TNCC NURSING PROCESS 2024 |
ALREADY GRADED A+ TESTBANK|100%
COMPLETE
A - primary survey - ANS- Across the room
- Airway
- Alertness (AVPU)
B - primary survey - ANSBreathing and ventilation
C - primary survey - ANSCirculation and bleeding (control of hemorrhage)
D - primary survey - ANSDisability (neurologic status) - GCS
E - primary survey - ANS- Expose
- Environment control
F - primary survey - ANS- Full set of vitals
- Facilitate family presence
G - primary survey - ANS- Get monitoring devices
- Give comfort (LMNOP)
GCS - part of D (disability (neurologic status) - ANSE/4 - spontaneous/4, speech/3,
pain/2, none/1
V/5 - oriented/5, confused/4, inappropriate/3 incomprehensible/2, none/1
M/6 - obeys/6, localizes/5, withdraws/4, decorticate/3, decerebrate/2, none/1
H - secondary survey - ANS- Head-to-toe assessment (LACE (secondary assessment)
- History: MIST (pre-hospital) and SAMPLE (pt hx)
I - secondary survey - ANSInspect posterior surfaces
J - secondary survey - ANSJust keep re-evaluating
L - ANSLabs
LACE - part of H (head-to-toe) - ANSlacerations, abrasions/avulsions, contusions,
edema/ecchymosis
M - ANSMonitor - obtain HR and rhythm
MIST - part of (H) pre-hospital report in secondary survey - ANSM - MOI
I - injuries sustained
S - S/Sx in the field
