correct answer(updated). TNCC - Trauma
Nursing Core Course
Initial Assessment - CORRECT ANSWER.1. Preparation and Triage
2. Primary Survey
3. Reevaluation
4. Secondary Survey
5. Reevaluation Adjuncts
6. Reevaluation and Post Resuscitation Care
7. Definitive Care or Transport
A (Primary Survey) - CORRECT ANSWER.Airway and alertness with simultaneous
cervical spinal stabilization.
Alertness Assessment - CORRECT ANSWER.A-Alert
V-Verbal
P-Painful
U-Unresponsive
Airway Assessment - CORRECT ANSWER.Inspect: tongue obstruction,
loose/missing teeth, foreign objects, blood, vomitus, secretions, edema, burns or
evidence of inhalation injury
Auscultate: listen for obstructive airway sounds (ie. snoring, gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony deformity, subcutaneous
emphysema
Airway Interventions: - CORRECT ANSWER.Suction
Remove foreign body if noted
, Jaw thrust maneuver (maintain cspine)
Nasopharyngeal airway (can be conscious) Oropharyngeal airway (no gag)
Consider definitive airway
A (AVPU) - CORRECT ANSWER.Alert. Will be able to maintain airway once clear.
V (AVPU) - CORRECT ANSWER.Verbal. Needs verbal stimuli to respond.
(Airway adjunct may be needed to prevent tongue obstruction)
P (AVPU) - CORRECT ANSWER.Painful. Responds only to painful stimuli.
(Airway adjunct may be needed while determining need for intubation)
U (AVPU) - CORRECT ANSWER.Unresponsive. Does not respond to any stimuli.
B (Primary Survey) - CORRECT ANSWER.Breathing and Ventilation
Breathing and Ventilation Assessment - CORRECT ANSWER.Inspect: spontaneous
breathing, symmetrical rise and fall, depth/pattern/rate of respirations, accessory
muscle use, diaphragmatic breathing, skin color (normal, pale, flushed, cyanotic),
contusions/abrasions/deformities (signs of underlying injury), open pneumothoraces
(sucking chest wound), JVD, tracheal position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at 2nd intercostal
space midclavicular line and bases at the fifth intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema, soft tissue injury,
JV pulsations at suprasternal notch or supraclavicular area
Life-threatening pulmonary injuries requiring immediate intervention: open
pneumothorax, tension pneumothorax, flail chest, hemothorax.
Breathing and Ventilation Intervention - CORRECT ANSWER.Breathing absent: jaw-
thrust maneuver, oral airway adjunct, assist ventilation with bag-mask device,
prepare for definitive airway
Breathing present: NRB. Determine if ventilation effective: etCO2 35-45, SpO2 94%
or higher. If ineffective: assist with bag-mask and determine need for definitive
airway
C (Primary Survey) - CORRECT ANSWER.Circulation and Control of Hemorrhage
Circulation and Control of Hemorrhage Assessment - CORRECT ANSWER.Inspect:
Uncontrolled external bleeding, skin color
Auscultate: Muffled heart sounds - may indicate pericardial tamponade
Palpate: carotid and/or femoral pulses for rate, rhythm, strength