Initial Assessment

Chapter 3

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 Initial Assessment

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 Standard Precautions

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 Initial Assessment

• Divided into two

phases
 Primary Assessment
 Secondary
Assessment

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 Initial Assessment

• Primary assessment
 A: Airway with cervical spine protection
 B: Breathing
 C: Circulation
 D: Disability
 E: Expose/Environmental

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 Initial Assessment

• Secondary assessment
 F: Full set of vital signs/focused
adjuncts/family presence
 G: Give comfort measures
 H: History and Head-to-toe assessment
 I: Inspect the posterior surfaces

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 Airway with Cervical Spine Protection

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 Assessment of Airway

• Vocalization
• Tongue obstructing the airway
• Loose teeth or foreign objects
• Blood, vomitus, or other secretions
• Edema

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 Assessment of Airway

• Observe
• Listen
• Device confirmation
• Chest radiograph

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 Airway: Interventions

• Airway patent
 Maintain cervical spine protection
 Allow patient to assume position of
comfort

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 Cervical Spine Protection

• Place patient in a
supine position
• Perform in-line
stabilization
• Apply immobilization
devices

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 Airway: Interventions

• Open and clear the airway

 Jaw thrust, chin lift
 Suctioning
• Insert an airway adjunct
• Assist ventilations
• Prepare for endotracheal intubation

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 Assessment of Breathing

• Spontaneous breathing
• Rise and fall of the chest
• Rate and pattern of breathing
• Use of accessory muscles,
diaphragmatic breathing
• Skin color
• Integrity of soft tissues and chest wall
• Breath sounds

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 Assessment of Breathing

Tracheal deviation and jugular venous

distention (JVD) are considered LATE
SIGNS of ventilatory compromise.

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 Breathing: Interventions

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 Breathing: Interventions

• Ventilate the patient via a bag-mask

device
• Assist with definitive airway
management
• Assist with or perform needle
thoracentesis
• Assist with chest tube insertion

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 Assessment of Circulation

• Palpate a central pulse

• Inspect and palpate the skin
• Inspect for signs of uncontrolled
bleeding
• Auscultate blood pressure

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 Circulation: Interventions

• Control bleeding
• Establish vascular
access
• Administer warm
isotonic crystalloid
solution

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 Circulation: Interventions

• Circulation Present: Ineffective

 Control any uncontrolled external bleeding
 Cannulate two veins with large-caliber
intravenous lines
 Infuse isotonic crystalloid solution
 Use warmed solutions, pressure bags
 Use blood administration tubing
 Consider alternative access methods

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 Circulation: Interventions

• Circulation: Absent
 Cardiopulmonary resuscitation
 Look for cause of the arrest
 Assist with emergency thoracotomy
 Discuss when to stop resuscitation

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 Disability—Brief Neurological
Assessment
• A: Alert
• V: Verbal
• P: Pain
• U: Unresponsive

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 Disability—Brief Neurological
Assessment
• Determine Glasgow Coma Scale (GCS)
score
• Assess pupils for size, shape, equality,
or reactivity to light
• Determine the presence of lateralizing
signs

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 Disability: Interventions

• Conduct further investigation during

secondary assessment
• Continue to monitor
• Manage neurological deterioration

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 Expose: Interventions

• Remove clothing
carefully and safely
• Ensure appropriate
decontamination
procedures
• Keep the patient
warm
• Remember clothing
may be evidence

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 Consider the Need for Transfer

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 Secondary Assessment

• Full set of vital signs/focused

adjuncts/family presence
• Give comfort measures
• History
• Head-to-toe assessment
• Inspection of posterior surfaces

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 Focused Adjuncts

• ECG monitor
• Pulse oximeter
• Exhaled CO2 detector
• Indwelling urinary catheter
• Gastric tube

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 Focused Adjuncts: Radiographic
and Diagnostic Tests
• Chest radiograph
• Pelvic radiograph
• Focused assessment sonography for
trauma (FAST)
• Diagnostic peritoneal lavage (DPL)
• Computerized tomography (CT) scans

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 Focused Adjuncts: Laboratory Studies

• Blood typing
• Other tests
 Hematocrit and hemoglobin
 Arterial blood gases
 Electrolytes
 Clotting studies
 Pregnancy test
 Toxicology screen

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 Facilitate Family Presence

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 Comfort Measures

• Pain
 Unpleasant sensation
 Emotional response

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 Comfort Measures: Assessment

• Sources of pain
 Injuries
 Procedures
 Diagnostic testing
 Environment
• Physical signs
• Pain rating scales

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 Comfort Measures: Interventions

• Remove pain-producing objects

• Determine level of pain
• Initiate pain management techniques
• Administer prescribed medications
• Monitor closely after pain medications
have been administered

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 History

• Prehospital
information
 MIVT
• Patient-generated
information
 Past medical history
 Co-morbid factors

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 Head-to-Toe Assessment

• General appearance
• Head-to-toe
assessment
 Head/face/neck
 Eyes/ears/nose
 Chest
 Abdomen
 Pelvis and genitals
 Extremities

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 Inspect Posterior Surfaces

• Palpate vertebral
column
• Palpate all
posterior surfaces
• Evaluate sphincter
tone

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 Additional Interventions for the
Secondary Assessment
• Additional laboratory studies
• Additional radiographs
• Angiography
• Wound care
• Tetanus prophylaxis
• Administration of medications
• Preparation for admission, surgery, or
transfer

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 Evaluation and Ongoing Assessment

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 Assessment of the Victim of Violence

• History
 Collect information in a
safe, private environment
• Physical assessment
 Injuries that may indicate
abuse
 Defensive wounds
 Bite marks
 Injuries to the breasts
 Injuries to the perineum

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 Assessment of the Victim of Violence

• Diagnostic procedures
 Radiographic studies
 Laboratory studies
 Other studies

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 Management of the Victim of Violence

• Ensure that the patient and staff are

safe
• Notify patient advocate
• Collect and document evidence using
appropriate protocols
• Notify appropriate authorities
• Provide appropriate discharge
information
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 Assessment of the Violent Patient

• Risk factors
 Report of violence at the scene
 Verbal threats
 Presence of weapons
 Previous violent behaviors
 Substance abuse
 Psychiatric disorders
 A patient who is being legally detained

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 Assessment of the Violent Patient

• Rule out organic cause

• Physical assessment
 Level of consciousness
 Evidence of substance abuse
 Violent behaviors
 Evidence of self injury
• Diagnostic studies

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 Management of the Violent Patient

• Place patient in a safe environment

• Use restraints according to policy
• Administer medications as prescribed
• Talk calmly to the patient
• Include the patient’s family if possible
• Notify the appropriate authorities
• Provide ongoing evaluation

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 Summary

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