Download Trauma Nursing Core Course (TNCC) 2023/2024 Update and more Exams Nursing in PDF only on Docsity! TNCC LATEST UPDATE 2023/2024 TNCC Physical Assessments What is the Trauma Assessment Mnemonic? - A = Airway with simultaneous cervical spine stabilization/immobilization B = Breathing C = Circulation D = Disability (neurologic status) E = Expose patient/Environmental Control F = Full set of VS/Focused Adjuncts/Facilitate Family Presence G = Give comfort measures H = History/Head-to-toe assessment I = Inspect posterior surfaces What is assessed in Airway while simultaneously protecting the cervical spine? - Assess: - Vocalization - Tongue obstructing airway - Loose teeth, foreign objects - Blood, vomitus, other secretions - Edema Interventions: - Position pt - Jaw thrust/Chin lift - Remove foreign objects - Suction blood, vomitus, secretions - Insert oropharyngeal or nasopharyngeal airway TNCC LATEST UPDATE 2023/2024 - Needle or surgical cricothyrotomy TNCC LATEST UPDATE 2023/2024 - Obtain a complete set of vital signs - Consider the focused adjuncts - Cardiac Monitor - Pulse Oximeter - Urinary catheter if not contraindicated - Gastric tube - Laboratory studies - Facilitate family presence What is assessed in Trauma Mnemonic under "G?" - - Assesses pain using an appropriate pain scale - Verbal reassurance - Initiates a nonpharmacologic pain intervention - Considers obtaining order for pain medication What is assessed for History? - - MIVT - Patient-generated information - PMH What is assessed under Head-to-toe assessment? - HEAD AND FACE - Inspect for wounds, ecchymosis, deformities, drainage from nose and ears, and check pupils - Palpate for tenderness, note bony crepitus, deformity NECK - Remove anterior portion of the rigid cervical collar to inspect and palpate the neck - Another team member must hold the pt's head while the collar is being removed and replaced - Inspect for wounds, ecchymosis, deformities, and distended neck veins TNCC LATEST UPDATE 2023/2024 - Palpate for tenderness, note bony crepitus, deformity, subcutaneous emphysema, and tracheal postion CHEST - Inspect for breathing rate and depth, wounds, deformities, ecchymosis, use of accessory muscles, paradoxical movement - Auscultate breath sounds and heart sounds - Palpate for tenderness, note bony crepitus, subcutaneous emphysema, and deformity ABDOMEN AND FLANKS - Inspect for wounds, distention, ecchymosis, and scars - Auscultate bowel sounds - Palpate all four quadrants for tenderness, rigidity, guarding, masses, and femoral pulses PELVIS AND PERINEUM - Inspect for wounds, deformities, ecchymosis, priapism, blood at the urinary meatus or in the perineal area - Palpate the pelvis and anal sphincter tone EXTREMITIES - Inspect for ecchymosis, movement, wounds, and deformities - Palpate for pulses, skin temperature, sensation, tenderness, deformities, and note bony crepitus How do you Inspect Posterior Services? - - Maintain cervical spine protection and support injured extremities while the pt is log-rolled. - Inspect the posterior surfaces for wounds, deformities, and ecchymosis - Palpate the posterior surfaces for tenderness and deformities - Palpate anal sphincter tone (if not performed previously) Planning and Implementation in General: - Studies: - Laboratory Studies - T&S or crossmatch TNCC LATEST UPDATE 2023/2024 - H&H - ETOH - Serum lactate level - Serum pregnancy test as indicated - Kleihauer-Betke test as indicated - ABG's Interventions: - OR intervention - Admission or Transfer - GCS and Revised Trauma Score - Psychosocial support of pt and family - Pain control - Nonpharmacological pain intervention - Meds as indicated: - Tetanus prophylaxis - Antibiotics - Pain meds - Neuromuscular blockers - Sedation Planning and Implementation for Head and Face: - Studies: - Plain X-ray's - CT scan - MRI's - Angiography Interventions: TNCC LATEST UPDATE 2023/2024 - Pneumatic antishock garment for splinting - External pelvic stabilization device Planning and Implementation for Extremities: - Studies: - X-rays - CT scan - MRI - Measurement of compartment pressures Interventions: - Immobilization/traction devices - Elevation - Ice Planning and Implementation for Posterior Services: - Studies: - X-rays - CT scan - MRI Interventions: - Spinal protection with vertebral column immobilization Planning and Implementation for Surface Trauma: - Interventions: - Irrigation - Wound care - Ice - Care for amputated parts - Tetanus prophylaxis TNCC LATEST UPDATE 2023/2024 - Antibiotics
