4534 - wk2

What is the primary assessment/survey?

• rapid assessment is used to ID + immediately address life-threatening problems

  • Focus = ABCDEFG

  • mostly ABC as they are life-threatening/fatal

What does ABCDEFG stand for in the primary assessment?

• A = Airway;

• B = Breathing;

• C = Circulation;

• D = Disability;

• E = Exposure;

• F = Full set of vital signs/facilitate family presence;

• G = Get resuscitation adjuncts.

What alternative sequence may be used when there is uncontrolled bleeding?

• C-ABCDE

  • uncontrolled bleeding present on arrival = circulation is moved to the beginning of the primary assessment

  • life-threatening hemorrhage = addressed immediately.

What does D represent in ABCDEFG?

D = Disability = neurological assessment

• level of consciousness

• pupils

• motor/sensory function.

• Cervical spine immobilization is maintained until X-rays confirm there is no injury when cervical spine injury is suspected.

What does E represent in ABCDEFG?

E = Exposure = exposed as necessary to identify injuries that may otherwise be missed

• environmental controls are maintained so the patient does not become hypothermic.

• risk of element exposure - hyper or hypothermia

What is the secondary assessment/survey?

• follows completion of the primary survey

• used to ID other injuries or abnormalities that are not immediately life-threatening

• HI:

  • H = history/head-to-toe assessment

  • I = inspect posterior surfaces.

What general impression should the emergency nurse form about the patient?

rapidly determine whether the patient is - LOOK

• SICK

• SICKER,

• or SICKEST

• helps establish the urgency and priority of care.

goal of primary assessment?

• rapidly obtain essential subjective & objective information

• interpret it

• identify life-threatening states

• immediately intervene when indicated

• why use ABCDE

What should happen if a life-threatening condition is identified during the primary assessment?

• assessment stopped momentarily until appropriate stabilizing interventions are initiated + priorities of care are achieved.

• Stabilization = priority over completing the assessment.

What subjective information is collected during the primary assessment of the chief complaint?

• brief one-line statement of what is wrong/why the patient came to the ER

• precipitating event or onset of symptoms

• mechanism of injury

• progression of the condition from the first symptom

• history of the illness/injury/chief complaint

  • location

  • duration

  • characteristics

  • aggravating symptom

  • relieving symptoms

  • treatment before arrival.

What objective information is collected during the primary assessment?

ABCDE

• Airway patency with cervical spine protection if suspected

  • jaw thrust

• effectiveness of breathing

• effectiveness of circulation

• disability/brief neurological check

• exposure/environmental controls.

What are the subjective data components of a normal/acceptable airway assessment?

• No history related to an airway problem

• no dyspnea, dysphagia, or dysarthria

What are the objective data components of a normal/acceptable airway assessment?

• patient can open the mouth widely and the airway appears clear

• patient can speak/vocalize appropriately for age without dysphonia or muffled speech

• no foreign material, drooling, or visible obstruction

• equal chest rise and fall

• absence of abnormal upper-airway noises such as grunting or stridor.

use AVPU

What does the patient's ability to speak clearly tell the nurse about the airway?

Ability to speak/vocalize appropriately without dysphonia or muffled speech suggests that the airway is protected and patent.

What airway findings suggest obstruction?

• Foreign material

• drooling

• vomit

• blood

• loose teeth

• debris

• angioedema

• inability to speak appropriately

• stridor

• cyanosis

• facial swelling

What are dyspnea, dysphagia, and dysarthria?

• Dyspnea = difficulty or discomfort with breathing.

• Dysphagia = difficulty swallowing

  • food/liquid

• Dysarthria = difficulty articulating speech due to impaired motor control of speech.

What is AVPU? - objective data - normal airway

rapid method for assessing alertness/level of consciousness + ability to protect airway

• A = Alert;

• V = responds to Verbal stimuli;

• P = responds only to Painful stimuli;

• U = Unresponsive.

What does A mean in AVPU?

A = Alert. The patient is awake and alert.

What does V mean in AVPU?

V = responds to verbal stimuli. The patient is not fully alert but responds when spoken to.

What does P mean in AVPU?

P = responds only to painful stimuli.

What does U mean in AVPU?

U = Unresponsive.

What spinal precaution should be taken when injury/symptoms/findings suggest spinal cord injury?

• Maintain spinal alignment

• Stabilize the cervical spine = applying a rigid collar.

What subjective findings may suggest a partially or completely obstructed airway?

• Trauma to the face, mouth, pharynx, neck, or chest

• Difficulty began while eating or drink

• recent vomiting

• contact with an allergen

• discovery that the patient placed an object into the mouth.

What objective findings may indicate airway obstruction?

• Absence of breathing

• Panic behaviour - hands on throat, waving arms/grabbing clothing

• inability to speak or vocalize appropriately

• substernal/intercostal retractions

• drooling in a patient other than an infant

• nasal flaring especially in infants

• facial weakness/paralysis

• facial engorgement with ruddy/bright-purple skin

• violent coughing with lacrimation

  • cough + tears

• tripod positioning

• decreased LOC

• inspiratory or expiratory stridor

• pale/cyanotic/dusky-gray skin, especially mucous membranes and nail beds

• from a fire

  • singed nasal/facial hair

  • carbonaceous sputum - black/grey

  • risk of soon-to-be-obstructed airway!!!

What does tripod positioning indicate?

significant respiratory/airway distress as the patient attempts to maximize ventilation.

What does stridor suggest?

abnormal upper-airway sound associated with airway obstruction or narrowing.

What does drooling suggest in an airway assessment?

particularly in a patient other than an infant, can indicate difficulty swallowing or an obstructed/compromised airway.

What does cyanosis indicate in the context of airway obstruction?

Pale, cyanotic, or dusky-gray skin, particularly involving mucous membranes and nail beds, can indicate inadequate oxygenation associated with significant airway obstruction.

What are possible causes of total airway obstruction?

• Current or pre-existing disease

• trauma including blunt or penetrating forces

• tongue obstruction

• saliva/sputum

• vomitus

• blood

• dislodged teeth, dentures, or loose/knocked-out teeth

• food

• foreign objects small enough to fit in the mouth or nose

• airway edema from allergen exposure.

What foods are specifically identified as possible airway obstructions?

Meat, fish, hot dogs, hard candy, gum, marshmallows, and nuts.

What foreign objects can cause airway obstruction?

Any item small enough to fit into the mouth or nose, including toys, marbles, LEGO pieces, coins, and balls.

What trauma-related findings can suggest airway compromise?

• Blunt or penetrating trauma

  • stab wound to the neck

  
  

• fire

  • inhalation injury with singed hairs

  • carbonaceous sputum.

breathing assessment - expose the?

chest

• look at the bare chest

• see rise fall

• intercostal breathing

• O2 sat

• SEE ABNORMALITIES

What is an effective/normal breathing assessment based on subjective data? - expose the chest

• Eupnea = normal, unlabored, effortless breathing that occurs without conscious effort, quiet or resting breathing

• no respiratory distress

• no history of injury to the head/chest/abdomen

• no deviation from the patient's usual breathing pattern.

What is eupnea?

Normal, unlabored, effortless breathing that occurs without conscious effort; quiet or resting breathing.

What objective findings indicate effective breathing?

• Chest rises and falls spontaneously

• exhaled air may be felt or heard escaping from the nose, mouth, or stoma

• respirations are smooth and even

• chest expansion is equal bilaterally

• oxygen saturation is 94–98% or at the patient's baseline.

• Mild tachypnea, retractions, wheezing, or accessory-muscle use may also be assessed as possible abnormal findings requiring attention.

What subjective findings suggest compromised or absent breathing?

• Blunt or penetrating injury to the neck, chest, back, or abdomen

• severe asthma

• emphysema

• cardiovascular disease

• dyspnea

• history of respiratory arrest.

4 points

What objective findings indicate compromised or absent breathing?

• Apnea or agonal breathing

• increased work of breathing/accessory muscle use

• abdominal or nasal flaring

• grunting in pediatric patients

• marked tachypnea

  • rapid/shallow breathing

• shallow, weak, or gasping respirations

• pallor/dusky/cyanotic skin

• markedly increased respiratory effort

• abnormal respiratory patterns

• decreased or absent breath sounds

• inability to converse in phrases or complete sentences

• severe retractions

22 points - objective findings indicate compromised or absent breathing?

• Open or sucking chest wounds

• paradoxical chest wall movement

• SpO₂ below 94% or below the patient's baseline

• abnormal/uncompensated ABG

• decreased respiratory rate

• chest-wall contusions/abrasions/deformities

• JVD or tracheal deviation

• inhalation injury including singed nares/facial burns

• inability to lie flat

• decreasing LOC

• tracheal deviation.

What are Kussmaul respirations?

• Regular, rapid, deep, laboured respirations

  • DKA/metabolic acidosis

  • children

  • newly dx DM pt

What are Cheyne-Stokes respirations?

alternating periods of hyperventilation and apnea

• neurologic/cardiac dysfunction.

• gradual increase then gradual decrease

biots breathing

completely abnormal breathing

• hyperventilate then apnea

not pattern to it

brain insult - stoke, brain infection

What are signs of severe respiratory distress?

• Marked tachypnea

  • severely rapid, shallow breathing

• increased work of breathing

• accessory muscle use

• severe retractions

• shallow/weak/gasping respirations

• abnormal skin colour

• inability to speak in phrases or complete sentences

• abnormal breath sounds

• low oxygen saturation.

Why is inability to converse in phrases or complete sentences concerning?

It indicates significant respiratory distress and inadequate ventilation because the patient's breathing difficulty interferes with normal speech.

What is paradoxical chest wall movement?

part of the chest moves opposite to the normal respiratory pattern.

• flail chest - traumatic chest injury

What are possible causes of compromised breathing? - 5 points

1. Current or pre-existing disease/illness

2. Trauma = blunt or penetrating forces, brain injury, cervical spine injury, burns

3. Aspiration

4. chemical/drug exposure

5. allergen/dust exposure.

stridor sounds - airway/breathing

5 must know airway obstructions - airway/breathing

S/S airway obstruction - airway/breathing

5 effective airway tips - airway/breathing

What does the C in ABCDEFG assess?

Circulation. The nurse assesses

• pulse

• heart rate

• rhythm

• skin characteristics

• bleeding

• perfusion.

What subjective findings indicate acceptable circulation?

• No report of

  • cardiac arrest

  • life-threatening dysrhythmia

  • significant blood loss.

What are normal/acceptable objective data circulation findings in an uncompromised adult?

• Central and peripheral pulses are palpable

  • central pulse = carotid artery neck then the femoral pulse

• heart rate is 60–100/min

• rhythm is regular

• skin = pink, warm, and dry?

What heart rate range is listed for uncompromised infants?

100–180 beats/min.

What heart rate range is listed for uncompromised small children?

80–120 beats/min.

What objective (or subjective?) findings indicate compromised/absent/unacceptable circulation?

• Unconsciousness or significant altered LOC

• reported cardiac arrest

• reported or suspected significant blood loss

• weak or absent peripheral/central pulses

• pale/dusky/cyanotic skin

• cool/clammy skin

• abnormal heart rate

• unresponsiveness/significantly altered LOC

• nonpalpable central or peripheral pulses

• uncontrolled bleeding.

What adult heart rate findings are considered concerning for circulation compromise?

HR

• less than 60

• or

• greater than 100

when weak in adults.

What infant heart rate findings are considered concerning for circulation compromise?

HR less than 100 or greater than 220 beats/min in infants.

What small-child heart rate findings are considered concerning for circulation compromise?

HR less than 80 or greater than 180 beats/min in small children.

What pulse findings indicate severe circulation compromise?

• nonpalpable central pulse - carotid or femoral pulse

• Nonpalpable peripheral pulse

What are possible etiologies of pulse abnormalities? x6 causes

1. Current or pre-existing illness

2. Trauma = blunt or penetrating forces, swollen/deformed extremities, rigid abdomen

3. chemical/drug exposure

4. hypothermia/hyperthermia

5. uncontrolled bleeding

6. arrhythmia.

What findings indicate adequate/acceptable bleeding?

subjective

• No history of disease or injury likely to result in significant bleeding

  • active external bleeding is easily controlled before arrival

objective

• no visible active bleeding

• any visible bleeding is limited to

  • oozing

  • low volume

  • dark red in color.

  • this means it is VENOUS blood

What subjective findings indicate unacceptable bleeding?

• Reported or suspected significant blood loss before arrival

  • inability to control external bleeding

What objective findings indicate unacceptable bleeding? - 6 points

1. uncontrolled/pulsating/high-flow bleeding

2. marked pallor = skin, lips margins, nail beds

3. large amounts of blood/clots in emesis, nares, oral cavity, stool, or vagina

4. gross swelling of injured extremities

   1. blood pools = damage to blood vessels/nerve

   2. affect distal circulation

   3. lead to compartment syndrome

5. distended, rigid abdomen

6. systolic BP below 90 mmHg in adults; rapid HR; and thready/weak pulse.

Why can gross swelling of an injured thigh indicate significant blood loss?

Blood can pool within the injured leg/thigh, resulting in significant internal blood loss even when external bleeding is not obvious.

• compartment syndrome etc

Why is a distended, rigid abdomen concerning for bleeding?

It can indicate internal abdominal bleeding, meaning blood is being lost into the abdominal cavity.

What possible etiologies are listed for unacceptable bleeding?

• Current or pre-existing diseases/illnesses

  • MI?

  • on beta blockers

  • etc

• blunt or penetrating trauma.

What is perfusion?

Perfusion refers to adequate blood flow delivering oxygen and nutrients to tissues and organs.

What are acceptable/normal perfusion subjective findings?

• No history of injury or disease likely to decrease perfusion

What are acceptable/normal perfusion objective findings?

• patient alert and oriented to person, place, time, and event

• skin warm and dry

• brisk capillary refill

• normal, palpable pulses in all extremities

• blood pressure within normal limits for age/weight.

What capillary refill value is identified as brisk in the presentation?

<3 seconds

• reliable in children only.

What subjective findings indicate unacceptable perfusion?

• Weakness, lightheadedness, nausea, visual dimming (black before faint)

• a feeling of impending doom,

• shortness of breath

• complaints suggesting acute inadequate organ perfusion such as

  • sudden painless visual loss - retinal artery occlusion

  • sudden-onset testicular pain - torsion

What objective findings indicate inadequate perfusion?

• Altered LOC = restlessness/anxiety/confusion/disorientation/obtundation

• increased respiratory effort/WOB

• diaphoresis; cool skin

• pallor/dusky/cyanotic skin; pallor/cyanosis of nail beds or lip margins

• weak/thready/rapid pulses

• vomiting/retching

• delayed capillary refill

• hypotension with SBP <90

• extremity injury with diminished/absent puls

• other indicators of acute organ-specific diminished perfusion.

What does hypotension of SBP <90 mmHg indicate in the presentation?

It is an unacceptable finding suggesting circulatory compromise and poor perfusion.

What possible etiologies are listed for unacceptable perfusion?

• current/pre-existing disease/illness

• trauma = blunt/penetrating forces

What does D represent in the primary assessment?

Disability, meaning a brief neurological assessment.

What subjective findings are acceptable during the disability assessment?

• No history of loss of consciousness

• neurological trauma

• onset of severe headache.

What objective findings are assessed during the disability assessment?

• Level of consciousness using AVPU

• pupil assessment - equal, reactive, round, briskly reactive to light & accommodate

• GCS

• motor movement of all four limbs with movement to command

• sensory function including pain and fine touch.

What are normal pupil findings?

Pupils are equal, reactive, round, and briskly reactive to light and accommodate.

What motor findings are acceptable during the disability assessment?

The patient moves all four limbs and can move them to command.

What sensory findings are assessed during the disability assessment?

Pain and fine touch.

What subjective findings indicate an unacceptable disability assessment?

• History of LOC or unconsciousness/coma

• head injury or traumatic brain injury

• sudden onset of severe headache

• history of

  • diabetes

  • alcohol abuse.

What objective findings indicate neurological compromise?

• Altered LOC such as restlessness, stupor, or coma;

• unequal, blown,

• slow, or absent pupillary reaction;

• abnormal flexion/extension positioning;

  • abnormal posturing - brain injury

• hypoglycemia

• elevated blood alcohol or positive drug screen

  • toxicology screen - taking right away by nurse

• loss of pain or fine-touch sensation.

What are possible etiologies of disability/neurological abnormalities? x7 points

1. Current or pre-existing disease

2. blunt or penetrating trauma

3. substance and/or alcohol use/abuse

4. medication toxicity

5. toxic environmental exposure

6. hyperthermia/hypothermia

7. electrolyte or acid-base disturbances.

What does E represent in ABCDEFG?

Exposure/environmental controls.

What is assessed during exposure?

The patient is exposed sufficiently to identify injuries that could otherwise be missed while environmental controls are maintained to prevent temperature-related complications.

What subjective findings are acceptable/stable during exposure?

• No history of unexposed injury

• prolonged exposure

• thermoregulatory disease

• critical infectious illness exposure

• head injury

• spinal cord injury

What objective findings are acceptable/stable during exposure?

• No injuries noted

• no petechial or purpura rash.

Why does the nurse cut off the patient's clothing during exposure?

Clothing may conceal injuries - must do thorough assessment

• nurse to cut the clothing straight up middle of pants/shirt = expose the body + assess for missed injuries.

• but must keep BODY WARM

  • blankets

  • warm IV fluids

What should the nurse do after exposing the patient?

The patient should be warmed using blankets and other environmental measures because exposure can result in heat loss.

What subjective findings indicate unstable exposure/environmental status?

• Complaints of chest, abdominal, extremity, spinal, or head injury/pain

• recent exposure to critical infectious illness

• prolonged exposure to environmental elements.

What objective findings indicate unstable exposure/environmental status?

• Observable head, spinal, chest, abdominal, or extremity injury

• petechial rash

• tachycardia/bradycardia

• subnormal or elevated temperature.

What are possible etiologies associated with exposure/environmental problems? x5 points

1. Current or pre-existing illness

2. blunt or penetrating trauma

3. substance/alcohol use or abuse

4. medication toxicity

5. environmental exposure.

What does F represent in ABCDEFG?

F = Full set of vital signs + facilitate family presence.

What is included in a full set of vital signs?

Serial vital-sign sets

• MAP

• blood pressure in both arms when chest trauma is present

  • dissection aneurysm

  • bleeding internally

• respiratory rate counted rather than guessed

• pulse rate, rhythm, and quality

  • central - apical/carotid/peripheral

  • peripheral

• temperature

  • frequent

Why is MAP mentioned in the full set of vital signs?

MAP is useful in assessing perfusion

• helpful with

  • children

  • older adults.

Where can central pulses be assessed? - F = full set VS

• Apical

• carotid

• femoral

Where can peripheral pulses be assessed? - F = full set VS

• Radial

• brachial

• posterior tibialis

• dorsalis pedis

What temperature routes/sites are listed? - F = full set VS

• Oral

• rectal

• axillary

• bladder

• tympanic,

• temporal artery