Documente Academic
Documente Profesional
Documente Cultură
Hospital Logo
Example
Patient Sticker
Date:
Pedestrian
Mechanism of Injury
Restraint Devices
Speed of vehicle ________ MPH Rollover Lap belt Airbag deployed
Ejected Shoulder belt Helmet
Number of vehicles
1 2
3
>3
Rearend Car seat Unrestrained
Steering wheel deformity T-Bone
Starred windshield
Head on
Fall Penetrating Blunt Thermal Other
Fell from: GSW Assault Burn Hanging
Stabbing
Height____________ ft. Other
Crush
Other
Cold exposure Animal related
Example
Initial Assessment
AIRWAY
DISABILITY
Patent
Suctioning
Glasgow Coma Score Initial Disch
Oral Airway Bag Mask
Eye Opening
Nasal Airway O2 __________________ L. Spontaneously 4
ET ________________ Commen ts
To Speech (Shout) 3
Trach
To Pain 2 ______ ______
Crico
_____________________________________ No Response 1
BREATHING
Verbal Response
Spontaneous Respiratory Effort Oriented (Coos, Babbles) 5
RL
Normal Agonal
Confused
4
(Consolable, Cry)
Lung sounds Shallow Nasal flaring
Clear Stridor Tachypnea
Inappropriate Words
3
(Persistent Cries, Screams)
Rales Dyspnea Grunting
Rhonchi/Wheezes Retracting Absent
2
Incomprehensible
Words (Grunts, Restless)
Decreased In tercostal Paradoxical
Absent Substernal Cough No Responses 1 ______ ______
Motor
Smoker
Yes
No
Unk
CIRCULATION
Obeys (Spontaneous) 6
Capillary Refill: None Delayed (> 2 sec) Normal (< 2 sec) Localized Pain 5
Pulses Present: Carotid Femoral Radial Pedal Withdrawal to Pain 4
Flexion to Pain
3
Palpated Pulse Regular Irregular
(Decorticate)
Heart tones Audible Absent
Jugular Vein Distension No
Yes
Extension to Pain 2
Area of Injury
Allergies
:
Tetanus: ________ LMP:_________ Wt: ___________
Procedures
Time Procedure
Results
ET Tube _____ Combitube ____
Size ______________________
Secured @ ______________cm
FiO2 ___________________ %
Central Line/ IV
Size ____________________ Fr
Site _______________________
Solution___________________
Warming Measures
Fluids
Mechanical
Bair Hugger
Blankets
NG Tube
Size _____________________
Color____________________
OW = Open
Foley / Quick Cath
Size ____________________ A = Abrasion Fc = Closed
Fracture
Wound
Color____________________
B = Burns Fd = Dislocation P = Paralysis
Neck immobilization
CMS:
C = Crepitus Fo = Open Fracture S = Edema
C-Collar Applied: ___________ Before___________________
After
____________________
D
=
Deformity
L = Laceration Ta = Total
__________________________
Splinting ___________ ___ ___ Location:__________________ E = Ecchymosis Na = Near
_________________________
Amputation
Amputation
Example
Secondary Assessment
Input
Output
Head/Scalp
Eyes
Mouth
Ears
Source
Prior
to
Arrival
ED
Total
Source
Prior
to
Arrival
ED
Total
Intact Rash PEARL
Intact No drainage
IVLaceration
Fluids Burns Urine
Raccoon eyes Teeth Drainage
Abrasions Pain EOMSEmesis
follows Missing teeth
Right
Left
Chest Tube
Bruising Battle
Visual Acuity OD ____/____
Dentures intact
Clear
Clear
Signs Other
OS ____/____
Comments_________
Blood
Clear
Neck
Chest
Heart Sounds
Blood
Intact C-Collar Symmetrical Chest Pain Present
Fresh
Frozen Pain
PlasmaAsymmetrical
Swelling
Location_______________ Distant
Trachea midline Paradoxical movement
Time of onset ___________ Absent
Trachea deviated
Location _____________
Activ ity @ onset ________
Sub-q emphysema Crepitus Flail
chest
Personal Belongings
Difficulty
Location_____________ Other _________________
Clothes swallo win g
Abdomen / Pelvis / GU
Purse
Abdomen
Bowel Sounds Pelvis
Wallet
Soft Distended Last Intake: Present Intact
Jewelry
____________________________________________________________________
Nontender
Rigid
Food ________________ Absent Pain ______________________
Given
to:
Tender
Liquid
_______________
Hyperactive ____________________________
Name ________________________________________________________________________
Hypoactive Blood at meatus ____________
Comments:
Relationship __________________________________________________________________
Blood at rectum ____________
Nursing Staff __________________________________________________________________
Instability _________________
Posterior
Extremities
Nurse
IntactNotes:
Intact
Deformity
Fracture
Pain
Pain
Comments _________________________________________ Deformity
____________________________________________________ Comments _________________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
Pupil Reaction Pain Scale
Comments
Time Tem
/
/
/
/
/
/
/
/
/
/
/
/
p P R BP SaO2 O2
L/min
S-slow
U-unequal
0-10
B-brisk
D-dilated
Pain
F-fixed
= - Equal
C-closed by swelling Scale Type
Right Left
Medication
Medications Given
Dose Route Time Given Initials
RN Signature: ______________________________________________________________________________
Q/trauma2/trauma/trsystemdevelopment/sdtaskford/flowsheetdraft/09-09