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7 TNCC The Nursing Process Completed
1.Preparation and Triage: 1. Activate the trauma team.
2.Prepare the Trauma Room.-Rapid infuser -Chest trauma equipment 3.States the need to don PPE
2.Across-the-room Observation: Assess for obvious uncontrolled external
hem- orrhage.
3.Primary Survey: Airway + Cervical Spinal Stabilization (A): 1. Assess
AVPU**
2.Ask a 2nd person to provide manual cervical spinal stabilization *AND* manually open the airway using the jaw-thrust maneuver.**
3.Determine airway patency:** (4)
-tongue obstruction -loose teeth 1 / 2
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7 -foreign objects -blood, vomitus, or other secretions -edema -snoring, gurgling, or stridor 4.Assess the need for an OPA** 5.Assess the need for a definitive airway 6.Reassess the airway after insertion of the OPA.
4.Primary Survey: Breathing & Ventilation (B): 1. Determine breathing
effective- ness: ** (4)
Inspect:
-Spontaneous breathing?-Symmetrical chest rise?-Depth/pattern/rate of respirations?-Increased WOB?-Skin colour?-Open wounds or
deformities? Palpate:
-SC Emphysema?
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