TNCC: The Nursing Process
Preparation and Triage - Answer - 1. Activate the trauma team. 2. Prepare the Trauma Room. - Rapid infuser - Chest trauma equipment 3. States the need to don PPE Across-the-room Observation - Answer - Assess for obvious uncontrolled external hemorrhage. Primary Survey: Airway + Cervical Spinal Stabilization (A) - Answer - 1. Assess AVPU** 2. Ask a 2nd person to provide manual cervical spinal stabilization *AND* manually open the airway using the jaw-thrust maneuver.** 3. Determine airway patency:** (4) - tongue obstruction - loose teeth - foreign objects - blood, vomitus, or other secretions - edema - snoring, gurgling, or stridor 4. Assess the need for an OPA** 5. Assess the need for a definitive airway 6. Reassess the airway after insertion of the OPA. Primary Survey: Breathing & Ventilation (B) - Answer - 1. Determine breathing effectiveness: ** (4) Inspect: - Spontaneous breathing? - Symmetrical chest rise? - Depth/pattern/rate of respirations? - Increased WOB? - Skin colour? - Open wounds or deformities? Palpate: - SC Emphysema? - Tracheal deviation or JVD? Auscultate: - Breath sounds present & equal? 2. Assess the need for assisted ventilation with BVM (If breathing is spontaneous, consider NRB).** Primary Survey: Breathing & V
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