TCRN REVIEW - CONTINUUM OF CARE FOR TRAUMA (INJURY PREVENTION, PATIENT SAFETY, PATIENT TRA, Exams of Nursing

Download TCRN REVIEW - CONTINUUM OF CARE FOR TRAUMA (INJURY PREVENTION, PATIENT SAFETY, PATIENT TRA and more Exams Nursing in PDF only on Docsity! TCRN REVIEW - CONTI NUUM OF CARE FOR TRAUMA (INJURY PREVENTION, PATIENT SAFETY, PATIENT TRANSFER, FORENSIC ISSUES, END-OF-LIFE ISSUES AND REHABILITATION) (21 QUESTIONS ON EXAM) What are the 8 components to the Trauma System? - 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? - ANSWER ☑☑Designed to prevent occurrence of the injury What is secondary prevention in the trauma continuum? - ANSWER ☑☑Designed to reduce the severity of the injury that has occurred What is tertiary prevention in the trauma continuum? - ANSWER ☑☑Improvement in outcomes related to traumatic injury What are the goals of primary prevention? - ANSWER ☑☑To reduce injury and save money What are the steps of injury prevention? (3) - 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? - 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? - ANSWER ☑☑Prevalence What is the number of people alive with the effects of a particular disease or illness? - ANSWER ☑☑Morbidity What is the term for the number of deaths in a specified time frame? - ANSWER ☑☑Mortality What is the term for measurable costs of healthcare such as medical care costs, costs of rehabilitation, etc.? - ANSWER ☑☑Direct costs What is the term for the value of foregone productivity? - ANSWER ☑☑Indirect Costs What is the term for costs like property damage, police and fire services, etc.? - ANSWER ☑☑Additional costs What are the 6 components of Injury Incidence? - 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 the considerations prior to air transport? - ANSWER ☑☑Air expands in altitude What are some interventions prior to air transport? - 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 - 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: - 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? - 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? - 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? - ANSWER ☑☑Recognize patients at high risk for falls Implement factors which may decrease falls Which patients are at high risk for falls? - 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. - 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. - 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? - 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? - ANSWER ☑☑No. This could cause mold or mildew. Describe the process for collecting non-clothing forensic evidence. - 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. - 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. - 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. What are the roles of the patient and family in the rehab team? - 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? - ANSWER ☑☑Teacher, caregiver, collaborator, client advocate What is the role of the physical therapist in the rehab team? - 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? - 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? - 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? - 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? - 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? - 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? - 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? - ANSWER ☑☑Income and lifestyle Family support and relationships Mood Personality Coping mechanisms What other factors should be considered when establishing potential for rehab? - ANSWER ☑☑Substance abuse (especially after discharge) Depression Patient Age Length of time since injury Secondary complications available resources Discuss a living will. - 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? - ANSWER ☑☑No What should you do if a patient with a living will arrests? - ANSWER ☑☑Start CPR. If ROSC, refer to document. Discuss a durable power of attorney for health care. - 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? - ANSWER ☑☑No If a patient with a durable power of attorney for health care arrests, what should you do? - ANSWER ☑☑Start CPR. If ROSC, refer to legal surrogate Discuss a DNR or an AND (allow natural death) - 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? - ANSWER ☑☑YES What should occur if a patient with a DNR experiences cardiac arrest? - ANSWER ☑☑do NOT begin CPR What are the procedures that should be in place for family to view the body? - 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? - 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. - 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? - ANSWER ☑☑Brain Death In regard to organ donation, prior to brain death, all conditions which impair neurological functions should be ruled out. Including: - 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? - 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? - ANSWER ☑☑Superficial Reflexes What is the term for reflexes that are worrisome if present after infancy? - ANSWER ☑☑Pathological Reflexes Describe the oculocephalic reflex. - 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 - 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. - ANSWER ☑☑Corneal Gag Swallow How do you test a corneal reflex? - 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? - ANSWER ☑☑Stimulate the back of the pharynx. A normal response is gagging. How do you test a swallow reflex? - ANSWER ☑☑Touch the uvula. A normal response is elevation of the uvula. List 2 pathological reflexes. - ANSWER ☑☑Babinski Grasp How do you test the babinski reflex? - 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? - ANSWER ☑☑Stimulate the palm of the hand. A worrisome finding is the patient closing their fist (grasping). Discuss apnea testing. - 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? - ANSWER ☑☑Obtain medical examiners approval. Describe obtaining the medical examiners approval for organ donation. - 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? - 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.