SPM 100 Skills Lab 7

Emergency Assessment

Daryl P. Lofaso, M.Ed, RRTClinical Skills Lab Coordinator

(Updated: 5-2004)

Initial Assessment Guide

Primary Assessment Observational Assessment

Appearance, WOB, and Circulation Intervention to any life-threatening condition

Secondary Assessment (Serial) Vital Signs GCS

Primary Assessment

A = Airway / C-spine immobilization B = Breathing C = Circulation D = Disability or Neurologic Status

Secondary Assessment E = Exposure and environmental

control to prevent heat loss F = Full set of vital signs, wt. G = Give comfort measures H = Head-to-toe assessment and

History (Hx) I = Inspect posterior surfaces

Triage Assessment

Emergent

Urgent

Non-urgent

Emergent Airway and Breathing Difficulties Cardiac Arrest C-spine compromise Seizure states Life or limb-threatening condition

Emergent (continued)

Severe medical problems (Overdose, poisoning, DM complications)

Obvious multiple injuries Excessive high temperature

(> 105oF or 40.5oC)

Cardiac CP Neurological Deficit – Stroke (CVA)

Urgent Chest Pain (Non-Cardiac) Burns ↓ LOC Persistent nausea, vomiting, or diarrhea Severe pain Temperature (102-105oF or 39o-40.5oC)

Delay of up to 2 hrs will not compromise life or limb

Non-Urgent

Chronic backache Moderate headache Minor Fx or other injuries Obviously dead on arrival (DOA) Stable illness or injury, wait > than

2 hrs without an increased risk of morbidity or mortality

Patient’s Condition

Stable – VS within normal limits. Pt conscious & comfortable.

Guarded – VS within normal limits. Pt has some discomfort.

Unstable – VS outside of normal limits. Major complications. Prognosis guarded.

Universal Precautions

All Patients are potentially infectious. Good Handwashing is the key to

reducing nosocomial infections Wash before and after patient contact Wear a mask, eye protection, gloves

and gown when needed

3 Types of Precautions

Airborne

Droplet

Contact

Pathogens Requiring Airborne Precautions

Tuberculosis

Measles (Rubeola)

Varicella (Chickenpox)

Airborne Precautions Management

Place patient in an isolation room with negative pressure

Keep door closed Wear N-95 mask

Pathogens Requiring Contact Precautions

Multi-drug resistance bacteria (e.g., VRE – Vancomycin Resistant Enterococci, MRSA - Methicillin Resistant Staphylococcus Aureus)

RSV - Respiratory Syncytial Virus

Clostridium difficile Scabies