Trauma Nursing Process - TNP - TNCC 9th Ed

What should you ask yourself after completing all of your interventions and reassessments? - Does this patient need to be transferred to another hospital, to surgery, or to critical care? What happens prior to patient arrival? 1-3 - 1. Activate trauma team 2. Prepare trauma room 3. Don PPE What happens following patient arrival but before a decision to intubate has been made? 4-8 may change based on C-ABC - 4. Assess for obvious uncontrolled external hemorrhage or unresponsiveness/apnea and the need to reprioritize to C-ABC 5**. Assess level of consciousness using AVPU 6. Open the airway 7**. Assess the patency and protection of the airway 8**. Assess breathing effectiveness Continue the TNP assuming the patient was intubated. 9-11 - 9**. 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 ETT. 12-15 **12, 13, and 15 are double-starred - 12**. 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 following assessments of circulation, neuro status, and removal of clothing to inspect for injury. 16-18 - 16. 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 using the LMNOP mnemonic. 19-23 - 19. 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 - 24. Non-pharmacological comfort measures 25. Consider analgesic med order 26. Obtain pertinent history Head-to-Toe 27-43 - 27. 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 After the head-to-toe, the learner should summarize injuries identified throughout the scenario and ask themselves: - "What interventions or diagnostics can you anticipate for this patient?" Following the completion of head-to-toe assessment in TNP, you must do what? 44 - 44. 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