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TNCC Study Guide

PRIMARY ASSESSMENT
Assessments Interventions A = Airway with simultaneous Cervical Spine stabilization and/or Immobilization While maintaining spinal stabilization Position the patient Vocalization Jaw thrust or chin lift Suction or remove foreign objects Tongue obstruction Oro/nasopharyngeal airway Loose teeth or foreign objects Bleeding Cervical spine stabilization Vomitus or other secretions Endotracheal intubalion Needle or surgical cricothyrotomy Edema B = Breathing Supplemental oxygen Spontaneous breathing Bag-valve-mask ventilation Chest rise & fall Needle thoracentesis Skin color Chest tube General rate & depth of respirations Nonporous dressing taped on 3 sides Soft Tissue & bony chest wall integrity Use of accessory and/or abdominal muscles Bilateral breath sounds Jugular veins & position of trachea C = Circulation Pulse general rate & quality Drectpressure over uncontrolled Skin color, temperature, degree of bleeding sites diaphoresis Two large-bore intravenous catheters with warmed lactated Ringers External bleeding solution or normal saline Infuse fluid rapidly with blood tubing Blood sample for typing Pneumatic antishock garment Pericardiocentesis ED thoracotomy Cardiopulmonary resuscitation & advanced lift support measures Blood administration Surgery D = Disability (neurological status) Level of consciousness (AVPU) Perform further investigation Pupils (PERL) Hyperventilation, if indicated

SECONDARY ASSESSMENT
E= Expose Patient / Environmental Control (remove clothing and keep patient warm) Remove clothing Blankets Warming Lights F =Full Set of Vital Signs, Five Interventions, and Facilitate Family Presence In addition to obtaining a complete set of vital signs Consider: the five interventions 1. Cardiac monitor 2. Pulse oximeter (SpO2) 3. Urinary catheter if not contraindicated 4. Gastric tube 5. Laboratory studies Facilitate family presence G =Give Comfort Measures Verbal reassurance Touch Pain central H = Head-To-Toe Assessment Inspect for wounds, ecchymosis, deformities. entrap, from nose & ears, & Head and Face check pupils Palpate for tenderness, note bony cuepitus, deformity Remove anterior portion of cervical collar to inspect & palpate the neck. Another team member must hold the patient's head while collar is being removed & replaced Neck Inspect for wounds, ecchymosis, deformities, &distended neck veins Palpate for tenderness, note bony crepitus, subcutaneous emphysema, & tracheal position Inspect for breathing role & depth, wounds, deformities, ecchymosis, use of accessory muscles; paradoxical movement Chest Auscultate breath & head sounds Palpate for tenderness, note bony crepitus, subcutaneous emphysema & deformity Inspect for wounds, distention, ecchymosis, and scars Auscultate bowel sounds Abdomen and Flanks Palpate all four quadrants for tenderness, rigidity, guarding, masses, and femoral pulses Inspect far wounds, deformities, ecchymosis, priapism, blood at the urinary Pelvis and meatus or in the perineal area Perineum Palpate the pelvis and anal sphincter tone Inspect for erachymosis movement wounds and deformities Extremities Palpate for pulses, skin temperature, sensation, tenderness, deformities, and note bony crepitus I=Inspect Posterior Surfaces Maintain cervical spine stabilization & support injured extremities while the patient is logrolled Posterior Inspect posterior surfaces for wounds, deformities, and ecchymosis Surface Palpate posterior surfaces for tenderness and deformities Palpate anal sphincter tone (if not performed previously)

PLANNING AND IMPLEMENTATION


Area General Diagnostic Studies Interventions Operative intervention Admission or transfer Glasgow Coma Scale score & Revised Trauma Score Psychosocial support of patient & family Pain medication, as prescribed Position patient Medications, as prescribed Intracranial pressure monitoring Vertebral column immobilization Steroids, as prescribed Chest tube Autotransfusion Needle thoracentesis Pericardiocentesis Urinary catheter Gastric tube Pneumatic antishock garment Urinary catheter Pneumatic antishock garment External before fester Immobilization Elevation Ice Spinal immobilization Irrigation Wound care Ice Care for amputated parts Tetanus prophylaxis and antibiotics

Head and Face

Radiographic studies Laboratory studies Radiographic studies Laboratory studies Radiographic studies Laboratory studies EGG Hemodynamic monitoring Radiographic studies Laboratory studies Diagnostic peritoneal lavage Radiographic studies Laboratory studies Radiographic studies Laboratory studies Radiographic studies Laboratory studies

Neck Chest

Abdomen and Flanks Pelvis and perineum Extremities

Posterior Surfaces Surface Trauma

Disability Mnemonic A=Alert V = Responsive to Verbal stimuli P = Responsive to Painful stimuli U = Unresponsive

Pre-hospital History Mnemonic M = Mechanism of injury I = Injuries sustained V = Vital signs T = Pre-hospital Treatment

Trauma Assessment Mnemonic A = Airway & Cervical Spine Stabilization B = Breathing C = Circulation D = Disability E = Expose patient/Environmental control F = Full set of vital signs/Five interventions/Facilitate family presence G = Give comfort measures H = Head-to-toe assessment I = Inspect posterior surfaces

4 Methods of Physical Exam Inspection Auscultation Percussion Palpation

6 Phases of the Nursing Process Assessment Nursing Diagnoses Outcome Identification Develop a Plan Implements Interventions Evaluate and Monitor