Módulos on-line do pré-curso do provedor da 9ª edição do TNCC-Processo de enfermagem de traumatologia (PET)

Processo de enfermagem de traumatologia (PET) - Referência de uma página

Pdf Summary

This document outlines the Trauma Nursing Process (PET) and the primary and secondary assessment sequence for trauma patients, based on the Emergency Nurses Association guidance.

It begins with preparation and triage: activate the trauma team, assign roles, prepare the room and special equipment, use PPE, and consider safety threats or the need for decontamination. The initial impression focuses on identifying uncontrolled bleeding, unresponsiveness, or apnea, and revising priorities to the C-ABC approach if needed.

The primary survey follows the A-G framework:
- <strong>A: Alertness and airway</strong> — maintain cervical spine stabilization, assess responsiveness using AVPU, and confirm airway patency.
- <strong>R: Breathing and ventilation</strong> — evaluate the effectiveness of breathing.
- <strong>C: Circulation and hemorrhage control</strong> — check pulse and skin signs, and anticipate shock-directed therapy.
- <strong>D: Neurologic dysfunction</strong> — assess Glasgow Coma Scale, pupils, and blood glucose if mental status is altered.
- <strong>E: Exposure and environmental control</strong> — remove clothing and provide warmth.
Additional steps include checking all vital signs, considering family presence, and using adjuncts such as laboratory tests, monitoring, nasogastric/orogastric tubes, oxygenation/capnography, and pain assessment/management.

The patient is then reassessed for transfer to a trauma center or preparation for definitive treatment.

The secondary survey includes:
- <strong>History</strong> — prehospital report and AMOSTRA.
- <strong>Head-to-toe examination</strong>.
- <strong>Inspection of posterior surfaces</strong>, turning and palpating the patient unless spinal or pelvic injury is suspected.

The process also emphasizes identifying at least three expected interventions or diagnoses and continuing reassessment of vital signs, injuries, intervention effectiveness, primary survey findings, and pain.

A key note explains that steps marked with two stars must be completed in order before moving forward, while one-star steps are essential but not sequence-dependent.

Keywords

Trauma Nursing Process

Primary Survey

Secondary Survey

A-G Framework

C-ABC Approach

Cervical Spine Stabilization

Glasgow Coma Scale

Hemorrhage Control

Trauma Assessment

Emergency Nurses Association