TNCC - Trauma Nursing Core Course Save
Terms in this set (42)
Inspect: tongue obstruction, loose/missing teeth, foreign
objects, blood, vomitus, secretions, edema, burns or evidence
of inhalation injury
Airway Assessment Auscultate: listen for obstructive airway sounds (ie. snoring,
gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony
deformity, subcutaneous emphysema
, Suction
Remove foreign body if noted
Jaw thrust maneuver (maintain cspine)
Airway Interventions:
Nasopharyngeal airway (can be conscious) Oropharyngeal
airway (no gag)
Consider definitive airway
A-Alert
V-Verbal
Alertness Assessment
P-Painful
U-Unresponsive
A (AVPU) Alert. Will be able to maintain airway once clear.
B (Primary Survey) Breathing and Ventilation
, Inspect: spontaneous breathing, symmetrical rise and fall,
depth/pattern/rate of respirations, accessory muscle use,
diaphragmatic breathing, skin color (normal, pale, flushed,
cyanotic), contusions/abrasions/deformities (signs of underlying
injury), open pneumothoraces (sucking chest wound), JVD,
tracheal position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at
Breathing and Ventilation 2nd intercostal space midclavicular line and bases at the fifth
Assessment intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema,
soft tissue injury, JV pulsations at suprasternal notch or
supraclavicular area
Life-threatening pulmonary injuries requiring immediate
intervention: open pneumothorax, tension pneumothorax, flail
chest, hemothorax.
Breathing absent: jaw-thrust maneuver, oral airway adjunct,
assist ventilation with bag-mask device, prepare for definitive
airway
Breathing and Ventilation
Intervention
Breathing present: NRB. Determine if ventilation effective:
etCO2 35-45, SpO2 94% or higher. If ineffective: assist with
bag-mask and determine need for definitive airway
Terms in this set (42)
Inspect: tongue obstruction, loose/missing teeth, foreign
objects, blood, vomitus, secretions, edema, burns or evidence
of inhalation injury
Airway Assessment Auscultate: listen for obstructive airway sounds (ie. snoring,
gurgling, stridor)
Palpate: palpate for possible occlusive maxillofacial bony
deformity, subcutaneous emphysema
, Suction
Remove foreign body if noted
Jaw thrust maneuver (maintain cspine)
Airway Interventions:
Nasopharyngeal airway (can be conscious) Oropharyngeal
airway (no gag)
Consider definitive airway
A-Alert
V-Verbal
Alertness Assessment
P-Painful
U-Unresponsive
A (AVPU) Alert. Will be able to maintain airway once clear.
B (Primary Survey) Breathing and Ventilation
, Inspect: spontaneous breathing, symmetrical rise and fall,
depth/pattern/rate of respirations, accessory muscle use,
diaphragmatic breathing, skin color (normal, pale, flushed,
cyanotic), contusions/abrasions/deformities (signs of underlying
injury), open pneumothoraces (sucking chest wound), JVD,
tracheal position, signs of inhalation injury
Auscultate: presence, absence and equality of breath sounds at
Breathing and Ventilation 2nd intercostal space midclavicular line and bases at the fifth
Assessment intercostal space anterior axillary line
Palpate: bony structures, possible rib fractures, SQ emphysema,
soft tissue injury, JV pulsations at suprasternal notch or
supraclavicular area
Life-threatening pulmonary injuries requiring immediate
intervention: open pneumothorax, tension pneumothorax, flail
chest, hemothorax.
Breathing absent: jaw-thrust maneuver, oral airway adjunct,
assist ventilation with bag-mask device, prepare for definitive
airway
Breathing and Ventilation
Intervention
Breathing present: NRB. Determine if ventilation effective:
etCO2 35-45, SpO2 94% or higher. If ineffective: assist with
bag-mask and determine need for definitive airway
