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Exam (elaborations)

Trauma Nursing Initial Assessment & Management

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A comprehensive guide for trauma nurses covering initial patient assessment (ABCDE), resuscitation, secondary survey, and management of various shock types and traumatic injuries. This document serves as a comprehensive resource for trauma nurses, outlining critical steps in patient assessment, intervention, and management of various traumatic conditions.

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Institution
TNCC
Course
TNCC

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TNCC EXAM



1.1. Preparation and Triage
2. Primary Survery (ABCDE) with resuscitation adjuncts (F,G)
3. Reevaluation (consideration of transfer)
4. Secondary Survey (HI) with reevaluation adjuncts
5. Reevaluation and post resuscitation care
6. Definitive care of transfer to an appropriate trauma nurse: Initial
Assessment
2.1. A- airway and Alertness with simultaneous cervical spinal stabilization
2. B- breathing and Ventilation
3. circulation and control of hemorrhage
4. D - disability (neurologic status)
5. F - full set of vitals and Family presence
6. G - Get resuscitation adjuncts
L- Lab results (arterial gases, blood type and crossmatch)
M- monitor for continuous cardiac rhythm and rate assessment
N- naso or orogastric tube consideration
O- oxygenation and ventilation analysis: Pulse oxygemetry and end-tidal
caron dioxide (ETC02) monitoring and capnopgraphy
H- History and head to toe assessment
I- Inspect posterior surfaces: ABCDEFGHI
3.Before the arrival of the pt: When should PPE be placed:
4.Pt is at hospital in the right amount of time, right care, right trauma
facility, right resources: Safe Care:
5.Uncontrolled Hemorrhage: Major cause of preventable death:
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, TNCC EXAM

6.reorganize care to C-ABC: If uncontrolled hemorrhage ..
7.Used at the beginning of the initial assessment

1. A Alert. If the pt is alert he or she will be able to maintain his or her
airway once it is clear.
2. V responds to verbal stimuli responds to pain. If the patient needs verbal
stimulation to respond, an airway adjunct may be needed to keep the
tongue from obstructing the airway.
3. P responds to pain. If the pt. responds only to pain, he or she may not be
able to maintain his or her airway adjunct may need to be placed while
further assessment is made to determine the need for intubation.
4. U Unresponsive. If the pt. is unresponsive, announce it loudly to the team
and direct someone to chk in the pt is pulseless while assessing if the
cause of the problem is the airway.: Airway and AVPU:
8.ask pt to pen his or her mouth: While assessing airway the patient is
alert and responds to verbal stimuli you should..




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, TNCC EXAM



9.jaw thrust maneuver to open airway and assess for obstruction. If pt has
a suspected csi, the jaw thrust procedure should be done by two
providers. One provider can maintain c-spine and the other can perform
the jaw thrust maneuver.: While assessing airway pt is unable to open
mouth, responds only to pain, or is unresponsive you should..
10.1. The tongue obstructing the airway
2. loose or missing teeth
3. foreign objects
4. blood, vomit, or secretions'
5. edema
6. burns or evidence of inhalation injury

Auscultiate or listen for:
1. Obstructive airway sounds such as snoring or gurgling
2. Possible occlusive maxillofacial bony deformity
3. Subcutaneous emphysema: Inspect the mouth for:
11.1. Check the presence of adequate rise and fall of the chest with
assisted ventilation
2. Absence of gurgling on auscultation over the epigastrium
3. Bilateral breath sounds present on auscultation
4. Presence of carbon dioxide (CO2) verified by a CO2 device or monitor: If
the pt has a definitive airway in what should you do?
12.1. Suction the airway
2, Use care to avoid stimulating the gag reflex
3. If the airway is obstructed by blood or vomitus secretions, use a rigid
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Institution
TNCC
Course
TNCC

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Uploaded on
June 3, 2025
Number of pages
17
Written in
2024/2025
Type
Exam (elaborations)
Contains
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