Trauma Nursing TCRN
Trauma Nursing Review TCRN
Which of the following findings suggest impending herniation in a patient with an acute left subdural hematoma?
A. Left pupillary dilatation, right-sided weakness
B. Right pupillary dilatation, left-sided weakness
C. Left pupillary dilatation, left-sided weakness
D. Right pupillary dilatation, right-sided weakness
Answer: A. Left pupillary dilatation, right-sided weakness
Subdural hematomas (SDHs) are typically the result of tearing of tiny bridging veins that link the brain surface to the dura. Cerebral lacerations and dural sinus tears are less common SDH etiologies. Bleeding is usually venous. As blood accumulates within the closed cranial vault, increasing pressure forces the brain downward, to the only natural opening, the foremen magnum. The patient with a LEFT subdural hematoma will experience LEFT (ipsilateral) pupil dilation, because the cranial nerves are PERIPHERAL nerves, and peripheral nerves do not cross. However, the patient will demonstrate RIGHT-SIDED (contralateral) weakness (paresis) and sensory dysfunction (paresthesia) because neural fibers to and from the motor and sensory strips in the brain DO cross.
A patient who fell 30 feet has multiple orthopedic injuries, rib fractures, and a closed head injury. Two hours after critical care unit admission, the nurse notes a distinct "bubble wrap" sensation on chest palpation. The surgeon is notified. What study is most likely to be performed to locate the site of injury?
A. Upright chest radiography
B. Chest computed tomography
C. Fiberoptic bronchoscopy
D. Video-assisted laryngoscopy
Answer: C. Fiberoptic bronchoscopy
A "bubble wrap" or "Rice Krispies" sensation on palpation indicates air in the subcutaneous tissues. In the thoracic trauma patient, the source of subcutaneous air is usually a tracheal or bronchial tear. In contrast to pneumothorax (air in the pleural space), air from tracheobronchial tears travels into the soft tissues along the fascial planes. Because air rises, it usually accumulates in the upper chest, neck, and face. However, air may also travel downward. Chest radiography and computed tomography readily identify air in the soft tissues, but do not localize the site of the tear. Laryngoscopy could identify an injury ABOVE the glottis, but fiberoptic bronchoscopy facilitates visualization below the cords, and most blunt tears occur within 1 inch of the carina. Large tracheobronchial defects require urgent surgical repair. Small injuries are managed conservatively.
A patient's open tibia-fibula fracture was surgically debrided and stabilized with an external fixator. On post-op Day 2, the patient is ambulating with assistance and is out of bed to the chair 3-4 times per day. Serosanguinous wound drainage has markedly increased today. This finding suggests
A. external fixator pin site contamination.
B. an allergic reaction to wound care products.
C. arterial flow compromise distal to the wound.
D. fluid mobilization from edematous tissue.
Answer: D. fluid mobilization from edematous tissue.
Increasing serosanguinous drainage from a wound, which occurs as patient activity intensifies, is an expected event. This is a particularly common finding 2-3 days after injury in the patient who is progressing well. As the body recovers and reestablishes homeostasis, excess resuscitation and intraoperative fluid is mobilized from the intracellular and interstitial spaces. This phenomenon is also manifest as increased urine output. Open fractures always place patients at risk for infection. Judicious use of perioperative antibiotics can reduce this risk, but not eliminate it. However, infected wounds typically produce pus, rather than serous fluid. Monitor the patient for signs of infection such as leukocytosis, fever, foul-smelling or discolored wound drainage, increasing pain, and erythematous wound margins.
A patient received moderate injuries while being held captive in a protracted hostage event one week ago. Wounds are healing well, but the trauma nurse notes the patient rarely sleeps, eats very little, and has refused to see most visitors. These findings suggest
A. chronic stress disorder.
B. posttraumatic stress disorder.
C. acute stress disorder.
D. Stockholm syndrome.
Answer: C. acute stress disorder.
Stress disorders are a common sequela of the emotional trauma many injured patients have faced. Technically, the condition is "acute stress disorder" for the first 30 days and becomes posttraumatic stress disorder on day 31. However, the symptoms are the same. Stress disorders are associated with a wide variety of findings. Bedside nurses--and the patient's close friends and family members--are in the optimal position to detect symptoms of traumatic stress. How is the patient coping? Is he sleeping and eating appropriately? Is he having nightmares? How does he interact with family members? etc. Stress disorders are real diagnoses that require our best efforts at prevention and treatment. Patients with a stress disorder do not "just get over it." EARLY intervention is crucial to better long term outcomes.
A patient is being transferred from a Level III trauma center to a regional burn unit. When handing off care to the receiving facility, the transport team must
A. document the time, name, and title of the receiving provider.
B. ensure EMTALA-mandated paperwork has been completed.
C. obtain the name and signature of the admitting physician.
D. deliver patient insurance information to the registration clerk.
Answer: A. document the time, name, and title of the receiving provider.
Clear documentation of the provider accepting responsibility for the patient and the exact time of transfer of care leaves no room for confusion regarding who was responsible for the patient at any given moment during the transport process. The admitting physician is often not immediately available. Fortunately, a physician's signature is not required. It is not the transport team's responsibility to deliver insurance documents or other paperwork to various departments. It is the sending facility's responsibility to complete and forward any EMTALA-mandated paperwork. These documents can be transmitted electronically.
Trauma Nursing Review TCRN
Trauma Nursing Review TCRN®
Pocket Study Guide Volume 1
Laura M. Criddle PhD RN CCRN CEN CNRN ONC FAEN
TCAR Faculty Members