TNCC Physical Assessments
1. What is the Trau- A = Airway with simultaneous cervical spine stabiliza-
ma Assessment tion/immobilization
Mnemonic? B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose patient/Environmental Control
F = Full set of VS/Focused Adjuncts/Facilitate Family Pres-
ence
G = Give comfort measures
H = History/Head-to-toe assessment
I = Inspect posterior surfaces
2. What is as- Assess:
sessed in Air- - Vocalization
way while simul- - Tongue obstructing airway
taneously pro- - Loose teeth, foreign objects
tecting the cervi- - Blood, vomitus, other secretions
cal spine? - Edema
Interventions:
- Position pt
- Jaw thrust/Chin lift
- Remove foreign objects
- Suction blood, vomitus, secretions
- Insert oropharyngeal or nasopharyngeal airway
- Needle or surgical cricothyrotomy
3. What is assessed Assess:
in Breathing? - Spontaneous breathing
- Rise and fall of chest
- Rate and pattern of breathing
- Use of accessory muscles/Diaphragmatic breathing
- Skin color
- Integrity of soft tissue and bony structures of chest wall
- Bilateral breath sounds
Interventions:
- Supplemental oxygen
- Bag-Mask ventilation
- Needle thoracentesis/Decompression
1/7
, TNCC Physical Assessments
- Chest tube
- Nonporous dsg taped on 3 sides
4. What is assessed Assess:
in Circulation? - Palpates central pulse for rate and quality
- Skin color, temperature and moisture
- External bleeding
Interventions:
- Direct pressure over uncontrolled bleeding sites
- Insert 2 large caliber IV's with warmed isotonic crystal-
loid solution
- Infuses fluid rapidly with blood tubing
- Blood sampling for typing
- Blood administration
- Pericardiocentesis
- Emergency thoracotomy
- Surgery
- Cardiopulmonary resuscitation and advanced life sup-
port measures
5. What is assessed Assess:
in Disability? - AVPU (LOC)
- Pupils (PERRL)
Interventions:
- Perform further investigation
- Hyperventilation, if indicated
6. What is as- EXPOSE PATIENT AND ENVIRONMENTAL CONTROL
sessed in Trauma (remove clothing and keep patient warm)
Mnemonic under Assess:
"E?" - Obvious wounds/Deformities
- Temperature Control
Interventions:
- Remove clothing
- Preserve clothing for evidence if indicated (don't cut
through bullet wounds, use paper bags)
- Cover with blankets
- Warming lights
- Increase ambient temperature
2/7
1. What is the Trau- A = Airway with simultaneous cervical spine stabiliza-
ma Assessment tion/immobilization
Mnemonic? B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose patient/Environmental Control
F = Full set of VS/Focused Adjuncts/Facilitate Family Pres-
ence
G = Give comfort measures
H = History/Head-to-toe assessment
I = Inspect posterior surfaces
2. What is as- Assess:
sessed in Air- - Vocalization
way while simul- - Tongue obstructing airway
taneously pro- - Loose teeth, foreign objects
tecting the cervi- - Blood, vomitus, other secretions
cal spine? - Edema
Interventions:
- Position pt
- Jaw thrust/Chin lift
- Remove foreign objects
- Suction blood, vomitus, secretions
- Insert oropharyngeal or nasopharyngeal airway
- Needle or surgical cricothyrotomy
3. What is assessed Assess:
in Breathing? - Spontaneous breathing
- Rise and fall of chest
- Rate and pattern of breathing
- Use of accessory muscles/Diaphragmatic breathing
- Skin color
- Integrity of soft tissue and bony structures of chest wall
- Bilateral breath sounds
Interventions:
- Supplemental oxygen
- Bag-Mask ventilation
- Needle thoracentesis/Decompression
1/7
, TNCC Physical Assessments
- Chest tube
- Nonporous dsg taped on 3 sides
4. What is assessed Assess:
in Circulation? - Palpates central pulse for rate and quality
- Skin color, temperature and moisture
- External bleeding
Interventions:
- Direct pressure over uncontrolled bleeding sites
- Insert 2 large caliber IV's with warmed isotonic crystal-
loid solution
- Infuses fluid rapidly with blood tubing
- Blood sampling for typing
- Blood administration
- Pericardiocentesis
- Emergency thoracotomy
- Surgery
- Cardiopulmonary resuscitation and advanced life sup-
port measures
5. What is assessed Assess:
in Disability? - AVPU (LOC)
- Pupils (PERRL)
Interventions:
- Perform further investigation
- Hyperventilation, if indicated
6. What is as- EXPOSE PATIENT AND ENVIRONMENTAL CONTROL
sessed in Trauma (remove clothing and keep patient warm)
Mnemonic under Assess:
"E?" - Obvious wounds/Deformities
- Temperature Control
Interventions:
- Remove clothing
- Preserve clothing for evidence if indicated (don't cut
through bullet wounds, use paper bags)
- Cover with blankets
- Warming lights
- Increase ambient temperature
2/7
