Trauma Nursing Process - TNP - TNCC
9th Ed
**A stands for ___ and ___. - correct answeralertness, airway
**B stands for ___ and ___. - correct answerbreathing, ventilation
**C stands for ___. - correct answercirculation
**D stands for ___. - correct answerdisability
**E stands for ___. - correct answerexposure
After all of the assessments, interventions, reassessments, etc. are done, what is the
last thing to ask? - correct answer"Is there anything you would like to add at this time?"
After how many breaths do you assess for the evidence of exhaled CO2? - correct
answerAfter 5 to 6 breaths.
After identifying potential interventions/diagnostics and completing your assessments
and interventions, you should ask yourself what? - correct answer"What findings will you
continue to reevaluate while the patient is in your care?"
"Just keep re-evaluating"
After the head-to-toe, the learner should summarize injuries identified throughout the
scenario and ask themselves: - correct answer"What interventions or diagnostics can
you anticipate for this patient?"
Continue the TNP assuming the patient was intubated. 9-11 - correct answer9**. If
intubated, assess endotracheal tube placement
10. If intubated, assess ETT position and securement
11. If intubated, state the need to begin mechanical ventilation or continue assisted
ventilation
Continue the TNP following assessments of circulation, neuro status, and removal of
clothing to inspect for injury. 16-18 - correct answer16. Provide warmth
17. Obtain a full set of vital signs and weight in kilograms (if not determined earlier)
18. Facilitate family presence
Continue the TNP following assessments of ETT. 12-15
**12, 13, and 15 are double-starred - correct answer12**. Assess circulation
13**. Assess neurologic status using GCS
14. Assess pupils
, 15**. Remove all clothing AND inspect for obvious abnormalities or injuries
Continue the TNP using the LMNOP mnemonic. 19-23 - correct answer19. L - trauma
panel labs
20. M - monitor (Cardiac, consider EKG)
21. N - consider need for NG/OG
22. O - assess O2 and end-tidal capnography
23**. P - assess pain using appropriate pain scale
Continue TNP after LMNOP (so after pain has been assessed). 24-26 - correct
answer24. Non-pharmacological comfort measures
25. Consider analgesic med order
26. Obtain pertinent history
Double-starred criteria include letters ___-___. - correct answerA-E
During the general impression in TNP, when alterations are identified, you must do
what? Then what? - correct answerIntervene as appropriate and continuously reassess
for efficacy
Following the completion of head-to-toe assessment in TNP, you must do what? 44 -
correct answer44. Identify at least THREE interventions or diagnostics
these may include the following:
Antibiotics
Consults
Head CT for any alterations in mental status
Imaging (other radiographs, CT, ultrasound, interventional radiology as indicated)
Law enforcement
Mandatory reporting
Psychosocial support
Social services
Splinting
Tetanus immunization
Wound care
For double-starred criteria, ___ and ___ must be completed prior to moving to the next
step. - correct answerassessments, interventions
Give at least 4 examples of things to inquire about when assessing breathing efficacy: -
correct answer- Breath sounds
- Depth, pattern, and general rate of respirations
- Increased work of breathing
- Open wounds or deformities
- Skin color
- Spontaneous breathing
9th Ed
**A stands for ___ and ___. - correct answeralertness, airway
**B stands for ___ and ___. - correct answerbreathing, ventilation
**C stands for ___. - correct answercirculation
**D stands for ___. - correct answerdisability
**E stands for ___. - correct answerexposure
After all of the assessments, interventions, reassessments, etc. are done, what is the
last thing to ask? - correct answer"Is there anything you would like to add at this time?"
After how many breaths do you assess for the evidence of exhaled CO2? - correct
answerAfter 5 to 6 breaths.
After identifying potential interventions/diagnostics and completing your assessments
and interventions, you should ask yourself what? - correct answer"What findings will you
continue to reevaluate while the patient is in your care?"
"Just keep re-evaluating"
After the head-to-toe, the learner should summarize injuries identified throughout the
scenario and ask themselves: - correct answer"What interventions or diagnostics can
you anticipate for this patient?"
Continue the TNP assuming the patient was intubated. 9-11 - correct answer9**. If
intubated, assess endotracheal tube placement
10. If intubated, assess ETT position and securement
11. If intubated, state the need to begin mechanical ventilation or continue assisted
ventilation
Continue the TNP following assessments of circulation, neuro status, and removal of
clothing to inspect for injury. 16-18 - correct answer16. Provide warmth
17. Obtain a full set of vital signs and weight in kilograms (if not determined earlier)
18. Facilitate family presence
Continue the TNP following assessments of ETT. 12-15
**12, 13, and 15 are double-starred - correct answer12**. Assess circulation
13**. Assess neurologic status using GCS
14. Assess pupils
, 15**. Remove all clothing AND inspect for obvious abnormalities or injuries
Continue the TNP using the LMNOP mnemonic. 19-23 - correct answer19. L - trauma
panel labs
20. M - monitor (Cardiac, consider EKG)
21. N - consider need for NG/OG
22. O - assess O2 and end-tidal capnography
23**. P - assess pain using appropriate pain scale
Continue TNP after LMNOP (so after pain has been assessed). 24-26 - correct
answer24. Non-pharmacological comfort measures
25. Consider analgesic med order
26. Obtain pertinent history
Double-starred criteria include letters ___-___. - correct answerA-E
During the general impression in TNP, when alterations are identified, you must do
what? Then what? - correct answerIntervene as appropriate and continuously reassess
for efficacy
Following the completion of head-to-toe assessment in TNP, you must do what? 44 -
correct answer44. Identify at least THREE interventions or diagnostics
these may include the following:
Antibiotics
Consults
Head CT for any alterations in mental status
Imaging (other radiographs, CT, ultrasound, interventional radiology as indicated)
Law enforcement
Mandatory reporting
Psychosocial support
Social services
Splinting
Tetanus immunization
Wound care
For double-starred criteria, ___ and ___ must be completed prior to moving to the next
step. - correct answerassessments, interventions
Give at least 4 examples of things to inquire about when assessing breathing efficacy: -
correct answer- Breath sounds
- Depth, pattern, and general rate of respirations
- Increased work of breathing
- Open wounds or deformities
- Skin color
- Spontaneous breathing
