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TNCC Assessment ( TNCC Trauma TNCC 106), Study notes of Nursing

TNCC Assessment Course TNCC - Trauma (TNCC 106) University Neumann University

Typology: Study notes

2022/2023

Available from 04/14/2024

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A: Airway and Alertness: You are assessing the patient’s ability to protect them
airway and the airways patency, all while maintaining spinal and cervical
immobilization.
Alertness Assessment
This is assessed using AVPU, A (alert), V (alert to verbal stimuli), P
(alert to pain), U (unresponsive to all stimuli)
Airway Assessment
Can the patient open and protect their airway
Inspect the mouth for anything that could be obstructing the airway
such as the tongue, teeth, foreign objects, blood, vomitus, secretions, edema,
and burns
Auscultate for obstructive airway sounds such as stridor
Palpate for bony deformity that could be obstructing airway
Assess the definitive airway if put in by EMS, make sure it has corrected
placement with no obstructions
Treatment if airway is not patent
Suction
Remove debris
Insert airway adjunct such as nasopharyngeal airway
Prepare to assist MD in inserting definitive airway such as an
endotracheal tube
B: Breathing: You are assessing to see if the patient is breathing adequately and
regularly.
Breathing Assessment
Inspect for spontaneous breathing, symmetrical rise and fall of chest,
depth, pattern, rate of respiration, signs of respiratory difficulty, skin color
(cyanotic or pale), wounds, contusions, abrasions, or deformities
Auscultate for breath sounds and heart sounds
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A: Airway and Alertness: You are assessing the patient’s ability to protect them

airway and the airways patency, all while maintaining spinal and cervical immobilization. Alertness Assessment This is assessed using AVPU, A (alert), V (alert to verbal stimuli), P (alert to pain), U (unresponsive to all stimuli) Airway Assessment Can the patient open and protect their airway Inspect the mouth for anything that could be obstructing the airway such as the tongue, teeth, foreign objects, blood, vomitus, secretions, edema, and burns Auscultate for obstructive airway sounds such as stridor Palpate for bony deformity that could be obstructing airway Assess the definitive airway if put in by EMS, make sure it has corrected placement with no obstructions Treatment if airway is not patent Suction Remove debris Insert airway adjunct such as nasopharyngeal airway Prepare to assist MD in inserting definitive airway such as an endotracheal tube

B: Breathing: You are assessing to see if the patient is breathing adequately and

regularly. Breathing Assessment Inspect for spontaneous breathing, symmetrical rise and fall of chest, depth, pattern, rate of respiration, signs of respiratory difficulty, skin color (cyanotic or pale), wounds, contusions, abrasions, or deformities Auscultate for breath sounds and heart sounds

Palpate bony structures of chest looking for any deformities, subcutaneous emphysema, or soft tissue injury (bruises or seat belt marks) Treatment if breathing is present Administer oxygen non-rebreather at 15 L Check breathing using end tidal CO Treatment if breathing is absent Open the airway, jaw thrust with second person Insert airway adjunct Assist ventilation with bag mask device Prepare to assist MD in inserting definitive airway such as an endotracheal tube

C: Circulation and Control of Hemorrhage: You are assessing the patient’s ability

to perfuse blood and assessing any uncontrolled bleeding. Circulation Assessment Palpate for presence of central and peripheral pulses, the rate and rhythm Check the skin color, temperature, and moisture Treatment if pulses are absent Initiate basic lifesaving CPR Assess for cause Hemorrhage Assessment Inspect for uncontrolled external/internal hemorrhage, skin color changes, bruising Treatment if there is uncontrolled hemorrhage Use pressure, elevate, tourniquets Initiate infusion of warmed isotonic crystalloid solution Prepare for possible blood administration and use of the rapid infuser

D: Disability: You are assessing the patient’s mental status.

Monitoring for cardiac rhythm and rate, telemetry Insertion of naos or orogastric tube, and foley catheter if patient is intubated or if needed due to injury Apply supplemental oxygenation, monitor with end tidal CO Pain assessment and treatment