Trauma Nursing Process (TNP)
Preparation and Triage
Activate trauma team
Prepare the room and any special equipment
Don PPE and consider need for decontamination
Across the Room Observation
Uncontrolled bleeding? Reprioritize to <C> ABC
Primary Survey [ABCDEFG] “When you mess, reassess”
A** Alertness (A1) and Airway (A2)
• Maintain cervical spinal stabilization
• AVPU (Alert, Verbal, Pain, Unresponsive)
• Assess airway patency (at least FOUR)
B** Breathing and Ventilation
• Assess breathing effectiveness (at least FOUR)
C** Circulation and Control of Hemorrhage
• Assess for uncontrolled hemorrhage, central pulse, skin color/temperature/
moisture (ALL THREE)
D** Disability (Neurologic Status)
• Glasgow Coma Scale
• Pupils
• *Consider head CT for any abnormalities
E** Exposure (E1) and Environmental Control (E2)
• Remove clothing, provide warmth
**Double starred items must be completed IN ORDER prior to moving to the next step
F Full Set of Vital Signs (F1) and Family Presence (F2)
G Get Monitoring Devices (G1) and Give Comfort (G2) [LMNOP]
L – Labs: blood typing, blood gases, and lactate
M – Monitor
N – Naso- or orogastric tube
O – Wean Oxygen based on Oximetry and assess capnography (required if sedated or intubated)
P* – Pain assessment AND management
Reevaluation for Transfer to Trauma Center or Preparation for Definitive Treatment
Secondary Survey [HI]
H History (H1) and Head-2-Toe (H2) Exam
• History (H1) – Prehospital report, patient- or family-generated, from electronic health record
• Head-2-Toe Assessment (H2)
I* Inspect Posterior Surfaces
• Unless contraindicated by suspected spine or pelvic injury – turn, inspect & palpate,
remove backboard
Anticipated Interventions or Diagnostics
• At least THREE
Just Keep Revaluating
Vital signs
•
Identified injuries and effectiveness of interventions
•
Primary assessment
•
Pain
•
Definitive Care or Transport
www.ena.org/TNCC
Emergency Nurses Association (2019). Trauma Nursing Core Course™: Provider manual. Schaumburg, IL: Author.
©2019 Emergency Nurses Association.
