Airway
What is the first step in assessing airway patency?
Look for obstructions such as vomit, blood or foreign bodies, signs of choking eg coughing
What vital sign tells you how many breaths a patient takes per minute?
Respiratory rate
Delayed capillary refill
Low blood pressure
Weak or absent pulses
What is AVPU and what does AVPU stand for?
AVPU is a simple assessment tool used to quickly gauge a person's level of consciousness
Alert (awake)
Verbal (responds to voice)
Pain (responds to pain)
Unresponsive (does not respond)
What is the purpose of exposure in the ABCDE primary assessment?
To check temperature
To look for hidden injuries
Check skin for rash, bruising, oedema
Name some signs/sounds of airway obstruction
Inability to speak
Stridor
Gurgling
Patient grabbing at neck
Snoring
A patient has a resp rate of 32 breaths per minute. What is the clinical term for this?
Tachypnonea
If your patient had a low blood pressure, what are some nursing interventions or further assessments you can action to help? Name two.
Check BP manually
Return to bed/elevate legs
ECG
Check if IV access insitu and patent
Check skin turgor
Check FBC - if negative encourage oral intake (being conscious of any fluid restriction)
Why is a rapid neurological assessment (AVPU) performed during the primary survey?
To quickly identify life-threatening neurological changes
What serious condition can occur if a patient is left uncovered and without blankets during exposure?
Hypothermia
If the patient has coherent speech, is likely the airway is patent or obstructed?
Patent
What position is recommended for a patient to be in, to assist with respiratory effort and why?
Sitting patient upright or high fowlers
Sitting upright helps by: (at least one)
- breathing by utilizing gravity to lower the diaphragm
- increases chest cavity volume
- improves lung expansion
- enhances oxygenation
When assessing the pulse in a patient during the primary survey, which characteristics should be recorded? (Three things to name)
Rate
Rhythm
Strength
When assessing disability, which of the following are included?
- AVPU/GCS
- Pupil assessment
- Blood glucose
All
Why does the nurse assess the dangers and the environment during the primary survey?
To keep the primary first responder safe
What actions can you take if your patient has an obstruction in their airway? Name two.
Apply oxygen
Suction
Head tilt/chin lift
Jaw thrust
Insert OPA or NPA
What does RATES stand for when assessing breathing?
R - Respiratory rate, rhythm
A- Auscultate lungs
T - Tracheal deviation
E - Effort/Work of breathing
S - Sp02 and speech
What does BURP stand for when assessing circulation?
B - Blood pressure
U - Urine output
R - Heart rate, rhythm (regular or irregular)
P - Pulses, perfusion (BP and HR)
Which pupil finding is concerning during the disability assessment?
Unequal or nonreactive pupils
How can the nurse maintain patient dignity during exposure?
By covering the patient after assessment or exposing one area at a time
Name one condition that places a patient at high risk for airway compromise during the primary survey
Facial trauma
Burns
Anaphylaxis
Decreased level of consciousness
Which lung sound indicates airflow through narrowed airways, is typically heard on expiration, and is commonly associated with asthma?
Wheezes
A patient has pale, cool fingers and delayed capillary refill, but a normal blood pressure and strong carotid pulse. Why might capillary refill not accurately reflect overall circulation in this case?
Peripheral perfusion can be reduced by factors like cold environment, vasoconstriction, or age, even when central circulation (blood pressure and major pulses) is adequate.
Why is glucose level often considered during the disability assessment?
Hypoglycaemia can cause altered mental status
Why is exposure the final step of the primary survey?
Because airway, breathing, and circulation problems must be treated first