RISNER Trauma/ER Nursing
Notes
Pgs. 111-119,
Emergency 135-137,
Room Nursing 622-624, 1161-1163, 1053-1055
• Reasons people seek ED care
o Abdominal pain
o Chest pain
o Breathing difficulty
o Injuries (especially falls)
o Headache
o Fever
o Pain (most common)
• Triage
o Process of rapidly determining patient acuity
o Represents a critical assessment skill
o Categorizes patients so most critical are treated first
o “rapid assessment of who is going to die first without treatment”
▪ Most critical are treated first
o 1.) Emergent
▪ Respiratory distress, chest pain, hemorrhage
o 2.) Urgent
▪ Abdominal pain, fractures, soft tissue injuries
o 3.) Non-urgent
▪ Skin rash, strains/sprains, “colds”
• Primary Survey
o Primary survey organizes order of approach to patient by:
▪ (A) Airway/Cervical Spine
• Is patient still breathing?
• Need to do CPR?
• **TEST QUESTION – Must align cervical spine before any other
care is done INCLUDING CPR
o 1.) cervical spine alignment/stabilization
o 2.) CPR
▪ (B) Breathing
• Are they breathing on their own?
▪ (C) Circulation
• What is their blood pressure?
▪ (D) Disability
• Fractures?
• What happened?
▪ (E) Exposure
• Exposed to chemicals?
• Gas burn?
o **VERY IMPORTANT
o Focuses on airway, breathing, circulation, disability and exposure (ABCDE)
, RISNER Trauma/ER Nursing
Notes
Pgs. 111-119, 135-137,conditions
o Identifies life-threatening 622-624, 1161-1163, 1053-1055
o If life-threatening conditions related to ABCD are identified during primary survey,
interventions are started immediately and before proceeding to the next step of the
survey
o **Patient who has an MI will go before a patient that has a fall, patient with a fall will go
before a patient with a 3 day cough
▪ Can’t go to step B without step A
• Can’t get a BP unless patient is breathing
o **Airway with cervical spine stabilization and/or immobilization
▪ Signs/symptoms in patient with compromised airway
• Dyspnea
• Inability to vocalize
• Presence of foreign body in airway
• Trauma to face or neck
• **Stabilize the cervical spine, align spine, then airway!!!
o Maintain airway: least to most invasive method
▪ Open airway using the jaw-thrust maneuver
▪ Suctions and/or remove foreign body
▪ Insert nasopharyngeal/oropharyngeal airway
▪ Endotracheal intubation
o 1.) Stabilize/immobilize cervical spine
▪ Face, head, or neck trauma and/or significant upper torso injuries
o 2.) Breathing
▪ Assess for dyspnea, cyanosis, paradoxic/asymmetric chest wall
movement, decreased/absent breath sounds, tachycardia, hypotension
• Many conditions cause breathing alterations including fractured ribs,
pneumothorax, penetrating injury, allergic reactions, pulmonary emboli,
and asthma attacks.
• *NOTE: Usually breathing is one of the answers, but if there is a neck
injury-neck injury trumps
▪ Life-threatening conditions, such as tension pneumothorax and flail chest,
can severely and quickly compromise ventilation.
▪ Treatment
• Administer high-flow O2 via a nonrebreather mask
• Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for
life-threatening conditions
• Monitor patient response
o 3.) Circulation
▪ Check central pulse (peripheral pulses may be absent because of injury
or vasoconstriction)
• If your patient is not breathing and there is no pulse = CPR
▪ If a pulse is felt, assess the quality and rate.
▪ Assess the skin for color, temperature, and moisture.
, RISNER Trauma/ER Nursing
Notes
Pgs. 111-119, 135-137,
▪ Altered mental status622-624, 1161-1163,
and delayed capillary refill (longer than1053-1055
3 seconds) are the
most significant signs of shock.
▪ Take care when evaluating capillary refill in cold environments because
cold delays refill.
• ***IF SUSPECTED SEPSIS -> draw lactic acid and have antibiotics on
board
• **REMEMBER: 30 mL/kg of fluids
▪ Insert two large-bore IV catheters
• 18/20 g in AC – large access – need to transfuse blood or aggressive
fluid resuscitated
▪ Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s
solution
• LR resembles plasma the most (lactated ringers)
• When in doubt, put an IV in
o Unless massive fracture or injury impacting lymph
▪ Mastectomy with lymph nodes removed
▪ Fistula
• Insert IV lines into veins in the upper extremities unless
contraindicated, such as in a massive fracture or an injury that affects
limb circulation.
▪ Apply direct pressure with a sterile dressing to any obvious bleeding sites.
▪ Obtain blood samples for typing to determine ABO and Rh group.
• **STOP THE BLEEDERS FIRST!!
o Get blood type ASAP, if they’re bleeding, they will need blood
o 4.) Disability
▪ Measured by patient’s LOC
▪ AVPU
• A – alert
• V – voice responsive
• P – pain responsive
• U – unresponsive
▪ Glasgow Coma Scale
▪ Pupils
o 5.) Exposure
▪ Remove clothing to perform a physical assessment
▪ Prevent heat loss
• **If they are in neurogenic shock – temperature will take that of
the room
o Take a rectal temp
• Secondary Survey
o Brief, systematic process to identify all injuries
▪ Full set of vital signs/five interventions/facilitate family presence
▪ Complete set of vital signs
▪ Blood pressure (bilateral)
Notes
Pgs. 111-119,
Emergency 135-137,
Room Nursing 622-624, 1161-1163, 1053-1055
• Reasons people seek ED care
o Abdominal pain
o Chest pain
o Breathing difficulty
o Injuries (especially falls)
o Headache
o Fever
o Pain (most common)
• Triage
o Process of rapidly determining patient acuity
o Represents a critical assessment skill
o Categorizes patients so most critical are treated first
o “rapid assessment of who is going to die first without treatment”
▪ Most critical are treated first
o 1.) Emergent
▪ Respiratory distress, chest pain, hemorrhage
o 2.) Urgent
▪ Abdominal pain, fractures, soft tissue injuries
o 3.) Non-urgent
▪ Skin rash, strains/sprains, “colds”
• Primary Survey
o Primary survey organizes order of approach to patient by:
▪ (A) Airway/Cervical Spine
• Is patient still breathing?
• Need to do CPR?
• **TEST QUESTION – Must align cervical spine before any other
care is done INCLUDING CPR
o 1.) cervical spine alignment/stabilization
o 2.) CPR
▪ (B) Breathing
• Are they breathing on their own?
▪ (C) Circulation
• What is their blood pressure?
▪ (D) Disability
• Fractures?
• What happened?
▪ (E) Exposure
• Exposed to chemicals?
• Gas burn?
o **VERY IMPORTANT
o Focuses on airway, breathing, circulation, disability and exposure (ABCDE)
, RISNER Trauma/ER Nursing
Notes
Pgs. 111-119, 135-137,conditions
o Identifies life-threatening 622-624, 1161-1163, 1053-1055
o If life-threatening conditions related to ABCD are identified during primary survey,
interventions are started immediately and before proceeding to the next step of the
survey
o **Patient who has an MI will go before a patient that has a fall, patient with a fall will go
before a patient with a 3 day cough
▪ Can’t go to step B without step A
• Can’t get a BP unless patient is breathing
o **Airway with cervical spine stabilization and/or immobilization
▪ Signs/symptoms in patient with compromised airway
• Dyspnea
• Inability to vocalize
• Presence of foreign body in airway
• Trauma to face or neck
• **Stabilize the cervical spine, align spine, then airway!!!
o Maintain airway: least to most invasive method
▪ Open airway using the jaw-thrust maneuver
▪ Suctions and/or remove foreign body
▪ Insert nasopharyngeal/oropharyngeal airway
▪ Endotracheal intubation
o 1.) Stabilize/immobilize cervical spine
▪ Face, head, or neck trauma and/or significant upper torso injuries
o 2.) Breathing
▪ Assess for dyspnea, cyanosis, paradoxic/asymmetric chest wall
movement, decreased/absent breath sounds, tachycardia, hypotension
• Many conditions cause breathing alterations including fractured ribs,
pneumothorax, penetrating injury, allergic reactions, pulmonary emboli,
and asthma attacks.
• *NOTE: Usually breathing is one of the answers, but if there is a neck
injury-neck injury trumps
▪ Life-threatening conditions, such as tension pneumothorax and flail chest,
can severely and quickly compromise ventilation.
▪ Treatment
• Administer high-flow O2 via a nonrebreather mask
• Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for
life-threatening conditions
• Monitor patient response
o 3.) Circulation
▪ Check central pulse (peripheral pulses may be absent because of injury
or vasoconstriction)
• If your patient is not breathing and there is no pulse = CPR
▪ If a pulse is felt, assess the quality and rate.
▪ Assess the skin for color, temperature, and moisture.
, RISNER Trauma/ER Nursing
Notes
Pgs. 111-119, 135-137,
▪ Altered mental status622-624, 1161-1163,
and delayed capillary refill (longer than1053-1055
3 seconds) are the
most significant signs of shock.
▪ Take care when evaluating capillary refill in cold environments because
cold delays refill.
• ***IF SUSPECTED SEPSIS -> draw lactic acid and have antibiotics on
board
• **REMEMBER: 30 mL/kg of fluids
▪ Insert two large-bore IV catheters
• 18/20 g in AC – large access – need to transfuse blood or aggressive
fluid resuscitated
▪ Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s
solution
• LR resembles plasma the most (lactated ringers)
• When in doubt, put an IV in
o Unless massive fracture or injury impacting lymph
▪ Mastectomy with lymph nodes removed
▪ Fistula
• Insert IV lines into veins in the upper extremities unless
contraindicated, such as in a massive fracture or an injury that affects
limb circulation.
▪ Apply direct pressure with a sterile dressing to any obvious bleeding sites.
▪ Obtain blood samples for typing to determine ABO and Rh group.
• **STOP THE BLEEDERS FIRST!!
o Get blood type ASAP, if they’re bleeding, they will need blood
o 4.) Disability
▪ Measured by patient’s LOC
▪ AVPU
• A – alert
• V – voice responsive
• P – pain responsive
• U – unresponsive
▪ Glasgow Coma Scale
▪ Pupils
o 5.) Exposure
▪ Remove clothing to perform a physical assessment
▪ Prevent heat loss
• **If they are in neurogenic shock – temperature will take that of
the room
o Take a rectal temp
• Secondary Survey
o Brief, systematic process to identify all injuries
▪ Full set of vital signs/five interventions/facilitate family presence
▪ Complete set of vital signs
▪ Blood pressure (bilateral)
