TNCC Trauma Nursing Process Skill Exam 2025

What is the first step of the trauma nursing process (TNP) - Correct Ans-Preparation & Triage What is happening in Preparation & Triage? - Correct Ans-1. Activate the team and assign roles 2. Prepare the trauma room 3. Don appropriate PPE What may need to be considered when preparing the trauma room? (5) - Correct Ans-IV equipment Airway equipment Fluid warmer Bariatric equipment Paediatric equipment What is the next step of the TNP (following preparation & Triage)? - Correct Ans General impression What is completed during the "General Impression"? - Correct Ans-Assessing for obvious life threatening circumstances and re-prioritizing the ABC's as necessary (C ABC) Specifically, what are some things we are assessing for in the general impression that would require immediate intervention and re-prioritization of primary survery? - Correct Ans-Apnea External Hemorrhage A systole Significant blood loss with signs of poor perfusion In the TNP, what do we do if there is not a pre-hospital notification prior to patient arrival? - Correct Ans-Complete the triage and Donning of PPE to protect yourself prior to entering the room, but complete general impression and preparation steps simultaneously. List the Mnemonic used for the primary Survery - Correct Ans-A: Airway and assessment of Alertness (stabilizing of Spine as well) B: Breathing and Ventilation C: Circulation and Control of Hemorrhage D: Disability (Neurological Status) E: Exposure and Environmental Control F: Full set of Vitals and Family Presence Nursing Nursing G: Get Adjuncts and Give Comfort (LMNOP) H: Head to toe assessment & History I: Inspect Posterior Surfaces J: Just keep Re-evaluating (Just keep swimming) What is the first step of the Primary Survey - Correct Ans-A: Airway & Assessment of alertness (with Cervical Spine Stabilization) What are the steps includes when it comes to assessing Airway & alertness? - Correct Ans-1. Assess level of consciousness (Using AVPU) 2. Open the airway 3. Assess for patency and protection of the airway How does one "open the airway" with alert patients vs. patients with possible CSIs? - Correct Ans-Alert: if able you can ask them to open their mouths for assessment ?CSI: require a second person to proceed manual cervical spine stabilization while you demonstrate manual Jaw-thrust maneuver to assess airway What are some things we are assessing for when evaluating patency and protection of airway (10) - Correct Ans-Bony deformity Burns Edema Fluids (Blood, Vomit, Secretions) Foreign Objects Inhalation Injuries (Burns & Soot) Loose or missing teeth Sounds (Snoring, gurgling, stridor) Tongue obstruction Vocalization In the event that there are alterations with airway patency, what may be some interventions to consider? (4) - Correct Ans-Need for intubation OPA or NPA insertion Removing any loose teeth or foreign objects Suctioning Fluids What is the Second Step of the Primary Survey? - Correct Ans-Breathing and Ventilation When assessing Breathing and Ventilation, what are we assessing specifically? (9) - Correct Ans-Breath sounds Depth, Pattern and Rate of Reps. Increased work of breathing Open wounds or deformities Skin colour Nursing Nursing Spontaneous Breathing Subcutaneous Emphysema Symmetrical Chest Rise & Fall Tracheal deviation or JVD What interventions may be considered when alterations are noted with Breathing & Ventilation? - Correct Ans-Chest Tube Intubation Decompression of Pneumothorax Supplemental Oxygen Provide bag-mask ventilations In the event we must intervene and intubate, what must me do? - Correct Ans-Assess Endotracheal tube placement, and secure the tube How do we assess ET tube placement? (3**) - Correct Ans-1. Attach CO2 detector after 5-6 breaths and assess for positive CO2 exhaled 2. Observe for chest rise and fall bilaterally with assisted manual ventilations 3. Auscultate over epigastrium for gurgling, and auscultate lung fields for bilateral breath sounds What is an additional recording used to determine tube placement? - Correct Ans Following securing the ET tube, note the number at the teeth or gums and record Immediately following intubation, what must be do? - Correct Ans-Provide mechanical ventilation What is the third step of the primary survey? - Correct Ans-Circulation & Control of Hemorrhage What are the 2 steps we MUST perform when assessing circulation? - Correct Ans-1. Palpate a pulse 2. Inspect AND palpate skin colour, temperature and moisture When alterations are noted during assessment of circulation, what potential interventions should we begin to consider? - Correct Ans-Goal-directed therapy for shock Cardiac Monitor Pelvic binder Traction splint Insert IV/IO (assess if pre-existing is patent) Compare central vs. peripheral pulses Consider sources of internal hemorrhage Control External Hemorrhage Draw labs Facilitate FAST or get radiographs to identify sources of internal hemorrhage Nursing Nursing Initiate Chets compressions and ACLS Palpate central pulse is peripheral is absent What consideration should we account for if circulation is compromised in a pregnant patient - Correct Ans-Tilt the patient or manually displace the uterus. What is the 4th step of the Primary Survey? - Correct Ans-Disability (Neurological Status) What algorithm do we use to assess neurological status? What three things does this tool specifically assess to provide numerical value? - Correct Ans-Glasgow Coma Scale (GCS) 1. Best eye opening 2. Best verbal response 3. Best motor function Other than the GCS what else should we assess when considering disability? - Correct Ans-Assess pupils When alterations are noted in the disability portion, what interventions may be anticipated? - Correct Ans-Head CT Intubation Blood Glucose Monitor What is the 5th assessment in the primary survey? - Correct Ans-Exposure and Environmental Control What is the first and second step when assessing exposure and environmental control? - Correct Ans-1. Remove all clothing and inspecting for obvious injuries (remove any transport devices still in place) 2. Providing warmth following removal of clothing How can we provide warmth following the removal of clothing? (4) - Correct Ans Blankets Increased room temperature Warmed fluids Warming lights What is the 6th assessment in the primary survey? - Correct Ans-Full set of Vital Signs & Family Presence What is included in a full set of Vital signs? (6) - Correct Ans-Blood Pressure MAP Heart Rate Res