"TNCC 8th Edition COMPLETE STUDY
GUIDE | Trauma Nursing Process, Triage,
Head Trauma, Shock, Pediatric Mods |
Final Exam Must-Haves"
Primary Survey B
Breathing and ventilation
Primary Survey C
circulation and control of bleeding
Primary survey D
Disability (neurological status)
Primary Survey E
Exposure and environmental control
Primary survey F
Full set of vitals and family presence
Primary Survey g
Get monitoring devices and give comfort
Secondary survey H
History & head to toe assessment
Secondary survey I
Inspect posterior surfaces
Secondary Survey J
Just keep reevaluating A-I
,Secondary Survey L
Labs T&S ABG lactate
Secondary survey M
Monitor for cardiac rhythm and rate assessment
Secondary survey N
Nasogastric or orogastic tube consideration
Secondary Survey O
Oxygenation and ventilation, end tidal ETCO2 or capnography for intubated or sedated patients
Secondary survey P
Pain assessment & management
The MARCH Mnemonic
Massive hemorrhage
Airway
Respiration
Circulation
Head injury/hypothermia
massive hemorrhage
Control life threatening bleeding with tourniquets, combat gauze, celox gauze, chito gauze,
replacement of blood loss RBC/PLT
airway
Establish airway/maintain patent airway
Respiration
Decompress suspected tension pneumothorax, seal open chest wounds, and support ventilation
& oxygenation as required
Circulation
Provide Vascular access, IV/IO and administer fluids to treat shock
Head Injury/Hypothermia
, Prevent or treat hypotension & hypoxia to prevent worsening of traumatic brain injury &
prevent or treat hypothermia
Double starred criteria
Alertness
Airway
Breathing and ventilation
Circulation and control of hemorrhage
Disability (neurologic status)
Exposure and environmental control
AVPU scale
Alert, Verbal, Pain, Unresponsive
ETCO2
Measurements between 35-45mm Hg shows effective ventilation
A level greater than 50mm Hg signifies depressed ventilation
Expedite transfer to the closest trauma center
A 56 y/o M involved in a MVC is brought to the ED. He complains of neck pain, SOB, and diffuse
abdominal pain. His GCS is 15, VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB
mask. Which is the priority intervention for this patient?
a pertinent medical hx is crucial
Which of the following considerations is the most important when caring for a geriatric trauma
pt?
Mitigation
Following a review of recent drills and a real disaster event, a hospital has identified deficiencies
and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life
cycle does this describe?
smell of alcohol on breath
EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs
screening guidelines, which assessment finding would prompt the RN to prepare the pt for a
radiologic spine clearance?
hemoglobin does not readily release O2 for use by the tissues
GUIDE | Trauma Nursing Process, Triage,
Head Trauma, Shock, Pediatric Mods |
Final Exam Must-Haves"
Primary Survey B
Breathing and ventilation
Primary Survey C
circulation and control of bleeding
Primary survey D
Disability (neurological status)
Primary Survey E
Exposure and environmental control
Primary survey F
Full set of vitals and family presence
Primary Survey g
Get monitoring devices and give comfort
Secondary survey H
History & head to toe assessment
Secondary survey I
Inspect posterior surfaces
Secondary Survey J
Just keep reevaluating A-I
,Secondary Survey L
Labs T&S ABG lactate
Secondary survey M
Monitor for cardiac rhythm and rate assessment
Secondary survey N
Nasogastric or orogastic tube consideration
Secondary Survey O
Oxygenation and ventilation, end tidal ETCO2 or capnography for intubated or sedated patients
Secondary survey P
Pain assessment & management
The MARCH Mnemonic
Massive hemorrhage
Airway
Respiration
Circulation
Head injury/hypothermia
massive hemorrhage
Control life threatening bleeding with tourniquets, combat gauze, celox gauze, chito gauze,
replacement of blood loss RBC/PLT
airway
Establish airway/maintain patent airway
Respiration
Decompress suspected tension pneumothorax, seal open chest wounds, and support ventilation
& oxygenation as required
Circulation
Provide Vascular access, IV/IO and administer fluids to treat shock
Head Injury/Hypothermia
, Prevent or treat hypotension & hypoxia to prevent worsening of traumatic brain injury &
prevent or treat hypothermia
Double starred criteria
Alertness
Airway
Breathing and ventilation
Circulation and control of hemorrhage
Disability (neurologic status)
Exposure and environmental control
AVPU scale
Alert, Verbal, Pain, Unresponsive
ETCO2
Measurements between 35-45mm Hg shows effective ventilation
A level greater than 50mm Hg signifies depressed ventilation
Expedite transfer to the closest trauma center
A 56 y/o M involved in a MVC is brought to the ED. He complains of neck pain, SOB, and diffuse
abdominal pain. His GCS is 15, VS: BP 98/71, HR 125, RR 26, SpO2 94% on high-flow O2 via NRB
mask. Which is the priority intervention for this patient?
a pertinent medical hx is crucial
Which of the following considerations is the most important when caring for a geriatric trauma
pt?
Mitigation
Following a review of recent drills and a real disaster event, a hospital has identified deficiencies
and is taking steps to minimize the impact of a future disaster . Which phase of the disaster life
cycle does this describe?
smell of alcohol on breath
EMS brings a pt who fell while riding his bicycle. Using the American College of Surgeobs
screening guidelines, which assessment finding would prompt the RN to prepare the pt for a
radiologic spine clearance?
hemoglobin does not readily release O2 for use by the tissues
