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Primary & Secondary Survey (PRIMARY (B - Breathing (NURSING…
Primary & Secondary Survey
PRIMARY
A - Airway
Airway Patency
Loose teeth or foreign bodies
Bleeding, vomitus, oedema
Respiratory distress
NURSING INTERVENTIONS
Suction
Jaw Thurst
Removal of Foreign Body
B - Breathing
Respiratory Rate, Rhythm & Depth
Trachea Positioning & Jugular Distension
Use of accessory muscles
Paradoxical Movement - Chest Wall - Inspiration & Expiration
Colour of nail beds, mucous membranes, skin
Auscultate Lungs
NURSING INTERVENTIONS
Have suction available
Oxygen therapy
Prepare to intubate
C - Circulation
Palpate Pulse quality & Rate
Assess skin colour, temp, capillary refill
Check for external bleeding
NURSING INTERVENTIONS
Control bleeding with pressure
Initiate CPR
Gain IV access
Blood Test
Prepare Fluids
Measure BP
D - Disability
Brief Neurological Assessment
LOC - GCS
AVPU
Pupil size, shape, equality & reactivity
NURSING INTERVENTIONS
Ongoing neurological assessments
Pt Positioning
Reassess Pain - Pain Scale
Immobilise obvious deformities
Identify obvious deformities
Brief Pain Assessment
E - Exposure
Remove clothing - examination
Assess full body for additional/related injuries
NURSING INTERVENTIONS
Keep Pt Warm
Warm IV fluids
Maintain Privacy
SECONDARY
F - Full set of vitals
Establish Baseline Vitals
NURSING INTERVENTIONS
Establish Baseline Vitals - Temp, HR, RR, SPO2, BP
Undertake ECG
Monitor BSL
Organise Xray, ultrasounds
Urinalysis
G - Give Comfort
Assess, treat & reassess pain/anxiety
NURSING INTERVENTIONS
Provide emotional support to pt & family
Additional comfort measures - distraction, ice, position, warm blanket, analgesia
H - History & Head to toe assessment
Details of accident, length of time since, tx provided
AMPLE
A - Allergies
M - Medication Hx
P - Past Health Hx
L - Last meal
E - Events preceding illness/injury
Inspect - Head, Chest, Abdomen, Pelvis, Extremities,
NURSING INTERVENTIONS
Can you identify a victim of violence
I - Inspect Posterior surfaces
Palpate Spine to identify deformity/puncture wounds
NURSING INTERVENTIONS
Log roll method