Your patient is arriving in 5 minutes....do you know where to start?

INITIAL ASSESSMENT

• Initial Assessment Divided into two assessment phases:

• Primary• Secondary

• Adherence to standard and transmission-based precautions

Primary Assessment

• A Airway (with simultaneous cervical spine stabilization and/or immobilization)

• B Breathing• C Circulation• D Disability

(neurologic status)

The key: Find immediate life-threatening problems really quickly

Secondary Assessment

• E Expose/Environmental control • F Full set of vital signs / Family presence• G Give comfort measures• H History and Head-to-toe assessment• I Inspect posterior surfaces

Now you have time to look again (secondary)At the rest of the issues

Airway Precautions

• Maintain cervical spine stabilization and/or immobilization

Any patient whose findings suggest spinal injury should be stabilized or remain immobilized

Never remove a cervical immobilisation collar until the c-spine has been clearedBy the MD

Airway Assessment• Vocalization• Tongue obstruction• Loose teeth or foreign objects• Bleeding• Vomitus or secretions• Edema

• Airway Obstructed?

Also think about potentialobstructions...Conditions could change quickly

Obstructed Airway• Position the patient

• Stabilize the cervical spine • Open and clear the airway• Insert airway• Consider endotracheal

intubation• Stop and intervene

before proceeding

You don’t go on to “B” until you have taken care of “A”

Breathing

• History (medical and trauma)• Blunt or penetrating trauma• Steering wheel• Other forces

What might cause thisPatient some breathingProblems?

Breathing Assessment

• Spontaneous breathing• Chest rise and fall• Skin color• Pediatric: see handout with pictures of

infant chest for comparison

What do you look for when assessing breathing?

Breathing Assessment (cont)

• Respiratory rate• Chest wall integrity• Accessory and/or abdominal muscle use• Bilateral breath sounds• Jugular veins/trachea

What might compromise this patient’s breathing?

Breathing: Effective

• Administer oxygen via a nonrebreathermask at a flow rate sufficient to keep the reservoir bag inflated (12 to 15 L/min or more)

All trauma patients need extra oxygen, even ifThey do not have respiratory system Compromise.....Why?

Breathing: Ineffective

• Altered mental status• Cyanosis• Asymmetrical chest wall expansion• Accessory and/or abdominal

muscle use• Sucking chest wounds• Paradoxical movement of chest wall• Tracheal shift from midline

What are some other ways that I can tell breathing is compromised?

Breathing: Ineffective• Inspect for distended external jugular

veins• Auscultate breath sounds to determine

if absent or diminished• Administer oxygen via

nonrebreather mask or with a bag-valve-mask or assist with intubation

What are the nurse’s responsibilitiesWhen the MD is intubating the patient?

Breathing Absent• Ventilate patient with bag-valve-mask with

attached oxygen reservoir• Assist with endotracheal intubation• Stop and intervene if there are any life-

threatening injuries

• Pediatric: see handout “pathways leading to cardiopulmonary arrest”

Circulation• Palpate • Pulse for quality and rate• Central pulse (carotid or femoral)• Skin for temperature and

moisture• Inspect• Skin for color• Any obvious signs of bleeding

What do I look for to assess circulation?

Circulation

• Auscultate blood pressure if other team members are available

• If not, proceed with primary assessment and auscultate blood pressure at beginning of secondary assessment

Why is it OK to do the blood pressure a little later in the assessment?Why is one blood pressure readingNot very helpful?

Circulation: Effective

• If the circulation is effective, proceed with assessment

Circulation: Ineffective

• Tachycardia• Altered level of consciousness• Uncontrolled external bleeding• Distended or abnormally flat external

jugular veins• Pale, cool, diaphoretic skin• Distant heart sounds

What do these signs and symptoms tell you is happening to the patient?

HypovolemicShock

This is the most common type of Shock....Don’t lookFor another type of Shock until you have ruled out low volume

Circulation: Effective or Ineffective

• Control any uncontrolled external bleeding• Cannulate 2 veins with large bore (14- or

16-gauge) catheters and initiate infusions of Normal Saline

• Obtain blood sample for typing• Administer blood as prescribed

Normal Saline will replace fluids, but what can’t it provide that red blood cells can?

Circulation: Absent• Begin cardiopulmonary resuscitation

(CPR)• Initiate advanced life support (ALS)• Administer blood as prescribed• Prepare for and assist with emergency

thoracotomy• Prepare for definitive

operative care

What is definitive care?

Disability

• Determine level of consciousness using the AVPU mnemonic – A Alert– V Verbal stimuli– P Painful stimuli– U Unresponsive

This is a simplified way of measuring brain activity.Does it provide complete information?

Brief NeurologicAssessment

• Extremity movement• Pupil reaction• Level of consciousness/orientation

This assessment will give you some more information about brain activity

Disability • If decreased level of consciousness is

present, conduct further investigation in secondary assessment

• Monitor ABCs for the patient who is not alert or verbal

• If the patient demonstrates signs of herniation or neurologic deterioration, consider hyperventilation

What is the nurse’s responsibility when the patient has decreased brain activity?

Secondary Assessment

• Identify ALL injuries• E Expose patient

Environmental control• F Full set of vital signs

Family presence• G Give comfort measures

What about hypothermia?

Why is the nurse the best person for this task?

Secondary Assessment

• HistoryPrehospital informationM Mechanism of injuryI InjuriesV Vital signsT TreatmentPatient-generated informationPast medical history (PMH) What impact could a

trauma patient’s medical history haveon today’s injuries?

Secondary Assessment• Head-To-Toe

Assessment– Head and face– Neck– Chest– Abdomen and flanks – Pelvis and perineum– Extremities– Posterior surfaces– General appearance

• Pediatric: see handout, “Injury patterns in a child” for comparison

Secondary Assessment

• Focused Survey• Pain Management• Tetanus Prophylaxis

Why is initial pain controlIn a trauma patient always given I.V.?

Focused means you can now pay close attention to extremity injuries, etc.

Glasgow Coma Scale

• Areas of Response– Eye opening– Best verbal response– Best motor response

• Pediatric: see handout “pediatric GCS”

Why is the GCS more helpful than AVPU?

Why is the measurement of children’s brain activity different from adult?

Revised Trauma Score

• Area of Measurement– Systolic blood pressure (mm Hg)– Respiratory rate (spontaneous

inspirations/ minute)– Glasgow coma scale score

• Pediatric: see handout “pediatric trauma service triage criteria”

Why is pediatric triage criteria different from adult?

Nursing Diagnoses(not medical diagnoses)

• Ineffective airway clearance• Aspiration risk• Impaired gas exchange• Fluid volume deficit• Decreased cardiac output

What is the nurse’s responsibility in each of these situations?

Nursing Diagnoses(not medical diagnoses)

• Altered tissue perfusion• Hypothermia• Pain• Anxiety and fear• Powerlessness

What is the nurse’s responsibility in each of these situations?

Evaluation and Ongoing Assessment

• Airway patency• Breathing effectiveness• Arterial pH, PaO2, PaCO2

• Oxygen saturation (SpO2 or SaO2)• Level of consciousness• Skin color, temperature, moisture• Pulse rate and quality • Blood pressure• Urinary output

The initial emergency is over, but the patient still has needs. WhatIs the nurse’s responsibilityNow?

Summary• A Airway (with simultaneous cervical spine

stabilization and/or immobilization)• B Breathing• C Circulation• D Disability (neurologic status)• E Expose/Environmental control• F Full set of vital signs/ Family presence• G Give comfort measures• H History and Head-to-Toe Assessment• I Inspect posterior surfaces