injury be concidered a tetraplegic or paraplegic?
When does the primary spinal cord injury occur?
At the time of impact
Where should a nurse being a motor assessment when evaluating the motor functioning of a spinal cord injury?
At the head and compare left to right
What does it indicate if there are the presence of reflexes below the level of injury?
Upper motor neuron injury
Who are at greater risk for the ocurrence and severity of shock states in spinal cord injuries?
The higher the injury.
The greater the autonomic nervous system dysfunction.
Greater the occurence and severity of the shock state.
When do you know that spinal shock has ended for a patient with an incomplete upper motor neuron spinal cord injury?
Return of relexes below the level of injury
How do you treat spinal shock?
At what vertebral level of incomplete spinal cord injury does an upper motor neuron injury occur?
At or above T12
What is the name for the clinical state in spinal cord injuries that is marked by massive vasodilation, hypotension and bradycardia?
What is the rold of the nurse when turning a spinal cord injury patient
Cervical spine immobilization
Why does spinal shock occur?
Autonomic nervous system is in dysfunction
What spinal tract is injuried in an incomplete spinal injury if the patient has altered or increased pain levels?
What type of bladder function does a patient with an incomplete upper motor neuron have?
Spastic neurogenic bladder
What type of incomplete spinal cord injury results in hyporeflexia responses and flaccidity below the level of injury?
Lower motor neuron injury
What type of spincal cord injury causes loss of motor and sensory function of the arms, trunk, legs and pelvic regions?
When does the secondary spinal cord injury occur?
Within a few minutes of the impact
How is neurogenic shock treated?
IV fluid resusicitation
Name examples of non-surgical stabilization methods used in spinal cord injuries.
Cervical tongs with traction
What type of spinal cord injury can be stabilized with a halp traction?
What is the name given to a spinal cord injury that involves injury from C1 - T1?
What medication is given as a 24 hour infusion in the early stage of care of the spinal cord injury patient to improve neurological outcome and minimize the effects of secondary spinal cord injury inflammations?
Where should a nurse being a sensory assessment when evaluating function of a spinal cord injury patient?
At the feet
Comparing the left to the right
What dies the presence of perineal reflexes indicate when there is a spinal cord injury?
Incomplete involving upper motor neuron injury
When does spinal shock occur?
Within 30-60 minutes of primary injury
What type of pulmonary complications are SCI patients at risk for which could cause impaired respiratory effectiveness?
What spinal tract is injured, if the patient presents with altered or exaggerated sensations to touch and vibrations?
Posterior or dorsal spinal tract
What is the etiology or reason that a secondary spinal cord injury occur?
d/t vascular injury to the injured spinal cord
At what vertebral level does a lower motor neuron injury occur?
What is the best way of mobilizing secretions in a SCI patient?
Chest PT on bed
Name the perineal reflexes that are assessed in SCIs.
The anal wink
The bulbocavernosus reflex
Why is suctioning to be avoided unless necessary and only then is done with extreme caution in patients with spinal cord injuries?
Suctioning can cause bradycardia and asystole
What type of SCI results in preservation of some degree of sensory and/or motor impulses below the level of injury?
What spinal tract is damaged if the patient is not able to differentiate temperature changes below the level of injury in an incomplete spinal injury?
What vertebral level of spinal cord injury will result in the patient be dependent upon a ventilator to breathe?
Describe the reflex function seen in an upper motor neuron incomplete SCI.
When does spinal shock end?
How does hypovolemic shock and neurogenic shock differ?
Hypovolemic shock - atrial hypotension and tachycardia.
Neurogenic shock - atrial hypotension and severe bradycardia.
What is the purpose of manual or surgical stabilization of SCI?