NURS 4526 ACUTE CARE - WEEK 1 (ADULTS)
QUESTIONS AND ANSWERS (SOLVED) 100% CORRECT.
What are the components of a Primary Survey(Assessment) in an Emergency?
Answer - E A B C D E2 F G
Remember, what is Absent or Not Seen/Heard is an important as what is
Seen/Heard
How do you assess E1- Environment? Answer - - No fire, no wire, no gas, no
glass, no rugs/drugs or thugs
- Assessed before entering the room
How do you assess A - Airway & Alertness? Answer - - AVPU (Alert, Verbal
stimuli, Painful stimuli, Unresponsive)
- GCS
--eyes - 4
- motor - 6
- verbal - 5
- ex. 10 T - pt has tube so unable to assess verbal response
- high level of interrelatability
- unconscious pt: tongue rolls back and obstructs airway (GSC >8)
- Is patient speaking in full sentences?
- C spine precautions (C4 above - respiratory injury;
C4 below - paraplegia)
,- Turn pt like a log or use collar to protect sc
If airway is compromised... Answer - Perform from least to most invasive:
- Head tilt, chin lift
- Jaw thrust: rescuer uses forearms to stabilize pt head and then applies
pressure w index fingers to push jaw forward
- Suctioning, removal of foreign bodies, inserting an airway to induce gagging
- Endotracheal intubation
- Rapid sequence intubation - preferred procedure to secure an
unprotected airway in the ED
- With suspected SC injury, cervical spine must be stabilized during airway
assessment
- Ensure your room has working oxygen and suction at all times
- SC trauma -> only use jaw thrust
How do you assess B - Breathing? Answer - - No distress in face
- Eye brows not raised
- Eyes not open widely
- Nostrils not flared
- Mouth not open or pursed
- No visible accessory muscle use
- No noises of distress
- Abnormal sounds: wheezing- high pitched whistling sound on expiration,
crackles - alveoli forcefully open (fine or coarse crackles)
What to do if breathing is unstable ? Answer - - Reposition client
- Unstable: start HIGH FLOW oxygen and titrate to maintain oxygen saturation
, - Monitor client's response through observation, auscultation and oxygen
saturation
- Importance of the room being ready
- Oxygen dissociation curve: ex. partial pressure changes (SPO2 not always
reliable)
what are interventions for unstable breathing? Answer - - positioning
- coached breathing
- oxygen
- bronchodilators
- intubation & ventilation (RSI)
How do you assess C- Circulation? Answer - Central Skin Colour, Temperature
and moisture
What to do if circulation is unstable? Answer - Prepare to insert large bore
Intravenous catheters in the larger veins (unless contraindicated)
- Administer isotonic fluids
- Code Omega
- If a cardiac issue - 12 lead ECG
How do you assess D - Disability Answer - - Stroke Scale
- AVPU
- GCS
What should be considered when a patient experiences a sudden onset of
confusion or altered level of consciousness (ALOC)?
A) Code Heart
QUESTIONS AND ANSWERS (SOLVED) 100% CORRECT.
What are the components of a Primary Survey(Assessment) in an Emergency?
Answer - E A B C D E2 F G
Remember, what is Absent or Not Seen/Heard is an important as what is
Seen/Heard
How do you assess E1- Environment? Answer - - No fire, no wire, no gas, no
glass, no rugs/drugs or thugs
- Assessed before entering the room
How do you assess A - Airway & Alertness? Answer - - AVPU (Alert, Verbal
stimuli, Painful stimuli, Unresponsive)
- GCS
--eyes - 4
- motor - 6
- verbal - 5
- ex. 10 T - pt has tube so unable to assess verbal response
- high level of interrelatability
- unconscious pt: tongue rolls back and obstructs airway (GSC >8)
- Is patient speaking in full sentences?
- C spine precautions (C4 above - respiratory injury;
C4 below - paraplegia)
,- Turn pt like a log or use collar to protect sc
If airway is compromised... Answer - Perform from least to most invasive:
- Head tilt, chin lift
- Jaw thrust: rescuer uses forearms to stabilize pt head and then applies
pressure w index fingers to push jaw forward
- Suctioning, removal of foreign bodies, inserting an airway to induce gagging
- Endotracheal intubation
- Rapid sequence intubation - preferred procedure to secure an
unprotected airway in the ED
- With suspected SC injury, cervical spine must be stabilized during airway
assessment
- Ensure your room has working oxygen and suction at all times
- SC trauma -> only use jaw thrust
How do you assess B - Breathing? Answer - - No distress in face
- Eye brows not raised
- Eyes not open widely
- Nostrils not flared
- Mouth not open or pursed
- No visible accessory muscle use
- No noises of distress
- Abnormal sounds: wheezing- high pitched whistling sound on expiration,
crackles - alveoli forcefully open (fine or coarse crackles)
What to do if breathing is unstable ? Answer - - Reposition client
- Unstable: start HIGH FLOW oxygen and titrate to maintain oxygen saturation
, - Monitor client's response through observation, auscultation and oxygen
saturation
- Importance of the room being ready
- Oxygen dissociation curve: ex. partial pressure changes (SPO2 not always
reliable)
what are interventions for unstable breathing? Answer - - positioning
- coached breathing
- oxygen
- bronchodilators
- intubation & ventilation (RSI)
How do you assess C- Circulation? Answer - Central Skin Colour, Temperature
and moisture
What to do if circulation is unstable? Answer - Prepare to insert large bore
Intravenous catheters in the larger veins (unless contraindicated)
- Administer isotonic fluids
- Code Omega
- If a cardiac issue - 12 lead ECG
How do you assess D - Disability Answer - - Stroke Scale
- AVPU
- GCS
What should be considered when a patient experiences a sudden onset of
confusion or altered level of consciousness (ALOC)?
A) Code Heart
