initial assssment ppt

Initial Assessment

Yunus Elon, S.Kep., Ns, MSN

Fakulty of Nursing

Adventist University of Indonesia

8/28/2016 Emergency and Critical Care 1

Definition

O Initial Assessment adalah suatu cara atau langkah-langkah yang digunakan untuk menilai hal-hal yang mengancam nyawa penderita pada kasus trauma dan bagaimana kita menanganinya dengan cepat dan benar.

8/28/2016 Emergency and Kritis 2

WHEN YOU REACH THE VICTIM

O Once you reach the scene of the accident, you will have to carry out four steps as expeditiously as possible:

1) INITIAL SCENE ASSESSMENT

2) THE PRIMARY SURVEY

3) THE SECONDARY SURVEY

4) COMMUNICATION WITH CD, CLINIC OR HOSPITAL


INITIAL SCENE ASSESSMENT Whether there are any hazards to the victim

or rescuers

The number of causalities

Whether you will need backup

The mechanism of Injury

Whether you will need any special

equipment to gain access to the victim

Establish Priorities


PRIMARY SURVEY

The Role of the primary survey is to identify any life-threatening problems or

injuries.

Whenever possible, treatment of any life –threatening problem is carried out as

soon as that problem is identified.

The primary survey follows the simple system of “ABCDEFGH”.


Airway and Cervical Control #1

As always, first priority goes

to the airway.

Is the airway open now?

Will it stay open?

IF THE VICTIM IS

UNCONSCIOUS, OPEN THE

AIRWAY by HEAD TILT-CHIN

LIFT or JAW TRUST. 8/28/2016 Emergency and Kritis 6

Airway and Cervical Control

That is maneuvers that will not move

the head out of neutral position.

A little bit of extension of the head

probably won’t hurt, but flexion of

the head may be catastrophic, so

AVOID FLEXING THE HEAD at all cost.


Airway and Cervical Control

Inspect the victims' mouth

quickly and suction out

secretion, blood or vomits.

If the victim is unconscious,

use an ORAPHARYNGEAL

(OPA) or NASOPHARYNGEAL

AIRWAY to help keep the

airway Patent.


If Suspected Cervical Injury

APPLY CERVICAL

COLLAR


AIR WAY MANAGEMENT

1. Gurgling

a. Logroll

b. Suction

c. Finger Sweep


AIR WAY MANAGEMENT

2. Snoring

a. Head tilt-chin lift

b. Jaw Trust

c. OPA/NPA


AIR WAY MANAGEMENT

3. Crowing

a. Airway definitive

b. Intubation

c. Needle cricothiroidotomi


BREATHING #2

If the victim is conscious,

listen to the TALK. Are they

able to speak in full

sentences without gasping

for breath.

If the victim is unconscious,

expose the chest, in order to

LOOK, LISTEN, AND FEEL

FOR BREATHING. 8/28/2016 Emergency and Kritis 13

Breathing #2

If the Victim is not

breathing, give (2) two full

breaths, cheek for a

carotid pulse, and start

CPR.


Breathing #2 If they are breathing, however, cheek the

adequacy of breathing by noting:

Respiratory RATE

DEPTH of respiratory

The NECK (Look & Palpate) is the trachea in

the midline)

The CHEST: Look for open wounds, bruises,

deformity, and flail segments.

Listen with a Statoscope in each axilla for

presence and equality of breath sounds. 8/28/2016 Emergency and Kritis 15

Cases in Breathing

Tension Pneumothorax: Treatment=Needle

thoracosisntesis Intercostal 2 mid claviculaline.

Open Pneumothorax: Kasa 3 sisi (Adhesive

dressing)

Massive Hematothorax: IV 2 Line with big

needle with warm NACL.

Flail Chest: Strong Analgetik

Cardiac Tamponade: Pericardio Synthesis.


CIRCULATION#3 O Assessment of the circulation begin as soon as

you encounter the victim and place a hand on

the forearm. If it is pale, cold and sweaty the

victim is in shock .

O Cheek the CAROTID PULSE, FEMORAL PULSE,

RADIAL PULSE once you’ve cheeked radial

pulse , cheek the finger nail For CAPILLARY

REFIL. Normal <2 second.

O External bleeding must be controlled during

the primary survey by direct pressure. 8/28/2016 Emergency and Kritis 17

CIRCULATION#3 O When the victim shows signs of

hypovolemic shock and the source of

bleeding is not obvious, Consider the 3

AREAS OF HIDDEN BLOOD LOSS: The

Chest, The Abdomen and The Thigh.

O Traumatic blood loss is correctly by

placing 2 Line Cannula 14-16 gauge. 2

Liters of Hartman Solution..(crystalloid sol)


DISABILITY#4

O The primary survey, only the briefest

Neurologic Evaluation is undertaken

especially:

O Assessment of pupil size and Reaction to

light .

O Level of Consciousness AVPU scale :

O A=Alert (Victim know his name, where he is)

O V=Verbal (responds to vocal stimuli)

O P=Pain (Responds only to painful stimuli)

O U=Unresponsive to any stimuli. 8/28/2016 Emergency and Kritis 19

EXPOSE#5

OThe principle of

exposure to find out

bleeding and the

wounds


FOLLEY CATETHER#6 O To observe Intake-Output .

O Contra-Indication of Inserting folley catheter

O Present of blood in the urethra

O Scrotum hematoma

O Normal Urine

Adult : 0,5-1cc/Kg BW(30-50 cc/hrs

Child : 1-2 cc/Kg BW/hrs

Baby :2-3 cc/kg BW/hrs


GASTRIC TUBE#7

O It is Advice to insert NGT in order to

prevent

O Gastric distention

O Avoid vomiting

O Medication route

O Warning: In fracture Basis cranial

Inserting NGT through mouth


HEART MONITOR#8


SECONDARY SURVEY

OA secondary survey should only be

performed when all life –

threatening condition have been

treated.

OSecondary survey is HEAD TO TOE

EXAMINATION


Head to Toe Examination#1


Secondary survey of multitrauma Victim

HEAD Depressed fracture, scalp laceration, Cerebrospinal fluid leak from ears

or Nose: Battle sign; Maxillofacial injury.

EYES Penetrating injury, Extraocular motion; Pupils and visual acuity

MOUTH Foreign bodies; loose or avulsed teeth. Broken dentures, blood, vomits,

secretions.

NECK Open wounds, tracheal deviation, jugular distention, tenderness or

bruises over cervical spine (assume in any case that cervical injury is

present)

CHEST Bruises, open injuries, equality of breath sounds; dullness or hyper

resonance

ABDOM

EN

Contusions and seat belt marks, open wounds, evisceration, distention,

rebound tenderness

PELVIS Stability on compression of iliac wings

EXTRE

MITIES

Deformity, Swelling, Collor, Temperature Pulses sensation and motion

TAKING THE HISTORY IN TRAUMA (SAMPLE)#2

O S= Sign & Symptoms

O A= Allergies

O M= Medications (that the victim takes regularly

or has taken today

O P= Past Medical History (Operations, Prev

hospitalization, other serious illnesses.

O L=Last Meal (the last time the victim had any

oral intake

O E= EVENTS (Mechanism of injury)


VITAL SIGN#3


GCS#4 EYE OPENING

4=Spontaneous When the victim is approached he

opens his eyes

3=Opening to

Speech

When the victim open his eyes to

speech

2=Opening to

Pain

When the victim open his eyes to

pain applied to the nail beds

1=No eye

opening

Neither open his eyes to painful

stimuli 8/28/2016 Emergency and Kritis 28

GCS#4

VERBAL RESPONSE 5=Oriented Give accurate answer to who they are, where

they are

4=Confused Unable to give accurate answer to the above,

but produce meaningless phrases

3=Inapropriate words Says only one or two words unrelated to the

question.

2=Incomprehens

ible

Groans, Moans or mumbles

1=No verbal

Response

No verbal response 8/28/2016 Emergency and Kritis 29

GCS#4 MOTOR RESPONSE

6= Obeys command Accurately respond to instruction such as

raise your right hand

5=Localize to Pain Can move an arm to locate the pain in an

effort to remove it

4=Withdraws from

pain

Pulls away from painful stimuli

3=Abnormal

Flexion

After painful stimuli at fingertips the

victim bends an arms at the elbow

2=Extensor

Response

when painful stimuli is applied the

elbow straightens

1=No response to

pain

No detacble motor response


initial assssment ppt

Healthcare