ALERTDon appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions. Show
Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1).undefined#ref5">5 The presence of an environmental hazard (e.g., fire, noxious fumes, potential for explosion, active shooter) that mandates immediate evacuation of the area takes priority over the primary assessment. Stabilize the cervical spine throughout the procedure if injury is suspected. Do not proceed to the next assessment step until interventions for life-threatening conditions have been implemented. OVERVIEWThe primary assessment is intended to assess and intervene rapidly for life-threatening conditions in critically ill or injured patients. The primary assessment is done at the initial point of patient contact and may be done again after the patient is transferred from the care of one team to another (e.g., when the emergency medical services team hands off the patient to the emergency department [ED] team members). To ensure that the primary assessment is thorough, a systematic approach should be taken, for example, following the widely used A-B-C-D-E mnemonic outlined in the procedure steps. EDUCATION
PROCEDURE
A = Airway and Alertness with Simultaneous C-spine Restriction
B = Breathing and Ventilation
C = Circulation and Control of Hemorrhage
D = Disability (Neurologic Status)
E = Exposure and Environmental Control
Completing the Procedure
MONITORING AND CARE
EXPECTED OUTCOMES
UNEXPECTED OUTCOMES
DOCUMENTATION
PEDIATRIC CONSIDERATIONS
OLDER ADULT CONSIDERATIONS
REFERENCES
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice. Elsevier Skills Levels of Evidence
What is the priority nursing intervention for a client bitten by a snake?What are the nursing interventions performed by the nurse in the order of priority? The nurse ensures that the client's airway is patent and that resuscitation equipment is immediately available after the client is bitten by a snake.
What is the primary goal of a triage system used by the nurse with patients presenting to the emergency department quizlet?The primary goal of the triage system is to facilitate the ED nurse's ability to prioritize care according to the acuity of the patient, having the clients with the more severe illness or injury seen first. Airway, breathing, and circulation are part of the primary survey.
Which client would the nurse prioritize when triaging clients in the emergency department?A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first? A client experiencing chest pain and diaphoresis would be classified as emergent and would be triaged immediately to a treatment room in the ED. The other clients are more stable.
Which assessment in a traumatized client does the nurse make with the Glasgow Coma Scale?The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses.
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