Assesstemic appraoch to the assessment of an emergency patient is essential
primary an secondary surveys provide the emergency nurse with a methodological approach to help identify and prioritize patients needs> primary assessment
The initial rapid ABCD (airway , breathing , circulation and disability resulting from spinal injuty ) Airway
does the patient have an open airway ? is the patient able to speak ? Check for air way obstructons such as loose teeth , foreign objects , bleeding , vomitus or other secretions .
Immediately treat anything that comprimise the airway Breathing
is the patient breathing ?? Assess for equal rise and fall of the chest , respiratory rate and pattern , skin color , use of accessory muscles , integrity of the chest wall , and position of the tachea .
All major trauma patients require supplemental oxygen via non breathing mask . Circulation
Is circulation in immediat jeopardy ??can you palpate a central pulse ?? what is the quality (strong , weak , slow , rapid ) is the skin warm and dry ? is the skin colore normal ?? obtain blood pressure .. Disability
Assess level of consciousness and pupils using AVPU scale
A ___is the patient alert ?
V___does the patient respond to voice?
P___does the patient respond to painfull stimuli ?
U __the patient un responsive to painfull stimuli ?? secondary assessment
the steps include
Expose / enviromental control
it is necessary to remove the patient's clothing in order to identify all injuries >> you must prevent heat loss by using warm blankets .
Full set of vital signs / five inteventions/ facilitate family presence
a__ obtain full set of vital signs includin BP , HR , RR, temprture ..
pulse oximetery for oxygen saturation
indwelling urinary catheter>>don't insert if noted blood at the meatus , blood at the scrotum or if you suspected pelvic fracture
gastric tube (if there is evidence of facial fracture insert the tube orally
lab studies facilitate family presenc
assess the familly needs and if any member of the family wishs to persent during CPR it is amperative to assign a staff member to that person to explain what is being done and offer support Give comfort measures
include verbal reassurance as well as pain managment as appropriate History
Obtain prehospital information from emergency personal , patient , family using MIVT
M_mechanism of injury
I _ Injury sustained or suspected
T__treatment befor arriving Head to toe assessment
we know already how to do it focused assessment
Any injuries that were identified during the primary and secondary survys require a detail assessment which include a team approach and radiographic studies ....