TCRN Review - Continuum of Care for Trauma Injury Prevention, Patient Safety, Patient Transfer,Forensic Issues, End-of-life Issues and
... [Show More] Rehabilitation
What are the 8 components to the Trauma System? - CORRECT ANSWER 1. Rapid identification of the injury, followed by easy access to EMS with a central dispatching system
2. Appropriately trained and appropriate level of EMS providers available on scene
3. Pre-hospital triage protocols authorizing EMS providers to make triage decisions before the patient is taken to the hospital
4. A communication system that allows direct conversation between pre-hospital providers, trauma center personnel, and physicians who provide medical direction
5. A designated trauma center with immediate availability of specialized surgeons, anesthesia providers, nurses, equipment, and radiologic capabilities.
6. A system that coordinates care among all levels of trauma centers and an interfacility transfer process that allows for prompt transfer of the patient to a higher level of care.
7. Access to rehabilitative services in both the acute and long-term phases of recovery.
8. A thorough performance improvement plan that includes all aspects of trauma care (pre-hospital through rehabilitation) and ensures "loop closure"
What is primary prevention in the trauma continuum? - CORRECT ANSWER Designed to prevent occurrence of the injury
What is secondary prevention in the trauma continuum? - CORRECT ANSWER Designed to reduce the severity of the injury that has occurred
What is tertiary prevention in the trauma continuum? - CORRECT ANSWER Improvement in outcomes related to traumatic injury
What are the goals of primary prevention? - CORRECT ANSWER To reduce injury and save money
What are the steps of injury prevention? (3) - CORRECT ANSWER 1. Injury incidence is monitored through data collection
2. Injury risk factors are identified and used to identify where, who, and with whom
3. Evaluate effectiveness of effort on injury occurrence
What is the term for the number of new cases of an injury that occur during a specified period of time in a population at risk for that injury? - CORRECT ANSWER Incidence
What is the term for the number of affected persons with a particular injury present in the population at a specified time divided by the number of persons in the population at that time? - CORRECT ANSWER Prevalence
What is the number of people alive with the effects of a particular disease or illness? - CORRECT ANSWER Morbidity
What is the term for the number of deaths in a specified time frame? - CORRECT ANSWER Mortality
What is the term for measurable costs of healthcare such as medical care costs, costs of rehabilitation, etc.? - CORRECT ANSWER Direct costs
What is the term for the value of foregone productivity? - CORRECT ANSWER Indirect Costs
What is the term for costs like property damage, police and fire services, etc.? - CORRECT ANSWER Additional costs
What are the 6 components of Injury Incidence? - CORRECT ANSWER 1. What is the magnitude of this injury (incidence and prevalence)?
2. What is the severity of this injury (mortality and morbidity)?
3. How preventable is this injury?
4. What are the costs of this injury (direct, indirect, other costs)?
5. Are some societal groups disproportionately affected?
6. What is the public's interest in this injury problem?
What are things to consider when identifying injury risk factors? - CORRECT ANSWER What human factors may lead to or contributed to the injury?
What factor in the agent (e.g. the motor vehicle) may lead to or contributed to the injury?
What physical factors in the environment may lead to or contributed to the injury?
What social factors in the environment may lead to or contributed to the injury?
What four factors might injury prevention focus on? - CORRECT ANSWER 1. Engineering (side impact airbags, athletic safety gear)
2. Enforcement/Legislation (driving while intoxicated or booster seat laws)
3. Education (PSA's, high school education)
4. Economic Incentives (fines for traffic offenses, increase insurance premiums)
List the critical injuries that the American College of Surgeons recommends for transfer to a Level 1 or Highest Regional Trauma Center. - CORRECT ANSWER Carotid or Vertebral Artery Injury
Torn Thoracic Aorta or Great Vessel
Cardiac Rupture
Bilateral Pulmonary Contusions with PaO2:FiO2 ratio <200 mmHg
Major abdominal vascular injuries
Grade 4 or 5 liver injuries requiring >6 units of RBC in 6 hours
List the life-threatening injuries that the American College of Surgeons recommends for transfer to a Level 1 or 2 Trauma Center. - CORRECT ANSWER Penetrating injury or open skull fracture
CVS Score <14 or lateralizing neurological signs
Spinal fracture or spinal cord defecit
<2 unilateral rib fractures or bilateral rib fractures with pulmonary contusion
Open long bone fracture
Significant torso trauma with advanced comorbid disease
When transporting patients between facilities, who is responsible for the care of the patient until the patient arrives at the receiving facility? - CORRECT ANSWER The Sending Facility
What are the 3 modes of transport? - CORRECT ANSWER Ground
Rotor-Wing
Fixed-Wing
What are the advantages to ground transport? - CORRECT ANSWER Can transport larger pieces of equipment
What are the disadvantages to ground transport? - CORRECT ANSWER Limited by inclement weather
May require longer transport times than air transport
What are the advantages to Rotor-Wing transport? - CORRECT ANSWER Rapid point-to-point transfer
Can land near patient pick-up point
Can reach areas of difficult terrain
Usually has advanced crew on board
What are the disadvantages of Rotor-Wing transport? - CORRECT ANSWER Expensive
Noise and Vibration
Limited to approximately 150 mile radius of base station
Weight limitations
Cabin generally not pressurized
What are the advantages of Fixed Wing transport? - CORRECT ANSWER Can travel long distances rapidly
Cabin is pressurized and normally roomy
Can transport multiple patients
Navigational equipment allows flight in inclement weather
What are the disadvantages of Fixed Wing transport? - CORRECT ANSWER Limited accessibility of the landing strip
Expensive
What are the considerations prior to air transport? - CORRECT ANSWER Air expands in altitude
What are some interventions prior to air transport? - CORRECT ANSWER Consider giving decongestant to patients with sinusitis
Place chest tubes even for small pneumothoraxes
Replace air in endotracheal tube cuff with saline
Decompress stomach with gastric tube
Do not use air-filled splints
What are the Institute for Health Care Improvements guidelines regarding Central Line Bundle - CORRECT ANSWER Hand hygiene
Maximal barrier precautions (cap, mask, sterile gown, sterile gloves, cover patient from head to toe with sterile drape)
Chlorhexidine skin antiseptic
Avoid femoral vein for central access
Daily review of central line necessity with prompt removal of unnecessary lines
Describe the application of chlorhexidine: - CORRECT ANSWER prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol, scrub for at least 30 seconds, do not wipe or blot, allow antiseptic solution time to dry completely before puncturing site.
What are the Institute for Health Care Improvements guidelines regarding Medication Safety? - CORRECT ANSWER Develop order sets or clinical pathways for treating patients with similar problems.
Standardize concentration and dose strengths to the minimum needed for safe care.
Consider including a centralized pharmacist or nurse to run anticoagulation, insulin management, and pain management services.
Use tall man lettering for high-risk drugs
Implement double-checks where appropriate
Develop protocols allowing for administration of reversal agents without having to contact the physician, and ensure antidotes and reversal agents are readily available.
What are the Institute for Health Care Improvements guidelines regarding Prevention of surgical site infections? - CORRECT ANSWER Prophylactic antibiotic within one hour of surgical incision but discontinued within 24 hours after surgery time.
Hair removal from surgical site only when necessary, with clippers (not razors).
What are the Institute for Health Care Improvements guidelines regarding Fall Reduction? - CORRECT ANSWER Recognize patients at high risk for falls
Implement factors which may decrease falls
Which patients are at high risk for falls? - CORRECT ANSWER Weak muscles
Drugs which increase sleepiness
Use of cane or walker
Need to use the bathroom frequently
List 8 factors that may decrease falls. - CORRECT ANSWER Monitor patient when they first ambulate after surgery/procedure.
Provide correct footwear.
Keep the bed in low position when patient is resting.
Ensure patient is comfortable, reposition frequently.
Ensure call light, TV remote, bedside table, tissue box, garbage can, water and telephone are within reach.
Educate family and patient about the need to call and wait for help before ambulating.
Encourage use of walker or other device to help them move safely.
Use an alert system, such as a wristband, signs, or other communication, to warn of patients with high risk for falls.
Describe the process of clothing removal related to forensic evidence. - CORRECT ANSWER Place two clean sheets on the floor.
Cut off clothing (do not cut through holes, stains, defects)
Do not put clothing in a pile.
Package each piece of clothing separately in a paper bag.
Avoid excess handling of patient clothing; change gloves frequently to prevent cross-contamination of evidence
Double fold the edge of the paper bag and apply tape from one end of the fold all the way across to the other end to provide a complete seal.
Initial across the tape to provide a tamper-resistant seal
Is it acceptable to allow a patient to remove their clothing instead of cutting it? - CORRECT ANSWER Yes. Allow a patient to undress themselves if appropriate, but assure the process is witnessed.
Can you place evidence in a plastic or airtight bag? - CORRECT ANSWER No. This could cause mold or mildew.
Describe the process for collecting non-clothing forensic evidence. - CORRECT ANSWER Place evidence on a piece of white paper, minimizing handling of evidence, wearing sterile, preferably powder-free gloves.
Fold the paper into thirds, with the evidence in the center of the paper.
Turn paper 90 degrees and fold into thirds a second time.
Tuck under third into lower third after second folding.
Place paper into clean, white envelope and tape (do not lick) it shut.
Label the envelope the same way clothing bags are labeled.
Describe the process for collecting evidence under fingernails. - CORRECT ANSWER Scrape or swab under fingernails
Allow evidence to fall onto clean white paper.
Clip broken nails
Separate evidence and nail clippings by right and left hands.
Describe the process of collecting body fluids for forensic evidence. - CORRECT ANSWER Identify using woods lamp
Scrape onto a clean glass slide
If difficult to remove, moisten cotton-tipped applicator with sterile water and swab the area.
Allow swab to dry before placing in envelope.
How do you prepare gunshot wounds for forensic evidence? - CORRECT ANSWER Cover victim's hands in paper bags to preserve residue on them.
Identify and document the presence or absence of any residue around a wound.
Never label gunshot wounds as "entrance" or "exit"
Minimize handling of the bullet if it is found in clothing or removed.
Do not use metal forceps to handle it as this may alter the markings on the outside of the bullet.
Wrap it in gauze and put it inside a clean container.
How do you handle a bullet that is evidence? - CORRECT ANSWER Use either a rubber tipped forceps or protect with gauze before using forceps to handle it.
Describe how to care for gunpowder with a gunshot wound. - CORRECT ANSWER If gunpowder exists around a wound, photograph it before cleaning the area. Scrape gunpowder onto a piece of white paper, placing it in an envelope as with non-clothing evidence.
Gunpowder may be preserved with tape set against a wound prior to cleansing it. The tape is then put on a glass slide and preserved in an envelope.
What is the chain of evidence collection with forensic evidence? - CORRECT ANSWER Minimize the number of people who handle the evidence.
Ensure that the evidence cannot be tampered with.
Evidence must be presented in a way that demonstrates the item's location and responsible party at any given time. Each time the evidence changes hands, a receipt is generated and signed by both parties (may also be documented in the patient's record).
What is the term for the process by which physical, sensory, and mental capacities are restored or developed in (and for) people with disabling conditions, reversing what has been called the disabling process, and therefore called the enabling process? - CORRECT ANSWER Rehabilitation
List the 4 stages of rehabilitation. - CORRECT ANSWER 1. Injury to resuscitation
2. Critical Care / Inpatient Phase
3. Rehabilitation Phase
4. Reintegration Phase
What is the goal of the first phase of rehabilitation (injury to resuscitation)? - CORRECT ANSWER Prevent further injury and complications
i.e. recognition & treatment of compartment syndrome to salvage limb and function, decrease ICP to minimize secondary brain damage
What is the goal of the second phase of rehabilitation (critical care / inpatient phase)? - CORRECT ANSWER Medical stabilization and prevention of complications
i.e. positioning to prevent pressure sores and contractures, early nutrition to assist with maintenance of body, early weight-bearing and ambulation
What is the goal of the third phase of rehabilitation (rehabilitation phase)? - CORRECT ANSWER Restoration, compensation and adaptation
In regard to rehabilitation, what is restoration? - CORRECT ANSWER The ability to recover normal function
In regard to rehabilitation, what is compensation? - CORRECT ANSWER Replace normal function with other strategies
In regard to rehabilitation, what is adaptation? - CORRECT ANSWER Change lifestyle, roles and expectations to adapt to disability
What is the goal of the 4th phase of rehabilitation (reintegration phase)? - CORRECT ANSWER Adaptation and compensation applied to prevent pre-morbid lifestyle.
List the 7 members of the Rehab team. - CORRECT ANSWER Patient and Family
Nurse
Physical Therapist
Respiratory Therapist
Occupational Therapist
Speech Pathologist
Physiatrist
What are the roles of the patient and family in the rehab team? - CORRECT ANSWER Must buy into goals for goals to be successful
Success requires patient motivation and family involvement
Patients and families tend to be more passive in the beginning, but as the crisis subsides, they become more interested and involved in decision-making.
What are the roles of the nurse in the rehab team? - CORRECT ANSWER Teacher, caregiver, collaborator, client advocate
What is the role of the physical therapist in the rehab team? - CORRECT ANSWER Encourages mobility, prevents contractures, involved in positioning techniques, and transfers to the chair, as well as weight-bearing
What is the role of the respiratory therapist in the rehab team? - CORRECT ANSWER Mobilization of respiratory secretions by percussion, vibration, and postural drainage (sometimes done by PT)
What is the role of the occupational therapist in the rehab team? - CORRECT ANSWER Assists ability to perform activities of daily living
Upper extremity positioning and mobility
Splinting for therapeutic positioning
What is the role of the speech pathologist in the rehab team? - CORRECT ANSWER Promote stimulation from coma
Cognitive rehabilitation
Communication through alternate methods and devices
Improvement of perceptual defecits
What is the role of the physiatrist in the rehab team? - CORRECT ANSWER Physician specialized in rehabilitation who expedites the implementation of rehabilitation care an guides the process (or this role may be done by a clinical nurse specialist, nurse practitioner, or case manager).
When establishing potential for rehabilitation, what are the physical factors to consider? - CORRECT ANSWER What is maximal outcome?
Multiple injuries will reduce rehabilitation potential
Pre-existing conditions may alter ultimate outcome
When establishing potential for rehab, what are the behavioral and cognitive factors to consider? - CORRECT ANSWER Ability to learn new things and solve problems
Educational level and readiness to learn
Prior experiences
When establishing potential for rehab, what are the psychosocial factors to consider? - CORRECT ANSWER Income and lifestyle
Family support and relationships
Mood
Personality
Coping mechanisms
What other factors should be considered when establishing potential for rehab? - CORRECT ANSWER Substance abuse (especially after discharge)
Depression
Patient Age
Length of time since injury
Secondary complications
available resources
Discuss a living will. - CORRECT ANSWER An individual indicates what treatments he does and does not want applied.
Applies only to terminal illness or a vegetative state.
Signed by the person to whom it applies.
Applies when person is unable to speak for themself.
Does a Living Will represent informed consent? - CORRECT ANSWER No
What should you do if a patient with a living will arrests? - CORRECT ANSWER Start CPR.
If ROSC, refer to document.
Discuss a durable power of attorney for health care. - CORRECT ANSWER Designates a surrogate decision maker when an individual is unable to make his own decisions.
May include limits or parameters for what type of medical treatment must be followed by the surrogate.
Signed by the person to whom it applies.
Applied when person cannot speak for themself.
Does a Durable power of attorney for health care represent informed consent? - CORRECT ANSWER No
If a patient with a durable power of attorney for health care arrests, what should you do? - CORRECT ANSWER Start CPR.
If ROSC, refer to legal surrogate
Discuss a DNR or an AND (allow natural death) - CORRECT ANSWER Order placed on a patient's chart that addresses what life-saving measures should be instituted.
May limit CPR or intubation, but does not exclude pain relief or other comfort measures.
Signed by a Physician
Applies immediately upon order.
Does a DNR represent informed consent? - CORRECT ANSWER YES
What should occur if a patient with a DNR experiences cardiac arrest? - CORRECT ANSWER do NOT begin CPR
Discuss an Out-of-Hospital DNR (Portable DNR) - CORRECT ANSWER Directs EMS to reserve cardiac/respiratory arrest resuscitation but may still provide assessment, assistance for choking, aggressive pain management and grief counselling.
Requires signature of HCP as well as patient/surrogate.
Applies immediately upon signature.
Does an Out-of-Hospital DNR represent informed consent? - CORRECT ANSWER YES
What should occur if a patient with an out-of-hospital DNR experiences cardiac arrest? - CORRECT ANSWER do NOT begin CPR
The unexpected nature of trauma means the family bypasses anticipatory grief, which may lead to complicated bereavement and potentially to _____. - CORRECT ANSWER PTSD
List the 4 signs of Traumatic Grief. - CORRECT ANSWER Somatic Expression
Cognitive Expression
Affective Expression
Behavioral Expression
What are the signs of somatic expression? - CORRECT ANSWER Physical complaints such as pain, nausea and headache
Loss of appetite, weight loss
Overeating, weight gain
Sleep disturbances and fatigue
What are the signs of Cognitive Expression? - CORRECT ANSWER Preoccupation with loss
Low self-esteem
Unable to concentrate or remember
Helplessness and hopelessness
Situations seem unreal
What are the signs of Affective Expression? - CORRECT ANSWER Anxiety
Guilt, resentment and aggression
Despair and depression
loneliness
defensiveness or self-blame
What are the signs of behavioral expression? - CORRECT ANSWER Agitation
Fatigue
Crying
Social WIthdrawal
Discuss family presence regarding trauma. - CORRECT ANSWER Ideally, families are provided time to be with the patient before death is pronounced as this aids with the bereavement process.
Determine if the family wants to be at the bedside and is appropriate to be there.
Ensure policies and procedures are in place for family presence
Warn the family about what they will experience in the room before escorting them to the bedside.
Ensure a dedicated staff member accompanies and stays with the family.
Act as a role model; speak directly to and touch the dying or dead patient.
Which words should be used as opposed to "flat-lined" "passed away" "eternal sleep" or "coded"? - CORRECT ANSWER Dead or Died
What are the 5 stages of Grief? - CORRECT ANSWER Shock or Denial (This isn't happening to me)
Anger (Why is this happening to me)
Bargaining (I promise I will be a better person if)
Depression (I don't care anymore)
Acceptance (I'm ready for whatever comes)
What are the procedures that should be in place for family to view the body? - CORRECT ANSWER Remove tubes (but consider coroner's case)
Wash off blood (consider cultures in which family members should do this)
Cover wounds with dressings
Dim the lights to make the skin look less pale
Lower the stretcher height and put chairs near the stretcher
What are some ways to reduce the risk of violence with emotional family members? - CORRECT ANSWER Do not hurry, instead engage in a conversation
attempt to establish a therapeutic alliance
allow verbalization of complaints
speak calmly
avoid confrontation
position so that the nurse is between the patient and the door
remove potentially harmful objects or furniture
stand sideways
keep hands visible
Discuss the response of the body after brain death. - CORRECT ANSWER Brain death > uncontrolled release of catecholamines (tachycardia, Increased SBO, Increased CO) > catecholamines deplete and regulatory mechanisms fail; posterior pituitary gland ceases to produce ADH; diabetes insipidus > Variable heart rates and arrhythmias, failure of hypothalymus leading to poikelothermy, vasodilation and hypotension, (at this point the goal is to keep SBP above 100 and Temp above 95).
What is the term for an irreversible cessation of circulatory or respiratory functions, or irreversible cessation of all functions of the entire brain - including the brain stem? - CORRECT ANSWER Brain Death
In regard to organ donation, prior to brain death, all conditions which impair neurological functions should be ruled out. Including: - CORRECT ANSWER Normalize electrolytes
Body temperature above 95
Consider drug levels which would impair neurologic reflexes (neuromuscular blockade, sedation, anesthetics)
What are the conditions of brain death? - CORRECT ANSWER Irreversible
Body Temp > 95
Fixed Pupils
No spontaneous movements in response to external stimuli
Apnea in the presence of hypercarbia (PaCO2 > 60)
No reflex activity (except that elicited by spinal cord). The pupils are fixed and dilated, and an absence of the following reflexes: gag, cough, oculocephalic, oculovestibular and corneal
What is the term for reflexes that are normal when present and whose absence indicates neurological function? - CORRECT ANSWER Superficial Reflexes
What is the term for reflexes that are worrisome if present after infancy? - CORRECT ANSWER Pathological Reflexes
Describe the oculocephalic reflex. - CORRECT ANSWER Move the head back and forth.
If the eyes remain focused forward, this is a normal finding; if the eyes move in the opposite direction of the head movement, this is an abnormal finding.
Describe the oculovestibular reflex - CORRECT ANSWER Water is instilled into the ear canal. Warm water should cause the eyes to deviate towards the same side; cold water should cause them to deviate towards the opposite side.
Lack of eye movement is consistent with brain death.
List 3 superficial reflexes. - CORRECT ANSWER Corneal
Gag
Swallow
How do you test a corneal reflex? - CORRECT ANSWER Brush a wisp of cotton against the cornea, or apply a small drop of water or saline. A normal response is rapid closing of the eyelid.
How do you test a gag reflex? - CORRECT ANSWER Stimulate the back of the pharynx. A normal response is gagging.
How do you test a swallow reflex? - CORRECT ANSWER Touch the uvula. A normal response is elevation of the uvula.
List 2 pathological reflexes. - CORRECT ANSWER Babinski
Grasp
How do you test the babinski reflex? - CORRECT ANSWER Stroke the lateral aspect of the foot.
A healthy response after infancy is curling of the toes; a worrisome response after infancy is fanning of the toes.
How do you test the grasp reflex? - CORRECT ANSWER Stimulate the palm of the hand. A worrisome finding is the patient closing their fist (grasping).
Discuss apnea testing. - CORRECT ANSWER Hyperoxygenate with 100% O2 for at least 10 minutes.
Remove from ventilator support, but provide oxygen via cannula at 6L/minute per ETT.
Monitor for spontaneous respiratory effort or more than 10% change in BP, HR or pulse oximetry
In organ donation, after determining brain death, what is the next step? - CORRECT ANSWER Obtain medical examiners approval.
Describe obtaining the medical examiners approval for organ donation. - CORRECT ANSWER State specific, usually require in cases such as homicide, suicide, accidental death, death within 24 hours of admission, death under the age of 18.
In organ donation, after obtaining the medical examiners approval, what is the third step? - CORRECT ANSWER Notify local organ procurement organization.
The organ procurement organization may help determine eligibility.
Ineligible patients may include those with septicemia, communicable diseases such as hepatitis or high risk for HIV.
Are most people with metastatic cancer eligible for organ donation? - CORRECT ANSWER Yes
After notifying the local organ procurement organization, what is the next step in organ donation? - CORRECT ANSWER Determine the patient's wishes.
Describe first person consent in organ donation. - CORRECT ANSWER If patient's wishes are clear (advanced directives, will, drivers' license) no further consent is needed.
If a patient's wishes regarding organ donation are unclear, consent is required. What is the legal next-of-kin route? - CORRECT ANSWER Agent
Spouse
Adult Child
Parent
Adult Sibling
Adult Grandchild
Grandparent
Guardian
Anyone who exhibited special care and concern
Other person having lawful authority to dispose of the body.
What are the transplantable organs? - CORRECT ANSWER Liver
Kidney
Heart
Pancreas
Intestines
What are the transplantable tissues? - CORRECT ANSWER Cornea
Bone
Pancreatic islet cells
Bone Marrow
Ligaments and Tendons
Heart Valves
Skin
Veins
Middle Ear
How long may bone procurement be delayed? - CORRECT ANSWER 10 hours
How long may heart valve procurement be delayed? - CORRECT ANSWER 6-10 hours
How long may skin and cornea procurement be delayed? - CORRECT ANSWER 24 hours
What are some points to remember regarding corneal donations? - CORRECT ANSWER Refrigerate eye donor when possible
Keep HOB elevated 20 degrees
Instill artificial tears
Tape eyes closed with paper tape
Place cool compresses over the eyes to prevent swelling [Show Less]