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Trauma Nursing Core Course 7th Edition

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Presentation on theme: "Trauma Nursing Core Course 7th Edition"— Presentation transcript:

1 Trauma Nursing Core Course 7th Edition
Chapter 5: Initial Assessment Instructor Course: Microteach Lecture Set 3 Trauma Nursing Core Course 7th Edition Chapter 5: Initial Assessment, begins on page 39 of the TNCC Provider Manual.

2 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

3 B–Breathing and Ventilation
Inspect for: Spontaneous breathing Symmetrical rise and fall of the chest Depth, pattern, and rate of respirations Signs of respiratory difficulty Skin color Wounds, contusions, abrasions, or deformities Breathing and ventilation is the next step of the primary survey. Inspect for: Spontaneous breathing Symmetrical rise and fall of the chest Depth, pattern, and rate of respirations Signs of respiratory difficulty such as the use of accessory muscles or diaphragmatic breathing Skin color (cyanosis) Contusions, abrasions, or deformities that may be a sign of underlying injury Open pneumothoraces (sucking chest wounds) Signs of inhalation injury (singed nasal hairs, blistering of the oral mucosa) Jugular venous distention (JVD) and the position of the trachea (tracheal deviation and JVD are late signs that may indicate a tension pneumothorax)

4 B–Breathing and Ventilation
Auscultate for: Breath sounds Presence Quality Comparison Heart sounds Palpate for: Bony structures Subcutaneous emphysema Soft tissue injury From Loyola University School of Medicine. Auscultate for: Breath sounds: Bilaterally at the second intercostal space, midclavicular line Bases at the fifth intercostal space at the anterior axillary line Presence, quality, and comparison of breath sounds Heart sounds: Muffled as in pericardial tamponade Palpate for: Bony structures and possible rib fractures, which may impact ventilation Subcutaneous emphysema, which may be a sign of a pneumothorax Soft tissue injury impacting respiratory efforts Jugular venous pulsations at the suprasternal notch or in the supraclavicular area

5 B–Breathing and Ventilation
If breathing is absent: Open the airway Jaw-thrust with second person Insert an airway adjunct Assist ventilations with bag-mask device Prepare for definitive airway If breathing is absent: Open the airway using the jaw-thrust maneuver with a second person maintaining manual cervical spinal stabilization Insert an airway adjunct, either an oropharyngeal or nasopharyngeal airway Assist ventilations with a bag-mask device Prepare for a definitive airway

6 B–Breathing and Ventilation
If breathing is present: Administer oxygen Nonrebreather mask at 15 L/min Avoid hyperoxia Determine ventilation effectiveness Use end-tidal CO2 monitoring If breathing is present, administer oxygen. Patients with multiple trauma need early supplemental oxygen; however, recent evidence suggests that hyperoxia can be just as lethal. Once stabilized, closely monitor and titrate oxygen delivery for stabilized trauma patients to avoid the detrimental physiologic effects of hyperoxia. Administer oxygen via a tight-fitting nonrebreather mask with a reservoir bag at 15 L/min The next step is to determine if ventilation is effective. Monitoring of end-tidal CO2 (ETCO2) can help guide this decision. This is discussed further in Chapter 6, Airway and Ventilation.

7 B–Breathing and Ventilation
If ventilation is ineffective: Assist ventilations with bag-mask device Deliver 10–12 breaths/min Oxygen 15 L/min Prepare for definitive airway Identify and treat life-threatening injuries If breathing is present, assess for effective ventilation. If ventilation is effective, maintain oxygen via nonrebreather mask at 15 L/min. If ventilation is ineffective: Assist ventilation with a bag-mask device connected to an oxygen source at 15 L/min to administer 10 to 12 breaths per minute or one every 5 to 6 seconds Determine the need for a definitive airway (ETT securely placed in the trachea with the cuff inflated) Identify life-threatening pulmonary injuries. They include: Open pneumothorax Tension pneumothorax Flail chest Hemothorax These injuries require rapid identification and immediate intervention before proceeding to the next step in the primary survey. See Chapter 11, Thoracic and Neck Trauma, for more information.


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