What should you ask yourself after completing all of your interventions and reassessments? -
Does this patient need to be transferred to another hospital, to surgery, or to critical care?
What happens prior to patient arrival? 1-3 - 1. Activate trauma team
2. Prepare trauma room
3. Don PPE
Wh...
Trauma Nursing Process - TNP - TNCC
9th Ed
What should you ask yourself after completing all of your interventions and reassessments? - ✔✔✔
Does this patient need to be transferred to another hospital, to surgery, or to critical care?
What happens prior to patient arrival? 1-3 - ✔✔✔1. Activate trauma team
2. Prepare trauma room
3. Don PPE
What happens following patient arrival but before a decision to intubate has been made? 4-8
may change based on C-ABC - ✔✔✔4. Assess for obvious uncontrolled external hemorrhage or
unresponsiveness/apnea and the need to reprioritize to C-ABC
5**. Assess level of consciousness using AVPU
6. Open the airway
7**. Assess the patency and protection of the airway
8**. Assess breathing effectiveness
Continue the TNP assuming the patient was intubated. 9-11 - ✔✔✔9**. 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 ETT. 12-15
**12, 13, and 15 are double-starred - ✔✔✔12**. 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 following assessments of circulation, neuro status, and removal of clothing to inspect
for injury. 16-18 - ✔✔✔16. 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 using the LMNOP mnemonic. 19-23 - ✔✔✔19. 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 - ✔✔✔24. Non-pharmacological
comfort measures
25. Consider analgesic med order
26. Obtain pertinent history
Head-to-Toe 27-43 - ✔✔✔27. Inspect and palpate head for injuries
28. Inspect and palpate face for injuries
29. Inspect and palpate neck for injuries
-- Demonstrate removal AND reapplication of cervical collar for assessment (if indicated).
30. Inspect and palpate chest for injuries
31. Auscultate breath sounds
32. Auscultate heart sounds
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