TNCC NURSING PROCESS 2025 |
ALREADY GRADED A+ TESTBANK|100%
COMPLETE
VIPP - part of J (just keep re-evaluating) - ANSV - vital signs
V/5 - oriented/5, confused/4, inappropriate/3 incomprehensible/2, none/1
T - tx in the field
SAMPLE - part of (H) pt hx in secondary survey - ANSS - S/Sx leading up to
S - S/Sx in the field
P - primary survey
P - past med hx
P - pain level
P - ANSPain assessment
O - ANSO2/ventilation assessment, capnography?
N - ANSNaso/orogastric tube placement. Caution in gastric by pass hx
MIST - part of (H) pre-hospital report in secondary survey - ANSM - MOI
M/6 - obeys/6, localizes/5, withdraws/4, decorticate/3, decerebrate/2, none/1
M - medications current
M - ANSMonitor - obtain HR and rhythm
LACE - part of H (head-to-toe) - ANSlacerations, abrasions/avulsions, contusions,
edema/ecchymosis
L - last ins/outs (incl menstrual)
L - ANSLabs
J - secondary survey - ANSJust keep re-evaluating
I - secondary survey - ANSInspect posterior surfaces
I - injuries sustained
I - injuries and interventions
H - secondary survey - ANS- Head-to-toe assessment (LACE (secondary assessment)
GCS - part of D (disability (neurologic status) - ANSE/4 - spontaneous/4, speech/3,
pain/2, none/1
G - primary survey - ANS- Get monitoring devices
F - primary survey - ANS- Full set of vitals
E - primary survey - ANS- Expose
E - events/enviro factors leading up to
D - primary survey - ANSDisability (neurologic status) - GCS
C - primary survey - ANSCirculation and bleeding (control of hemorrhage)
B - primary survey - ANSBreathing and ventilation
A - primary survey - ANS- Across the room
A - allergies
- History: MIST (pre-hospital) and SAMPLE (pt hx)
- Give comfort (LMNOP)
- Facilitate family presence
- Environment control
- Alertness (AVPU)
