Primary and Secondary Emergency Assessment

Primary and Secondary Emergency Assessment

التقييــــم المبدئي و الثانوي لحالات الطوارئ

A systematic approach to the assessment of an emergency patient is essential. Usually, the most dramatic injury is not the most serious. The primary and secondary surveys provide the emergency nurse with a methodical approach to help identify and prioritize patient needs

إن النظرة بشكل منظـــــم لتقيم أي حالة طارئة ضرورياً. عادة معظم الإصابات المثيرة ليست الأكثر خطورة. يزود التقييم المبدئي و الثانوي ممرض الطوارئ نظرة منهجية لتساعده في تميز أولويات و احتياجات المريض

Primary Assessment

The initial, rapid, ABCD (airway, breathing, and circulation, as well as neurologic disability resulting from spinal cord or head injuries) assessment of the patient is meant to identify life-threatening problems. If conditions are identified that present an immediate threat to life, appropriate interventions are required before proceeding to the secondary assessment

التقييم المبدئي :

أولي و بشكل سريع ( مجرى الهواء, التنفس , الدورة الدموية , بالإضافة لعجز الجهاز العصبي الناتجة من إصابات الحبل ألشوكي أو إصابات الرأس ) تقييم المريض يقصد به تميز المشاكل الخطرة . إذا وضع و حالة المريض تبين إن هناك تهديد لحياتــه. ومن الضروري عمل التدخلات الملائمة قبل المضي بعمل التقييم الثانوي.

Airway
Does the patient have an open airway? Is the patient able to speak? Check for airway obstructions such as loose teeth, foreign objects, bleeding, vomitus or other secretions. Immediately treat anything that compromises the airway

مجرى الهواء:
هل مجرى الهواء مفتوح؟ هل المريض قادر أن يتكلم؟ افحص أي انسداد لمجرى الهواء كمثل الأسنان الغير ثابتة, جسم غريب , النزيف , الاستفراغ أو إفرازات أخرى . يعالج أي شئ يعيق مجرى الهواء فوراً.

Breathing

Is the patient breathing? Assess for equal rise and fall of the chest (check for bilateral breath sounds), respiratory rate and pattern, skin color, use of accessory muscles, integrity of the chest wall, and position of the trachea. All major trauma patients require supplemental oxygen via a nonrebreather mask

التنفس:

هل المريض يتنفس؟ قيّم ارتفاع و امتلأ الرئتين بالهواء( افحص صوت الهواء الداخل للرئتين ), قيّم سرعة و نمط التنفس, لون الجلد , استعمال عضلات مساعدة للتنفس, سلامة الصدر من الإصابات و موقع القصبة الهوائية . كل مرضى الإصابات الكبيرة يتطلب أمدادهم بالأكسجين بواسطة قناع غير قابل لإعادة التنفس.

Circulation

Is circulation in immediate jeopardy? Can you palpate a central pulse? What is the quality (strong, weak, slow, rapid)? Is the skin warm and dry? Is the skin color normal? Obtain a blood pressure - in both arms if chest trauma is suspected

الدورة الدموية:

هل هناك خطورة على الدورة الدمــــويةًَ؟ هل تستطيع جس النبض المركزي؟ ما هي جودة او نمط النبض(قوي, ضعيف. بطئ, سريع) هل الجلد دافئ و جاف؟ هل لون الجلد طبيعي؟ قياس ضغط الدم ( من كلتا اليدين إذا هناك احتمالية إصابات بالصدر)

Disability

Assess level of consciousness and pupils (a more complete neurologic survey will be completed in the secondary survey). Assess level of consciousness using the AVPU scale

عجز الجهاز العصبي:

قيّم مستوى الوعي و بؤبؤ العيــــنين واستجابتهما للضوء (تقيم الجهاز العصبي سيكمّل في التقييم الثانوي)
تقيم مستوى الوعي باستخدام درجـــة ( (AVPU

Is the patient ِِِAlert

هل المريض يقظ و مدرك؟

Does the patient respond to Voice

هل المريض يستجيب للصوت؟

Does the patient respond to Painful stimulus

هل المريض يستجيب للألم ؟

The patient is Unresponsive even to painful stimulus

المريض لا يستجيب حتى بالألم

Secondary Assessment

The secondary assessment is a brief, but thorough, systematic assessment designed to identify all injuries. The steps include Expose/environmental control, Full set of vital signs/Five interventions/Facilitate family presence, and Give comfort measures

التقييم الثانوي :

التقييم الثانوي ملخص لكن تقييم منظم وشامل صمم ليتم التعرف على كل الإصابات. الخطوات تشمل الكشف عن المريض والسيطرة على المحيط البيئي, معرفة وقياس العلامات الحيوية . التدخلات الخمس. تسهيل حضور اهل المريض. إعطاء الطمأنينة والراحة .

Expose/environmental control

It is necessary to remove the patient's clothing in order to identify all injuries. You must then prevent heat loss by using warm blankets, overhead warmers, and warmed I.V. fluids

الكشف عن المريض/ السيطرة على المحيط البيئي:

ضروري لإبعاد ملابس المريض عند الطلب لسهولة الفحص و مشاهدة كل الإصابات إن وجدت. يجب المحافظــــة على درجة الحرارة الجسم باستخدام بطانية دافئة . تدفئة رأس كذلك استخدام محاليل وريدية دافئة

vital signs/five interventions/facilitate family presence

العلامات الحيوية/ التدخلات الخمس / تسهيل حضور اهل المريض:

Obtain a full set of vital signs including blood pressure, heart rate, respiratory rate, and temperature. obtain blood pressure in both arms if chest trauma is suspected

أخذ جميع العلامات الحيوية وتتضمن ضغط الدم, عدد النبض , عدد مرات التنفس و قياس الحرارة ويأخذ ضغط الدم من كلا اليدين إذا كان هناك احتمالية إصابة الصدر

Five interventions

التدخلات الخمس

Pulse oximetry to measure the oxygen saturation

قياس نسبة تشبع الدم بالأكسجين

Insert urinary catheter : do not insert if you note blood at the meatus, blood in the scrotum, or if you suspect a pelvic fracture

ادخال القسطرة البولية : ( لا تدخل القسطرة البولية اذا كان هناك دم: بالمجرى البولي, دم في كيس الصفن او هناك احتمالية كسور الحوض )

Gastric tube : if there is evidence of facial fractures, insert the tube orally

انبوبة رايل : ( اذا كان هناك كسور بالوجه , يتم ادخال الانبوب عن طريق الفم)

Laboratory studies frequently: include type and crossmatching, hemoglobin and hematocrit, electrolytes, prothrombin time (PT) and partial thromboplastin time, and pregnancy test if applicable

الفحوصات المخبرية المتنوعة وتشمل ( توافق الدم , الهيموجلوبين , حجم خلايا الدم و إلكترولايت و سرعة تجلط الدم و إختبار الحمل)

Facilitate family presence: It is important during assessment for obtaining history support the patient and to explain for them any procedure or to sign any consent

تسهيل حضور أهل المريض : جدا مهم خلال التقييم للحصول على التاريخ المريضي للمريض ودعم المريض اثناء أي اجراء والشرح لهم أي أجراء قد يتطلب موافقتهم

Give comfort measures

These include verbal reassurances as well as pain management as appropriate. Do not forget to give comfort measures to the family during the resuscitation process

تقديم الطمأنينة والمؤاساة :

ويشمل طمأنت المريض بالكلام ومعالجة الألم بقـــــدر الإمكان . لا تنسى ان تقدم الطمأنينة والمؤاساة لأهل المريض اثناء عملية الانعاش او اي اجراء .

The steps includ

Overview i.e. overall visual assessment of trauma patient’s status, to establish priorities and formulate a management plan. A good guide to elicit relevant history is to use the mnemonic "AMPLE"
A: Allergies
M: Medication
P: Past illness and synergy
L: Last meal
E: Events preceding accident

Primary Survey: Following an overview, a primary survey using the "ABCDE system" is completed to identify life-threatening conditions, like loss of airway, inadequate ventilation, uncontrolled hemorrhage, cardiac tamponade or contusion, and an intracranial mass lesion

A) Airway maintenance -with cervical spine control
Look for chest wall movements, retraction, and nasal flaring
Listen for breath sounds, stridor, and obstructed ventilation
Feel for air movement

B) Breathing -give supplemental oxygen

Determine whether ventilation is adequate
Inspect chest to exclude open pneumothorax, sucking, chest wound, or flail segment
Auscultate for bilateral breath sounds Provide assisted ventilation for ventilatory failure

C) Circulation -establish venous access

Check peripheral pluses, capillary refill, and blood pressure
Obtain electrocardiogram Grade shock according to vital signs
Correct hypovolemia and obtain blood samples

D) Disability (determine neurologic status) Evaluate central function: A: alert V: responds to vocal stimulus P: responds to painful stimulus U: Unresponsive Evaluate pupil response to light

E) Expose patient for complete examination

Resuscitation is done simultaneously during the primary survey and an IV acces is obtained using 2 large bore canulae, following which rapid infusion of fluids is started. Rapid infusion systems with fluid and blood warming facilities are ideal for this purpose

Secondary survey: It is done after the primary survey is over and resuscitation is in progress. It involves detailed head-to-toe evaluation of the patient

Head: observation and palpation, pupil size and reactivity, ears, tympanic membrane examined for blood or CSF. Battle’s sign of mastoid ecchymosis (base of skull fracture) etc. is elicited. Maxillofacial injuries, cervical spine injuries are sought

Neck: may be immobilized if any cervical spine injury is anticipated. Lateral cervical radiographs (C1-C7) are done

Chest: inspection, palpation, percussion and auscultation and chest x-ray. Wide mediastinum, rib fractures, flail segment, haemothorax, pneumothorax, pulmonary contusion etc. are sought for

Abdomen: Aimed at detecting acute conditions requiring surgical intervention. Decision on peritoneal lavage, CT or immediate laparotomy is taken

Rectal: presence of blood suggests rectal perforation, high-riding prostrate gland suggests male urethral transection, palpable pelvic fracture through rectal wall

Examination of Extremities: for evidence of vascular or musculoskeletal injuries. Absence of peripheral pulses is an indication for aortography

Neurologic examination: Assessment of functions at cerebral hemispheric, brainstem and spinal levels

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Head injury with loss of consciousness

Assessment: Check to see if pupils react equally to light, have the person grasp your hands, check gait (if the person walks straight). Check for ear drainage
Intervention: Arouse every two hours. Send to ER if vomiting, dizzy, or disoriented to time, place, or person. Take to Clinic if these symptoms are absent but an evaluation is needed

Seizures

Assessment: Keep track of the time that the seizures last
Intervention: During seizures protect from injury, make sure airway is open, roll onto side. Send to ER if this is the first seizure

Diabetic Student with medical problems

Assessment: The person may have low blood sugar (hypoglycemia) if he/she exercised too much or had too little to eat. Signs and symptoms include: cool, moist skin, faintness, confusion, bluish pallor. If the person has vomiting or diarrhea they may develop high blood sugar, i.e. hyperglycemia. Signs and symptoms include dry, flushed skin, abdominal pain, deep acetone smelling breath, thirst, and increased urination. Intervention: Give quick-acting sugar, e.g. juice or pop for hypoglycemia. Call emergency if losing consciousness

Lacerations

Assessments and Interventions: If the laceration is 2 inches long or does not close with sterile strips, send to Clinic or ER. Check last tetanus date

Burns

Assessment: Note color of skin and size of burn
Intervention: Run cold water over burn for five minutes. If severe, send to Clinic or ER

Student with fever of 101 degrees F or above

Assessment: Use thermometer from Hall Director’s first aid box
Intervention: Give Tylenol from RA first aid box. Take to Clinic for treatment

Eye injuries or foreign body in the eye

Assessment: Check vision, examine eye
Intervention: Leave embedded object in the eye. An eye patch may be obtained from Hall Director’s first aid box. Send to Clinic or ER

Drug Overdose

Assessment: If conscious, ask when, what drug, and how much was taken. Also ask “Why?” to determine if it was an accidental overdose, a cry for help, or a deliberate attempt at suicide
Intervention: Call emergency. Help the person call someone he/she trusts to be with them. Stay until a trusted family member, police, or campus security comes. Reassure him/her that it was the right decision to tell you

Asthma with difficulty breathing

Assessment: Check rate and depth of respirations and if wheezing. Look at color of lips and fingernails, check for weakness or dizziness
Intervention: Clinic or ER, depending on severity

Persistent abdominal pain, vomiting, or diarrhea

Assessment: Ask if blood is in stools or if the color is tar-like. Take temperature. Look for signs of dehydration: sunken eyes, dry mouth, tongue, and lips, no urine or a low amount that is dark yellow, light headedness – especially when getting up quickly, dry skin that does not spring back when pinched, dizziness, confusion, weakness, increase in breathing and heart rate, and thirst
Intervention: Encourage drinking 2 cups of clear fluids such as water or Gatorade per hour. Try Imodium AD for diarrhea, and after 12 hours try solid food. If symptoms persist, see a medical doctor. If there is blood in the stools or signs of dehydration

Combination of headache and stiff neck

Assessment: Ask the person to touch chin to chest. Take temperature
Intervention: If this is quite painful send to a medical doctor, as it could be early signs of meningitis
Meningitis is potentially fatal and occurs in two forms; bacterial and viral. The viral form is less severe and generally resolves without specific treatment. Bacterial meningitis can cause permanent bran damage, hearing loss, learning disabilities, limb amputations, kidney failure, or even death. Two or more of these symptoms warrant a trip to the clinic or ER: high fever, neck stiffness, fatigue, nausea, sensitivity to light, vomiting, rash, severe headache. Without proper treatment, the disease can lead to shock and death within hours of the first symptoms. -A vaccine is available through Health Services

Dislocation or deformity of any joint or severe joint pain after injury, certain sprains and strains

Assessment: Check if there is deformity and proper body alignment. In case of sprains and strains, check color and pulse of extremity and whether there is numbness and ability to move the extremity
Intervention: Use RICE = Rest the injured area for 24-48 hours, Ice packs to area15 minutes every hour for 48 hours, Compress with Ace Bandage, and Elevate the injured extremity to about the heart level. Use crutches if it is difficult to bear weight. See M.D. if severe pain exists, the toes develop a pale or blue color, there is absence of a pulse in the foot, if little weight bearing progress has been made after 72 hours, or if there is increased swelling

Chest pain lasting over 2 minutes

Assessment: Check pulse for rate and regularity. Ask on a scale of 1 to 10 how severe the pain is and whether it radiates
Intervention: Call ambulance if it does not appear to be muscular in origin

Any problems with level of awareness

Assessment: Check if the person knows place, date, time, and person. Check for illness, injury, medical, and family history
Intervention: Send to ER

Severe throat or ear pain

Assessment: See if there is white exudates at back of the throat and if tonsils are enlarged. Ask when throat or ear pain began. Take temperature. Ask if their neck glands feel swollen
Intervention: See a M.D. for severe pain and/or fever

Tooth knocked out

Intervention: If tooth is found, put back in socket or place in milk. See a dentist

Severe nosebleed

Assessment: Note how long it has lasted
Intervention: Send to M.D. if it persists after pinching the nose for 30 minutes or so

Bites – human or animal

Assessment: Contain the animal or give description to Animal Control. Ask about last tetanus shot. Clean and apply sterile dressing. Send to doctor for possible antibiotic. Be aware that a human bite can cause worse infections than an animal bite, so be sure the person gets treated

Sexual assault

Assessment: Note any physical harm and check emotional status
Intervention: Tell the person not to douche, shower, clean nails, or change clothes. Encourage filling out an incident report, seeking counseling, and going to the ER for a rape kit. Be there to listen and give support. Remain calm to avoid upsetting the victim further

Suicidal plans

It is important to assess immediate risk of death when talking to someone who is suicidal. If intoxicated, tearful, or unclear about what has been ingested, take to ER or call ambulance. If talking about committing suicide and a means is available to do it, this also requires a trip to the ER or call ambulance. For example, if the person is holding a knife, sharp object, a gun, or if there is a lethal amount of drugs, call ambulance. If a student talks about being suicidal but does not have an immediate plan, he/she needs to see a counselor as soon as possible

Depression

Assessment: Note tearfulness, mood swings, overwhelming sadness, sleep disturbances, change in appetite and weight, difficulty focusing, withdrawing from people and activities, and fears and thoughts of death
Intervention: Encourage counseling

Lice -head or pubic

Assessment: Have the person take a comb and look for tiny black dots, called nits, which cause itching
Intervention: Use over-the-counter Rid as directed. Advise washing sheets, combs, and brushes in hot water

Urinary tract infection

Assessment: Note burning on urination, frequency and urgency
Intervention: Send to Clinic, even if UTI is recurrent. Ask them to drink 8-10 glasses of water plus cranberry juice daily

STD’s (Sexually Transmitted Diseases), including AIDS

Assessment: Different STD’s have different symptoms, from visible signs to pain to discharge. Some are asymptomatic (meaning no symptoms) in the early stages
Intervention: Various diagnostic and treatment centers are available. Call for hours and location

Pregnancy

Assessment: Pregnancy tests are free in the Health Services Office and are available at local pharmacies
Intervention: The person may want to discuss options with the nurse or counselor- gives options

ميرسى جدا على المعلومات الجميله دى بجد انتى سعدينى كتير
انا عندى امتحان ودى اول سنه ليا فى مدرسة التمريض وكنت محتاسه
شكرا بجدد سعدينى كتير

العفو يا حبيبتى

وانا تحت امرك فى اى حاجه تحتاجيها

وان شاء الله مفيش حوسه ولا حاجه

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