ASSESSMENT OF THE TRAUMA PATIENT April MorgenrothRN, 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
Airway • Inspect the patient’s airway while maintaining cervical spine stabilization. • Observe for speaking, tongue obstructing airway , bleeding , vomiting, and swelling.
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
Breathing Assess for rise and fall of chest, respiratory rate and pattern.
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
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.
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
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
Secondary Assessment Obtain Vital Signs Head to Toe Assessment Medical History
Full Set Vital Signs • Obtain vital signs: respirations, pulse, blood pressure, temperature, pulse oximetry, pain. • Obtain Laboratory studies if necessary.
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
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).
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/
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
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)
Neck • Inspect for: • Signs of trauma • Observe position of trachea and appearance of external jugular veins. n
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
Abdomen/Flanks • Inspection • Soft tissue injuries • Auscultation • Bowel sounds • Palpation • Rigidity, guarding, masses, areas of tenderness.
Pelvis/Perineum • Inspect for external soft tissue injuries, deformities, exposed bone, blood at the perineum • Palpate for stability of pelvic bones
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
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
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