TNCC Physical Assessments

What is the Trauma Assessment Mnemonic? A = Airway with simultaneous cervical spine stabilization/immobilization B = Breathing C = Circulation D = Disability (neurologic status) E = Expose patient/Environmental Control F = Full set of VS/Focused Adjuncts/Facilitate Family Presence G = Give comfort measures H = History/Head-to-toe assessment I = Inspect posterior surfaces What is assessed in Airway while simultaneously protecting the cervical spine? Assess: - Vocalization - Tongue obstructing airway - Loose teeth, foreign objects - Blood, vomitus, other secretions - Edema Interventions: - Position pt - Jaw thrust/Chin lift - Remove foreign objects - Suction blood, vomitus, secretions - Insert oropharyngeal or nasopharyngeal airway - Needle or surgical cricothyrotomy 00:22 01:08 What is assessed in Breathing? Assess: - Spontaneous breathing - Rise and fall of chest - Rate and pattern of breathing - Use of accessory muscles/Diaphragmatic breathing - Skin color - Integrity of soft tissue and bony structures of chest wall - Bilateral breath sounds Interventions: - Supplemental oxygen - Bag-Mask ventilation - Needle thoracentesis/Decompression - Chest tube - Nonporous dsg taped on 3 sides What is assessed in Circulation? Assess: - Palpates central pulse for rate and quality - Skin color, temperature and moisture - External bleeding Interventions: - Direct pressure over uncontrolled bleeding sites - Insert 2 large caliber IV's with warmed isotonic crystalloid solution - Infuses fluid rapidly with blood tubing - Blood sampling for typing - Blood administration - Pericardiocentesis - Emergency thoracotomy - Surgery - Cardiopulmonary resuscitation and advanced life support measures What is assessed in Disability? Assess: - AVPU (LOC) - Pupils (PERRL) Interventions: - Perform further investigation - Hyperventilation, if indicated What is assessed in Trauma Mnemonic under "E?" EXPOSE PATIENT AND ENVIRONMENTAL CONTROL (remove clothing and keep patient warm) Assess: - Obvious wounds/Deformities - Temperature Control Interventions: - Remove clothing - Preserve clothing for evidence if indicated (don't cut through bullet wounds, use paper bags) - Cover with blankets - Warming lights - Increase ambient temperature What is assessed in Trauma Mnemonic under "F?" FULL SET OF VS/FOCUSED ADJUNCTS/FACILITATE FAMILY PRESENCE Assess: - Obtain a complete set of vital signs - Consider the focused adjuncts - Cardiac Monitor - Pulse Oximeter - Urinary catheter if not contraindicated - Gastric tube - Laboratory studies - Facilitate family presence What is assessed in Trauma Mnemonic under "G?" - Assesses pain using an appropriate pain scale - Verbal reassurance - Initiates a nonpharmacologic pain intervention - Considers obtaining order for pain medication What is assessed for History? - MIVT - Patient-generated information - PMH What is assessed under Head-to-toe assessment? HEAD AND FACE - Inspect for wounds, ecchymosis, deformities, drainage from nose and ears, and check pupils - Palpate for tenderness, note bony crepitus, deformity NECK - Remove anterior portion of the rigid cervical collar to inspect and palpate the neck - Another team member must hold the pt's head while the collar is being removed and replaced - Inspect for wounds, ecchymosis, deformities, and distended neck veins - Palpate for tenderness, note bony crepitus, deformity, subcutaneous emphysema, and tracheal postion CHEST - Inspect for breathing rate and depth, wounds, deformities, ecchymosis, use of accessory muscles, paradoxical movement - Auscultate breath sounds and heart sounds - Palpate for tenderness, note bony crepitus, subcutaneous emphysema, and deformity ABDOMEN AND FLANKS - Inspect for wounds, distention, ecchymosis, and scars - Auscultate bowel sounds - Palpate all four quadrants for tenderness, rigidity, guarding, masses, and femoral pulses PELVIS AND PERINEUM - Inspect for wounds, deformities, ecchymosis, priapism, blood at the urinary meatus or in the perineal area - Palpate the pelvis and anal sphincter tone EXTREMITIES - Inspect for ecchymosis, movement, wounds, and deformities - Palpate for pulses, skin temperature, sensation, tenderness, deformities, and note bony crepitus How do you Inspect Posterior Services? - Maintain cervical spine protection and support injured extremities while the pt is log-rolled. - Inspect the posterior surfaces for wounds, deformities, and ecchymosis - Palpate the posterior surfaces for tenderness and deformities - Palpate anal sphincter tone (if not performed previously) Planning and Implementation in General: Studies: - Laboratory Studies - T&S or crossmatch - H&H - ETOH - Serum lactate level - Serum pregnancy test as indicated - Kleihauer-Betke test as indicated - ABG's Interventions: - OR intervention - Admission or Transfer - GCS and Revised Trauma Score - Psychosocial support of pt and family - Pain control - Nonpharmacological pain intervention - Meds as indicated: - Tetanus prophylaxis - Antibiotics - Pain meds - Neuromuscular blockers - Sedation