Emergency Room (ER) Assessment ■ Circulation

■ priority→peripheral pulses of upper &

lower torso
● Primary Survey/Assessment↔organized ■ check if normal rat esp sa distal body
approach to identify threat and apply parts (peripheral)
interventions ■ intiate BP taking + apical pulse
○ Resuscitation interventions needs securing (discrepancy)
the {{envt}} ■ evaluate skin color
■ includes→PPE ■ skin temperature (check if diaphoretic)
■ uncover obvious bleeding
ABCDE ■ need {{4092812833573358::two large
bore}} IV lines
■ Airway/cervical spine↓
■ start
■ cervical spine injury is always
{{5085015058761044::isotonic}}
suspected when the person falls, how
fluids
high?→taller than their height
■ blood loss→fluids and blood is required
■ priority→estb patient airway
■ what if no pulses?→CPR
■ AIRWAY
■ CAB→compression, airway, breathing
■ always immobilize cervical spine
■ life threatening→bleeding, hemorrhage,
■ implement short conversation w/
cardiac tamponade
pt (if pt can speak then they have
■ Disability
a patent airway)
■ DISABLE
■ reposition pt w/ neck in midline
■ do neurologic assessment (GCS)
(head tilt-chin lift method)
■ immobilization is maintained
■ ways of opening airway is
■ size of pupil and reactivity
implemented
■ reactivity (PERLA)→pupil equally
■ allot time in checking for
round reactive to light
obstructions
accomodation
■ common causes→tongue,
■ AVPU = rapid screening tool for LOC
blood, loose teeth or vomit
■ A→alert
■ you should clear obstructions
■ V→respond to voice?
■ how to get rid of
■ P→responsive to pain
obstructions→jaw thrust
■ U→unresponsive
method, suctioning,
■ be mindful of LOC impairment causes
intubation (if wlala na estb
■ Alcohol = CNS depressant
ang airway)
■ Epilepsy = problem w/ electrolytes
■ Breathing
■ Insulin = hypo/hyperglycemia
■ assess→respi rate, breath sounds
■ Opiates = dec LOC
and respiratory effort
■ Uremia = problems with kidney
■ pulse oxi and use of accessory muscles
■ Trauma = esp if naay bleeding
■ evaluate chest wall movement
■ Infection
(asymmetrical or nah)
■ Poisoning
■ tracheal deviation
■ Psychosis
■ administer O2 via BVM (Ambubag)
■ Syncope
(100%)
■ leave C-collar unless SCI is not
■ airway adjuncts
confirmed (aka wait for xray)
■ oral/nasopharyngeal airway
■ enhance secondary assessment if it
■ ET tube
isnt alert
■ suctioning PRN
■ Exposure/envt
■ remove obstructive foreign bodies
■ remove clothing of pt to perform
■ life-threatening
thorough assessment (cover w/ drape
condition→pneumothorax, hydrothorax,
lang dayun)
hemothorax
■ prevent hypothermia
 ■ observe evidence preservation as ■ cover neurologic status assessment
policy ■ uncover pain via frequent assessment
■ warm fluids/blanket if needed ■ secure follow-up measures
■ determine extent of injury
● Secondary Survey/Assessment↔identify other
injuries or other issues that need to be
assessed; head-to-toe assessment for ALL
injuries
○ FGHI
■ Full set of vital signs
■ vs= TPR, BP, O2
■ biometrics = H&W
■ vs evaluated serially
■ Give comfort measures (Pain assessment)
■ Assess pain (5th vs)
■ PQRST→provoking factors, quality of
pain, radiation, severity, timing
■ wong-baker faces pain scale
■ chief complaints
■ non-pharma measures first
■ History taking→while doing head to toe
assessment
■ health hx
■ focus on chief complaints (not a dx
tho!)
■ contact reliable source of information
■ organize adequate history with
SAMPLE (types of info
needed)→subjective; allergies;
medications; past medical hx; last meal
eaten, tetatnus shot, period; events
leading to injury
■ open-ended but direct questioning
■ family and social history
■ Institute head to toe assessment
■ elaborate causes of altered LOC
■ head, face, neck
■ chest and abdomen
■ pelvis and perineum
■ both extremities
■ posterior surfaces
● Ongoing Assessment/Focus
Assessment↔integrated throughout the nsg
process; identify problems that is overlooked
earlier; q15 min follow-up
○ indications→identify response to
interventions and to determine
improvement or deterioration in patient
status; need for RE-assessment
○ example→I&O hourly monitoring
○ FOCUS
■ facilitate trauma score calculation
■ often repeat for vs taking