Trauma Nursing Core Course 7th Edition Chapter 5: Initial Assessment Instructor Course: Microteach Lecture Set 5 Trauma Nursing Core Course 7th Edition Chapter 5: Initial Assessment, begins on page 39 of the TNCC Provider Manual.

Objectives Recognize competence in the initial assessment process. It is the foundation of trauma nursing practice. Demonstrate the components of the initial assessment process Differentiate between goals of the primary and secondary surveys Determine actual and potential threats to life and limb using the initial assessment process Select interventions to manage life-threatening conditions identified during the initial assessment process

D–Disability (neurologic status) Inspect pupils PERRL Assess Glasgow Coma Scale Best eye opening Best verbal response Best motor response Assess the pupils to see if they are equal in size, round, and reactive to light. Complete the Glasgow Coma Scale (GCS) score. The GCS is a standardized method for quickly evaluating level of consciousness It facilitates communication among care providers Scores range from 3, indicating deep unconsciousness, to 15, indicating a patient who is alert, converses normally, and is able to follow commands Assess the GCS score upon patient arrival and repeat to trend changes in neurologic status See Chapter 9, Brain, Cranial, and Maxillofacial Trauma, for more information

D–Disability (neurologic status) Head CT ABGs Glucose If there are abnormal assessment findings at D, you may need to: Consider the need for computed tomography (CT) of the head. Consider ABGs. A decreased level of consciousness may be an indicator of decreased cerebral perfusion, hypoventilation, or acid/base imbalance. Perform point-of-care testing for glucose. Hypoglycemia may play a role in the patient’s neurologic status. Any changes in level of consciousness are thought to be the result of central nervous system injury until proven otherwise. NOTE: CT scan of patient with brain injury

E–Exposure and Environmental Control Assessment Remove all clothing Uncontrolled bleeding Note obvious injuries Interventions Evidence collection Keep warm Remove the patient’s clothing and keep the patient warm: Carefully and completely undress the patient Use caution as there may be needles, glass shards, weapons, or other sharp items in the clothing Inspect for any uncontrolled hemorrhage and quickly note any obvious injuries Interventions Trauma patients lose body heat for many reasons, including blood loss and environment. Maintain body temperature by: Covering the patient with warm blankets Keeping the ambient temperature warm Administering warmed IV fluids Using forced air warmers Using radiant warming lights When using devices to warm patients, use care to prevent burns or overwarming. Use temperature probes or frequent assessment of body temperature.

F-Resuscitation Adjuncts Full set of vital signs Obtain baseline Trend for changes Facilitate family presence Preferred by patients and family Assign a liaison or advocate Obtain and trend vital signs at regular intervals, including blood pressure, pulse, respirations, and temperature. Facilitate family presence as soon as possible: Evidence shows that patients prefer to have family members present during resuscitation There is also strong evidence supporting that family members wish to be offered the option to be present during invasive procedures and resuscitation of a family member Provide a member of the trauma team to act as liaison to the family The Emergency Nurses Association, along with several other professional organizations, supports the option of family presence during resuscitation

G-Resuscitation Adjuncts G–Get Resuscitation Adjuncts L–Laboratory studies M–Monitor for cardiac rhythm and rate assessment N–Naso- or orogastric tube consideration O–Oxygenation or ventilation analysis P–Pain assessment and management Consider the mnemonic LMNOP to remember these resuscitation adjuncts: L–Laboratory analysis: Arterial or venous blood gases: Give values of oxygen (O2), carbon dioxide (CO2), and base excess (NaHCO3 ) values Laboratory specimen for blood typing Lactic acid, which can indicate the adequacy of tissue perfusion M–Monitor cardiac rate and rhythm: Assess for dysrhythmias—such as premature ventricular contractions, atrial fibrillation, or S-T segment changes—that may indicate blunt cardiac trauma Pulseless electrical activity (PEA) may point to cardiac tamponade, tension pneumothorax, or profound hypovolemia N–Naso- or orogastric tube consideration Insertion can provide for evacuation of stomach contents and guard against gastric distention, which may help to prevent vomiting and/or aspiration If mid-face fractures or head injury are suspected, insert an orogastric tube O–Oxygenation and ventilation assessment Pulse oximetry detects changes in oxygenation that cannot be readily observed clinically It is noninvasive and measures the oxygen saturation of arterial blood or percentage of bound hemoglobin Accurate readings are dependent on adequate peripheral perfusion Remember that oximetry does not demonstrate evidence of ventilation Use monitoring (or capnography) for information regarding ventilation Normal values are 35 to 45 mm Hg P–Pain assessment and management The assessment and management of severe pain is an important part of trauma care Many injuries sustained by the trauma patient may be life-changing for both the patient and family, so spiritual and psychosocial support are essential. See Chapter 8, Pain