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TNCC 8: STUDENT WORKBOOK

TNP POINTERS………………………………………………. 001

BLANK TNP SCENARIO…………………………………… 003
AIRWAY / VENTILATION…………………………………013
SHOCK……………………………………………………………017
HEAD TRAUMA………………………………………………021
ABDOMIAL / PELVIC TRAUMA……………………….025
THORACIC / NECK TRAUMA…………………………..027
PSYCHOSOCIAL………………………………………………031
DISASTER : START TRIAGE………………………………033
TRAUMA READY SCORE SHEET………………………035
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 Trauma Nursing Process (TNP)
Preparation and Triage
Activate trauma team

Prepare the room and any special equipment

Don PPE and consider need for decontamination

Across the Room Observation
Uncontrolled bleeding? Reprioritize to <C> ABC

Primary Survey [ABCDEFG] “When you mess, reassess”
A** Alertness (A1) and Airway (A2)
• Maintain cervical spinal stabilization
• AVPU (Alert, Verbal, Pain, Unresponsive)
• Assess airway patency (at least FOUR)
B** Breathing and Ventilation
• Assess breathing effectiveness (at least FOUR)
C** Circulation and Control of Hemorrhage
• Assess for uncontrolled hemorrhage, central pulse, skin color/temperature/
moisture (ALL THREE)
D** Disability (Neurologic Status)
• Glasgow Coma Scale
• Pupils
• *Consider head CT for any abnormalities
E** Exposure (E1) and Environmental Control (E2)
• Remove clothing, provide warmth
**Double starred items must be completed IN ORDER prior to moving to the next step

F Full Set of Vital Signs (F1) and Family Presence (F2)

G Get Monitoring Devices (G1) and Give Comfort (G2) [LMNOP]
L – Labs: blood typing, blood gases, and lactate
M – Monitor
N – Naso- or orogastric tube
O – Wean Oxygen based on Oximetry and assess capnography (required if sedated or intubated)
P* – Pain assessment AND management

Reevaluation for Transfer to Trauma Center or Preparation for Definitive Treatment

Secondary Survey [HI]
H History (H1) and Head-2-Toe (H2) Exam
• History (H1) – Prehospital report, patient- or family-generated, from electronic health record
• Head-2-Toe Assessment (H2)
I* Inspect Posterior Surfaces
• Unless contraindicated by suspected spine or pelvic injury – turn, inspect & palpate,
remove backboard
Anticipated Interventions or Diagnostics
• At least THREE
Just Keep Revaluating
Vital signs
•
Identified injuries and effectiveness of interventions
•
Primary assessment
•
Pain
•
Definitive Care or Transport

www.ena.org/TNCC
Emergency Nurses Association (2019). Trauma Nursing Core Course™: Provider manual. Schaumburg, IL: Author.
©2019 Emergency Nurses Association.
001
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002
 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
Preparation and Triage
1. States the need to activate the trauma
team

“Is there any specific equipment that you would prepare?”

2. States the need to prepare the trauma These may include but are not limited to the
room following:
• Fluid warmer
• Pediatric equipment
• Bariatric equipment
• Difficult airway or IV equipment
3. States the need to don PPE Consider potential need for decontamination
or other safety threats to trauma team

“The patient has just arrived.”

Across-the-Room Observation

4. Assesses for obvious uncontrolled If uncontrolled hemorrhage is identified,

external hemorrhage start with “C” of the primary survey. This
includes controlling uncontrolled bleeding
and assessing circulation. If circulation is
compromised, initiate IV fluid and blood
replacement as indicated before returning to
“A.” With multiple team members available,
airway and breathing may be assessed at
this time but do NOT take priority over
circulation interventions.

Primary Survey

Alertness and Airway with Simultaneous Cervical Spinal Stabilization

5. Assesses the patient’s level of **
consciousness using AVPU

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
003
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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
6. IF cervical spinal injury is suspected, I’ll maintain cervical spinal stabilization
states the need for a second person to while you open the airway.
provide manual cervical spinal
stabilization AND demonstrates manual
opening of the airway using the jaw-
thrust maneuver
If the patient is alert, it is acceptable to
ask the patient to open their mouth to
assess the airway.
7. Demonstrates and describes techniques These may include but are not limited to the **
to determine the patency and following:
protection of the airway, using • Suction the airway
inspection, auscultation, and palpation
• Remove any loose teeth or foreign
(identifies at least FOUR):
objects
• Is the tongue obstructing?
• Insert an oral or nasopharyngeal
• Are there any loose or missing teeth? airway
• Are there any foreign objects? • Indicate the need for intubation
• Is there any blood, vomit, or
secretions?
Patient response is reassessed.
• Is there any edema?
NOTE: Clear speech in an alert patient may
• Is there any snoring, gurgling, or indicate an open and maintainable airway.
stridor? For learning purposes, all the assessment
• Is there any bony deformity? criteria are listed throughout the course.

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
004
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 8th Edition Provider Course
TNP for Students
Skill Steps
Breathing and Ventilation
8. Demonstrates and describes techniques
for determining breathing effectiveness,
using components of inspection,
auscultation, and palpation (identifies at
least 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?
• 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?
9. IF intubated, assesses endotracheal
tube placement (must identify ALL
THREE):
• Attaches a CO2 detector device; after
5 to 6 breaths, assesses for evidence
of exhaled CO2
• Observes for rise and fall of the chest
with assisted ventilations
• Auscultates over the epigastrium for
gurgling AND lungs for bilateral
breath sounds
10. IF intubated, states the need to assess
ETT position by noting the number at
the teeth or gums AND secures the ETT
Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
Emergency Nurses Association • 930 E. Woodfield Road, Schaumburg, IL 60173 • Course Operations: 800.942.0011 • Email: CourseOps@ena.org • Revision Date: April 2019
Demonstrated
Instructor Responses
Yes No
These may include but are not limited to the **
following:
• Apply oxygen
• Provide ventilations with a bag-mask
device
• Indicate the need for intubation
• Indicate the need for a needle
decompression
• Indicate the need for a chest tube
Patient response is reassessed.
Examples include but are not limited to the
following:
• Is work of breathing improved after
the intervention?
• Is there chest rise and fall with bag-
mask ventilation?
• Assessment of endotracheal tube
(ETT) placement (see # 9 for required
steps to confirm tube placement)
NOTE: If the learner chooses a capnography **
sensor instead of the one-time-use
detection device, credit is also given in #24.
NOTE: If the learner chooses to insert a
gastric tube and/or requests a chest
radiograph, it can be done here without
penalty for order. Credit is also given in #22
and/or #48.
The ETT is secured and the number at the
level of the teeth or gums is documented.
005
 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
11. IF intubated, states the need to begin Ventilations continue.
mechanical ventilation or continue
assisted ventilation
Circulation and Control of Hemorrhage

12. Demonstrates and describes techniques
for determining the adequacy of
circulation, using components of
inspection, auscultation, and palpation
(must identify ALL THREE):
• Inspects for any uncontrolled external
hemorrhage
• Palpates a central pulse
• Inspects AND palpates the skin for
color, temperature, and moisture
13. States the need for administration of
warmed, isotonic crystalloid with blood
tubing AND at a controlled (or bolus)
rate
Disability (Neurologic Status)
These may include but are not limited to the **
following:
• Control uncontrolled hemorrhage
• Initiate chest compressions and
advanced life support
• Assess patency of prehospital IV line
• Obtain IV or IO access (2 access sites)
• Labs may be drawn at this time –
credit is also given in #20.
• Administer a bolus of warmed isotonic
crystalloid
• Consider need for blood products and
balanced resuscitation
• Apply a pelvic binder
Patient response is reassessed.
Learner indicates if fluids at a controlled **
rate are indicated IF circulation is adequate.
Learner indicates if a fluid bolus is indicated
IF circulation is inadequate.
Indicates the need to continue with
balanced resuscitation and identify a source
of shock IF circulation remains inadequate
after bolus.
Patient response is reassessed.

14. Describes the assessment of neurologic
status using the GCS:
• What is the best eye opening?
• What is the best verbal response?
• What is the best motor response?
These may include but are not limited to the **
following:
• Indicate the need for intubation
• Indicate the need for a head CT*
• Assess bedside blood glucose

15. Assesses pupils

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are

006
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.

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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
Exposure and Environmental Control

16. States the need to remove all clothing Interventions for uncontrolled bleeding and **
AND inspect for uncontrolled life-threatening injuries are implemented as
hemorrhage or obvious injuries indicted. Patient response is reassessed.

17. States need to provide warmth A warming method has been applied.
(identifies at least ONE):
• Blankets
• Warming lights
• Increase room temperature
• Warmed fluids
• Warmed oxygen

NOTE: If the learner did not intervene to correct life-threatening findings in the primary survey and/or did not
complete all double-starred criteria, the instructor may stop the station, review the purpose of the primary survey,
and notify the course director.

Full Set of Vital Signs

18. Obtains a full set of vital signs • BP: / mm Hg MAP: mm Hg

• HR: beats/minute
• RR: breaths/minute
• T: °F ( °C)
• SpO2: %

Facilitate Family Presence

19. States the need to facilitate family

presence

Get Monitoring Devices and Give Comfort (LMNOP)

20. States the need for laboratory analysis

(blood typing, blood gases, and lactate)
21. Attaches patient to a cardiac monitor

22. States need to consider insertion of

naso- or orogastric tube

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are

007
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.

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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
23. Weans oxygen based on pulse oximetry

24. Attaches the patient to capnography

(for patients receiving manual
ventilation or sedation)
25. States the need to assess pain using an The patient’s pain is assessed using an *
appropriate pain scale appropriate pain scale, revealing moderate
pain.
26. Gives appropriate nonpharmacologic
comfort measure (identifies at least
ONE):
• Applies ice to swollen areas
• Repositioning
• Places padding over bony
prominences
• Other, as appropriate
27. States the need to consider obtaining
order for analgesic medication

Reevaluation for Transfer to Trauma Center or Definitive Treatment

“At this time, is there a need to consider transfer to a trauma center or preparation for definitive treatment?”
Secondary Survey

History

28. Obtains pertinent history (identifies at

least ONE):
• Prehospital report
• Past medical history (patient- or
family-generated; from electronic
health record)

Head-to-Toe Assessment

NOTE: The learner describes and demonstrates the head-to-toe assessment by describing appropriate inspection
techniques and demonstrating appropriate auscultation and palpation techniques.

29. Inspects AND palpates head for injuries

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
008
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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
30. Inspects AND palpates face for injuries

31. Inspects AND palpates neck for injuries

32. Inspects AND palpates chest for injuries

33. Auscultates breath sounds

34. Auscultates heart sounds

35. Inspects the abdomen for injuries

36. Auscultates bowel sounds

37. Palpates all four quadrants of the

abdomen for injuries

38. Inspects AND palpates the flanks for

injuries

39. Inspects the pelvis for injuries

40. Applies gentle pressure over iliac crests

downward and medially

41. Applies gentle pressure on the

symphysis pubis

42. Inspects the perineum for injuries

43. States need to assess for indications and

contraindications for placement of a
urinary catheter
44. Inspects AND palpates all four
extremities for neurovascular status and
injuries

Inspects Posterior Surfaces

NOTE: If the patient has a suspected spinal or pelvic injury, imaging is obtained PRIOR to turning the patient. The
log roll maneuver may cause secondary injuries including spinal injury or hemorrhage. In these patients, the
preferred method for removing a patient from the spine board is the 6+ person lift technique.

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
009
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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
45. Inspects AND palpates posterior *
surfaces (not required if suspected
spinal or pelvic injury)
46. States the need to consider removal of
transport device

NOTE: Summarize injuries identified, listed below, throughout the scenario. If the learner has not already identified
them all, ask for any additional noted at this time.

47. Identifies all simulated injuries Instructor summarizes identified injuries and
provides an opportunity for review if
needed.

“What interventions or diagnostics can you anticipate for this patient?”

48. Identifies at least THREE interventions These may include but are not limited to the
or diagnostics. following:
• Imaging (radiographs, CT, US,
interventional radiology)
• Consults
• Psychosocial support
• Antibiotics
• Revised trauma score
• Pain medication and sedation
• Social services
• Law enforcement
• Laboratory studies
• Wound care
• Splinting
• Tetanus immunization

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are

010
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.

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 8th Edition Provider Course
TNP for Students

Demonstrated
Skill Steps Instructor Responses
Yes No
Just Keep Reevaluating

“What findings will you continue to reevaluate while the patient is in your care?”
49. States the need to reevaluate vital signs

50. States the need to reevaluate all

identified injuries and effectiveness of
interventions
51. States the need to reevaluate primary
survey

52. States the need to reevaluate pain

Definitive Care or Transport

“What is the definitive care for this patient?”
53. States consideration of transfer to a
trauma center or admission to hospital

“Is there anything you would like to add at this time?”

Double starred (**) criteria to be done in order – assessments and interventions must be completed prior to moving to
the next step:

**Alertness and Airway

**Breathing and Ventilation

**Circulation

**Disability

**Exposure

Single starred (*) criteria to be done, sequence not critical:

*Reassessment of primary survey interventions

*Head CT if any alterations noted in Disability

*Pain assessment using an appropriate scale

*Inspects Posterior Surfaces (unless contraindicated by suspected spine or pelvic injury)

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.
011
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 8th Edition Provider Course
TNP for Students

Skills Performance Results Evaluation Form

 Station successfully completed

• All ** critical steps demonstrated in order
• All * demonstrated
• Demonstrated at least X of X points (70%)
 Incomplete; needs minimal instruction before re-evaluation
 Incomplete; needs considerable instruction before re-evaluation

Potential Instructor (Must achieve 90%)  Yes  No

Demonstrated all ** steps in order  Yes  No

Demonstrated all * items  Yes  No
Demonstrated points Number Percentage
• Total possible = 100%
• Learner demonstrated =

Double starred (**) criteria must be completed in order BEFORE moving to the next step. The single starred criteria (*) are

012
essential skill steps and are expected to be performed during the skill station demonstration but their sequence is not critical.

Emergency Nurses Association • 930 E. Woodfield Road, Schaumburg, IL 60173 • Course Operations: 800.942.0011 • Email: CourseOps@ena.org • Revision Date: April 2019
 AIRWAY / VENTILATION
Jaw Thrust

Oropharyngeal Airway (OPA)

Nasopharyngeal Airway (NPA)

013
 Bag Valve Mask

Endotracheal Tube (ETT)

Colormetric Device

014
Supraglotic Airway (LMA)

Pulse Oxymetry SP02

ETCO2

End Tidal CO2

015
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016
 Mechanism of injury that may lead to this type of shock

How Obstructive Shock Impacts Hemodynamics:

OBSTRUCTIVE SHOCK Other Clues

Blood Pressure

Heart Rate

Respiratory Rate

Preload

Afterload

Contractility

Goal-Directed Therapy:

017
 Mechanism of injury that may lead to this type of shock

How Cardiogenic Shock Impacts Hemodynamics:

CARDIOGENIC SHOCK Other Clues

Blood Pressure

Heart Rate

Respiratory Rate

Preload

Afterload

Contractility

Goal-Directed Therapy:

018
 Mechanism of injury that may lead to this type of shock

How Distributive Shock Impacts Hemodynamics:

DISTRIBUTIVE SHOCK Other Clues

Blood Pressure

Heart Rate

Respiratory Rate

Preload

Afterload

Contractility

Goal-Directed Therapy:

019
 Mechanism of injury that may lead to this type of shock

How Hypovolemic Shock Impacts Hemodynamics:

HYPOVOLEMIC SHOCK Other Clues

Blood Pressure

Heart Rate

Respiratory Rate

Preload

Afterload

Contractility

Goal-Directed Therapy:

020
HEAD TRAUMA

Cerebral Perfusion Pressure

EARLY Sings of Increased ICP

Late Signs of Increased ICP

021
HEAD TRAUMA

Treatment Goals

Effects of CO2 on Vessels

OSMOTIC DIURETICS

022
HEAD TRAUMA

PUPILLARY CHANGES

Subdural vs Epidural
S

MILD TBI

023
HEAD TRAUMA
Lefort I
Facial Fractures

Lefort II

Lefort III

Ocular Trauma

Glascow Coma Score

Eye Openning…………..1-4
Verbal Response……….1-5
Motor Response………..1-6

Total = 3-15

024
 ABDOMINAL / PELVIC TRAUMA
(Table 8-2, pages 145-146) to identify:

Key history questions to The implications to injury

include in the patient that are revealed from
assessment assessing the mechanism
FALLS

MVC

PENETRATING
TRAUMA

BLUNT
TRAUMA

025
BLANK

026
 THORACIC / NECK TRAUMA
Airway Obstruction

Tracheobronchial Disruption

Esophageal Disruption

027
 THORACIC / NECK TRAUMA
Flail Chest

Open Pneumothorax

TENSION PNEUMOTHORAX

028
 THORACIC / NECK TRAUMA
HEMO THORAX

PULMONARY CONTUSION

Blunt Cardiac Injury

029
 THORACIC / NECK TRAUMA
Pericardial Tamponade

Diaphragmatic Tear

Thoracic Aortic Injury

030
 PSYCHOSOCIAL

• What do trauma patients and their families need?

• How can you mitigate violence/keep yourself safe

when interacting with trauma patients and their
families?

• How can you recognize compassion fatigue and

burnout in yourself or your colleagues?

• What do you or your facility do to manage the

impact of trauma on the trauma team and help
develop resiliency?

031
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032
DISASTER MANAGEMENT
Appendix 18-1 pp 366

033
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034
 TRAUMAREADY
TEAM NAME: _________________
What was the ? Worth Running
Total

GRAND TOTAL

WAGER FOR FINAL QUESTION?____________

FINAL ANSWER

035