Assess the Pt's level of consciousness/responsiveness
Is the Pt awake/responsive or unconscious
Primary Survey
"A" - "E"
Position Pt to
... [Show More] open airway & keep C-Spine stable
Airway & Alignment (C-Spine)
Manually open the airway with the jaw-thrust maneuver to maintain C-Spine stabilization
Demonstrates and describes techniques to assess airway patency - Identify at least 3
Vocalization or abnormal airway sounds
Tongue obstruction
Loose teeth or foreign objects
Blood, drooling, secretions, or vomit
Edema
Preferred posture
Dysphagia
Demonstrate and describes required interventions to clear the airway - Identify at least 1
Suction
"Sniffing" Position - place head in a neutral position by placing a towel between shoulder blades
Remove foreign objects
Nasopharyngeal/Oropharyngeal Airway (OPA)
"B"
Breathing & Ventilation
Demonstrates and describes techniques to determine effectiveness of breathing - Identify at least 3
Level of consciousness (LOC)
Spontaneous respirations
Rate & depth of respirations
Decreased/Increased ability
Symmetric & equal chest rise and fall
Presence & quality of breath sounds
Open chest wounds/deformities
Skin color
Begin or maintain oxygen therapy or assisted ventilations using:
~ 100% oxygen w/ NRB mask
~ Bag-mask with 100% oxygen
**Assess effectiveness of ventilation
Equal rise/fall of chest
Auscultates breath sounds
States need for intubation
Prepare for:
- Endotracheal Intubation (ET)
- Rapid Sequence Intubation (RSI)
- Needle/surgical cricothyroidotomy
Signs of increased work of breathing
Nasal flaring
Retractions
Head Bobbing
Expiratory grunting
Accessory muscle use
Breathing Interventions - Identify at least 1
Maintain position of comfort
Provide supplemental oxygen
Provide bag-mask ventilation
Reassessment of breathing effectiveness should occur prior to proceeding w/primary assessment
Prepare for Endotracheal Intubation (ET)
Assessment of tube placement should be done prior to proceeding w/primary assessment
Insert Nasogastric (NG) or Orogastric (OG) tube to reduce abdominal distention
"C"
Circulation & Control of Hemorrhage
Circulation Assessment
Identify 2+
Central AND peripheral pulse rate & quality
Skin color AND temp
Capillary refill
Jugular vein distention (JVD) & tracheal position
Circulation Interventions
Identify 1+
Perform cardiopulmonary resuscitation & advanced life-support measures
Control any obvious bleeding
Prepare for defibrillation/synchronized cardioversion
Obtain IV or IO access
Administer 20mL's/kg fluid bolus of Isotonic Crystalloid solution
Administer meds
Administer blood/blood products
Correct electrolyte & acid-base imbalances
Prepare for needle thoracentesis
"D"
Disability (Neuro Status)
Disability (Neuro) Assessment
★ GCS Score
★ Assess pupils
PERRLA
★Assess level of consciousness with AVPU
A - Alert
V - Responds to Verbal Stimuli
P - Responds to Painful Stimuli
U - Unresponsive
Disability (Neuro) Interventions
Perform further investigation during secondary assessment
Administer pharmacological therapy
"E"
Exposure & Environmental Control
Exposure & Environmental Control Assessment
Remove all clothing to assess for any skin abnormalities
Sources of heat loss
Exposure & Environmental Control Interventions
Identify 1+
Warm blankets
Overhead warming light
Radiant warmer or approved warming device
Maintain warm ambient environment
Increase room temp as needed
Warm IV fluids
Warm/humidified oxygen
Secondary Assessment
"F" - "I" & "L-M-N-O-P
"F"
Full Set of Vital Signs
Facilitate Family Presence
Focused Adjuncts
Full set of VS
Heart Rate (HR)
Respiratory Rate (RR)
Blood Pressure (BP)
Oxygen Saturation (SpO2)
Temp
Weight (kg)
Use a scale for most accurate weight in kg's for proper medication dosage
Estimate weight using a length-based tape (Broselow)
Family Presence
Identification of family members and their relationship to the child
Family needs
Need for additional support & desire to be in the resuscitation room
Facilitate & support family involvement
Assign 1 person to:
Liaison w/family
Explain what to expect/see, procedures, &
plan of care
Provide support [Show Less]