1. 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.

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. 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

4. 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

5. 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.

6. 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

7. 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