TRAUMA NURSING PROCESS TNP TNCC
REVISION HANDBOOK 2026 AIRWAY
BREATHING CIRCULATION AND TRAUMA
ASSESSMENT
◉ What is caused by the tear of the bridging veins or middle
meningeal artery?
Answer: Subdural and Epidural Hematoma
◉ Affect concentration, memory, sleep, mode, and libido. Causes
headaches, dizziness and nausea.
Answer: Postconcussive Syndrome/ Mild Traumatic Brain Injury
◉ Signs and symptoms similar to early signs of increased ICP but do
not worsen.
Answer: Postconcussive Syndrome/ Mild Traumatic Brain Injury
◉ Cerebral Perfusion Pressure = ______-______
Answer: MAP - ICP
◉ What is the range for CO2 to maximize perfusion?
Answer: 35-45
,◉ Does hypoventilation cause dilation or constriction? Increase or
decrease ICP?
Answer: Dilation and increase in ICP due to high CO2
◉ Hyperventilation cause dilation or constriction?
Answer: Constriction d/t low CO2
◉ Pupils with pressure on cranial nerve
Answer: Fixed and dilated
◉ Pupils with opiates vs stimulants
Answer: small; large
◉ Pupils with anticholinergics such as atropine, ipratropium, and
scopolamine
Answer: large
◉ Sluggish reaction of pupils is an early sign of what?
Answer: Increasing ICP
◉ Glasgow Coma Score with Mild, Moderate, and Severe TBI
,Answer: Mild = 13-15
Moderate = 9-12
Severe = 3-8
◉ Goal value for ICP
Answer: <15
◉ Goal value for Cerebral Perfusion Pressure (CPP)
Answer: >60
◉ Le Fort Fracture
Answer: Fracture of the maxilla
◉ What decrease ICP by decreasing cellular edema?
Answer: Osmotic diuretics (such as 3% saline and mannitol)
◉ Becks Triad is a sign of what? And includes what three symptoms?
Answer: Cardiac Tamponade;
1. Hypotension
2. JVD
3. Muffled heart sounds
, ◉ What is pulsus paradoxus? And what is it a sign of?
Answer: Drop in blood pressure with inspiration, sign of cardiac
tamponade
◉ Tachycarida, weak pulses, hypotension, cool periphery, delayed
cap refill, anxiety and agitation are signs of what type of shock? Seen
with what?
Answer: Obstructive Shock; Cardiac Tamponade
◉ Persistent blood loss following chest tube insertion is a sign of
what?
Answer: Hemothorax
◉ Ipsilateral diminished breath sounds and chest movement is a
sign of what?
Answer: Hemothorax
◉ Tearing chest/back pain, unequal blood pressure and pulses are a
sign of what? Caused by a high mechanism of injury.
Answer: Thoracic Aortic Disruption
◉ Dysrhythmia, ischemic changes, and persistent unexplained
tachycardia are signs of what?
Answer: Myocardial contusion from Blunt Cardiac Injury
REVISION HANDBOOK 2026 AIRWAY
BREATHING CIRCULATION AND TRAUMA
ASSESSMENT
◉ What is caused by the tear of the bridging veins or middle
meningeal artery?
Answer: Subdural and Epidural Hematoma
◉ Affect concentration, memory, sleep, mode, and libido. Causes
headaches, dizziness and nausea.
Answer: Postconcussive Syndrome/ Mild Traumatic Brain Injury
◉ Signs and symptoms similar to early signs of increased ICP but do
not worsen.
Answer: Postconcussive Syndrome/ Mild Traumatic Brain Injury
◉ Cerebral Perfusion Pressure = ______-______
Answer: MAP - ICP
◉ What is the range for CO2 to maximize perfusion?
Answer: 35-45
,◉ Does hypoventilation cause dilation or constriction? Increase or
decrease ICP?
Answer: Dilation and increase in ICP due to high CO2
◉ Hyperventilation cause dilation or constriction?
Answer: Constriction d/t low CO2
◉ Pupils with pressure on cranial nerve
Answer: Fixed and dilated
◉ Pupils with opiates vs stimulants
Answer: small; large
◉ Pupils with anticholinergics such as atropine, ipratropium, and
scopolamine
Answer: large
◉ Sluggish reaction of pupils is an early sign of what?
Answer: Increasing ICP
◉ Glasgow Coma Score with Mild, Moderate, and Severe TBI
,Answer: Mild = 13-15
Moderate = 9-12
Severe = 3-8
◉ Goal value for ICP
Answer: <15
◉ Goal value for Cerebral Perfusion Pressure (CPP)
Answer: >60
◉ Le Fort Fracture
Answer: Fracture of the maxilla
◉ What decrease ICP by decreasing cellular edema?
Answer: Osmotic diuretics (such as 3% saline and mannitol)
◉ Becks Triad is a sign of what? And includes what three symptoms?
Answer: Cardiac Tamponade;
1. Hypotension
2. JVD
3. Muffled heart sounds
, ◉ What is pulsus paradoxus? And what is it a sign of?
Answer: Drop in blood pressure with inspiration, sign of cardiac
tamponade
◉ Tachycarida, weak pulses, hypotension, cool periphery, delayed
cap refill, anxiety and agitation are signs of what type of shock? Seen
with what?
Answer: Obstructive Shock; Cardiac Tamponade
◉ Persistent blood loss following chest tube insertion is a sign of
what?
Answer: Hemothorax
◉ Ipsilateral diminished breath sounds and chest movement is a
sign of what?
Answer: Hemothorax
◉ Tearing chest/back pain, unequal blood pressure and pulses are a
sign of what? Caused by a high mechanism of injury.
Answer: Thoracic Aortic Disruption
◉ Dysrhythmia, ischemic changes, and persistent unexplained
tachycardia are signs of what?
Answer: Myocardial contusion from Blunt Cardiac Injury
