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Trauma Nursing Process - TNP - TNCC 9th Ed.pdf

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Trauma Nursing Process - TNP - TNCC 9th E

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Trauma Nursing Process
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Institución
Trauma Nursing Process
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Trauma Nursing Process

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Subido en
11 de febrero de 2025
Número de páginas
26
Escrito en
2024/2025
Tipo
Examen
Contiene
Preguntas y respuestas

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**A stands for ___ and ___. - ansalertness, airway

**B stands for ___ and ___. - ansbreathing, ventilation

**C stands for ___. - anscirculation

**D stands for ___. - ansdisability

**E stands for ___. - ansexposure

After all of the assessments, interventions, reassessments, etc. are done, what is the
last thing to ask? - ans"Is there anything you would like to add at this time?"

After how many breaths do you assess for the evidence of exhaled CO2? - ansAfter 5 to
6 breaths.

After identifying potential interventions/diagnostics and completing your assessments
and interventions, you should ask yourself what? - ans"What findings will you continue
to reevaluate while the patient is in your care?"

"Just keep re-evaluating"

After the head-to-toe, the learner should summarize injuries identified throughout the
scenario and ask themselves: - ans"What interventions or diagnostics can you
anticipate for this patient?"

Continue the TNP assuming the patient was intubated. 9-11 - ans9**. If intubated,
assess endotracheal tube placement
10. If intubated, assess ETT position and securement
11. If intubated, state the need to begin mechanical ventilation or continue assisted
ventilation

Continue the TNP following assessments of circulation, neuro status, and removal of
clothing to inspect for injury. 16-18 - ans16. Provide warmth
17. Obtain a full set of vital signs and weight in kilograms (if not determined earlier)
18. Facilitate family presence

Continue the TNP following assessments of ETT. 12-15
**12, 13, and 15 are double-starred - ans12**. Assess circulation
13**. Assess neurologic status using GCS
14. Assess pupils
15**. Remove all clothing AND inspect for obvious abnormalities or injuries

Continue the TNP using the LMNOP mnemonic. 19-23 - ans19. L - trauma panel labs
20. M - monitor (Cardiac, consider EKG)

,21. N - consider need for NG/OG
22. O - assess O2 and end-tidal capnography
23**. P - assess pain using appropriate pain scale

Continue TNP after LMNOP (so after pain has been assessed). 24-26 - ans24. Non-
pharmacological comfort measures
25. Consider analgesic med order
26. Obtain pertinent history

Double-starred criteria include letters ___-___. - ansA-E

During the general impression in TNP, when alterations are identified, you must do
what? Then what? - ansIntervene as appropriate and continuously reassess for efficacy

Following the completion of head-to-toe assessment in TNP, you must do what? 44 -
ans44. Identify at least THREE interventions or diagnostics

these may include the following:
Antibiotics
Consults
Head CT for any alterations in mental status
Imaging (other radiographs, CT, ultrasound, interventional radiology as indicated)
Law enforcement
Mandatory reporting
Psychosocial support
Social services
Splinting
Tetanus immunization
Wound care

For double-starred criteria, ___ and ___ must be completed prior to moving to the next
step. - ansassessments, interventions

Give at least 4 examples of things to inquire about when assessing breathing efficacy: -
ans- Breath sounds
- Depth, pattern, and general rate of respirations
- Increased work of breathing
- Open wounds or deformities
- Skin color
- Spontaneous breathing
- Subcutaneous emphysema
- Symmetrical chest rise and fall
- Tracheal deviation or jugular venous distention

, Give at least 4 examples of things to inquire about when assessing the patency and
protection of the airway: - ansAcceptable things to ask about during this step include
assessments for:
- Bony deformity
- Burns
- Edema
- Fluids (blood, vomit, or secretions)
- Foreign objects
- Inhalation injury (burns, soot)
- Loose or missing teeth
- Sounds (snoring, gurgling, or stridor)
- Tongue obstruction
- Vocalization

Head-to-Toe 27-43 - ans27. Inspect and palpate head for injuries
28. Inspect and palpate face for injuries
29. Inspect and palpate neck for injuries
-- Demonstrate removal AND reapplication of cervical collar for assessment (if
indicated).
30. Inspect and palpate chest for injuries
31. Auscultate breath sounds
32. Auscultate heart sounds
33. Inspect the abdomen for injuries
34. Auscultate bowel sounds
35. Palpate all four quadrants of the abdomen for injuries
36. Inspect and palpate the flanks for injuries
37. Inspect the pelvis for injuries
38. Apply gentle pressure over iliac crests downward and medially
39. Apply gentle pressure on the symphysis pubis (if iliac crests are stable)
40. Inspect the perineum for injuries
41. Consider GU - urinary output
42. Inspect and palpate all four extremities for neurovascular status and injuries
43. Inspect and palpate posterior surfaces -- NOT if the patient has suspected spinal or
pelvic injuries

How do you assess ETT position? - ansby noting the number at the teeth or gums

How do you first assess for pelvic instability? Then what do you do? - ansApply gentle
pressure over iliac crests downward and medially. If iliac crests are stable, then apply
gentle pressure on the symphysis pubis.

Identify at least one of the following when obtaining pertinent history: - ans- Medical
records/documents
- Prehospital report
- SAMPLE
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