TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Tra, Exams of Medicine

Download TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Tra and more Exams Medicine in PDF only on Docsity! TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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" TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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) TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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. TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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. TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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. TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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 TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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). TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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. TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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. TCRN Review - Continuum of Care for Trauma (Injury Prevention, Patient Safety, Patient Transfer, Forensic Issues, End-of-life Issues and Rehabilitation) (questions and answers) 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