Trauma Nursing Assessment Tools

About

➀ Read and Learn

The following course content

Introduction   

Trauma is the leading cause of death worldwide. In the United States alone, trauma is the leading cause of death in adults under 45 years old and accounts for about ten percent of deaths in all men and women equally. There are approximately 50 million visits to the emergency department annually related to trauma (1). Trauma clients can present with a wide range of injury severities (mild to severe), which can potentially lead to disability or mortality (2). Per the World Health Organization, 50% of all trauma deaths usually occur within the first hours of the sustained injury, with the most common causes including brain injury, hemorrhage, cardiopulmonary arrest, and multiple organ dysfunction syndromes (1). The disabilities and mortalities caused by trauma bring heavy burdens for both society and families.  

All healthcare providers involved must take an organized and systematic approach to assessing trauma victims. When caring for a trauma victim, physicians, nurses, and support staff must work together and communicate effectively. The goal of evaluating trauma victims is to identify immediate life threats and stabilize the patient. Excellence in trauma nursing is believed to contribute to optimal client outcomes and the prevention of complications, long-term consequences, and death for clients. Since significant trauma can be life-threatening and affect multiple systems and body regions, it is the treatment and care that have strict timelines. As assessors, implementers, coordinators, managers, and educators, nurses are vital in reducing client mortality and morbidity regarding traumas (3).  

Studies have shown that trauma clients who are assessed and treated in well-organized trauma care systems with trained trauma health professionals have significantly lower mortality and morbidity rates (3). Because trauma is a leading cause of death, nurses and healthcare professionals must receive trauma-related education or adequate trauma-related training. The nurse’s role is of the utmost importance since they are either at the site of the injury during the prehospital phase or present upon arrival (4). They are typically the emergency care and critical care professionals involved in the initial assessment (4). They help initialize care via triage, participate in the primary evaluation, prepare patients for operations, assist surgeons during operations, and monitor the client (4). Trauma nurses are essential to the trauma treatment team, and their assessment skills and tools affect clients’ overall outcomes.  

The primary purpose of this course is to provide healthcare providers with evidence-based guidance on trauma assessment tools for nurses. This course will provide necessary information and assessment tools set forth by trauma guidelines and highlight the roles of the interprofessional team when assessing a client who has endured trauma. It will cover different assessment tools used by nurses in a trauma setting. It aims to improve healthcare providers’ knowledge and assessment skills in trauma. It will also include proper organization and the process that should be followed for clients who have suffered a traumatic injury, as well as strategies for improving client outcomes.  

Trauma 

Let us first look at what characterizes an injury as trauma. Traditionally, traumatic injuries were considered a result of accidents. However, from a public health perspective, traumatic injury is now considered a disease, which emphasizes its predictable and preventable nature (5). Trauma is dangerous, complicated, and changeable and could lead to immediate mortality or severe disability and complications such as sepsis, septic shock, and multiple organ dysfunction syndrome (3). A traumatic injury or trauma refers to any physical injury that occurs suddenly and is potentially severe in form, requiring immediate medical assistance such as resuscitation or other interventions to prevent permanent disability or death (4). Major trauma is usually caused by external forces such as falls, road accidents, assaults, crush injuries, or burns (4). A severe traumatic injury typically requires an assessment done by hospital healthcare providers, potential treatment, and rehabilitation, dependent upon the full extent of the injuries, diagnostics, and therapeutic procedures (4). Often, a client who experiences any physical trauma will face long-term psychological difficulties due to the shock of the unexpected injury (4).  

Trauma Causes (5) 

Like most other diseases, trauma has well-defined causes. Unlike other diseases or viruses, which are caused by bacteria or viruses, trauma is caused by energy. Different types of energy lead to trauma, and it is crucial to understand what these are to correctly identify, treat, and care for the injuries properly. The amount of energy or force will determine the level or complexity of the injury; however, it is not the only factor to consider. Other factors to consider and will play an essential part in the severity of the trauma include:   

• Client characteristics  
• Gender 
• Age 
• Risk-taking behaviors 
• Objects involved 
• Blunt 
• Sharp 
• Tissue type 

The mechanism of injury can be determined by how energy is transferred and damages the tissues. Table 1 shows the primary mechanisms of injury with examples of the resulting injuries. Blunt injuries are considered the most common type of trauma.  

Table 1: Mechanisms of Injury  

It is important to remember that burns affect children and older people unequally, and the complexity of their management often presents significant challenges to healthcare providers. Other causes that are not as common include: 

• Suicide 
• Drowning 
• Poisoning 

Trauma Networks (6) 

Trauma clients often require complex, coordinated care throughout their hospital stay; a well-trained and experienced healthcare team must deliver this to optimize recovery. Excellent trauma care relies on a well-functioning trauma system. The trauma system works to provide critical information on trauma to those who are affected by trauma, which includes healthcare providers, policymakers, and the public.  

Many people believe that if they were to suffer a trauma injury, their local hospital could provide all the care they need. Given the drastic nature of some trauma injuries, this is not the case. Over the last several decades, steps have been taken to ensure that clients with critical or multiple injuries seamlessly receive the proper care in the correct locations, with appropriate interventions, and, if necessary, transfer to a hospital able to provide the best and most appropriate care.   

In the United States, the American trauma system is designed to provide an organized response to the injury and operates at the local and state government levels. It is guided by national societies such as the American Trauma Society (ATS). Trauma networks include all facilities with the capability of caring for trauma injuries.  

Trauma Centers (10, 11) 

A trauma center is different than a regular emergency room. A trauma center is a designated portion of the hospital trained and staffed to provide comprehensive care to clients with traumatic injuries. In a trauma center, surgical specialists are available around the clock daily. Everything in the center is designed to meet the unique physical and emotional needs of people who have been through trauma, including loved ones. It is a center where clients are treated by healthcare professionals who specialize in trauma care. Trauma centers work closely with: 

• Orthopedic surgeons  
• Neurosurgeons 
• Plastic surgeons 
• Ear, nose, and throat (otolaryngology) specialists 
• Thoracic surgeons 
• Interventional radiology specialists 

Trauma centers are verified/designated by the state or local government authority or verified by the American College of Surgeons (ACS). Centers are selected and assigned a level based on guidelines specific to each state.  

• Level I  
  • Highest designation level for trauma service 
  • Admit at least 1,200 trauma patients yearly  
  • 24-hour immediate coverage by general surgeons and by the specialties of orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, and critical care 
  • Dedicated trauma program, trauma team, and medical director 
  • Orthopedic specializing in traumatology  
  • Cardiothoracic surgery is available around the clock with cardiopulmonary bypass equipment. 
  • Provide continuing education to trauma team members  
  • Actively involved in teaching and research in trauma care  
  • Led by an ICU physician boarded in surgical critical care 
• Level II 
  • Similar capabilities as a Level I Trauma center 
  • Transfer agreements in place to provide transport to a Level I center if needed 
  • Specialty services such as cardiac surgery, microvascular surgery, and acute in-house hemodialysis are not required. 
  • Emergency room personnel and equipment should be the same as a Level I  
  • Operating rooms and personnel are not required to be available 24 hours a day  
  • Must always have access to MRI and CT scans 
• Level III 
  • Provide prompt assessment, resuscitation, emergency operations, and stabilization. 
  • Have 24-hour general surgery coverage. 
  • Ability to arrange for transfer to a facility that can provide definitive trauma care if needed 
  • Participate in regional disaster management plans and exercises 
  • 24-hour immediate coverage by emergency medicine physicians and trauma advanced practice providers and the prompt availability of general surgeons and anesthesiologists 
• Level IV 
  • Provide the initial evaluation and assessment of injured clients 
  • Ability to transfer clients with a transfer plan in place 
  • Ensure 24-hour emergency resuscitation, with coverage by a registered nurse and physician or mid-level provider, and it must have a physician director 

Trauma Teams (8, 9) 

Time is often crucial for the client’s outcome after a trauma. Early interventions minimize secondary injuries and reduce mortality, thus improving survival rates. In the first hour following a trauma, the client has the highest possibility of life-threatening conditions being reversed. This hour is often referred to as the ‘Golden Hour.’ One vital task for the trauma team is to minimize the time until definite management is established.  

A trauma team aims to resuscitate and stabilize the client rapidly and reduce the time needed for diagnosis and treatment to improve survival rates. A team approach allows for the distribution of several tasks in assessing and resuscitating the client among several people. A trauma team approach can lead to a reduction in time from injury to critical interventions.  

The treatment of a client who has suffered trauma requires rapid injury assessment and the implementation of life-saving interventions. The trauma team leader is often an emergency room physician who helps coordinate care and ensure adherence to Advanced Trauma Life Support (ATLS) guidelines. The team leader typically assigns the roles and oversees the direction and decision-making upon the client’s arrival and throughout the assessment.  

Other team members typically include emergency room nurses, radiology techs, pharmacists, phlebotomists, blood banks, and respiratory therapists. The nurses assist the physician and perform various tasks, such as obtaining vital signs, obtaining I.V. access, drawing blood, and placing urinary or gastric catheters if needed. They also play a role in the documentation process. Radiology technicians are present to provide X-rays of the thorax and pelvis.  

Establishing a trauma team aims to ensure the early mobilization and involvement of more experienced medical staff, thereby improving patient outcomes. It is also important not to have an excess number of people present. Having too many healthcare providers present can make it difficult to overview the trauma client and adhere to ATLS guidelines. Information from emergency medical services before arrival will help ensure the necessary healthcare providers are present.

Advanced Trauma Life Support (ATLS) (4, 7) 

Most trauma deaths occur within the first hours after injury, often known as the “golden hour.” Many of the causes are usually extensive nervous and/ or cardiovascular system damage. The mechanism of the injuries leading to death typically follows a predictable pattern and is closely related to individual client characteristics and environmental conditions. Identifying these patterns can make the difference between life and death for the client. The study of these patterns led to the development of Advanced Trauma Life Support (ATLS). 

Advanced Trauma Life Support (ATLS) is a course for healthcare providers that provides the framework for assessing and treating clients who suffer traumatic injuries. The primary basis of the program is to create universal principles in the evaluation of the trauma client, using assessment steps that help healthcare professionals identify and manage the most life-threatening conditions concerning the severity of the risk they pose. If nothing else, the guiding principles of ATLS are primary and secondary surveys. Utilizing these surveys and the skills that accompany them allows all interprofessional team members to treat clients under one standardized method and communicate using one common language.  

It is designed to streamline the assessment and treatment of every client, allowing them to receive definitive care faster and improve their outcomes. ATLS’s advantage is that in moments of stress, it acts as a tool to off-load distractions cognitively and gives providers more time to assess their clients and communicate effectively with other team members. Trauma injuries are often time-sensitive and have added stresses such as limited knowledge of the mechanism of injury or history, which can make these cases very overwhelming. Trauma care principles outlined in ATLS provide healthcare providers with knowledge and steps to implement and improve client care. ATLS has four major components: prehospital care, hospital, post-hospital care, and injury prevention education. 

Prehospital (1) 

This is considered the first step in trauma assessment, which begins before the client arrives at the hospital. During this phase, the healthcare providers on the scene (police, EMS, and fire) must coordinate with the hospital emergency team. Emergency medical services (EMS) will notify the hospital receiving the client to prepare resources and members. At the hospital, the trauma team will gather themselves and any necessary equipment and share initial information. Trauma teams may vary based on the hospital size, location, and staffing but should, at a minimum, include a physician and nurse. 

EMS should provide information, including the mechanism of injury, vital signs, any apparent injuries, current interventions, and the client’s age and sex, if available. Regarding the client, airway management, hemorrhage and shock control, immobilization, and quick transfer to the nearest capable facility are of priority. After receiving this information, the trauma team members should begin thinking of possible injuries that may be a threat to the client’s life. Before the client arrives, the team should be present, and roles should be assigned. One individual must be designated as a team leader, usually the physician. Other roles may include documentation, airway management, IV access, attaching monitoring devices, and medication administration.  

With the initial information provided by EMS and the team assembled all equipment should be gathered and prepared. It is crucial to have all the equipment readily available for intubation, cardiac monitoring, intravenous access, intraosseous access, and any other intervention that may be indicated by the initial information received. All equipment should be prepared and properly functioning. All trauma team members should wear standard protection clothing and take standard precautions (gowns, gloves, X-ray lead vests, masks). Additional equipment and interventions might be required beyond initially anticipated, so access to additional resources is also essential. 

Primary Survey (1,4, 7) 

EMS should briefly present the client and their findings upon their arrival at the emergency department. An immediate assessment must take place to determine the client’s status. While receiving a report from EMS, the client is placed on a cardiac monitor, pulse oximeter, and blood pressure monitor to obtain a baseline set of vital signs. This initial assessment and data collection will dictate the client’s preliminary management. Advanced Trauma Life Support (ATLS), developed by the American College of Surgeons, promotes the primary survey sequence as airway, breathing, circulation, disability, and exposure (ABCDE) with the most vital areas taking place. This is the beginning of the primary survey.  

Airway 

Airway obstruction is a major, preventable cause of death in trauma victims, and assessing the patency of the airway is the initial step of the primary survey. Check for foreign bodies, tongue swelling, blood, vomit, or saliva occluding the oropharyngeal space. If the client is conscious, ask questions to see if they respond clearly and appropriately. If hoarseness, weakness, gurgling, or stridor is noted, it may indicate airway damage. Visual inspection includes looking for signs of respiratory distress, deformities in the neck (hematoma, foreign bodies, perioral and perinasal burns, soot), or anything that could potentially occlude the trachea. Inspect the face, oral cavity, and neck, and palpate the neck and face for any oral or dental injury, obstructions to intubation, such as unstable midface fractures, and even location for possible cricothyrotomy.  

In addition to airway patency, it is crucial to maintain and assess midline cervical-spine alignment at this time. It should be applied if a cervical collar is not already in place. Cervical stabilization should always be maintained throughout treatment, including transfers, logrolls, etc.  

If it is determined the client’s airway is compromised in any way, immediate intervention is required. This can include but is not limited to: 

• Head tilt, chin lift 
• Jaw thrust 
• Insertion of the artificial airway 
  • Oropharyngeal airways (OPA) 
  • Nasopharyngeal airways (NPA),  
  • Supraglottic airways such as a laryngeal mask airway (LMA) 
  • Intubation with an endotracheal tube (ETT) 
• Surgical airway 
  • Needle cricothyroidotomy 
  • Surgical cricothyroidotomy 

The nurse makes the initial observable assessment of the airway, listens for breath and feels for possible fractures, uses manual methods to open obstructed airways, and intervenes in the case of compromised airways using essential airway interventions as previously discussed. The nurse also helps in the maintenance of the advanced airway, delivers O2 when needed, continually reassesses the patient with the use of the relevant monitors, communicates the condition of the client to the doctor, interacts with the client, and informs the family and friends about the client’s status as necessary.  

Breathing  

Breathing and ventilation should be assessed once the airway is secured or managed. This involves visual inspection of the client’s chest and diaphragm. Trauma can often lead to rib fractures, flail chest, tension pneumothorax, diaphragmatic rupture, bronchial rupture, penetrating injury, or tracheal deviation. This part of the survey also includes auscultation of the lungs and palpitation of the chest. The client’s oxygen saturation should be evaluated via a pulse oximeter, which counts the patient’s respiratory rate and increases or abnormal breathing patterns. Ultrasound or X-ray imaging of the chest should be considered in addition to the initial assessment. Treatment and interventions will depend on the injury and its severity.  

A nurse can examine the client for general signs of respiratory distress, abnormal respiratory rate and rhythm, inadequate depth of breath, and asymmetrical chest movement. During the breathing assessment, the nurse also checks the chest’s color, condition, and bony structures. Other steps in the evaluation include measuring oxygen saturation using a pulse oximeter or taking an arterial blood sample for blood gas analysis.  

Circulation  

The primary survey includes assessing the cardiovascular system, managing hemorrhage, and maintaining adequate perfusion. The main components of the circulatory system are the heart, vasculature, and blood. Hemorrhage is the most common cause of preventable death in trauma victims. After initial vital signs, assess central and peripheral pulses and inspect the skin for color, warmth, or any deformities that can disrupt blood flow. In the presence of external bleeding, direct pressure should be applied to the area to control the bleeding. If an arterial bleed from an extremity, a tourniquet can be applied. Imaging commonly used to evaluate circulation is ultrasound for the FAST exam protocol and X-ray or CT examination. Treatment of hemorrhage depends on the source and severity of the bleed, and therefore, establishing adequate IV access in trauma clients is also of critical importance. Two large-bore peripheral I.V.s, or functioning intraosseous access, should be established early in the evaluation period. Cardiac monitoring and serial vital sign readings should also be established as soon as possible to determine the client’s circulatory trajectory throughout their treatment. 

During the assessment of the client’s circulation, the necessary actions performed by a nurse are taking a blood sample for routine hematological, biochemical, coagulation, microbiological, and cross-matching testing, blood pressure monitoring, skin temperature, heart rate monitoring, core temperature, capillary refill time (CTR), as well as other general signs consistent of abnormal heart output. 

Disability  

This part of the survey includes assessing the client’s neurological status/function. For a quick assessment of the client’s consciousness, the Awake, Voice, Pain, and Unresponsive (AVPU) system can be used by nurses. With the use of this system, it is easily determined whether the client is awake and responds to the environment (A), responds to voice stimuli (V), responds to pain (P), or is unresponsive (U). If there are still concerns after this test, the Glasgow Coma Scale (GCS) should be used (Table 2). The GCS is a more detailed, reliable, and universal test that measures the level of consciousness. Scores from each section help evaluate disruptions in nervous system function and help healthcare providers track changes. Assessment of pupils for size and reactivity, blood glucose levels, and drug and alcohol levels should also be done. During this time, motor ability and sensation in all four extremities should be assessed for any signs of spinal cord injury. Cervical spine immobilization should be continuously maintained. Suppose a client has altered mentation and/or neurological deficits. In that case, they will require a CT examination of the brain as well as a CT of the cervical spine to evaluate for a neck injury. 

Table 2: Glasgow Coma Scale (11) 

GCS scores range from 15 to 3 (11) 

It should be considered if definitive airway control has not been performed for patients with a GCS of 8 or less.  

The Glasgow Outcome Scale (GOS) is an assessment utilized by the trauma team if there has been a suspected brain injury (11). The GOS will help to determine the next step in the client’s care. There are five possible measures in the GOS: 

• Dead  
  • Severe injury or death without recovery of consciousness 
• Vegetative 
  • Severe damage with a prolonged state of unresponsiveness 
  • Lack of higher mental function  
• Severely disabled 
  • Severe injury with permanent need for help with daily living 
• Moderately disabled  
  • No need for assistance in everyday life 
  • Employment is possible but may require assistance 
• Good recovery  
  • Light damage with minor neurological and psychological deficits 

Blood glucose levels should also be measured, along with the client’s pupil reaction using the PERRLA exam: (13) 

• Pupils 
• Equal 
• Round 
• Reactive 
• Light 
• Accommodation 

PERRLA is an essential exam in trauma assessment: 

• Brain injury indicator: 
  • Unequal pupil size and sluggish or absent pupil response to light can be signs of a brain injury, including head trauma, stroke, or brain tumor.  
• Rapid assessment: 
  • A quick and non-invasive test that can be performed rapidly during initial trauma assessment to identify potential neurological compromise 
• Monitoring changes: 
  • Repeated PERRLA assessments can help track changes in a client’s neurological status over time, allowing for early detection of worsening brain injury 

The nurses are the primary healthcare providers who utilize these tools during trauma assessment. During this stage, a nurse can also assess for orthopedic injuries that typically involve pain, swelling, and instability. The nurse palpates the injury site, looking for signs of tenderness, swelling, malformation, or crepitus, and assesses the motor function of all extremities. 

The client’s motor function can also be assessed during this stage of the primary survey. During a trauma injury assessment, assessing the motor function of extremities involves evaluating each limb’s strength and range of motion by asking the client to actively move their muscles against resistance, noting any asymmetry between sides, and using standardized grading systems and evaluation tools (14).   

Key components of a motor function assessment in trauma include: (14) 

• Observation 
  • Visual inspection for deformities, swelling, or apparent injuries to limbs 
  • Observe spontaneous movements of extremities  
  • Note any involuntary movements like tremors or muscle twitching 
• Active Range of Motion (ROM): 
  • Ask the client to move each joint through its full range of motion actively 
  • Note any limitations or pain with movement  
  • Compare the range of motion bilaterally between limbs 
• Muscle Strength Testing (MRC Scale):  
  • Test key muscle groups in each limb, including shoulder flexion/extension, elbow flexion/extension, wrist flexion/extension, hip flexion/extension, knee flexion/extension, and ankle dorsiflexion/plantarflexion 
  • Grade muscle strength according to the MRC scale: 
    • 0: No muscle contraction  
    • 1: Trace twitching without active ROM  
    • 2: Movement possible, but not against gravity  
    • 3: Movement possible against gravity, but not resistance  
    • 4: Movement possible against some resistance  
    • 5: Normal muscle strength, full ROM 

Exposure  

The fifth and final step of the primary survey includes removing all clothing to assess for signs of injury or deformities, lacerations, bruising, foreign objects, gunshot wounds, stab wounds, abrasions, or any other traumatic findings. During this stage, it is essential to remember to keep the client warm as many trauma clients lose body heat quickly and can become hypothermic, which can lead to multiorgan failure. 

All steps in the primary assessment phase should be repeated throughout the client’s care. Any critical areas must be reassessed in subsequent order. Any deterioration or change in the client’s clinical status mandates a repeat primary survey, including a reassessment of previous interventions to ensure they remain effective. 

In this stage, a nurse should thoroughly examine the client from head to toe after removing all clothes, including while maintaining dignity. The nurse also notes the client’s temperature and prevents heat loss if necessary. The nurse carefully documents all information relating to the client and reviews it throughout the treatment plan.  

Case Study  

A 32-year-old male was brought to the emergency room (ER) by ambulance following a high-speed motor vehicle collision (MVC). The client was unrestrained and ejected from the vehicle, which rolled multiple times. Emergency Medical Services (EMS) reports that the client was found unconscious at the scene but regained consciousness en route to the hospital. Vital signs at the scene were: blood pressure 90/60 mmHg, heart rate 120 bpm, respiratory rate 24 breaths/min, SpO2 92% on a non-rebreather mask, and Glasgow Coma Scale (GCS) score of 10 (E3, V3, M4).  

In the emergency room, the client is alert but lethargic, with an apparent facial laceration and swelling. There is no significant stridor or gurgling. The airway is patent but requires continuous monitoring. The client’s respiratory rate is 28 breaths/min, with shallow chest movements. Auscultation reveals decreased breath sounds on the left side. The client has cool, clammy skin and weak radial pulses. Blood pressure is 85/55 mmHg, and heart rate remains tachycardic at 122 bpm. Two large lacerations on the left thigh and scalp are actively bleeding. The GCS is reassessed: E3 (eyes open to voice), V3 (inappropriate words), M4 (withdraws from pain), indicating moderate traumatic brain injury. Pupils are equal but sluggishly reactive to light. The client is fully exposed to assess for other injuries, revealing multiple abrasions and deformities to the left arm. 

Secondary Survey (1, 7) 

Once the client is stabilized and does not need immediate surgical intervention, a secondary assessment (head-to-toe evaluation and focused history) is performed to identify all injuries and underlying conditions. This is when the healthcare team gathers more details about the events that led to the client’s injuries and learns about their medical history to individualize the treatment plan. The four most missed diagnoses during the survey are blunt abdominal trauma with internal organ injury, penetrating abdominal trauma, penetrating thoracic trauma, and extremity trauma such as fractures and compartment syndrome. Therefore, it is crucial to make sure all elements are covered. The elements to cover can be remembered using S.A.M.P.L.E.: 

• Signs and Symptoms 
  • Any new developments that have occurred post-trauma 
  • Information on pain or discomfort 
    • Constant or intermittent radiation, severity, progression, and any alleviating or precipitating factors 
• Allergies 
  • Specifically to medications 
• Medication List 
  • Anticoagulation and platelet inhibitors 
• Past Medical History 
  • Previous surgeries 
• Last Meal (time) 
• Event: 
  • Events that led up to the injury 
  • Any pertinent information that can help the providers understand how severe the trauma was 

Case Study 

A 32-year-old male, Mr. Alex Carter, is brought to the ER following a motorcycle collision. The client was found lying on the roadside, and bystanders reported he was thrown approximately 20 feet from the bike. He was wearing a helmet, which showed visible damage. EMS reports an initial Glasgow Coma Scale (GCS) score of 14 (confusion but no loss of consciousness), with stable vital signs en route to the hospital. 

Upon arrival in the ER, the primary survey was completed, and the following were stabilized: 

• Airway: Patent (the patient can talk but has mild slurring of speech). 
• Breathing: Adequate, with shallow breaths at 22 breaths per minute. 
• Circulation: No external hemorrhage, capillary refill 3 seconds, blood pressure 110/70 mmHg, heart rate 105 bpm. 
• Disability (neurologic status): GCS of 14, pupils reactive but slightly unequal (right: 3mm, left: 2mm). 
• Exposure: No immediate life-threatening injuries were identified; the patient is covered to maintain normothermia. 

The patient is moved to the trauma bay for a secondary assessment.  

• Focused History (AMPLE): 
  • Allergies: No known drug allergies. 
  • Medications: None reported. 
  • Past medical history: Healthy, no significant history. 
  • Last Meal: Four hours before the incident. 
  • Events leading to injury: Motorcycle collision, helmeted, thrown from the bike. 
• Head-to-Toe Examination: 
  • Head and Neck: 
    • Contusion on the right temporal region with mild swelling 
    • Tenderness along the cervical spine (collar in place) 
    • Slight slurring of speech noted. 
    • Helmet damage indicates potential head injury. 
  • Chest: 
    • Bruising over the left anterior chest wall. 
    • Breath sounds are present bilaterally but diminished on the left. 
    • No crepitus or subcutaneous emphysema 
  • Abdomen: 
    • Soft but tender in the left upper quadrant. 
    • No bruising or distension 
  • Pelvis: 
    • Stable, no deformities or open wounds 
  • Extremities: 
    • Abrasions on both knees and elbows 
    • Swelling and tenderness in the right forearm; immobilized with a splint 
    • Pulses present in all extremities 
  • Back: 
    • No abrasions, bruising, or deformities. 
    • Spine board in place 
  • Neurological: 
    • GCS remains 14 
    • Slightly unequal pupils 

Diagnostic findings include: 

• Chest X-ray:  
  • Left-sided pneumothorax 
• FAST exam: 
  • Negative 
• CT of the head: 
  • Mild cerebral contusion in the right temporal region 
• Right forearm X-ray: 
  • Closed distal radius fracture 

Trauma Nursing Tools/Attributes (2) 

Trauma clients can present to the emergency room (ER) with a wide range of various injuries from mild to severe, potentially leading to disability and or death. It is essential for healthcare professionals, especially nurses, to prioritize and provide specialized care for severe trauma clients in emergency settings. Clients suffering from severe trauma may experience polytrauma, where multiple systems within the body can sustain damage simultaneously. This often requires prompt and rapid assessment, prioritized treatment and nursing care, and resuscitation for optimal client outcomes. Failure to provide prompt treatment and nursing care may lead to the client’s death or permanent disability. Research has shown that the timely and efficient delivery of acute care in the ER can positively impact the client’s prognosis and chances of survival. 

In this regard, extensively experienced and well-trained trauma nurses enhance the timeliness of interventions in the ER. Nurses who have the skills and knowledge to enable efficient resuscitation are more likely to enhance appropriate interventions for trauma clients. Therefore, ER nurses with high trauma nursing competency are essential for providing successful treatment and care to trauma clients.  

In addition to possessing the specialized knowledge and skills needed in emergency trauma settings, nurses responsible for the care of trauma clients must maintain a foundational understanding of injury mechanisms, various injury types, evidence-based treatment interventions, and client safety measures, including damage prevention. The significance of professional team collaboration, adherence to evidence-based research, and establishing and applying standards must also be highlighted and stressed regarding the appropriate tools needed to care for trauma injury clients. This enables nurses to play a crucial role in providing trauma clients with professional and integrated care while supporting them and their families. 

Rapid initial assessments considering mechanisms of injury  

Trauma injuries often simultaneously affect multiple parts and systems of the body, so it is crucial to conduct a systematic initial assessment for probable diagnosis and treatment immediately after its occurrence. This is one of the core responsibilities trauma nurses must have to deliver professional care. This includes gathering information about mechanisms of injury: 

• Cause of injury  
  • Car Accident 
  • Fall  
  • Blunt injury 
• Direction of force  
• Location of injury  

Trauma nurses caring for clients who have sustained a traumatic injury should use specialized knowledge focused on the mechanisms of injury and the pathophysiological responses to trauma. This knowledge enables them to define predictable clinical signs and symptoms. Since clients who have sustained traumatic injuries often have limited time for medical professionals to administer treatment, nurses must understand the mechanism of injury during the initial assessment. This understanding will help to prioritize the necessary treatment plan for the client who has sustained a trauma. 

Priority determinations based on degrees of urgency and severity  

The timing of initial interventions in the ER can be a deciding factor for the client’s potential outcomes. Nursing prioritization guides the actions of the trauma nurse in critical and complex situations, facilitating accurate decision-making and the implementation of appropriate interventions. In settings where resources may be limited, and traumas are of high complexity, trauma nurses can swiftly conduct interventions to address the essential problems based on priority according to urgency and severity. The knowledge and skill to prioritize based on urgency and service will allow the nurse to implement interventions for optimal client outcomes. Such actions can prevent early mortality and improve the prognosis of those suffering from trauma injuries. 

Clinical knowledge of trauma nursing 

Trauma nursing requires appropriate knowledge to manage clients with trauma effectively. Understanding specialized topics such as mechanisms of injury and injury patterns and correlating evidence-based interventions that concentrate on pathophysiological responses to the effects of damage is essential. As a result, several nursing education courses promote trauma nursing competency and education to improve trauma nurses’ understanding and clinical knowledge. 

Skills in trauma nursing 

Skills in trauma nursing are based on the latest findings and scientific evidence, and trauma nurses must maintain these up-to-date trauma management skills to provide high levels of acute care to trauma clients. Highly skilled and trained nurses can conduct advanced procedures and interventions during the primary survey, potentially even before the physician arrives. Trauma nurses must have the knowledge and skill set to provide care at all aspects and stages of trauma management. Trauma nurses need to be proficient in trauma care skills such as: 

• Initial trauma assessment 
• Trauma resuscitation 
• Management of the airways and wounds 
• Prevention of trauma-related infections 

Interprofessional teamwork 

As previously discussed, in departments dealing with clients suffering from acute traumas, a trauma team is necessary because time-sensitive and diverse medical resources from various specialties must be rapidly organized simultaneously, and nurses are essential team members. Each team member must possess expertise in their respective field, and trauma nurses who specialize in competency and teamwork are vital elements in managing trauma clients. Effective communication and interaction among team members ensure everyone works together successfully. In this regard, trauma nurses should communicate client information verbally and in a documented format, which includes but is not limited to the following:  

• Condition 
• Mechanisms of injury 
• Previous interventions 
• Current interventions 
• Pertinent medical history   

Emotional care 

Trauma nurses often encounter clients who may be in a state of panic following a traumatic injury; therefore, it is essential to recognize the anxiety of clients and their families caused by sudden trauma and have the ability and knowledge to attend to their psychological needs. Continuous communication and observational responses with clients who have experienced a traumatic injury are valuable indicators of treatment response. Factors such as:  

• Explaining safety measures 
• Preparing them for potential pain 
• Using a calm tone of voice 
• Maintaining physical contact 
• Recognizing clients as individuals  

These factors help contribute to a positive experience and foster a sense of safety for clients with traumatic injuries. In the event of a trauma-induced crisis, one of the most critical steps nurses can take is to provide family members with appropriate and detailed information so that they can comprehend their condition. Therefore, trauma nurses must have the knowledge and skills needed to meet the psychological requirements of clients and their loved ones in treatment and education of the plan of care and treatment interventions.  

Trauma Nursing Core Course (TNCC) (12) 

Excellence in trauma nursing contributes to optimal client outcomes and preventing complications, long-term consequences, and death for clients. The Emergency Nurses Association’s (ENA) Trauma Nursing Core Course (TNCC) has provided registered nurses with the evidence-based knowledge to assess and manage injured clients. The course includes a provider manual, pre-course learning modules, and instructor-led classroom time. TNCC provider verification is awarded to those learners who complete a skills case scenario and score at least 80% on a 50-item online cognitive examination. This course enhances the nurse’s ability to deliver exceptional care in a trauma setting.  

• Specialized Knowledge and Skills: 
  • Equips nurses with specialized knowledge and skills specific to trauma nursing 
  • Covers various topics: 
    • Trauma assessment 
    • Patient stabilization 
    • Diagnostic procedures 
    • Surgical interventions. 
  • Learn about different types of traumas, which allows them to provide comprehensive care to trauma patients: 
    • Head injuries 
    • Orthopedic trauma  
    • Abdominal traumas 
• Systematic Approach to Trauma Assessment: 
  • It focuses on a systematic approach to trauma assessment to ensure that no critical injuries are missed and that appropriate interventions are initiated effectively.  
  • Learn to perform rapid and comprehensive trauma assessments 
    • Focusing on primary and secondary surveys 
  • Acquire numerous skills related to:  
    • Identify life-threatening injuries 
    • Prioritize interventions 
    • Communicate findings effectively  
• Evidence-Based Practice in Trauma Care  
  • It enables nurses to deliver effective and efficient care, improving client outcomes and reducing complications. 
  • Incorporates evidence-based practice guidelines in trauma care 
  • It focuses on the latest research and recommendations in trauma nursing, ensuring that their care is based on the best available evidence. By  
  • Applies evidence-based practice 
• Critical Thinking and Decision-Making: 
  • Enhances critical thinking and decision-making skills in trauma scenarios, which are essential in high-pressure trauma settings where seconds can impact client outcomes. 
  • Case studies and interactive discussions help: 
    • Analyze complex situations 
    • Anticipate potential complications 
    • Make informed decisions quickly 
• Team Collaboration and Communication: 
  • Effective teamwork and communication are vital in trauma nursing to help deliver and coordinate efficient trauma care.  
  • Emphasizes the importance of interdisciplinary collaboration and clear communication among healthcare providers 
  • Learn different strategies for effective teamwork: 
    • Role clarification 
    • Closed-loop communication 
    • Debriefing techniques.  
• Hands-On Skills Practice: 
  • Learning and practicing essential skills through simulation-based scenarios enhances their confidence and competence in providing hands-on care.  
    • Airway management 
    • Wound care 
    • Splinting 
    • Immobilization techniques.  
• Professional Growth and Recognition: 
  • Enhances commitment to advancing knowledge and skills in trauma care. 
  • Valuable credential that showcases expertise and dedication to providing exceptional care to trauma clients 

TNCC equips nurses with specialized knowledge, systematic assessment skills, evidence-based practice, critical thinking abilities, teamwork and communication strategies, hands-on skills, and opportunities for professional growth. TNCC nurses are well-prepared to master the art of trauma nursing and deliver exceptional care to clients in critical trauma situations. 

Advanced Trauma Care for Nurses (ATCN) (15)  

ATCN is concurrently taught with an approved Advanced Trauma Life Support (ATLS) Course. This course and education allow healthcare providers caring for trauma clients to share a common language and approach to trauma care. ATCN was developed for nurses and provides significant benefits in the emergency room by equipping nurses with specialized skills and knowledge to rapidly assess, stabilize, and manage critically injured clients. This leads to improved client outcomes and more efficient trauma resuscitation teams, especially in high-acuity situations like multiple trauma incidents. Key benefits of ATCN in the emergency room include: 

• Rapid assessment and prioritization: 
  • Quickly identify life-threatening injuries using a systematic approach 
    • Allows immediate intervention and treatment prioritization based on the client’s most critical needs.  
• Enhanced clinical decision-making: 
  • Make informed decisions regarding necessary interventions in rapidly evolving situations:  
    • Medication administration 
    • Fluid management 
• Improved teamwork and communication: 
  • Ensures everyone understands roles and responsibilities during resuscitation efforts  
• Advanced trauma resuscitation techniques: 
  • Hands-on practice with advanced trauma life support (ATLS) techniques allows nurses to provide immediate life-saving interventions.  
    • airway management 
    • hemorrhage control 
    • wound care 
• Early recognition of complications: 
  • Identify and address issues early, potentially preventing further complications and improving client outcomes 
• Psychological preparedness: 
  • Proper skills to manage the stress and emotional demands of caring for severely injured clients 
  • Promotes better coping mechanisms in high-pressure situations 

Conclusion

Potential deaths from trauma injuries can be prevented if treated appropriately and timely. It, therefore, becomes evident that the survival of clients and the prevention of disabilities rely on ensuring that the correct client receives the most appropriate treatment in the shortest time possible. To save the client’s life, a multidisciplinary team of health professionals must collaborate closely. These professionals must work together to assess and manage the trauma client. The main goal is to quickly resuscitate and stabilize the trauma client, determine the nature, extent, and severity of the injuries, prioritize management, and transport or prepare the client for definitive care.  

That said, the nurse’s role is of the utmost importance in all the stages of the treatment to keep the client alive and stable and help initiate the necessary steps for treatment. The survival of the trauma client is not dependent on various chance factors but on the fast and synchronized collaboration of different healthcare providers. Treating trauma clients calls for adequately trained nurses who are essential to an organized team, adept at quick decision-making, knowledgeable in clinical tools, and able to follow protocols. Therefore, they must continuously research, follow new developments, maintain their skills, increase their knowledge base, and be further educated to keep up with the ever-rising needs in their field. 

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate