1 / 28

ASSESSMENT OF THE TRAUMA PATIENT

ASSESSMENT OF THE TRAUMA PATIENT. April Morgenroth RN, MN. Initial Assessment. Early recognition of injury + early intervention = better patient outcomes . http://www.healthsavers.info/images/ist2_449711_healthy_heart.jpg. Primary Assessment . Airway. Breathing. Circulation. Disability.

sirvat
Télécharger la présentation

ASSESSMENT OF THE TRAUMA PATIENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ASSESSMENT OF THE TRAUMA PATIENT April MorgenrothRN, MN

  2. Initial Assessment Early recognition of injury + early intervention = better patient outcomes http://www.healthsavers.info/images/ist2_449711_healthy_heart.jpg

  3. Primary Assessment Airway Breathing Circulation Disability

  4. Remember …

  5. Airway • Inspect the patient’s airway while maintaining cervical spine stabilization. • Observe for speaking, tongue obstructing airway , bleeding , vomiting, and swelling.

  6. Interventions for Ineffective Airway • Maintain Cervical Spine Stabilization and/or immobilization • Proper positioning for airway patency • Jaw thrust • Chin lift • Removal of or foreign objects or debris • Suctioning

  7. Breathing Assess for rise and fall of chest, respiratory rate and pattern.

  8. Signs of Ineffective Breathing

  9. Interventions for Ineffective Breathing • Administer Oxygen via a mask or nasal cannula. • Ventilate the patient via a non-rebreather mask. • Insert Artificial Airway http://uemshealthcare.org/images/basicairwaystill.jpg

  10. Circulation • Palpate Pulses: Are they normal, weak or strong? • Inspect skin: Is the color normal? Is it warm or cold? Clammy or dry? • Look for obvious bleeding. • Obtain blood pressure.

  11. Signs of Ineffective Circulation

  12. Interventions for Ineffective Circulation Initiate IV access Fluid resuscitation with Normal Saline or Lactated Ringer’s Consider planning for a blood transfusion, if ordered and available • Control any uncontrolled bleeding by: • Apply direct pressure to the wound and/or apply a pressure dressing • Use a tourniquet only when other methods to control bleeding have failed

  13. Disability – Neurologic Status The patient’s level of consciousness can show immediate signs of brain injury. A – Alert and responsive V – Responds to verbal stimuli P – Responds to only painful stimuli U - Unresponsive Pupils Assess pupils for size, shape, equality, and reactivity to light

  14. Secondary Assessment Obtain Vital Signs Head to Toe Assessment Medical History

  15. Full Set Vital Signs • Obtain vital signs: respirations, pulse, blood pressure, temperature, pulse oximetry, pain. • Obtain Laboratory studies if necessary.

  16. History http://www.handcrafted-pens.com/img/PK-PEN.jpg • Mechanism of Injury and time it happened • Description of Injuries and pain • Past medical history, previous hospitalizations • Age • Medications / Allergies • Immunization history • Use of drugs or alcohol, smoking history • Last menstrual period

  17. 7. Head-to-Toe Assessment

  18. General Appearance: • Take note of the patient’s level of distress (mild, moderate, severe), • body position, • posture, • rigidity or flaccidity of muscles, • unusual odors (alcohol, gasoline, chemicals, body fluids).

  19. Head and Face • Loose teeth or foreign objects which may compromise the airway • Soft tissue injuries • Deformities • Eyes • Ears • Nose • Neck http://www1.istockphoto.com/

  20. Head and Face • Assess for: • Gross visual acuity • Bruising, bleeding, or swelling around the eyes • Pupils: equal sizes, shape, reactivity Eyes http://upload.wikimedia.org/wikipedia/commons/6/65/Eye_iris.jpg

  21. Head and Face • Inspect for: • Bruising behind the ear (Battle’s sign) • Soft tissue injury • Unusual drainage from ears or nose, such as blood or clear fluid. DO NOT pack it to stop drainage as it may be cerebrospinal fluid (CSF). • Avoid inserting a nasogastric tube if such drainage is present. Ears/Nose http://www.immediateactionservices.com/battlessign.jpg (Battle’s Sign)

  22. Neck • Inspect for: • Signs of trauma • Observe position of trachea and appearance of external jugular veins. n

  23. Chest • Inspection • Observe breathing for rate, depth, effort, use of accessory muscles, asymmetrical chest rise • Auscultation • Note any abnormal lung sounds • Palpation • Palpate clavicles, sternum, and the ribs for bony crepitus or deformities

  24. Abdomen/Flanks • Inspection • Soft tissue injuries • Auscultation • Bowel sounds • Palpation • Rigidity, guarding, masses, areas of tenderness.

  25. Pelvis/Perineum • Inspect for external soft tissue injuries, deformities, exposed bone, blood at the perineum • Palpate for stability of pelvic bones

  26. Extremities • Circulation • Inspect color • Palpate skin temperature • Palpate pulses • Soft tissue injuries • Bony injuries • Motor function: • Check motor function on both sides – does the patient move both sides of the body equally? • Hand grasp and foot strength

  27. Inspect The Back • Maintain cervical spine stabilization • Support extremities with suspected injuries • Logroll patient with at least 3 other team members • Palpate all posterior surfaces for deformity and areas of tenderness http://www.itim.nsw.gov.au/images/logroll-bloody_back.jpg

  28. Glasgow Coma Scale • A measure of the patient’s level of consciousness • Score ranges from 3-15 • Severe head injury • <8 • Moderate head injury • 9-12 • Minor head injury • 13-15

More Related