Download as PDF, PPTX
More Related Content
Similar to Trauma Assessment
Trauma Assessment
- 1. Your patient isarriving in 5 minutes.... do you know where to start?
- 2. INITIAL ASSESSMENT • InitialAssessment Divided into two assessment phases: • Primary • Secondary • Adherence to standard and transmission-based precautions
- 3. Primary Assessment • AAirway (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
- 4. 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
- 5. Airway Precautions • Maintaincervical 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 cleared By the MD
- 6. Airway Assessment Also think about potential • Vocalization obstructions...Conditions • Tongue obstruction could change quickly • Loose teeth or foreign objects • Bleeding • Vomitus or secretions • Edema • Airway Obstructed?
- 7. Obstructed Airway • Positionthe patient You don’t go on to “B” until you have taken care of “A” • Stabilize the cervical spine • Open and clear the airway • Insert airway • Consider endotracheal intubation • Stop and intervene before proceeding
- 8. Breathing • History (medical and trauma) • Blunt or penetrating trauma • Steering wheel • Other forces What might cause this Patient some breathing Problems?
- 9. Breathing Assessment What do you look for when assessing breathing? • Spontaneous breathing • Chest rise and fall • Skin color • Pediatric: see handout with pictures of infant chest for comparison
- 10. 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?
- 11. Breathing: Effective • Administeroxygen via a nonrebreather mask 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 if They do not have respiratory system Compromise.....Why?
- 13. Breathing: Ineffective What are some other ways that I can tell breathing is • Altered mental status compromised? • Cyanosis • Asymmetrical chest wall expansion • Accessory and/or abdominal muscle use • Sucking chest wounds • Paradoxical movement of chest wall • Tracheal shift from midline
- 14. 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 responsibilities When the MD is intubating the patient?
- 15. Breathing Absent • Ventilatepatient 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”
- 16. Circulation • Palpate What do I look for to assess circulation? • Pulse for quality and rate • Central pulse (carotid or femoral) • Skin for temperature and moisture • Inspect • Skin for color • Any obvious signs of bleeding
- 17. Circulation • Auscultate bloodpressure 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 reading Not very helpful?
- 18. Circulation: Effective • Ifthe circulation is effective, proceed with assessment
- 19. 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?
- 20. Hypovolemic Shock This is the most common type of Shock....Don’t look For another type of Shock until you have ruled out low volume
- 21. 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?
- 22. Circulation: Absent • Begincardiopulmonary 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?
- 23. Disability • Determine levelof 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?
- 24. Brief Neurologic Assessment • Extremity movement • Pupil reaction • Level of consciousness/orientation This assessment will give you some more information about brain activity
- 25. Disability • If decreasedlevel 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?
- 26. Secondary Assessment • IdentifyALL injuries • E Expose patient What about hypothermia? Environmental control • F Full set of vital signs Family presence Why is the nurse • G Give comfort measures the best person for this task?
- 27. Secondary Assessment • History Prehospital information M Mechanism of injury I Injuries V Vital signs T Treatment Patient-generated information Past medical history (PMH) What impact could a trauma patient’s medical history have on today’s injuries?
- 28. Secondary Assessment • Head-To-Toe • Pediatric: see Assessment handout, “Injury – Head and face patterns in a child” for – Neck comparison – Chest – Abdomen and flanks – Pelvis and perineum – Extremities – Posterior surfaces – General appearance
- 29. Secondary Assessment • Focused Survey • Pain Management • Tetanus Prophylaxis Why is initial pain control In a trauma patient always given I.V.? Focused means you can now pay close attention to extremity injuries, etc.
- 30. Glasgow Coma Scale •Areas of Response Why is the GCS more helpful than AVPU? – Eye opening – Best verbal response – Best motor response • Pediatric: see handout “pediatric GCS” Why is the measurement of children’s brain activity different from adult?
- 31. 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?
- 32. 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?
- 33. 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?
- 34. Evaluation and OngoingAssessment • Airway patency • Breathing effectiveness • Arterial pH, PaO2, PaCO2 • Oxygen saturation (SpO2 or SaO2) • Level of consciousness • Skin color, temperature, moisture • Pulse rate and quality The initial emergency is over, but the patient • Blood pressure still has needs. What Is the nurse’s responsibility • Urinary output Now?
- 35. 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