TNCC: The Nursing Process

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 + Cervical Spinal Stabilization (A) 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) 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 Assess ET tube placement: ** (1) Attach CO2 detector (2) Observe for bilateral rise & fall of chest + auscultate over the epigastrium + bilateral breath sounds. (3) Observe the CO2 detector for 'yellow' after 5-6 breaths. (4) Assess for improvement in skin colour. - Assess ETT position AND secure the ETT, identifying method used. - Assess the need to begin mechanical ventilation or continue assisted ventilation. Primary Survey: Circulation & Control of Hemorrhage (C) 1. Determine the adequacy of circulation: ** - Inspect for uncontrolled hemorrhage. - Palpate a central pulse. - Inspect & palpate the skin for colour, temperature, & moisture. 2. Assess the patency of prehospital IVs. 3. Assess the need for additional large-caliber IV.** 4. Assess the need for the administration of warmed, isotonic crystalloid w/ blood tubing AND @ a controlled rate. Disability/Neurologic Status (D) 1. Assess GCS ** - Eye Opening - Verbal Response - Motor Response 2. Assess Pupils (PERRL) 3. Assess the need for CT of the head & cervical spine. ** Exposure & Environment (E) 1. Remove all clothing AND inspect for uncontrolled bleeding/obvious injuries. 2. Keep patient warm: - blankets - warming lights - increased room temperature - warmed fluids - warmed oxygen Resuscitation Adjuncts (F, G) - Full set of vitals - Family presence Get resuscitation adjuncts: (LMNOP) - Labs - Monitor (cardiac) - NG tube - Oxygen - Pain + Nonpharmacologic comfort measures ***Consider obtatining order for analgesics. Secondary Survey (H) History (MIST, SAMPLE) Head-to-Toe - Head: Inspect for LACE feel for TIC - Neck: obtain assistance to stabilize the cervical spine while removing the collar to inspect & palpate. - Chest: Inspect for LACE feel for TIC, auscultate breath sounds & heart sounds. - Abdomen: Inspect, auscultate, palpate. - Pelvis: Inspect pelvis & perineum for injuries, apply gentle pressure over iliac crests downward & medially, then apply gentle pressure on the symphys pubis. Consider a foley. - Extremities: inspect & palpate, CSM, pulses. Secondary Survey (I) Inspect Posterior Surfaces - Maintain cervical & spinal stabilization to logroll patient. - Inspect & palpate posterior spine. - Consider removal of spine board. Reevaluation Adjuncts 1. Summarize injuries identified. 2. Reevaluation adjuncts - CT - Xray - Clean & dress wounds - Tetanus immunization - Antibiotics - FAST 3. What findings would you re-evaluate? (1) Primary Assessment (2) Vitals (3) Pain (4) Identified injuries & effectiveness of interventions. 4. Determine the definitive care of the patient (transfer, admission, surgery, etc.)