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TNCC: The Nursing Process

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Preparation and Triage 1. Activate the trauma team. 2. Prepare the Trauma Room. - Rapid infuser - Chest trauma equipment 3. States the need to don PPE Across-the-room Observation Assess for obvious uncontrolled external hemorrhage. 00:16 01:08 Primary Survey: Airway + Cervic...

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  • May 11, 2022
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  • 2021/2022
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TNCC: The Nursing Process
Preparation and Triage - answer 1. Activate the trauma team.
2. Prepare the Trauma Room.
- Rapid infuser
- Chest trauma equipment
3. States the need to don PPE

Across-the-room Observation - answer Assess for obvious uncontrolled external
hemorrhage.

Primary Survey: Airway + Cervical Spinal Stabilization (A) - answer 1. Assess AVPU**
2. Ask a 2nd person to provide manual cervical spinal stabilization *AND* manually
open the airway using the jaw-thrust maneuver.**
3. Determine airway patency:** (4)
- tongue obstruction
- loose teeth
- foreign objects
- blood, vomitus, or other secretions
- edema
- snoring, gurgling, or stridor
4. Assess the need for an OPA**
5. Assess the need for a definitive airway
6. Reassess the airway after insertion of the OPA.

Primary Survey: Breathing & Ventilation (B) - answer 1. Determine breathing
effectiveness: ** (4)
Inspect:
- Spontaneous breathing?
- Symmetrical chest rise?
- Depth/pattern/rate of respirations?
- Increased WOB?
- Skin colour?
- Open wounds or deformities?
Palpate:
- SC Emphysema?
- Tracheal deviation or JVD?
Auscultate:
- Breath sounds present & equal?

2. Assess the need for assisted ventilation with BVM (If breathing is spontaneous,
consider NRB).**

Primary Survey: Breathing & Ventilation - Intubation - answer Assess ET tube
placement: **
(1) Attach CO2 detector
(2) Observe for bilateral rise & fall of chest + auscultate over the epigastrium + bilateral
breath sounds.

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