Author(s): Antoinette A. Bradshaw, PhD, MS, BSN, RN, 2011
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UNIVERSITY OF MICHIGAN
EMERGENCY MEDICINE AND
PROJECT HOPE
KATH
EMERGENCY NURSING
TRAINING PROGRAM
MODULE ~ 2
Antoinette A. Bradshaw, PhD,
MS, BSN, RN
ASSESSMENT
AND
RESUSCITATION
~
Emergency Care
Episodic and crisis-oriented care
provided to patients with serious
or potential life-threatening
injuries ...
PRIORITIES & MAJOR GOALS OF
EMERGENCY MANAGEMENT

~
To preserve life
To prevent deterioration before more
definitive treat...
Emergency Assessment
Systematic Approach
~
The primary and secondary
surveys provide the emergency
nurse and physician wit...
Injuries to face, neck and
chest that impairs respiration
are the highest priorities!
Primary Assessment
Airway
Breathing
Circulation
Disability (Neurological Status)
Airway
The protection and maintenance
of a clear passageway for gases
(principally oxygen and carbon
dioxide) to pass betw...
Breathing
Inflation and deflation of the
lungs (respiration) via the
airway.
Circulation
Providing an adequate blood
supply to tissue, especially
critical organs, so as to deliver
oxygen to all cells...
AVPU Scale
A system by which a first aider,
ambulance crew or health care
professional can measure and
record a patient's
...
Neurological Status
Alert
Voice
Pain
Unresponsive
BLS
Basic life support consists of a
number of life-saving techniques
focused on the "ABC"s
of emergency care:
Assess the patient s level of
consciousness (LOC) by asking
loudly "Are you okay?"
Instructing someone to call for
help. If outside of the hospital
call for EMS and if an AED is
available, it should be ret...
If the patient has no
suspected cervical spine
trauma, open the airway using
the head-tilt/chin lift
maneuver.
Airway/Cervical Spine Protection

Source Unknown
Spinal Cord Stabilization

Source Unknown
Soft Cervical Collar

Source Unknown
Rigid Collars

Source Unknown

Source Unknown
If the patient has suspected
neck trauma, the airway should
be opened with the jaw thrust
technique. If the jaw-thrust is
...
Jaw Thrust Technique
The practitioner uses their thumbs
to physically push the posterior
(back) aspects of the mandible
up...
Look, listen, and feel for
breathing for at least 5 seconds
and no more than 10 seconds.
If the patient is breathing
normally, then the patient
should be placed in the recovery
position, monitored and
transporte...
If the patient is not breathing,
unresponsive or only gasping,
once the airway is secured, give
2 rescue/artificial breath...
If chest does not rise and fall,
reposition the airway using the
appropriate technique and try
again.
If ventilation is still
unsuccessful and the patient
is unconscious………
It is possible that they have a
foreign body in their airway.
Removal of Debris

Source Unknown
Mouth to Mouth Technique

Source Unknown
A disposable BVM Resuscitator

Source Unknown
Adjuncts to airway
management
There are a variety of artificial
airways which can be used to
keep a pathway between the
lu...
The most commonly used in long term
or critical care situations is the
endotracheal tube, a plastic tube which
is inserted...
In some cases, a laryngeal mask
airway (LMA) is a suitable alternative to
an endotracheal tube, and has the
advantage of r...
In the case of a choking patient,
laryngoscopy or even
bronchoscopy may be
performed in order to visualize
and remove the ...
An oropharyngeal airway or
nasopharyngeal airway can be used to
prevent the tongue from blocking the
airway. When these ai...
Circulation
If the ventilations are successful,
assess for the presence of a pulse at
the carotid artery.
If a pulse is detected, then the
patient should continue to
receive artificial ventilation's
at an appropriate rate.
Average Respiratory Rates By Age:
Newborns: 30-40 breaths per minute
Less Than 1 Year: 30-40 breaths per
minute
1-3 Years:...
Otherwise, begin CPR at a
ratio of 30:2 compressions to
ventilation's at 100
compressions/minute for 5
cycles.
Compressions

Source Unknown
After 5 cycles of CPR, the BLS protocol
should be repeated from the beginning,
assessing the patient's airway, checking
fo...
If an AED/defibrillator is available after
5 cycles of CPR, it should be attached,
activated, and (if indicated) defibrill...
BLS protocols continue until (1) the
patient regains a pulse, (2) the
rescuer is relieved by another
rescuer of equivalent...
At the end of five cycles of CPR,
always reassess for a shockable
rhythm, and if indicated, prepare
for defibrillation. Re...
The CPR cycle is often abbreviated
as 30:2 (30 compressions, 2
ventilation's or breaths).
Infant CPR

The U.S. Army, flickr
Note CPR for infants and children
uses a 15:2 cycle when two
rescuers are performing CPR (but
still uses a 30:2 if there i...
The GCS or Glasgow Coma Scale
is the most widely used scoring
system used in quantifying level of
consciousness following ...
The neurological scale aims to
give a reliable, objective way of
recording the conscious state of
a person for initial as ...
The scale comprises three tests:
eye, verbal and motor
responses. The three values
separately as well as their sum
are con...
GCS is the scale used by nurses,
first aid, EMS and doctors as being
applicable to all acute medical and
trauma patients i...
Eye Opening
1. Does not open eyes
2. Opens eyes in response to
painful stimuli
3. Opens eyes in response to voice
4. Opens...
Verbal
1. Makes no sounds
2. Incomprehensible sounds
3. Utters inappropriate words
4.Confused, disoriented
5.Oriented, con...
Motor
1. Makes no movements
2.Extension to painful stimuli
(decerebrate response)
3. Abnormal flexion to painful stimuli
(...
~GCS Interpretation~
Individual elements as well as the
sum of the score are important.
14-15 Normal/mild dysfunction
11-1...
If nothing proves to be
imminently life threatening then
you can proceed to a more
detailed, focused secondary
assessment.
Secondary Assessment
Should be brief, thorough,
systematic assessment
designed to identify all injuries.
The Steps Include:
Exposure/Environmental Controls
Full Set of Vital Signs
Give Comfort Measures
History and Head to Toe A...
Exposure/Environmental
Considerations
Remove clothes and keep
patient warm
Full Set of Vital Signs
Blood Pressure
Pulse/Heart Rate
Respiratory Rate
Temperature
Pain
Assessing Pain
Onset
Provocation
Quality
Radiation
Severity
Time/Duration

stovak, flickr
COLDERRA Pain Questions
Characteristics
Onset
Location
Duration
Exacerbation
Radiation
Relief
Associated Signs and Symptom...
Five Interventions
Oxygen Administration
Diagnostics
(X-rays/Labs/EKG)
Appropriate Monitoring
Control Bleeding
Pain Manage...
Give comfort measures and
facilitate family presence
Empathize, encouragement
and support patient & family
~
Keep patient ...
History

Community Eye Health Journal photos, flickr
History
Symptoms
Allergies
Medications
Past Medical History
Last Oral Intake
Events Leading up to the Illness or Injury
Anatomical Planes
Anterior ~ Front
Posterior ~ Back
Midline ~ line drawn through nose
and umbilicus
Midclavicular ~ Middle...
Directional Terms for Assessment
Right
Left
Lateral
Medial
Superior
Inferior
Proximal
Distal
Dorsal
Ventral
Palmar
Plantar
Abdominal Quadrants
RUQ
LUQ
LLQ
LUQ
Focused Assessment Practices
Background
Skin
Head/Face
Neck
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Urinary...
Background
Biographical Data
Chief Complaint
Medications
PMH
Family History
Social History
Skin
Itching/Dryness
Color/Temperature
Ask about changes in bathing,
soaps or lotions
Observe for rashes
Lacerations
Cuts/...
Head/Face
Often c/o Headaches, Vertigo,
Syncope. Ask about change in
vision, hearing, tinnitus, nasal
snoring & last denta...
Facial Inspection
Head shape, characteristics of facial
features. Palpate the head for evidence of
skull fracture, look fo...
Facial Inspection continued
Look around the eyes for bruising (bruising
that completely circles around the eye on
one or b...
Eye Inspection
Assess to see if the eyes appear to
protrude abnormally from the skull
(indicates a hematoma behind the eye...
Eye Assessment
 

 

Assess the eyes for movement in upward,
rightward, downward and leftward
directions (if the eyeball...
Eye Inspection
  Assess

for black material coming
out of the eye (this indicates a
globe rupture and should be
treated w...
Ear Assessment
 

 

 

Look in the ears assessing for blood in the
canal, clear fluid draining from the ear (sign
of a...
Mouth and Buccal Mucosa
  Have

the patient open the mouth
to look inside. Note any loose
teeth or missing teeth. (an
avu...
Mouth and Buccal Mucosa
  Note

any intra-oral lacerations,
any wounds to the tongue and
any hematoma under the tongue
(a...
Nose Inspection
  Assess

the nose for patency of airway,
bleeding or leakage of clear fluid (a
sign of skull fracture).
...
Examine eye movement, pupil
response, drainage, color.

Pupils
Equal
Round
React
Light Reactivity
Accommodation
Neck
  Reassess

the neck by noting the
position of the trachea (shifting of the
trachea to one side indicates a
problem ...
  If

Neck continued

they are not intoxicated and don t
have a major other injury then you
can ask them to turn their ne...
Neurologic
Changes in Mental Status,
cognition, sleeping patterns,
seizures, paresthesias
Exam: Mental status, orientation...
Cardiovascular
Palpitations, chest pain & cold
extremities
Exam: Heart sounds, pulses,
edema, nailbeds for cyanosis or
clu...
Respiratory
Cough, Shortness of breath,
hemoptysis
Exam: Anterior/posterior chest for
respiratory effort, symmetry of
effo...
Gastrointestinal
  Assess

the GI area for obvious
bruising or open wounds.
  Gently palpate the abdomen in all 4
quadra...
Genitourinary
Ask about nocturia, dysuria,
urgency or hesitancy
Observe patient s hygiene, skin
condition, lesions, draina...
Reproductive
Impotence (men)
Menstrual history (women)
Examine for lesions, discharge
and odors
Examine the pelvis by pressing
directly down on the pelvis,
press in from the sides and
finally press down over the
pubis....
Musculoskeletal
  Musculoskeletal

exam starts with
examining the extremities to note any
obvious deformities.
  Then co...
Look for open wounds or bruising.
Feel for possible from the opposite
side of the bruise. Finally, if the limb
appears uni...
Inspection of posterior
surfaces and/or Logroll

ejwalsh102, "y020121", flickr,CC: BY-NC-ND 2.0, .
Nursing Analysis
&
Differential Nursing Diagnoses
(Possible explanation for the
problem)
Collaborative Problems
requiring
Team Interventions
Discussion
Planning
Implementation/Interventions
Be Proactive and Assertive
within Nursing Scope!
Intubated patient suddenly deteriorates

Displaced Tube
Obstruction of Tube
Pneumothorax
Equipment Failure
What medications should you
anticipate and prepare if the
doctors are discussing
intubation?
What would you begin to
prepare for if you received a
patient with a pneumothorax or
hemothorax?
Chest Tube
Supplies Needed?
Emergency Intubation
Equipment Preparations
Appropriate size ET Tube
Suction
Laryngoscope
Lubricant
Stethoscope
Stylet
Tap...
Customer Service
5 things that we can do to be more
customer focused
1. Address patient by name
2. Introduce yourself to p...
Evaluation
and
Ongoing Monitoring

jasleen_kaur, flickr
Glenlarson, wikimedia commons

Jeremy Brooks, flickr
Documentation
of
Nursing Assessment and Care
Document, Document,
Document!!
Why is Documentation Important?
Effective Communication
Saves Time
Fewer Errors
Legal Considerations
Professionalism
Medication Administration
Name of Medication
Dosage of Medication
Date & Time of Administration
Route of Administration
Re...
Additional Documentation
Examples for Discussion
Chest Tube Output
Elevated Temperature
Color of Urine Changed from
Yellow...
~Review~
Stabilize suspected Cervical Spine Injuries
ABC
Control hemorrhage & its consequences
Prevent and treat shock, maintain or...
Subjective Data Collection
Objective Data Collection
Age Related Considerations
*Pediatrics
treehouse1977, flickr

*Geriatrics
dyniss, flickr
Q&A
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GEMC - Nursing Assessment and Resuscitation

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This is a lecture by Antoinette Bradshaw from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC - Nursing Assessment and Resuscitation

  1. 1. Author(s): Antoinette A. Bradshaw, PhD, MS, BSN, RN, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
  2. 2. Citation Key for more information see: http://open.umich.edu/wiki/CitationPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. UNIVERSITY OF MICHIGAN EMERGENCY MEDICINE AND PROJECT HOPE KATH EMERGENCY NURSING TRAINING PROGRAM MODULE ~ 2
  4. 4. Antoinette A. Bradshaw, PhD, MS, BSN, RN
  5. 5. ASSESSMENT AND RESUSCITATION ~
  6. 6. Emergency Care Episodic and crisis-oriented care provided to patients with serious or potential life-threatening injuries or illnesses.
  7. 7. PRIORITIES & MAJOR GOALS OF EMERGENCY MANAGEMENT ~ To preserve life To prevent deterioration before more definitive treatment can be given To restore the patient to useful living
  8. 8. Emergency Assessment Systematic Approach ~ The primary and secondary surveys provide the emergency nurse and physician with a methodical approach to help identify and prioritize patient needs. ~
  9. 9. Injuries to face, neck and chest that impairs respiration are the highest priorities!
  10. 10. Primary Assessment Airway Breathing Circulation Disability (Neurological Status)
  11. 11. Airway The protection and maintenance of a clear passageway for gases (principally oxygen and carbon dioxide) to pass between the lungs and the atmosphere.
  12. 12. Breathing Inflation and deflation of the lungs (respiration) via the airway.
  13. 13. Circulation Providing an adequate blood supply to tissue, especially critical organs, so as to deliver oxygen to all cells and remove metabolic waste, via the perfusion of blood throughout the body.
  14. 14. AVPU Scale A system by which a first aider, ambulance crew or health care professional can measure and record a patient's responsiveness, indicating their level of consciousness. (LOC)
  15. 15. Neurological Status Alert Voice Pain Unresponsive
  16. 16. BLS Basic life support consists of a number of life-saving techniques focused on the "ABC"s of emergency care:
  17. 17. Assess the patient s level of consciousness (LOC) by asking loudly "Are you okay?"
  18. 18. Instructing someone to call for help. If outside of the hospital call for EMS and if an AED is available, it should be retrieved and prepared for use.
  19. 19. If the patient has no suspected cervical spine trauma, open the airway using the head-tilt/chin lift maneuver.
  20. 20. Airway/Cervical Spine Protection Source Unknown
  21. 21. Spinal Cord Stabilization Source Unknown
  22. 22. Soft Cervical Collar Source Unknown
  23. 23. Rigid Collars Source Unknown Source Unknown
  24. 24. If the patient has suspected neck trauma, the airway should be opened with the jaw thrust technique. If the jaw-thrust is ineffective at opening/ maintaining the airway, a very careful head-tilt/chin-lift should be performed.
  25. 25. Jaw Thrust Technique The practitioner uses their thumbs to physically push the posterior (back) aspects of the mandible upwards. When the mandible is displaced forward, it pulls the tongue forward and prevents it from occluding (blocking) the entrance to the trachea, helping to ensure a patent (secure) airway
  26. 26. Look, listen, and feel for breathing for at least 5 seconds and no more than 10 seconds.
  27. 27. If the patient is breathing normally, then the patient should be placed in the recovery position, monitored and transported. Do not continue the BLS sequence.
  28. 28. If the patient is not breathing, unresponsive or only gasping, once the airway is secured, give 2 rescue/artificial breaths. Verify that the chest rises and falls.
  29. 29. If chest does not rise and fall, reposition the airway using the appropriate technique and try again.
  30. 30. If ventilation is still unsuccessful and the patient is unconscious………
  31. 31. It is possible that they have a foreign body in their airway.
  32. 32. Removal of Debris Source Unknown
  33. 33. Mouth to Mouth Technique Source Unknown
  34. 34. A disposable BVM Resuscitator Source Unknown
  35. 35. Adjuncts to airway management There are a variety of artificial airways which can be used to keep a pathway between the lungs and mouth/nose.
  36. 36. The most commonly used in long term or critical care situations is the endotracheal tube, a plastic tube which is inserted through the mouth and into the trachea, often with a cuff which is inflated to seal off the trachea and prevent any vomit being aspirated into the lungs.
  37. 37. In some cases, a laryngeal mask airway (LMA) is a suitable alternative to an endotracheal tube, and has the advantage of requiring a lower level of training that an ET tube. It is a supraglottic airway developed by a British Anesthesiologist.
  38. 38. In the case of a choking patient, laryngoscopy or even bronchoscopy may be performed in order to visualize and remove the blockage.
  39. 39. An oropharyngeal airway or nasopharyngeal airway can be used to prevent the tongue from blocking the airway. When these airways are inserted properly, the rescuer does not need to manually open the airway with a head tilt/chin lift or jaw-thrust maneuver. Aspiration of blood, vomitus, and other fluids can still occur with these two adjuncts.
  40. 40. Circulation If the ventilations are successful, assess for the presence of a pulse at the carotid artery.
  41. 41. If a pulse is detected, then the patient should continue to receive artificial ventilation's at an appropriate rate.
  42. 42. Average Respiratory Rates By Age: Newborns: 30-40 breaths per minute Less Than 1 Year: 30-40 breaths per minute 1-3 Years: 23-35 breaths per minute 3-6 Years: 20-30 breaths per minute 6-12 Years: 18-26 breaths per minute 12-17 Years: 12-20 breaths per minute Adults Over 18: 12–20 breaths per minute
  43. 43. Otherwise, begin CPR at a ratio of 30:2 compressions to ventilation's at 100 compressions/minute for 5 cycles.
  44. 44. Compressions Source Unknown
  45. 45. After 5 cycles of CPR, the BLS protocol should be repeated from the beginning, assessing the patient's airway, checking for spontaneous breathing, and checking for a spontaneous pulse. Laypersons are commonly instructed not to perform reassessment, but this step is always performed by healthcare professionals.
  46. 46. If an AED/defibrillator is available after 5 cycles of CPR, it should be attached, activated, and (if indicated) defibrillation should be performed. If defibrillation is performed, 5 more cycles of CPR should be immediately repeated before re-assessment.
  47. 47. BLS protocols continue until (1) the patient regains a pulse, (2) the rescuer is relieved by another rescuer of equivalent or higher training, (3) the rescuer is too physically tired to continue CPR, or (4) the patient is pronounced dead by a medical doctor.
  48. 48. At the end of five cycles of CPR, always reassess for a shockable rhythm, and if indicated, prepare for defibrillation. Repeat assessment before doing another five cycles.
  49. 49. The CPR cycle is often abbreviated as 30:2 (30 compressions, 2 ventilation's or breaths).
  50. 50. Infant CPR The U.S. Army, flickr
  51. 51. Note CPR for infants and children uses a 15:2 cycle when two rescuers are performing CPR (but still uses a 30:2 if there is only one rescuer). Two person CPR for an infant also requires the "two hands encircling thumbs" technique for the rescuer performing compressions.
  52. 52. The GCS or Glasgow Coma Scale is the most widely used scoring system used in quantifying level of consciousness following traumatic brain injury. It is used primarily because it is simple, has a relatively high degree of reliability and because it correlates well with outcome following severe brain injury.
  53. 53. The neurological scale aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment
  54. 54. The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).
  55. 55. GCS is the scale used by nurses, first aid, EMS and doctors as being applicable to all acute medical and trauma patients in hospitals as well as in monitoring chronic patients in intensive care.
  56. 56. Eye Opening 1. Does not open eyes 2. Opens eyes in response to painful stimuli 3. Opens eyes in response to voice 4. Opens eyes spontaneously 5. N/A 6. N/A
  57. 57. Verbal 1. Makes no sounds 2. Incomprehensible sounds 3. Utters inappropriate words 4.Confused, disoriented 5.Oriented, converses normally 6. N/A
  58. 58. Motor 1. Makes no movements 2.Extension to painful stimuli (decerebrate response) 3. Abnormal flexion to painful stimuli (decorticate response) 4. Flexion / Withdrawal to painful stimuli 5. Localizes painful stimuli 6. Obeys commands
  59. 59. ~GCS Interpretation~ Individual elements as well as the sum of the score are important. 14-15 Normal/mild dysfunction 11-13 Moderate to severe dysfunction 10 or less: Severe dysfunction
  60. 60. If nothing proves to be imminently life threatening then you can proceed to a more detailed, focused secondary assessment.
  61. 61. Secondary Assessment Should be brief, thorough, systematic assessment designed to identify all injuries.
  62. 62. The Steps Include: Exposure/Environmental Controls Full Set of Vital Signs Give Comfort Measures History and Head to Toe Assessment Inspect Posterior Surfaces
  63. 63. Exposure/Environmental Considerations Remove clothes and keep patient warm
  64. 64. Full Set of Vital Signs Blood Pressure Pulse/Heart Rate Respiratory Rate Temperature Pain
  65. 65. Assessing Pain Onset Provocation Quality Radiation Severity Time/Duration stovak, flickr
  66. 66. COLDERRA Pain Questions Characteristics Onset Location Duration Exacerbation Radiation Relief Associated Signs and Symptoms
  67. 67. Five Interventions Oxygen Administration Diagnostics (X-rays/Labs/EKG) Appropriate Monitoring Control Bleeding Pain Management Hmwith, wikimedia commons Source Unknown Glenlarson, wikimedia commons
  68. 68. Give comfort measures and facilitate family presence Empathize, encouragement and support patient & family ~ Keep patient and family informed about treatment and communicate care plan
  69. 69. History Community Eye Health Journal photos, flickr
  70. 70. History Symptoms Allergies Medications Past Medical History Last Oral Intake Events Leading up to the Illness or Injury
  71. 71. Anatomical Planes Anterior ~ Front Posterior ~ Back Midline ~ line drawn through nose and umbilicus Midclavicular ~ Middle of the clavicle, parallel to the midline Midaxillary ~ In the middle of the axilla, parallel to the midline
  72. 72. Directional Terms for Assessment Right Left Lateral Medial Superior Inferior Proximal Distal Dorsal Ventral Palmar Plantar
  73. 73. Abdominal Quadrants RUQ LUQ LLQ LUQ
  74. 74. Focused Assessment Practices Background Skin Head/Face Neck Neurologic Cardiovascular Respiratory Gastrointestinal Urinary Reproductive Musculoskeletal
  75. 75. Background Biographical Data Chief Complaint Medications PMH Family History Social History
  76. 76. Skin Itching/Dryness Color/Temperature Ask about changes in bathing, soaps or lotions Observe for rashes Lacerations Cuts/Sores/lesions Prior healed incisions
  77. 77. Head/Face Often c/o Headaches, Vertigo, Syncope. Ask about change in vision, hearing, tinnitus, nasal snoring & last dental exam.
  78. 78. Facial Inspection Head shape, characteristics of facial features. Palpate the head for evidence of skull fracture, look for open wounds or hematomas. Look behind the ears for bruising (this is called Battle s sign and indicates a fracture through the base of the skull.
  79. 79. Facial Inspection continued Look around the eyes for bruising (bruising that completely circles around the eye on one or both sides is called raccoon eyes and is a sign of skull fracture, bruising that is only under the eyes is associated with a nasal fracture or a facial bone fracture under the eye. Note any cut or wound on the face.
  80. 80. Eye Inspection Assess to see if the eyes appear to protrude abnormally from the skull (indicates a hematoma behind the eye).   Assess the whites (conjunctiva) of the eyes for redness in thin lines (irritated blood vessels of the eye) could indicate a foreign body in the eye) or bleeding under the conjunctiva (subconjunctival hemorrhage)   Also assess the pupil to see if it reacts (non-reactive pupils indicate a potential head injury).  
  81. 81. Eye Assessment     Assess the eyes for movement in upward, rightward, downward and leftward directions (if the eyeball cannot move in every direction then you must suspect either a facial fracture that has trapped one of the eye muscles preventing it from working or bleeding behind the eyeball). Check vision by holding fingers a few feet away from the patient and ask them to count fingers.
  82. 82. Eye Inspection   Assess for black material coming out of the eye (this indicates a globe rupture and should be treated with antibiotics like an open fracture.   Look at the colored part of the eye called the iris for a hyphema (blood layering in the front part of the eye).
  83. 83. Ear Assessment       Look in the ears assessing for blood in the canal, clear fluid draining from the ear (sign of a skull fracture and spinal fluid leak) or blood behind the tympanic membrane (hemotympanum) (a sign of skull fracture). Look for ecchymosis behind the ear (battle s sign ~ also a sign of fracture of the base of the skull). Check to see if eardrum is intact or if you see cerumen or drainage from ears.
  84. 84. Mouth and Buccal Mucosa   Have the patient open the mouth to look inside. Note any loose teeth or missing teeth. (an avulsed tooth ~ a tooth that was knocked our during the current trauma.   If teeth are missing or broken you should describe which tooth is broken.
  85. 85. Mouth and Buccal Mucosa   Note any intra-oral lacerations, any wounds to the tongue and any hematoma under the tongue (a sign of a jaw fracture).   Palpate the mandible and then have the patient bite down and see if the teeth align normally (if abnormal can indicate a mandible fracture).
  86. 86. Nose Inspection   Assess the nose for patency of airway, bleeding or leakage of clear fluid (a sign of skull fracture).   Assess the septum (middle wall of the nose) for a hematoma (blood clot that compress the cartilage of the nose and cause it to necrose, the treatment of this is to drain the hematoma to be done by a doctor.   Palpate the face looking for fractures.
  87. 87. Examine eye movement, pupil response, drainage, color. Pupils Equal Round React Light Reactivity Accommodation
  88. 88. Neck   Reassess the neck by noting the position of the trachea (shifting of the trachea to one side indicates a problem with the lung on the opposite side of the chest).   Palpate lymph nodes, thyroid, carotid pulses and feel for enlarged nodules.   Assess for any air under the skin, which feels like crackling under the skin (called crepitus) this indicates an injury to the esophagus, trachea or lung).
  89. 89.   If Neck continued they are not intoxicated and don t have a major other injury then you can ask them to turn their neck from side to side and then touch the chin to their chest.   If they can do both of those and have no tenderness, it is very unlikely that they have a neck fracture.   Never move the patient s neck for them. If a fracture is present and you move the neck, you will injure the spinal cord.
  90. 90. Neurologic Changes in Mental Status, cognition, sleeping patterns, seizures, paresthesias Exam: Mental status, orientation to person, place and time and responsiveness to language stimulation
  91. 91. Cardiovascular Palpitations, chest pain & cold extremities Exam: Heart sounds, pulses, edema, nailbeds for cyanosis or clubbing
  92. 92. Respiratory Cough, Shortness of breath, hemoptysis Exam: Anterior/posterior chest for respiratory effort, symmetry of effort, lung sounds for wheezing, rhonchi & stridor All lung fields should be clear
  93. 93. Gastrointestinal   Assess the GI area for obvious bruising or open wounds.   Gently palpate the abdomen in all 4 quadrants, finally perform more deep palpation.   If the patient has tenderness, (tightening of the abdominal muscles to prevent you from irritating the injured organs) correlate the tenderness with the anatomy.
  94. 94. Genitourinary Ask about nocturia, dysuria, urgency or hesitancy Observe patient s hygiene, skin condition, lesions, drainage, etc.
  95. 95. Reproductive Impotence (men) Menstrual history (women) Examine for lesions, discharge and odors
  96. 96. Examine the pelvis by pressing directly down on the pelvis, press in from the sides and finally press down over the pubis. If the pelvis move with compression, the patient has a pelvic fracture and needs to have the pelvis immobilized.
  97. 97. Musculoskeletal   Musculoskeletal exam starts with examining the extremities to note any obvious deformities.   Then continue by palpating each extremity from the most proximal aspect (meaning near the torso to the most distal aspect (the toes and fingers).   Look for point tenderness, which is focal tenderness at one spot (sign of a fracture).
  98. 98. Look for open wounds or bruising. Feel for possible from the opposite side of the bruise. Finally, if the limb appears uninjured then passively move all joints of the extremity. Limits of ROM & change in gait Also check for symmetry of right and left sides, muscle strength, signs of DVT and distal pulses
  99. 99. Inspection of posterior surfaces and/or Logroll ejwalsh102, "y020121", flickr,CC: BY-NC-ND 2.0, .
  100. 100. Nursing Analysis & Differential Nursing Diagnoses (Possible explanation for the problem)
  101. 101. Collaborative Problems requiring Team Interventions Discussion
  102. 102. Planning Implementation/Interventions Be Proactive and Assertive within Nursing Scope!
  103. 103. Intubated patient suddenly deteriorates Displaced Tube Obstruction of Tube Pneumothorax Equipment Failure
  104. 104. What medications should you anticipate and prepare if the doctors are discussing intubation?
  105. 105. What would you begin to prepare for if you received a patient with a pneumothorax or hemothorax?
  106. 106. Chest Tube Supplies Needed?
  107. 107. Emergency Intubation Equipment Preparations Appropriate size ET Tube Suction Laryngoscope Lubricant Stethoscope Stylet Tape NG Tube 10cc & 20cc Syringe
  108. 108. Customer Service 5 things that we can do to be more customer focused 1. Address patient by name 2. Introduce yourself to pt & family 3. Address language barriers 4. Include patient and family in care 5. Communicate and update patient and family (explain care)
  109. 109. Evaluation and Ongoing Monitoring jasleen_kaur, flickr Glenlarson, wikimedia commons Jeremy Brooks, flickr
  110. 110. Documentation of Nursing Assessment and Care
  111. 111. Document, Document, Document!!
  112. 112. Why is Documentation Important? Effective Communication Saves Time Fewer Errors Legal Considerations Professionalism
  113. 113. Medication Administration Name of Medication Dosage of Medication Date & Time of Administration Route of Administration Reaction to Medication (if any) Initial Entry
  114. 114. Additional Documentation Examples for Discussion Chest Tube Output Elevated Temperature Color of Urine Changed from Yellow to Bright Red CHI LOC Decreased No Pedal Pulses with Femur Fracture
  115. 115. ~Review~
  116. 116. Stabilize suspected Cervical Spine Injuries ABC Control hemorrhage & its consequences Prevent and treat shock, maintain or restore effective circulation Splint suspected fractures and protect wounds with sterile dressings Monitor patient s vital sign, neurological state, to guide in decision making
  117. 117. Subjective Data Collection Objective Data Collection
  118. 118. Age Related Considerations *Pediatrics treehouse1977, flickr *Geriatrics dyniss, flickr
  119. 119. Q&A
  120. 120. Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy Slide 50, Image 1: The U.S. Army, "www.army.mil", flickr, http://www.flickr.com/photos/soldiersmediacenter/2744774870/, CC: BY 2.0, http://creativecommons.org/licenses/by/2.0/. Slide 65, Image 1: stovak, "Shoulder pain", flickr, http://www.flickr.com/photos/stovak/2152016411/, CC: BY-NC-SA 2.0, http:// creativecommons.org/licenses/by-nc-sa/2.0/. Slide 67, Image 1: Glenlarson, 12 lead generated sinus rhythm", wikimedia commons, http://commons.wikimedia.org/wiki/File: 12_lead_generated_sinus_rhythm.JPG, Public Domain. Slide 67, Image 2: Hmwith, "Plastic oxygen mask on an ER patient", wikimedia commons, http://commons.wikimedia.org/wiki/ File:Plastic_oxygen_mask_on_an_ER_patient.jpg, Public Domain. Slide 69, Image 1: Community Eye Health Journal photos, PL-20017", flickr, http://www.flickr.com/photos/ 24560044@N08/5595577384/, CC: BY-NC 2.0, http://creativecommons.org/licenses/by-nc/2.0/. Slide 97, Image 1: ejwalsh102, "y020121", flickr, http://www.flickr.com/photos/ejwalsh102/1009006153/, CC: BY-NC-ND 2.0, http://creativecommons.org/licenses/by-nc-nd/2.0/. Slide 107, Image 1: jasleen_kaur, "sphygmomanometer", flickr, http://www.flickr.com/photos/jasleen_kaur/4388052026/, CC: BY-SA 2.0, http://creativecommons.org/licenses/by-sa/2.0/. Slide 107, Image 2: Glenlarson, 12 lead generated sinus rhythm", wikimedia commons, http://commons.wikimedia.org/wiki/ File:12_lead_generated_sinus_rhythm.JPG, Public Domain. Slide 107, Image 3: Jeremy Brooks, "Sickoscope", flickr, http://www.flickr.com/photos/jeremybrooks/6149369450/, CC: BY-NC 2.0, http://creativecommons.org/licenses/by-nc/2.0/. Slide 116, Image 1: treehouse1977, "Sleeping son", flickr, http://www.flickr.com/photos/treehouse1977/3320819162/, CC: BYSA 2.0, http://creativecommons.org/licenses/by-sa/2.0/. Slide 116, Image 2: dyniss, "Grandfather Healing", flickr, http://www.flickr.com/photos/dyniss/6213421710/, CC: BY-SA 2.0, http://creativecommons.org/licenses/by-sa/2.0/.

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