Nursing Assessment and Resuscitation

CHAPTER 1 Nursing Assessment and Resuscitation



Jean A. Proehl, RN, MN, CEN, CCRN, FAEN



MAJOR TOPICS



Primary Assessment


Overview of Major Components

Individual Components of Primary Assessment

Resuscitation


Airway/Cervical Spine Protection

Breathing

Circulation/Bleeding

Disability (Neurologic Status)

Expose/Environmental Controls

Secondary Assessment


Full Set of Vital Signs/Focused Adjuncts/Facilitate Family Presence

Give Comfort Measures

History and Head-to-Toe Assessment

Inspect Posterior Surfaces

Focused Assessment


Diagnostic Procedures


Analysis: Differential Nursing Diagnoses/Collaborative Problems


Planning and Implementation/Interventions


Evaluation and Ongoing Monitoring


Documentation of Nursing Assessments and Resuscitation


Subjective Data Collection

Objective Data Collection

Analysis: Differential Nursing Diagnosis/Collaborative Problems

Planning and Implementation/Interventions

Evaluations and Ongoing Monitoring

Age-Related Considerations


Pediatric

Geriatric

Note: Standard universal infection control precautions should be observed and personal protective equipment worn as indicated.



I. PRIMARY ASSESSMENT


The goal of the primary assessment is to rapidly identify potentially life-threatening conditions requiring immediate intervention. The assessment process does not continue until treatment is initiated for all significant abnormalities found in the primary assessment.



A. Overview of Major Components




1. Subjective data collection


a. Brief one-line statement

1) Precipitating event/onset of symptoms

2) Mechanism of injury (see Chapters 30 and 33)

b. Progression of condition from first symptom or injury to initiation of care

1) History of present illness/injury/chief complaint

2. Objective data collection


a. Airway patency with simultaneous cervical spine protection for trauma patients

b. Breathing effectiveness

c. Circulation effectiveness

d. Disability (brief neurologic assessment)

e. Expose/environmental controls


B. Individual Components of Primary Assessment




1. Airway, with simultaneous cervical spine (C-spine) protection if indicated


a. Assessment

1) Open and clear
a) Subjective data collection
(1) No history related to airway problem

(2) No dyspnea, dysphagia, or dysarthria

b) Objective data collection
(1) Patient able to speak or appropriately vocalize for age without dysphonia or muffled speech

(2) No foreign material, drooling, or obstruction visible in upper airway (e.g., blood, vomitus, loose teeth, foreign bodies, debris, angioedema)

(3) Equal rise and fall of chest with ventilations

(4) Absence of adventitious upper airway noises (e.g., stridor, grunting)

c) Action/intervention
(1) If mechanism of injury, symptoms, or physical findings suggest a spinal cord injury, the cervical spine must be protected

(2) Verify that airway is established, open, clear, and that patency is maintained

2) Partially obstructed or obstructed/unacceptable requiring immediate intervention
a) Subjective data collection
(1) Trauma to face, mouth, pharynx, neck, or chest

(2) Patient eating or drinking when difficulty began

(3) Recent vomiting

(4) Contact with allergen

(5) Patient discovered putting objects into mouth

b) Objective data collection
(1) Absence of breathing

(2) Panic behavior, hands on throat, waving arms, grabbing at clothing

(3) Patient unable to speak or vocalize appropriate for age

(4) Substernal, intercostal retractions

(5) Drooling in patient other than infant

(6) Nasal flaring, especially in an infant

(7) Facial weakness or paralysis

(8) Facial engorgement: ruddy/bright purple coloring

(9) Violent coughing with lacrimation

(10) Sitting up and leaning forward; tripod position

(11) Decreased level of consciousness

(12) Inspiratory and/or expiratory stridor

(13) Pale, cyanotic, dusky-gray skin color, especially mucous membranes and nail beds

b. Possible etiologies of airway obstruction

1) Current or preexisting diseases/illness

2) Trauma: blunt or penetrating forces, inhalation injury

3) Tongue, occluding upper airway in an unconscious patient

4) Saliva/sputum

5) Vomitus

6) Blood

7) Dislodged teeth/dentures (may be loose or knocked out as a result of facial injury)

8) Food (e.g., meat, fish, hot dogs, hard candy, marshmallows, or nuts)

9) Any item small enough to fit into mouth or nose (e.g., marbles, small toy parts, coins, latex balloons, plastic bags, or bean bag foam balls)

10) Airway endema secondary to allergen exposure

c. Analysis: differential nursing diagnoses/collaborative problems

1) Ineffective airway clearance

2) Impaired gas exchange

3) Anxiety/fear

d. Planning and implementation/interventions (Interventions for ineffective airway clearance must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

e. Evaluation and ongoing monitoring (see Appendix B)

1) Airway patency

2. Cervical spine


a. Assessment

1) Acceptable/stable
a) Subjective data collection
(1) No history of injury; none suspected

(2) No history of degenerative bone disease (e.g., ankylosing spondylitis, osteoporosis)

(3) No complaints of pain on movement or with palpation of neck

b) Objective data collection
(1) Movement in all extremities without limitation or weakness

(2) Breathing effective: no intercostal retractions or abdominal breathing

(3) If mechanism of injury suggests potential for injury, stabilize or immobilize patient’s neck

2) Unacceptable or requiring immediate intervention/unstable
a) Subjective data collection
(1) Mechanism of injury with potential for cervical trauma (e.g., direct injury to head or neck; trauma involving sudden deceleration as in motor vehicle crash or fall; high-voltage electrical shock [see Chapter 30])

(2) Symptoms: inability to move extremities, cervical spine pain or tenderness, palpable deformity

b) Objective data collection: possibility of no objective findings as nondisplaced fractures of cervical spine may not compromise neurologic system
(1) Paralysis or paresthesia

(2) Abdominal breathing indicating possible diaphragm paralysis

(3) Decreased or absent movement/sensation below level of injury

(4) Weakness

(5) Bowel or bladder incontinence or retention

(6) Loss of sympathetic outflow
(a) Hypotension

(b) Bradycardia

(7) Flaccid paralysis

(8) Loss of sphincter tone

(9) Priapism

(10) Warm, dry skin

(11) Bounding peripheral pulses

(12) Hypothermia; poikilothermy: loss of temperature regulation and patient’s body assumes temperature of external environment

(13) Inability to shiver or sweat

b. Possible etiologies of cervical spine injury

1) Current or preexisting diseases/illness

2) Trauma: blunt or penetrating forces

c. Analysis: differential nursing diagnoses/collaborative problems

1) Ineffective airway clearance

2) Ineffective breathing pattern

3) Impaired gas exchange

4) Ineffective tissue perfusion: renal, cerebral, cardiopulmonary, spinal cord, gastrointestinal, peripheral

5) Risk for injury

6) Ineffective thermoregulation

d. Planning and implementation/interventions (interventions to stabilize and protect the cervical spine must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

e. Evaluation and ongoing monitoring (see Appendix B)

1) Cervical spine stabilization and protection

3. Breathing


a. Assessment

1) Effective
a) Subjective data collection
(1) No distress

(2) No history of injury to chest or abdomen

(3) No deviation from patient’s usual breathing pattern

b) Objective data collection
(1) Chest rises and falls spontaneously

(2) Exhaled air may be felt or heard escaping from nose, mouth, or stoma

(3) Respiration quality smooth, even

(4) Chest expansion equal bilaterally

(5) Possible mild tachypnea, retracting, wheezing, and accessory muscle use

(6) Oxygen saturation measured by pulse oximetry (SpO2) equal or greater than 95% (or patient’s normal baseline)

2) Compromised or absent/unacceptable requiring immediate intervention that differs depending on whether breathing is compromised or absent
a) Subjective data collection
(1) Blunt or penetrating injury to neck, chest, back, or abdomen

(2) Severe asthma, emphysema, cardiovascular disease

(3) Dyspnea

(4) History of respiratory arrest

b) Objective data collection
(1) Apnea

(2) Agonal breathing (slower than 10 breaths/minute in adults)

(3) Marked tachypnea

(4) Shallow, weak, gasping respirations

(5) Cyanosis, diaphoresis

(6) Marked increase in respiratory effort

(7) Kussmaul’s respirations: regular, rapid, deep, labored

(8) Cheyne-Stokes respirations: alternating periods of hyperventilation and apnea

(9) Absent breath sounds, unilaterally or bilaterally

(10) Inability to converse in phrases or complete sentences

(11) Severe retractions

(12) Open or sucking chest wounds

(13) Paradoxical chest wall movement

(14) Pulse oximeter SpO2 less than 95% (or patient’s baseline)

(15) Arterial blood gas acutely abnormal/uncompensated

b. Possible etiologies

1) Current or preexisting diseases/illness

2) Trauma: blunt or penetrating forces

3) Aspiration

4) Chemical/drug exposure

5) Allergen or dust exposure

c. Analysis: differential nursing diagnoses/collaborative problems

1) Ineffective breathing pattern

2) Impaired gas exchange

3) Anxiety/fear

d. Planning and implementation/interventions (interventions for compromised or absence of breathing must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

e. Evaluation and ongoing monitoring (see Appendix B)

1) Respiratory rate and effort

4. Circulation


a. Pulse

1) Assessment
a) Acceptable or adequate
(1) Subjective data collection
(a) No report of cardiac arrest prior to arrival

(b) No report of life-threatening dysrhythmia

(c) No report or suspicion of significant blood loss

(2) Objective data collection
(a) Radial pulse palpable

(b) Heart rate: approximately 60 to 100 beats/minute in uncompromised adults

(c) Heart rate: approximately 100 to 180 beats/minute in uncompromised infants, approximately 80 to 120 beats/minute in uncompromised small children

(d) Rhythm regular

b) Compromised or absent/unacceptable requiring immediate intervention
(1) Subjective data collection
(a) Unconsciousness or significantly altered level of consciousness

(b) Reported cardiac arrest

(c) Reported or suspected significant blood loss

(2) Objective data collection
(a) Heart rate: less than 60 beats/minute or greater than 100 beats/minute and weak in adults

(b) Heart rate: less than 100 beats/minute in infants, less than 80 beats/minute in small children

(c) Unresponsive or significantly altered level of consciousness

(d) Nonpalpable carotid and/or femoral pulses

2) Possible etiologies of pulse abnormalities
a) Current or preexisting diseases/illness

b) Trauma: blunt or penetrating forces

c) Chemical/drug exposure

d) Hypothermia/hyperthermia

3) Analysis: differential nursing diagnoses/collaborative problems
a) Decreased cardiac output

b) Ineffective tissue perfusion: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral

4) Interventions (interventions for inadequate circulation must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

5) Evaluation and ongoing monitoring (see Appendix B)
a) Central or peripheral pulses: quality, rate

b. Bleeding

1) Assessment
a) Acceptable or adequate
(1) Subjective data collection
(a) No history of disease or injury that could result in significant bleeding

(b) Active external bleeding easily controlled prior to arrival

(2) Objective collection
(a) No visible active bleeding

(b) Any visible bleeding is limited to oozing, low volume, dark red color

b) Unacceptable requiring immediate intervention
(1) Subjective data collection
(a) Reported or suspected significant blood loss prior to arrival

(b) Inability to control external bleeding en route

(2) Objective data collection
(a) Uncontrolled, pulsating, or high-flow bleeding

(b) Marked pallor of skin, lip margins, or nail beds

(c) Large amount of bleeding or clots in emesis, nares or oral cavity, stool, or vagina

(d) Gross swelling of injured extremities (e.g., thigh)

(e) Distended, rigid abdomen

(f) Systolic blood pressure less than 90 mm Hg in adults, rapid heart rate, thready, weak pulse

2) Possible etiologies
a) Current or preexisting diseases/illness

b) Trauma: blunt or penetrating forces

3) Analysis: differential nursing diagnoses/collaborative problems
a) Impaired gas exchange

b) Deficient fluid volume

c) Decreased cardiac output

d) Ineffective tissue perfusion: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral

e) Anxiety/fear

4) Planning and implementation/interventions (interventions for bleeding must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

5) Evaluation and ongoing monitoring (see Appendix B)
a) Blood loss controlled

c. Perfusion

1) Assessment
a) Acceptable
(1) Subjective data collection
(a) No history of injury or disease that could result in decreased perfusion

(2) Objective data collection
(a) Patient alert and oriented to person, place, time, and event

(b) Skin warm and dry

(c) Capillary refill brisk, less than 2 to 3 seconds (reliable in children only)

(d) Pulse rate within normal limits; palpable in all extremities

(e) Blood pressure within normal limits for age/weight

b) Unacceptable/requiring immediate intervention
(1) Subjective data collection
(a) Patient weak, lightheaded, nauseated, experiencing visual dimming

(b) Patient verbalizes sense of impending doom

(c) Patient verbalizes feeling short of breath

(d) Complaints suggestive of acute, inadequate organ perfusion (e.g., sudden onset of painless visual loss [retinal artery occlusion], sudden onset of testicular pain [testicular torsion])

(2) Objective data collection
(a) Confusion, disorientation

(b) Increased respiratory effort

(c) Diaphoretic, cool skin

(d) Pale, dusky skin color

(e) Pallor of nail beds or lip margins

(f) Restlessness or anxiety

(g) Peripheral pulses weak, thready, and rapid

(h) Vomiting, retching

(i) Capillary refill delayed greater than 2 seconds (reliable in children only)

(j) Hypotension

(k) Extremity injury with diminished/absent pulse; pallor

(l) Other indicators of acute, organ-specific, diminished perfusion (may be identified during more in-depth secondary or focused assessment, (i.e., retinal artery occlusion [see Chapter 23], testicular torsion [see Chapter 17])

2) Possible etiologies
a) Current or preexisting diseases/illness

b) Trauma: blunt or penetrating forces

3) Analysis: differential nursing diagnoses/collaborative problems
a) Deficient fluid volume

b) Decreased cardiac output

c) Ineffective tissue perfusion: cardiopulmonary, renal, gastrointestinal, peripheral

d) Anxiety/fear

4) Planning and implementation/interventions (interventions for inadequate perfusion must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

5) Evaluation and ongoing monitoring (see Appendix B)
a) Peripheral and/or organ-specific tissue perfusion

5. Disability (brief neurologic assessment)


a. Assessment

1) Acceptable
a) Subjective data collection
(1) No history of loss of consciousness

(2) No history of neurologic trauma

(3) No sudden onset of severe headache

b) Objective data collection
(1) Determine gross level of consciousness using “AVPU scale” (Box 1-1)

(2) Pupil assessment: pupils equal and briskly reactive to light

(3) Glasgow Coma Scale or Pediatric Coma Scale scores 15 (see Appendix C)

(4) Motor/movement
(a) Ability to respond to commands (avoid commands such as hand grasping, which may be reflexive)

(b) Moves all four extremities

2) Unacceptable/requiring immediate intervention
a) Subjective data collection
(1) History of loss of consciousness or unconscious

(2) Head or traumatic brain injury

(3) Sudden onset of severe headache

b) Objective data collection
(1) Altered level of consciousness

(2) Pupillary assessment: unequal, “blown,” slow, or absent reaction to light

(3) Abnormal flexion/extension positioning

b. Possible etiologies

1) Current or preexisting diseases/illness

2) Trauma: blunt or penetrating forces

3) Substance and/or alcohol use/abuse

4) Medication toxicity

5) Toxic environmental exposure

6) Hyperthermia/hypothermia

7) Electrolyte/acid-base balance disturbance

c. Analysis: differential nursing diagnoses/collaborative problems

1) Risk for ineffective airway clearance

2) Ineffective breathing pattern

3) Impaired gas exchange

4) Ineffective tissue perfusion: cerebral

5) Risk for aspiration

6) Risk for injury

d. Planning and implementation/interventions (interventions for acute neurologic disability must be implemented before proceeding in the primary assessment [see Section II, Resuscitation])

e. Evaluation and ongoing monitoring (see Appendix B)

1) Level of consciousness

6. Expose/environmental controls


a. Assessment

1) Acceptable/stable
a) Subjective data collection
(1) No history of unexposed injury

(2) No history of prolonged environmental exposure

(3) No history of thermoregulatory disease

(4) No history of critical infectious illness exposure

b) Objective data collection
(1) No injuries noted

(2) No petechial/purpura rash

2) Unacceptable/requiring immediate interventions/unstable
a) Subjective data collection
(1) Complaint of chest, abdominal, extremity injury or pain

(2) Recent exposure to critical infectious illness

(3) Prolonged exposure to environmental elements

b) Objective data collection
(1) Observable chest, abdominal, extremity injury

(2) Petechial rash

(3) Tachycardia/bradycardia

(4) Subnormal/elevated temperature

b. Possible etiologies

1) Current or preexisting diseases/illness

2) Trauma: blunt or penetrating forces

3) Substance and/or alcohol use/abuse

4) Medication toxicity

5) Environmental exposure

c. Analysis: differential nursing diagnoses/collaborative problems

1) Risk for injury

2) Hypothermia

Related posts:

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  3. Disaster Preparedness and Response
  4. Cardiovascular Emergencies

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Nursing Assessment and Resuscitation

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