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
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
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
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
