Assessment Findings for Spinal Cord Injury: Identifying the Type and Associated Symptoms, Exams of Clinical Psychology

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TNCC LATEST EDITION. QUESTION AND

ANSWERS WORKSHEET graded A+

Duringtheprimarysurveyofanunconscious pt with multi-system trauma, the nurse notes

snoring respirations. Whatpriority nursing interventions should be preformed next?

globerupture-A35y/o Mpresentswithfacialtraumaafterbeingstruckinthefacewitha baseball.

A teardrop-shaped left pupil is noted on exam. What type of injury issuspected?

compensated - A trauma pt is restless and repeatedly asking "where am i?" VS

uponarrival:BP110/60,HR96,RR24.Herskiniscoolanddry.CurrentVSareBP104/84,HR 108, RR 28. The pt is demonstrating s/sx of which stage of shock?

ventilate with a bag mask device - An unresponsive trauma pt has an

oropharygealairwayinplace,shallowandlaboredrespirations,andduskyskin.Thetrauma

teamhasadministeredmedicationsfordrugassistedintubationandattemptedintubationbutw asunsuccessful.What is the most appropriate immediate next step?

within24 hrsoftrauma-Whenisthetertiarysurveycompletedforatraumapt?

pressure-AnintubatedandsedatedptintheEDhasmultipleextremityinjurieswiththepotential

for causing compartment syndrome. What is the most reliable indication ofcompartment syndrome in a patient who is unconscious?

worseningpneumothorax-Whichofthefollowingispossiblecomplicationofpositive-pressure

ventilation?

pelvicstability-themostreassuringfindingforamaleptwithhippainafterafalliswhich of the

following?

narrowed - Whichofthefollowingpulsepressuresindicateearlyhypovolemic shock?

dysrhythmias-Patientswithacrushinjuryshouldbemonitoredforwhichofthefollowing conditions?

subduralhematoma-Tearingofthebridgingveinsismostfrequentlyassociatedwithwhich brain injury?

straight cath for urine sample - A 20 y/o M presents to the ED complaining of severelowerabdpainafterlandinghardonthebicyclecrossbarswhilepreforminganaerialBM X maneuver. Secondary assessment reveals lower abd tenderness and scrotalecchymosis. Which of the following orders would the RN question?

placental abruption - You are caring for a pt who was involved in a MVC and is 32weeks pregnant. Findings of your secondary survey include abd pain on palpation,fundal ht at the costal margin, and some dark bloody show. Varying accelerations anddecelerationsarenotedoncariocgraphy.Thesefindingsaremostconsistentwithwhichof the following?

itcanworsencorddamagefromanunstablespinalinjury -Whichofthefollowingistrueabout the log-roll?

defusings-AlloftheseareconsideredacriticalcommunicationpointintraumacareEXCEPT which of the following? pulseoximetryandcapnography- Whatbedsidemonitoringparametersareusedtoassess for adequacy of O2 and effectiveness of ventilation?

paddingtheupperbackwhilestabilizingthecervicalspine -Caregiverscarryina2y/ointo the ED who fell out of a second-story window. The pt is awake and crying withincreasedworkofbreathingandpaleskin.Whichofthefollowinginterventionshas thehighest priority?

bowel-WhichofthefollowinginjuriesisLEASTlikelytobepromptlyidentified?

Initiatetransfertoatraumacenter -AptisbroughttotheEDofaruralhospitalfollowinga highspeed MVC. When significant abd and pelvic injuries are noted in the primarysurvey, which of the following is the priority interventions?

bardycardiaandabsentmotorfunctionbelowthelevelofinjury -Aptwithacompletespinal cord injury in neurogenic shock will demonstrate hypotension and which otherclinical signs?

applysplintandelevateabovetheleveloftheheart -a37y/oFhasadeformityof theLwrist afterafall. She isreluctanttomoveherhand duetopain.Which of thefollowingisthe most appropriate intervention?

theaortaistornatitsattachmentwiththeligamentumarteriosum -whichofthefollowing occurs during the third impact of a motor vehicle crash?

Report your suspicion of maltreatment in accordance with local regulations - a 5 y/ochildpresentstotheEDwithbruisestotheupperarmandbuttocksinvariousstagesofhealin g and multiple small, clean, round burns to the back. There are no abnormalitiesfound based on the pediatric assessment triangle or primary survey. Which of thefollowingistheprioritysurvey.Whichofthefollowingistheprioritynursingintervention?

toguageend-organperfusionandtissuehypoxia -Whyisameasureofserumlactateobtained in the initial assessment of a trauma patient?

elevating the extremity to the level of the heart - A pt with a lower extremity fracturecomplainsofseverepainandtightnessinhiscalf,minimallybypainmedications.Which of the following is the priority nursing intervention?

WhichofthefollowingistheMOSTappropriateimmediateintervention? after a physical examination if the pt has no radiologic abnormalities on CT - EMSarriveswiththeintoxicateddriverofacarinvolvedinaMVC.EMSreportssignificantdamag e to the drivers side of the car. The pt is asking to have the cervical collarremoved. When it is appropriate to remove the cervical collar?

MARCH-Whichofthefollowingmnemonicscanhelpthenurseprioritize careforatrauma patient with massive uncontrolled hemorrhage?

Whatiskinematics? -Abranchofmechanics(energytransfer)thatreferstomotionanddoes not consider the concepts of force and mass of the object or body.

WhatisNewton'sFirstLaw? - Abodyatrestwill remainatrest.Abodyinmotion willremain in motion until acted on by an outside force.

WhatistheLawofConservationofEnergy? -Energycanneitherbecreatednordestroyed. It is only changed from one form to another.

WhatisNewton'sSecondLaw? - Forceequalsmassmultipliedbyaccelerationofdeceleration.

Whatiskineticenergy(KE)?-KEequals1/2themass(M) multipliedbythevelocitysquared.

WhatistheMnemonicfortheInitialAssessment? -A=Airwaywith simultaneouscervical spine protection B = Breathing C=Circulation D=Disability(neurologicstatus) E=Expose/Environmentalcontrols(removeclothingandkeepthepatientwarm)

What is the Mnemonic for the Secondary Assessment? - F = Full set of VS/Focusedadjuncts(includescardiacmonitor,urinarycatheter,andgastrictube)/Familypr esenceG = Give comfort measures (verbal reassurance, touch, and pharmacologic andnonpharmacologic management of pain). H=HxandHead-to-toeassessmentI = Inspect posterior surfaces

Where do you listen to auscultate breath sounds? - Auscultate the lungs bilaterally atthesecondintercostalspacemidclavicularlineandatthefifthintercostal spaceattheanterior axillary line.

Whatarethelatesignsofbreathingcompromise?--Tracheal deviation - JVD

Whataresignsofineffectivebreathing?--AMS

• Cyanosis,especiallyaroundthemouth

-Asymmetricexpansionofchestwall -Paradoxicalmovementofthechestwallduringinspirationandexpiration -Useofaccessorymusclesorabdominalmusclesorbothordiaphragmaticbreathing -Suckingchestwounds -Absentordiminishedbreathsounds -AdministerO2viaNRBorassistventilationswithabag-maskdevice,asindicated - Anticipatedefinitiveairwaymanagementtosupportventilation.

Uponinitialassessment,whattypeofoxygenshouldbeusedforaptbreathingeffectively? - A tight-fitting nonrebreather mask at 12-15 lpm.

Whatinterventionshouldbedoneifaptpresentswitheffectivecirculation? --Insert2large caliber IV's -Administerwarmedisotoniccrystalloidsolutionatanappropriaterate

Whataresignsofineffectivecirculation?- -Tachycardia -AMS -Uncontrolledexternalbleeding -Pale,cool,moist skin -Distendedorabnormallyflattenedexternaljugularveins -Distantheartsounds

WhataretheinterventionsforEffective/IneffectiveCirculation? --Controlanyuncontrolled external bleeding by: -Applyingdirectpressureoverbleedingsite -Elevatingbleedingextremity -Applyingpressureoverarterialpressurepoints - Usingtourniquet(lastresort). -Cannulate2large-caliberIV'sandinitiateinfusionsofanisotoniccrystalloidsolution -Usewarmedsolution -UsepressurebagstoincreasespeedofIVFinfusion -Usebloodadministrationtubingforpossibleadministrationofblood -Userapidinfusiondevicebasedonprotocol -UseNS0.9%insametubingasblood product -IV=surgicalcut- down,centralline,orboth. -BloodsampletodetermineABOandRhgroup -IOinsternum, legs,armsorpelvis -Administerbloodproducts -PASG(withoutinterferingwithfluidresuscitation)

HowdoyouassessMnemonic"D"?-DISABILITYA = Alert V=VerbalP = Pain U= Unresponsive

• GCS

WhatshebedoneaftertheSecondaryAssessment?-Reassess:

• Primarysurvey,
• VS
• Pain
• Anyinjuries

Whatarefactorsthatcontributetoineffectiveventilation?--AMS

• LOC
• Neurologicinjury
• SpinalCordInjury
• IntracranialInjury
• Blunttrauma
• Paincausedbyribfractures
• PenetratingTrauma
• Preexistinghxofrespiratorydiseases
• Increasedage

Whatmedicationsareusedduringintubation?-LOADMnemonic: L =Lidocaine O=Opioids A=Atropine D=Defasiculatingagents

WhataretheRapidSequenceIntubationSteps?-PREPARATION:

gatherequipment,staffing,etc.PREO XYGENATION:

Use100%O2(preventriskofaspiration).PRETREAT MENT:

• Decrease S/E's of intubationPARALYSISWITHINDUC TION:
• PthasLOC,thenadministerneuromuscularblockingagentPROTECTION AND POSITIONING:

Applypressureovercricoidcartilage(minimizeslikelihoodofvomitingandaspirationPLACEM ENT WITH PROOF

• EachattemptNOTtoexceed30seconds,maxof 3attempts.Ventilatept30 - 60 seconds between attempts.
• Afterintubation,inflatethecuff
• Confirmtubeplacementw/exhaledCO 2 detector.POSTINTUBATION MANAGEMENT:
• SecureETtube
• Setventilatorsettings
• ObtainChestx-ray
• Continuetomedicate
• RecheckVSandpulseoxtimetry

WhatisaCombitube?-Adual-lumen,dual-cuff airwaythatcanbeplacedblindlyintothe esophagus to establish an airway. If inadvertently placed into trachea, it can beused 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 aninflatable,elliptical,siliconerubbercollaratthedistalend.Itisdesignedtocoverthesupraglot tic area.

ILMA,doesnotrequirelaryngoscopyandvisualizationofthechords.

WhatisNeedleCricothyrotomy-Percutaneoustranstrachealventilation.(temporary)

Complications include:

• inadequateventilationcausinghypoxia -hematomaformation -esophagealperforation
• aspiration -thyroidperforation -subcutaneousemphysema

What is Surgical Cricothyrotomy? - Making an incision in cricothyroid membrane andplacingacuffedendoortrachtubeintotrachea.Thisisindicatedwhenothermethodsof airway management have failed and pt cannot be adequately ventilated andoxygenated.

Complications include:

• Aspiration -Hemorrhageorhematomaformationorboth -Lactotracheaoresophagus -Creationofafalsepassage -Laryngeal stenosis

HowdoyouconfirmETTube/AlternativeAirwayPlacement? --Visualizationofthechords -Usingbronchoscopetoconfirmplacement -Listeningtobreathsoundsovertheepigastrumandchestwallswhileventilatingthept -CO2detector -Esophagealdetectiondevice -Chestx- ray

Howdoyouinspectthechestforadequateventilation?-Observe: -mentalstatus -RRandpattern -chestwallsymmetry -anyinjuries

• patient'sskincolor(cyanosis?)

-Mitralvalveinsufficiency -dysrhythmias -CardiacFailure

ExplainObstructiveShock.-Resultsfrominadequatecirculatingbloodvolumebecauseof an obstruction or compression of great veins, aorta, pulmonary arteries, or heartitself.

Some causes: -Cardiactamponade(maycompresstheheartduringdiastoletosuchandextentthatatria cannot adequately fill, leading to decreased stroke volume). -Tensionpneumothoraxmayleadtoinadequatestrokevolumebydisplacinginferiorvena cava and obstructing venous return to right atrium. -Airembolusmayleadtoobstructionofpulmonaryarteryandsubsequentobstructionto right ventricular outflow during systole, with resulting obstructive shock

ExplainDistributive Shock. -ResultsfromdisruptioninSNScontrolofthetoneofbloodvessels, which leads to vasodilation and maldistribution of blood volume and flow.(NeurogenicandSepticShock).Neurogenicshockmayresultfrominjurytospinalcordin cervical or upper thoracic region.

Spinalshock=areflexiaandflaccidityassociatedwithlowermotorneuroninvolvementin complete cord injuries; reflexes return with resolution of spinal shock.

Septic shock from bacteremia is distributive shock. Endotoxins and other inflammatorymediatorscausevasodilation,shuntingofbloodinmicrocirculation,andotherp erfusionabnormalities.

Whatisvascularresponse?- Asbloodvolumedecreases,peripheralbloodvesselsvasoconstrict as a result of sympathetic stimulation via inhibition of baroreceptors.Arterioles constrict to increase TPR and BP.

Whatisrenalresponse?-Renalischemiaactivatesreleaseofrenin.

Kidneysdonotreceiveadequatebloodsupply,reninisreleaseintocirculation.

Renincausesangiotensinogen,normalplasmaprotein,toreleaseangiotensinI.

Angiotensin-convertingenzymefromthelungsconvertsintoangiotensin II.

AngiotensinIIcauses: -Vasoconstrictionofarteriolesandsomeveins -Stimulationofsympatheticnervoussystem -Retentionofwaterbykidneys -Stimulationofreleaseofaldosteronefromtheadrenalcortex(sodiumretention hormone)

*Decreasedurinaryoutput=earlysignrenalhypoperfusionandanindicatorthatthere'ssystem ic hypoperfusion.

Explainadrenalglandresponse. - WhenadrenalglandsarestimulatedbySNS,releaseofcatecholamines(epinephrineandnore pinephrine)fromadrenalmedullawillincrease.

Epi stimulates receptors in heart to increase force of cardiac contraction ( positiveinotropy)andincreaseHR(positivechronotropy)toimprovecardiacoutput,BPandtis sue perfusion.

Shock stimulates hypothalamus to release corticotropin-releasing hormone thatstimulatespituitarytoreleaseACTHthatstimulatesadrenalglandtoreleasecortisol.

Effectofcortisolreleaseiselevationinbloodsugarandincreasedinsulinresistanceandglucone ogenesis, hepatic process to produce more sugar.

Cortisolalsocausesrenalretention ofwaterandsodium,acompensatorymechanismto conserve body water.

ExplainHepaticResponse.-Livercanstoreexcessglucoseasglycogen.

Asshockprogresses,glycogenolysisisactivatedbyepitobreakdownglycogenintoglucose.

Inacompensatoryresponsetoshock,hepaticvesselsconstricttoredirectbloodflowtoother vital areas.

ExplainPulmonaryResponse.-Tachypneahappensfor2reasons: 1.Maintainacid-basebalance 2.Maintainincreasedsupplyofoxygen

• Metabolic acidosis from anaerobic metabolism will be a stimulus for the lungs toincreaserateofventilation.IncreasedRRisanattempttocorrectacidosis+augmentsoxygen supply to maximize oxygen delivery to alveoli.

ExplainIrreversibleShock.- Shockuncompensatedorirreversiblestageswillcausecompromises to most body systems. -Inadequatevenousreturn -inadequatecardiacfilling -decreasedcoronaryarteryperfusion -Membranesoflysosomesbreakdownwithincellsandreleasedigestiveenzymesthatcause intracellular damage.

Howwouldyouassesssomeoneinhypovolemicshock?-(UseInitialAssessment)and then:

WhataretheearlysignsandsymptomsofincreasedICP?--Headache -N/V -Amnesiaregardingeventsaroundtheinjury -AlteredLOC -Restlessness,drowsiness,changesinspeech,orlossofjudgement

WhatarethelateobservablesignsofsymptomsofincreasedICP? --Dilated,nonreactive pupil -Unresponsivenesstoverbalorpainfulstimuli -Abnormalmotorposturingpatterns -Wideningpulsepressure -Increasedsystolicbloodpressure -ChangesinRRandpattern

• Bradycardia

WhatisCushing'sphenomenonorCushing'sReflex? -TriadofprogressiveHTN,bradycardia and diminished respiratory effort.

Whatarethetwotypesof herniationthatoccurswithICP?-1.Uncalherniation 2.Centralortranstentorial herniation

Whydoesherniationoccur?Whatarethesymptoms? -Becauseofuncontrolledincreases in ICP.

S/E's -Unilateralorbilateralpupillarydilation -AsyDimmetricpupillaryreactivity -Abnormalmotorposturing -Otherevidenceofneurologicdeterioration

Defineuncalherniation. -Theuncus(medialaspectofthetemporallobe)isdisplacedoverthe tentoriumintotheposteriorfossa.Thisherniationisthemore commonof thetwo types of herniation syndromes.

Define central or transtentorial herniation. - A downward movement of the cerebralhemisphereswithherniationofthediencephalonandmidbrainthroughtheelongated gap of the tentorium.

Disruptions of the bony structures of the skull can result in what? - Displaced ornondisplacedfx'scausingCSFleakageb/coflactotheduramater,creatingapassage for CSF.

CSFleaksthroughthenose(rhinorrhea)ortheears(otorrhea).Apotentialentranceforinvading bacteria. Also:meningitisorencephalitisorbrainabscess

DefineMinorHeadTrauma.-GCS13- 15

DefineModerateHeadTrauma-PostresuscitativestatewithGCS9-13.

DefineSevereHeadTrauma.-PostresuscitativestatewithGCSscoreof8orless.

• Abnormalposturing

Whatisaconcussionanditssignsandsymptoms? - Atemporarychangeinneurologicfunction that may occur as a result of minor head trauma. S/S:

• TransientLOC
• H/A
• Confusionanddisorientation
• Dizziness
• N/V
• Lossofmemory
• Difficultywithconcentration
• Irritability
• Fatigue

Whatarethesignsandsymptomsofpostconcussivesyndrome?--PersistentH/A

• Dizziness
• Nausea
• Memoryimpairment
• Attentiondeficit
• Irritability
• Insomnia
• Impairedjudgement
• Lossof libido
• Anxiety
• Depression

Whatisdiffuseaxonalinjuryanditssignsandsymptoms? - (DAI)iswidespread,ratherthan localized, through the brain. Diffuse shearing, tearing and compressive stressesfrom rotational or accerleration/deceleration forces resulting in microscopic damageprimarily to axons within the brain. S/S:

• Immediateunconsciousness
• mildDAI,coma=6- 24 hrs
• severeDAI,coma=weeks/monthsorpersistentvegetativestate
• ElevatedICP

-ProgressivedecreaseinLOC

• Ataxia
• Incontinence -Sz's

Whatareintracerebralhematoma'sanditsS/S? -Occurdeepwithinbraintissue,maybe single or multiple and commonly associated with contusions (frontal & temporallobes).Theyresult in significantmass effect,leading toincreasedICP and neurologicdeterioration. S/S: -ProgressiveandoftenrapiddeclineinLOC -H/A -SignsofincreasingICP -Pupilabnormalities -Contralateralhemiplegia

WhataretheS/Sofalinearskull fx?--H/A -PossibledecreasedLOC

WhataretheS/Sofadepressedskullfx?--H/A -PossibledecreasedLOC -Possibleopenfx -Palpabledepressionofskulloverthefxsite

WhataretheS/Sofabasilarskullfx?--H/A -AlteredLOC -Periorbitalecchymosis(raccooneyes),mastoidecchymosis(Battle'ssign),orbloodbehind tympanic membrane (hemotympanum) -Facialnerve(VII)palsy -CSFrhinorrheaorotorrhea

Howwouldyouassessaptwithacranialinjury? (Initialassessment)INSPECTION: -Assessairway -RR,patternandeffort -Assesspupilsizeandresponsetolight -Unilateralfixedanddilatedpupil=oculomotornervecompressionfromincreasedICP +herniationsyndrome -Bilateralfixedandpinpointpupilsindicateapontinelesionoreffectsofopiates -Mildlydilatedpupilw/sluggishresponsemaybeearlysignofherniationsyndrome -Widelydilatedpupiloccasionallyoccursw/directtraumatoglobeofeye -Determineifptuseseyemeds -Abnormalposturing? -Inspectcraniofacialareaforecchymosis/contusions -Periorbitalecchymosis

• Mastoid'sprocessecchymosis

-Bloodbehindtympanicmembrane -Inspectnoseandearsfordrainage -Drngpresentw/outblood,testdrngw/chemicalreagantstrip.Presenceofglucoseindicated drng of CSF -Ifdrngpresentandmixedwithblood,testbyplacingdropoffluidonlinenorgauze.Ifa light outer ring forms around dark inner ring, drng contains CSF - Assessextraoculareyemovement(Testscranialnerves,III,IV,VI)

• Performingextraoculareyemovementsindicatesfunctioningbrainstem -Limitationindicatesorbitalrimfxw/entrapmentorparalysisofeitheracranial nerveorocular muscle

DetermineLOCwithGCSPALPATION -Palpatecranialareafor: -Pointtenderness -Depressionsordeformities - Hematomas -Assessall4extremities for: -Motorfunction,musclestrengthandabnormalmotorposturing

• Sensory functionDIAGNOSTICPROCED URES -LabStudies PLANNINGANDIMPLEMENTATION -(Initialassessment) -Clearairway(stimulationofgagreflexcanproducetransientincreaseinICPorvomiting with subsequent aspiration. -AdministerO2viaNRB -AssistwithearlyETintubation -Administersedative/neuromuscularblockingagent -Considerhyperventilation -PaCO2above45mmHgmaycauseincreasedcerebral vasodilation,increasedCBF,increased ICP. -ProlongedhyperventilationNOTRECOMMENDED.
  • Hypocarbia occurs as result of hyperventilation causes cerebral vasoconstriction,decreasedCBF,decreasedICP.Andischemiasecondarytoseverevasoco nstriction. -Hyperoxygenateptwith100%O2viabag-mask -Applydirectpressuretobleedingsitesexceptdepressedskullfractures -Cannulate2largeIV's -Hypotensiondoublespt'sdeathrate(w/severeheadtrauma) - VasopressorsusedtomaintainCPP. -InsertOGorNGT.OGshouldbeusedwithseverefacialtrauma. -Positionpt,elevateheadtodecreaseICP(butmayalsoreduceCPP). -Positionheadmidlinetofacilitatevenousdrng.Rotateheadtocompressveinsinneck and result in both venous engorgement and decreased drng from brain - PrepareforICPmonitoringdevice -Administermannitolasprescribed. -Mannitol,hyperosmolar,volume- depletingdiuretic,decreasescerebraledema+ICPby pulling interstitial fluid into intravascular space for eventual excretion by kidneys.