Primary and Secondary Survey

B C

A client is transported to the ED with an acute respiratory infection. Vital signs are T 102F, P 110bpm, RR 32 breaths/min. Circumoral cyanosis is noted, and oxygen saturation is 85%. What should be the immediate actions by the nurse caring for this client? Select all that apply A. Encouraging deep breathing and coughing B. Initiate oxygen at 6/L min via nasal cannula C. Place client in high fowlers position D. Encourage pursed lip breathing E. Maintain sidelying with one pillow

B

A mother who is visibly upset caries her 2 month old infant into the crowded ED. The child appears limb and lifeless. The mother screams to the nurse for help. The nurses first action should be? A. To take the infant from the mother and offer to help B. To take the infant from the mother back to a treatment room C. To call the resuscitation team and the supervisor D. To assess the child's pulse and respirations

A

A school aged child is brought to an emergency department by ambulance. The child is minimally responsive, hypotensive, tachycardic, and has a high fever. Orders are written by a health care provider (HCP). Which order should the nurse initiate first? A. Saline bolus per weight based protocol B. Blood cultures times 2 C. Ampicillin (ampicin) 25mg/kg IV q6h D. Oxygen at 40% FIO 2

primary

ABCDE make up what kind of assessment?

inspect posterior surfaces

Back and posterior aspects of the head, arms and legs Bleeding Abrasions Ecchymosis- size and color of bruising, location, mark it Need to log roll these patients as one unit

Disability

Conduct a brief neurological assessment using AVPU mnemonic A = Alert: is the patient alert and responsive? V = Verbal: Does the patient respond to verbal stimuli? P = Pain: Does the patient respond to painful stimuli? U = Unresponsive: Is the patient unresponsive to all stimuli, including pain?

Circulation

Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia. Main places blood had to go to (brain, heart, lungs) Possible IV access- most likely 18 gauge in the antecubital

breathing

Evaluation of Breathing Focused respiratory assessment Includes: -Is the person SOB -Are they holding their chest -Are they getting more anxious -shallow breathing -tense muscles important for the nurse to limit the patients activities if they are having problems breathing -this enables the patient to get more O2 in

Secondary

FGHI make up what kind of assessment?

Pulse Oximetry (SpO2)

Fast easy tool used to assess oxygen saturation Want 02 saturations greater than 90/92%

head to toe

Head & face -Want to se theta there are not bruises to the face, what do their eyes look like (edema, symmetrical) Neck -What does the trach look like, what does the neck look like (No deviation, trach is midline) Chest -Pulmonary & cardiac function assessment -Want to see that the chest is rising Abdomen Pelvis and perineum -Inspection, auscultation, palpation, percussion -Bleeding, femoral pulses, distension in the belly, discoloration, bowel sounds, voiding, -Pain -be careful with turning and repositioning with fractures Extremities -movement -sensation

full set of vitals

Indicate physiologic status -tells you if they hemodynamically unstable BP, HR, RR, temperature, oxygen saturation and weight are measured -weight can help gauge if they are varying from their baseline

Focused Respiratory Assessment

Inspection: looking at the patients chest is it expanding (symmetric) Auscultation: What sounds might you hear? -Rhonchi (indicates something in the airway) -Wheezes (fluids) -Crackles (narrowing of the airway/ tightened) -Rales -Normal (clear) -Nothing ( no air flow/no movement)

bariatric

More prone to respiratory failure, acute kidney injury, pneumonia, DVT, pressure ulcers Need to encourage turning, coughing, and deep-breathing exercises to prevent atelectasis Challenges with inserting IV lines and airways Need to be in upright positions to assess blood volume and adequate perfusion Go indicator that some one has good circulation if you can't feel a pulse? -Color, temp, cap refill -Of the foot/arm is warm it is getting blood flow to it

give comfort

Pain assessment Pharmacologic -Not started on the highest dose bc they want to make sure the patient will respond to questions Non-pharmacologic -Ice, blankets, positioning

Airway

Provide adequate ventilation, employing resuscitation measures when necessary. (Trauma patients must have the cervical spine protected and chest injuries assessed first, immediately after the airway is established.) -If a patient is on C-spine precautions, neck brace cannot be removed unit it is cleared by X-ray Observe for: -Rise and fall of chest- Equal? -If not equal could be pneumothorax, hemothorax? Open Airway -Intubate: purpose is to establish and maintain the airway --balloon at the end of tube should be inflated to keep aureate patency --may be rapid, want to make sure tube is secured

History

Relevant: AMPLE mnemonic A= meds or environment? M= what kind of meds are they on, what do they take routinely, over the counter? P= what is health hx L= incase they need surgery E= specific detailed hx of what happened Complete Head to toe

Exposure

Something they came in contact with that brought them in Ex/ burns, chemicals, seat belt injury

DVT PE A fib

The geriatric population is at risk for?

Airway Breathing Circulation Disability Exposure

What does ABCDE stand for?

A = Allergies M = Medications P = Past health history L = last meal eaten E = events leading to illness/injury

What does AMPLE stand for?

Alert Verbal Pain Unresponsive

What does AVPU stand for?

Full set of vitals Give comfort Hx & head to toe Inspect posterior surfaces

What does FGHI stand for?

BP low less than 90 Heart rate Altered mental status Capillary refill Weak/ thready pulses

What would tell you some one doesn't have enough fluid in the body?

C

When a primary survey of a trauma patient is conducted, what is considered one of the priority actions? A. Obtain a complete set of vital sign measurements B. Palpate and auscultate the abdomen C. Perform a brief neurological assessment D. Check the pulse oximetry reading

secondary assessment

an assessment of the patient triaged to the emergent or resuscitation category that commences after the primary survey is completed and life-threatening insults addressed; includes obtaining vital signs, completing a head-to-toe examination, and obtaining the patient's pertinent medical-surgical history, including the history of the current event

primary assessment

an assessment of the patient triaged to the emergent or resuscitation category that focuses on stabilizing life-threatening conditions; uses the mnemonic ABCDE, which stands for airway, breathing, circulation, disability, and exposure Goal -Assessment does not progress until treatment is initiated for all significant abnormalities Major Components: -Subjective data collection- what the patient is saying --Need to ask specific, direct questions

intraosseous infusion (IO)

is the process of injecting directly into the marrow of a bone. This provides a non-collapsible entry point into the systemic venous system. This technique is used to provide fluids and medication when intravenous access is not available or not feasible. Done when : -no pulses are present -circulation is ineffective

geriatric trauma

present with many comorbidities Emergencies can be more difficult to manage in this age group May have limited sources of social and financial support- may need referrals to support services Nonspecific symptoms, such as weakness and fatigue, episodes of falling, incontinence, and change in mental status, may be manifestations of acute, potentially life-threatening illness ABCD Mental status change- brain can store o2 or glucose, being more combative or restless and they are not normally like that