Head to Toe Critical Care Assessment for the Trauma Patient, Study Guides, Projects, Research of Nursing

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Head to Toe Assessment

for the Trauma Patient

Objectives

1. Learn Focused Trauma Assessment

2. Learn Frequently Seen Trauma Injuries

3. Appropriate Nursing Care for Trauma Patients

Primary Survey

• Begins immediately on patient’s arrival
• Collection of information of injury event and past medical history depend on severity of condition
• Conducted in Emergency Room simultaneously with resuscitation
• Focuses on detecting life threatening injuries
• Assessment of ABC’s Trauma Trust

Primary Survey

Components

 A irway with simultaneous c-spine protection and A lertness  B reathing and ventilation  C irculation and C ontrol of hemorrhage  D isability – Neurological: Glasgow Coma Scale [GCS] or Alert, Voice, Pain, Unresponsive [AVPU]  E xposure and E nvironmental Controls  F ull set of vital signs and F amily presence  G et resuscitation adjuncts (labs, monitoring, naso/oro gastric tube, oxygenation and pain)

A – Airway and Alertness

with C–Spine

• Maintain patent airway  Maintain neutral c-spine position
• Note abnormal sounds  Gurgling, stridor
• Gentle suction, if necessary
• Manual airway opening – jaw thrust for trauma
• Ability to maintain airway on their own  If awake and breathing, patient may position themselves to maximize ability to breath. Ensure interventions don’t cause further compromise. Medica-chemistry.blogspot.com

A – Airway and Alertness

with C–Spine

• Open and inspect airway while maintaining c-spine precautions.
• Observe for the following:  Vocalization  Can the patient talk, cry or moan  Tongue obstructing airway  Loose teeth or foreign objects  Blood, vomitus, or other secretions  Edema
• Insert oro/nasopharyngeal airway, if appropriate
• Prepare for intubation, if not done in the field www.youtube.com

B – Breathing / Ventilation

• Is the patient breathing on their own?
• Rate should be between 12 – 29
• Symmetrical rise in fall of chest?
• Palpate for possible rib fractures or subcutaneous emphysema
• What do lungs sound like? Do you need to breathe for the patient?
• Consider assisted ventilation and/or intubation www.medictests.com

B – Breathing and Ventilation

Nursing Interventions:

• If breathing is inadequate or absent;  Open airway with jaw thrust, insert airway adjunct  Assist ventilations with a bag-mask device 10-12 breaths per min or one breath every 5-6 seconds  Prepare for definitive airway www.emedicine.medscape.com

B – Breathing and Ventilation

Life Threatening Pulmonary Injuries:

• Open Pneumothorax
• Tension Pneumothorax
• Flail Chest
• Hemothorax

These injuries should be rapidly identified

for immediate intervention before

proceeding to the next step

www.lhsc.on.ca

C – Circulation / Control

of Hemorrhage

• Does the patient have a pulse? (If no, then begin CPR)
• IV access  Preferably 2 large bore catheters (18 gauge or larger)  If present, are they patent?
• External bleeding present  Stop bleeding! Apply direct pressure over hemorrhage sites.
• Skin Vitals  Inspect and palpate skin: temperature, color, moisture

C – Circulation / Control

of Hemorrhage

Consider the following as a potential cause

of absent pulses:

 Penetrating wound to heart  Pericardial tamponade  Tension Pneumothorax  Rupture of the great vessels (aorta, vena cava)  Abdominal or pelvic hemorrhage  Exsanguination (uncontrolled external bleeding)

D – Disability (Neuro Status)

• Brief Neuro Exam
• AVPU A lert Responsive to V erbal Responsive to P ain U nresponsive
• GCS: Eve 4, Verbal 5, Motor 6
• Pupil Exam
• Any change in LOC (level of consciousness) is thought to be the result of a central nervous system injury until proven otherwise (American College of Surgeons) http://www.mcleishoptometrists.com

F – Full Set of Vital Signs /

Family Presence

• Obtain baseline vital signs and re-check at regular intervals to trend for changes Blood Pressure Heart Rate Respiratory rate Pulse-oximetry
• Facilitate family as soon as possible
• Evidence shows that patients prefer to have family members present during resuscitation. (ENA) www.freepik.com

G – Get Resuscitation

Adjuncts

L = Labs  ABG, SpO2, CO2, base excess, blood typing, lactic acid (which can indicate the adequacy of tissue perfusion) M = Monitoring cardiac rate and rhythm N = Naso / oro gastric tube O = Oxygenation and ventilation  SpO2 (dependent on adequate peripheral perfusion) and CO2 monitoring (normal value 35-45 mm Hg) P = Pain assessment and management  Pain management is both pharmacological and non- pharmacological (ice, elevation, splinting)