Nursing Assessment and Trauma Resuscitation

CHAPTER 31 Nursing Assessment and Trauma Resuscitation



Reneé Semonin Holleran, RN, PhD, CEN, CCRN, CFRN, CTRN, FAEN



MAJOR TOPICS



Primary Assessment1


Overview of Major Components

Individual Components of Primary Assessment

Resuscitation2


Airway Management

Breathing Management

Circulation Management

Disability Management

Exposure and Environmental Management

Secondary Assessment3


Major Components of Secondary Assessment

Focused Assessment

Consider Need for Transfer2


Indications

Emergency Medical Treatment and Active Labor Act (EMTALA)

Analysis: Differential Nursing Diagnoses/Collaborative Problems


Planning and Implementation/Interventions


Evaluation and Ongoing Monitoring


Continuously Monitor and Treat as Indicated

Monitor Patient Response/Outcomes and Modify Nursing Care Plan as Appropriate

If Patient Outcomes Are Not Demonstrated, Reevaluate Assessment and/or Plan of Care

Documentation of Interventions and Patient Response


Subjective Data Collection

Objective Data Collection

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Age-Related Considerations


Pediatric

Geriatric

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



I. PRIMARY ASSESSMENT1


The goal of the primary assessment in the traumatically injured patient 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 history of present injury/chief complaint

1) Mechanism of injury (see Chapter 30)

2) Pain: location (see Chapter 9)

b. Brief past medical history

1) Current or preexisting diseases, illnesses, surgical procedures, especially any conditions that may have contributed to the cause of the injury (e.g., hypoglycemia)

2) Past/current substance and/or alcohol use/abuse

3) Last normal menstrual cycle: female patients of childbearing age

4) Current medications
a) Prescription

b) Over-the-counter/herbal

5) Allergies

6) Immunization status

2. Objective data collection


a. Airway patency with simultaneous cervical spine protection

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 protection


a. Open, clear, patent

1) Vocalization present

2) No tongue obstruction

3) No loose teeth or foreign objects in oral cavity

4) No bleeding, vomitus, or other secretions in oral cavity

5) No facial/neck edema or wounds

b. Partially obstructed or obstructed/unacceptable requiring immediate intervention

1) Subjective data collection
a) Trauma to face, mouth, pharynx, neck, or chest

2) Objective data collection
a) Absence of breathing

b) Patient unable to speak or vocalize appropriate for age

c) Substernal, intercostal retracting

d) Decreased level of consciousness

e) Inspiratory and/or expiratory stridor

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

g) Facial/neck injury compromising airway

c. Planning and implementation/interventions (interventions for obstructed airway must be implemented before proceeding in the primary assessment; see Section II [Resuscitation])

1) If mechanism of injury, symptoms, or physical findings suggest a spinal cord injury, the cervical spine must be stabilized and protected

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

2. Cervical spine


a. Acceptable, stable

1) Subjective data collection

a) No history of head, neck, chest injury

b) No complaints of pain with movement or palpation of cervical spine

2) Objective data collection

a) Movement in all extremities without limitation or weakness

b) Breathing effective: no intercostal retractions or abdominal breathing

c) Active full range of motion of neck without limitation or tenderness with palpation

b. Unacceptable or requiring immediate intervention/unstable

1) Subjective data collection

a) Mechanism of injury (see Chapter 30) with potential for cervical trauma (e.g., direct injury to head or neck, trauma involving sudden deceleration [motor vehicle crash or fall], high-voltage electrical shock)

b) Symptoms: inability to move extremities

c) Pain with movement of neck

2) Objective data collection: possibility of no objective findings as nondisplaced fractures of cervical spine may not compromise neurologic system

a) Tenderness in cervical spine with movement or palpation

b) Paralysis or paresthesia

c) Abdominal breathing indicating possible paralysis of diaphragm

d) Decreased or absent movement/sensation below level of injury

e) Weakness

f) Bowel or bladder incontinence or retention

g) Loss of sympathetic outflow

1) Hypotension

2) Bradycardia

h) Flaccid paralysis

i) Loss of sphincter tone

j) Priapism

k) Warm, dry skin

l) Bounding peripheral pulses

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

n) Inability to shiver or sweat

3) Planning and implementation/interventions (interventions for cervical spine protection must be implemented before proceeding in the primary assessment; see Section II [Resuscitation])

3. Breathing


a. Effective

1) Subjective data collection

a) No respiratory difficulty

b) No neck, chest, abdominal injury

2) Objective data collection

a) Spontaneous breathing

b) Rate, pattern of breathing normal for patient’s age

c) Chest symmetry and no use of accessory muscles or diaphragmatic breathing

d) Skin color: absence of paleness, duskiness

e) Integrity of the soft tissue and bony structures of the chest wall

b. Compromised or absent/unacceptable requiring immediate intervention will differ depending on whether breathing is compromised or absent

1) Subjective data collection

a) Blunt or penetrating injury to neck, chest, back, or abdomen

b) Dyspnea

2) Objective data collection

a) Apnea

b) Agonal breathing (fewer than 10 breaths/minute in adults)

c) Marked tachypnea

d) Shallow, weak, gasping respirations

e) Cyanosis, diaphoresis

f) Marked increase in respiratory effort

g) Absent breath sounds, unilaterally or bilaterally

h) Severe retractions

i) Open or sucking chest wounds

j) Paradoxical chest wall movement

3) Planning and implementation/interventions (interventions for ineffective or absent breathing must be implemented before proceeding in the primary assessment; see Section II [Resuscitation])

4. Circulation


a. Acceptable or adequate

1) Subjective data collection

a) No report or suspicion of significant blood loss

2) Objective data collection

a) Radial pulse palpable

b) Rate: approximately 60 to 80 beats/minute in uncompromised adults

c) Heart rate: between 100 and 160 beats/minute in infants, between 80 and 130 beats/minute in small children (see Appendix D)

d) No external hemorrhage

b. Compromised or absent/unacceptable requiring immediate intervention

1) Subjective data collection

a) Unconsciousness or significantly altered level of consciousness

b) 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, or sustained tachycardia

c) Unresponsive or significantly altered level of consciousness

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

e) Distended, rigid abdomen

f) Carotid and/or femoral pulses not palpable

g) Auscultate blood pressure: if other members of the trauma team available, blood pressure may be obtained. Systolic blood pressure less than 90 mm Hg in adults, rapid heart rate and thready, weak pulse indicate poor circulation. If no other trauma team members available, continue with primary assessment and obtain blood pressure during the secondary assessment

5. Disability


a. Acceptable

1) Subjective data collection

a) No history of loss of consciousness

b) No history of neurologic trauma

2) Objective data collection

a) Determine gross level of consciousness using AVPU scale

A = Alert, awake; responsive to voice; oriented to person, time, and place

V = Verbal; responds to voice but not fully oriented to person, time, or place

P = Pain; does not respond to voice but responds to painful stimuli

U = Unresponsive; does not respond to voice or painful stimuli

b) Pupil assessment: pupils equal and briskly reactive to light

c) Pediatric Coma Scale scores 15 (see Appendix C)

d) Moves all four extremities

e) No lateralizing signs (neurologic assessment findings on one side of the body) coma scale.

b. Unacceptable/requiring immediate intervention

1) Subjective data collection

a) History of loss of consciousness or unconscious

b) Neurologic injury

2) Objective data collection

a) Altered level of consciousness

b) Abnormal flexion/extension posturing

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

d) Lateralizing signs: unilateral deterioration in motor movements or unequal pupils, aid in locating area of injury in the brain

3) Planning and implementation/interventions

a) Continue to monitor for compromise to airway, breathing, or circulation

b) Consider limited hyperventilation if patient is exhibiting signs of herniation, or neurologic deterioration unresponsive to other resuscitative measures

6. Exposure/environment controls


a. Remove patient’s clothing to quickly identify life-threatening injuries

1) Cut clothing, without destroying physical or forensic evidence (see Chapter 43), if possible

2) Exercise caution for possible sharp objects (e.g., needles) or weapons in pockets


II. Resuscitation2


The goal of resuscitation in the primary assessment is to correct all life-threatening deviations from normal. Resuscitation priorities follow the same A-B-C-D-E mnemonic because interventions occur simultaneously during the primary assessment.



A. Airway Management4




1. Airway patent


a. Apply/maintain cervical spine protection

Related posts:

  1. Genitourinary Emergencies
  2. Wounds and Wound Management
  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 Trauma Resuscitation

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