TRAUMA NURSING PROCESS - TNP - TNCC 9TH ED

TRAUMA NURSING PROCESS - TNP -
TNCC 9TH ED

What6should6you6ask6yourself6after6completing6all6of6your6interventions6and6reassessme
nts?6-
6Does6this6patient6need6to6be6transferred6to6another6hospital,6to6surgery,6or6to6critical6car

e?

What6happens6prior6to6patient6arrival?61-36-61.6Activate6trauma6team
2.6Prepare6trauma6room
3.6Don6PPE

What6happens6following6patient6arrival6but6before6a6decision6to6intubate6has6been6made
?64-8

may6change6based6on6C-ABC6-
64.6Assess6for6obvious6uncontrolled6external6hemorrhage6or6unresponsiveness/

apnea6and6the6need6to6reprioritize6to6C-ABC
5**.6Assess6level6of6consciousness6using6AVPU
6.6Open6the6airway
7**.6Assess6the6patency6and6protection6of6the6airway
8**.6Assess6breathing6effectiveness

Continue6the6TNP6assuming6the6patient6was6intubated.69-116-
69**.6If6intubated,6assess6endotracheal6tube6placement

10.6If6intubated,6assess6ETT6position6and6securement
11.6If6intubated,6state6the6need6to6begin6mechanical6ventilation6or6continue6assisted6vent
ilation

Continue6the6TNP6following6assessments6of6ETT.612-15
**12,613,6and6156are6double-starred6-612**.6Assess6circulation
13**.6Assess6neurologic6status6using6GCS
14.6Assess6pupils
15**.6Remove6all6clothing6AND6inspect6for6obvious6abnormalities6or6injuries

Continue6the6TNP6following6assessments6of6circulation,6neuro6status,6and6removal6of6clo
thing6to6inspect6for6injury.616-186-616.6Provide6warmth
17.6Obtain6a6full6set6of6vital6signs6and6weight6in6kilograms6(if6not6determined6earlier)
18.6Facilitate6family6presence

, Continue6the6TNP6using6the6LMNOP6mnemonic.619-236-619.6L6-6trauma6panel6labs
20.6M6-6monitor6(Cardiac,6consider6EKG)
21.6N6-6consider6need6for6NG/OG
22.6O6-6assess6O26and6end-tidal6capnography
23**.6P6-6assess6pain6using6appropriate6pain6scale

Continue6TNP6after6LMNOP6(so6after6pain6has6been6assessed).624-266-624.6Non-
pharmacological6comfort6measures6
25.6Consider6analgesic6med6order
26.6Obtain6pertinent6history

Head-to-Toe627-436-627.6Inspect6and6palpate6head6for6injuries
28.6Inspect6and6palpate6face6for6injuries
29.6Inspect6and6palpate6neck6for6injuries
--
6Demonstrate6removal6AND6reapplication6of6cervical6collar6for6assessment6(if6indicated).

630.6Inspect6and6palpate6chest6for6injuries

31.6Auscultate6breath6sounds
32.6Auscultate6heart6sounds
33.6Inspect6the6abdomen6for6injuries
34.6Auscultate6bowel6sounds
35.6Palpate6all6four6quadrants6of6the6abdomen6for6injuries
36.6Inspect6and6palpate6the6flanks6for6injuries
37.6Inspect6the6pelvis6for6injuries
38.6Apply6gentle6pressure6over6iliac6crests6downward6and6medially
39.6Apply6gentle6pressure6on6the6symphysis6pubis6(if6iliac6crests6are6stable)
40.6Inspect6the6perineum6for6injuries
41.6Consider6GU6-6urinary6output6
42.6Inspect6and6palpate6all6four6extremities6for6neurovascular6status6and6injuries
43.6Inspect6and6palpate6posterior6surfaces6--
6NOT6if6the6patient6has6suspected6spinal6or6pelvic6injuries



After6the6head-to-
toe,6the6learner6should6summarize6injuries6identified6throughout6the6scenario6and6ask6th
emselves:6-6"What6interventions6or6diagnostics6can6you6anticipate6for6this6patient?"

Following6the6completion6of6head-to-toe6assessment6in6TNP,6you6must6do6what?6446-
644.6Identify6at6least6THREE6interventions6or6diagnostics



these6may6include6the6following:
Antibiotics
Consults
Head6CT6for6any6alterations6in6mental6status
Imaging6(other6radiographs,6CT,6ultrasound,6interventional6radiology6as6indicated)
Law6enforcement
Mandatory6reporting