TNCC Trauma NURSING PROCESS

Prep & States the need to activate the trauma team

Triage States need to prepare the trauma room
States the need to don PPE
Across Assesses for obvious uncontrolled external hemorrhage
Room
Assesses the patient’s level of consciousness using AVPU **
If spinal cord injury is suspected states the need for a second person to provide manual cervical spinal stabilization AND
demonstrates manual opening of the airway using the jaw-thrust maneuver
Demonstrates and describes techniques to determine the patency and protection of the airway, using inspection, **
auscultation, & palpation (identifies FOUR+):
• Is the tongue obstructing?

A • Are there any loose or missing teeth?

• Are there any foreign objects?
• Is there any blood, vomitus, or secretions?
• Is there any edema?
• Is there any snoring, gurgling, or stridor?
• Is there any bony deformity?
Perform appropriate airway interventions if necessary and reassess for effectiveness. Including:
- Suction Airway - Insert OPA or BPA - Request Intubation
Demonstrates and describes techniques for determining breathing effectiveness, using inspection, auscultation, & **
palpation (identifies FOUR+):
• Is there spontaneous breathing?
• Is there symmetrical chest rise and fall?
• What are the depth, pattern, and general rate of respirations?
• Is there increased work of breathing? (Abnormal positioning, grunting, retractions/accessory muscle use, head

B bobbing, nasal flaring)

• What is the skin color?
• Are there open wounds or deformities?
• Are breath sounds present and equal?
• Is there subcutaneous emphysema?
• Is there any tracheal deviation or jugular venous distention?
Perform appropriate breathing interventions if necessary and reassess for effectiveness. Including: **
- Request Intubation - Apply Oxygen - BVM ventilation - Needle thoracentesis - Chest tube
If intubating confirms at least three:
- CO2 Detector Device
- Observes for rise and fall of the chest with assisted ventilations
- Auscultates for bilateral breath sounds
- Auscultates over the epigastrium
- Positive capnography
- Assesses for improvement in her skin color
If intubated states the need to secure tube and note the position at the lip line / states need to continue ventilations
Demonstrates and describes techniques for determining the adequacy of circulation, using components of inspection, **
auscultation, and palpation
• Inspects for any uncontrolled external hemorrhage
C • Inspects and palpates the skin for color, temperature, and moisture
• Palpates a central pulse
• Assesses capillary refill
Perform appropriate circulation interventions if necessary and reassess for effectiveness. Including:
- Bleeding Control - Chest compressions and advanced life support - Assesses the prehospital IV - starts second IV/IO
- Cardiac Monitor - Fluid Bolus
Describes the assessment of neurologic status using: FOUR SCORE or GCS **

D Assesses pupils
Perform appropriate disability interventions if necessary and reassess for effectiveness. Including:
- Need for intubation
- Glucometry

States the need to remove all clothing AND inspect for uncontrolled hemorrhage or obvious injuries *

E States need to provide warmth (identifies at least ONE):

Blankets, Warming lights, Increase room temperature, Warmed fluids, Warmed oxygen
 Obtains a full set of vital signs Blood Pressure Heart Rate Respiratory Rate Temperature

F States the need to facilitate family presence

States the need for laboratory analysis

G Attaches patient to cardiac monitor

States need to consider insertion of naso- or orogastric tube
Attaches the patient to pulse oximetry AND capnography
States the need to assess pain using an appropriate pain scale *
Gives appropriate nonpharmacologic comfort measure (identifies at least ONE):
apply ice repositioning padding over bony prominences reassurance other
Gives appropriate pharmacologic comfort measure
“At this time, is there a need to consider transfer to a trauma center or preparation for surgery?”
Obtains pertinent history (identifies at least ONE): • MIST • Past medical history (patient- or family-generated) SAMPLE

H Head Inspects AND palpates head

Inspects face or injuries
Neck Inspects AND palpates neck for injuries
Chest Inspects AND palpates chest for injuries
Auscultates breath sounds
Auscultates heart tones
Abdomen Inspects the abdomen
Auscultates bowel sounds
Palpates all four quadrants of the abdomen for injuries
Inspects and palpates the flanks
Pelvis/Perineum Inspects the pelvis for injuries
Applies gentle pressure over iliac crests downward and medially
Applies gentle pressure on the symphysis pubis
Inspects the perineum for injuries
States need to assess for indications and contraindications for placement of a urinary catheter
Extremities Inspects AND palpates all four extremities for neurovascular status/injuries
States the need to maintain manual cervical and spinal stabilization to turn patient for posterior assessment *

I States the need to consider removal of rigid spine board

Identifies all simulated injuries *

States need for reevaluation adjuncts (identifies at least THREE):
• Consults • CT scans • Radiographs • FAST • Psychosocial Support • Law
Enforcement • Wound Care • Antibiotics • Tetanus immunization • Oral Rehydration
Reevaluation and Post-resuscitation Care

J States the need to reevaluate primary assessment

States the need to reevaluate vital signs
States the need to reevaluate pain
States the need to reevaluate all identified injuries and effectiveness of interventions
Definitive Care or Transport
States consideration of transfer to a trauma center or admission to hospital