1: Assessment Procedures

Section One Assessment Procedures





PROCEDURE 1 Primary Assessment







PROCEDURAL STEPS




1. Assess airway patency while simultaneously maintaining cervical spine alignment with manual stabilization. Airway patency is assessed by looking for chest rise and fall and by listening and feeling for air movement from the nose and mouth. If the airway is partially or completely obstructed, implement the appropriate intervention. Potential interventions include the following and are described elsewhere in this text:


Procedure 3—Airway Positioning

Procedure 4—Airway Foreign Object Removal

Procedure 5—Oral Airway Insertion

Procedure 6—Nasal Airway Insertion

Procedure 7—Laryngeal Mask Airway

Procedure 812—Endotracheal Intubation

Procedure 14—Combitube Airway

Procedure 15—Cricothyrotomy

Procedure 16—Percutaneous Transtracheal Ventilation

Procedure 17—Tracheostomy

Procedure 29—Pharyngeal Suctioning

2. If the patient is at risk for cervical spine injury, have an assistant manually stabilize the head until the primary and secondary assessments are complete and more definitive immobilization can be instituted (see Procedure 111). In the absence of an assistant, towel rolls or foam blocks set alongside the head will help maintain alignment and remind a conscious patient not to move. Do not tape down the head and blocks until the patient is fully strapped to a backboard. Cervical spine immobilization should be maintained until the neck is cleared by x-ray or clinical examination.


3. Assess breathing adequacy by observing the respiratory rate, depth, and difficulty. Briefly auscultate breath sounds bilaterally. Implement pulse oximetry monitoring for all seriously injured or ill patients (see Procedure 21). If respirations are absent or abnormal, implement appropriate interventions. Potential interventions include the following and are described elsewhere in this text:


Procedure 18—Positioning the Dyspneic Patient

Procedure 25—General Principles of Oxygen Therapy and Oxygen Delivery Devices

Procedures 2931—Suctioning

Procedure 32—Bag-Mask Ventilation

Procedure 38—Emergency Needle Thoracentesis

Procedure 39—Chest-Tube Insertion

Use a flutter valve (occlusive dressing taped on three sides) for open pneumothorax (sucking chest wound).


Nov 8, 2016 | Posted by in NURSING | Comments Off on 1: Assessment Procedures

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