Welcome to the initial assessment pre-course module. One of the most important things you will learn in ENPC or TNCC is a systematic process to guide your care of pediatric or trauma patients. The initial assessment chapter of each provider manual describes the process in detail. You can also reference the performance checklist that will be used in class. We refer to this as the Pediatric Nursing Process, or PNP, and the Trauma Nursing Process, or TNP. This is a template that will be used to present a variety of patient care scenarios. I will talk you through the process first. Then you will watch a video showing how it might look in class. The ENPC and TNCC criteria differ slightly, but the prioritization sequence for assessment and intervention is the same. If you received pre-hospital notification about the patient, you have a few minutes to activate the team, prepare the room and any equipment, and don PPE. The across-the-room observation provides a general impression of the patient's condition. Is there any need to reprioritize to see ABC because of uncontrolled hemorrhage or a need for chest compressions? In the pediatric patient, you will use the Pediatric Assessment Triangle to determine if the child is sick, sicker or sickest. If you did not receive pre-notification of the patient's arrival, you will activate the team, assess for safety risks and don PPE before performing interventions. Embrace and airway, breathing and ventilation, circulation and control of hemorrhage, disability, and exposure and environmental control are the A, B, C, D, E of the primary survey. Listed on the screen are the assessment criteria for each letter. Each letter must be assessed in order, making them double-starred steps of the pediatric or trauma nursing process. Doing these steps out of order can easily result in missing a life-threatening condition. If any abnormalities are noted, the learner must immediately intervene and reassess prior to moving on to the next letter. Interventions may include, but are not limited to, insertion of an airway, bag mask ventilation, intravenous fluid or blood administration, assessment of a blood glucose, and controlling any external hemorrhage. We do appreciate that in real life, these assessments take seconds and interventions may occur simultaneously with multiple team members present. It is, however, feasible that there may come a time when you are the only person available to manage the initial assessment. More importantly, breaking the process down into very specific assessment criteria and interventions which must be stated and performed in order is a proven teaching-learning strategy to make the process second nature for you when managing a real patient. F and G are considered adjuncts to the primary survey. In F, you will facilitate family presence and obtain a full set of vital signs. In G, you will obtain labs, attach a cardiac monitor to the patient, consider the need for a nasal or orogastric tube, assess and manage oxygenation and ventilation, and address pain. Addressing pain includes an assessment using an appropriate pain scale and managing pain with non-pharmacologic and pharmacologic measures as needed. Pain assessment is considered a single-starred step. This must be done before the completion of the scenario but can be done at any time. Sequence is not vital. The secondary survey is designed to identify all injuries or indications of illness. This is accomplished with a thorough history and head-to-toe exam. Critical findings can be missed if this exam does not include the back, so inspecting the posterior is an important reminder. If the patient is still on any sort of a transfer device or longboard, it should be removed at this time. Before log rolling the patient, consider the possibility of a spine or pelvic injury based on the patient assessment. It may be safest to obtain imaging first or use alternate techniques to move the patient, as log rolling may worsen cord injury in the unstable spine or cause hemorrhage in the unstable pelvis. The nurse will now anticipate interventions or diagnostics based on the patient's scenario. At this point, the team has likely left the patient's bedside. It is the nurse's responsibility to just keep re-evaluating. The nurse will communicate any concerns with the team and intervene as appropriate to changes in the patient's condition. Can you see how this systematic process will help you turn chaos into order and prioritize when you have a very sick patient in front of you? Don't worry if it doesn't, just keep studying your provider manual and your instructors will help you apply it in class. Six teaching scenarios will be used in class to reinforce this systematic assessment process. We will now show you an example of what this looks like in real time. Follow along with your pediatric or trauma nursing process reference. OK. Your pre-hospital report. An ambulance is in route with a 58-year-old male involved in a motor vehicle crash. He was ambulatory on the scene, but is becoming less responsive. Oxygen is being administered by a non-rebreather mask at 15 liters per minute. He has one large caliber IV with isotonic crystalloid solution infusing. His vital signs are blood pressure of 118 over 64 with a heart rate of 118 and respiratory rate of 20 breaths per minute. He is in a rigid cervical collar and on a long backboard for transport. The patient is expected in three minutes. Please begin your initial assessment process. OK. I'm going to go ahead and activate the trauma team. The trauma team is activated. And I'm going to go ahead and prepare our room. At the very least, I want to make sure that there's a fluid warmer there. And because of the patient's decreasing level of consciousness, make sure that there's intubation equipment available as well. OK. So your preparation is complete. Great. I'm going to don my PPE and make sure that my team dons their PPE. The PPE has been done by the team. Your patient has just arrived. All right. I'm going to do my across the room assessment on the patient, looking for any uncontrolled hemorrhage to see if there's any need to reprioritize to CABC. There is no uncontrolled external hemorrhage and no need to consider reprioritizing to CABC. All right. I'm going to go ahead and start my primary survey by assessing his level of alertness, his airway, and maintaining cervical spine stabilization all at the same time. So what is his FPU? The patient is becoming less responsive and responds minimally to pain. OK. And I'm going to have someone maintain spinal stabilization for him while I go ahead and do a jaw thrust maneuver on him to look into the airway. I'm assessing for any sort of foreign objects, teeth, tongue, edema, snoring, gurgling, blood, vomitus, or any foreign objects. Do I see any of those? So there is tongue obstruction as noted by the snoring, which is relieved with a jaw thrust maneuver. No loose or missing teeth are noted. No foreign objects are noted. No blood, vomit, secretions are noted. No edema. But snoring is heard when that jaw thrust is released. No gurgling or stridor and no bony deformity. OK. Because of that snoring, I want to go ahead and use an airway adjunct on the patient, either nasopharyngeal or oropharyngeal airway. I'll assess for gag reflex. If there's no gag reflex, then I'll go ahead and place the oropharyngeal airway. OK. So the oropharyngeal airway has been placed. And does that relieve the gurgling? There's no snoring or gurgling heard at this point. The airway is now patent, and oxygen is being administered. OK. Then because he accepted an oropharyngeal airway, he's going to need definitive airway. So I'm going to go ahead and alert the team for the need for intubation in this patient. So the team is preparing. So please proceed with your assessment. All right. So I am going to go ahead and assess his breathing. Is spontaneous breathing present? Does he have equal chest rise and fall? Can I hear lung sounds bilaterally? What is his skin color? Does he have increased work of breathing? So breathing is spontaneous and shallow. Chest rise and fall is symmetrical and shallow. Respirations are shallow, irregular, and slow. There is no increased work of breathing. The skin color is dusky. There are contusions noted, and bony crevice palpated over the left chest. Breast sounds are very diminished bilaterally. No subcutaneous emphysema, no tracheal deviation, or jugular venous distension. OK, because of the shallow respirations and the dusky color, I'm going to go ahead and start to bag valve mask this patient using a good CE seal on the patient. We're going to go ahead and press the bag about halfway. OK, so ventilations are being assisted. So your patient has just been intubated using drug-assisted intubation. What is your next step? All right, we need to assess the airway to make sure that it's been properly placed. We're going to do that by placing end-tidal CO2 onto the airway. And we will monitor chest rise and fall while he's being bagged. We're going to take a listen in five places, starting over the epigastrum, and then four areas of the chest to listen for clear and equal breath sounds. OK, so once your CO2 detector is attached and you've delivered five to six breaths, there is positive evidence of CO2 indicated that the tube is correctly placed in the trachea. Chest rises and falls equally with assisted ventilation. There is no gurgling heard over the epigastrum. And breath sounds are equal bilaterally. OK, then we're going to go ahead and secure the endotracheal tube with a commercial tube holder. We're going to mark the placement at the teeth. And we're going to go ahead and get him set up to a mechanical ventilator. OK, so the ET is secured. And the number at the level of the teeth is documented. And we are now applying the ventilator. OK, so we've addressed airway, breathing. I'd like to move on to circulation. OK, so I'm going to, again, assess for any signs of uncontrolled hemorrhage. We're going to check central pulses on this patient. And we're going to look at skin color, temperature, and moisture. So there is no uncontrolled external hemorrhage. The central pulse is rapid and weak. Skin is pale, cool, and diaphoretic. OK, so that indicates to me that he has a problem with circulation. So I'm going to go ahead and check the first IV from the field to make sure that it's still patent. And it is patent. And we're going to go ahead and get a second IV catheter placed, a large bore. We're going to hook that up to blood tubing. And we're going to start a fluid bolus of 500 mLs of warm crystalline isotonic solution. OK, so your additional catheter has been placed if 500 mL bolus of warm isotonic crystalline solution is infusing via blood tubing. OK, and I'm going to reassess his pulses and his color, temperature, and moisture after the bolus has been administered. OK, so your central pulse is now less rapid and stronger. Skin is pale, cool, and dry. OK, so that shows a slight improvement. We're going to go ahead and continue with a balanced resuscitation for this patient. OK, the team will continue to administer fluids and a balanced resuscitation protocol. All right, so we've addressed airway, breathing, and circulation. I'd like to move on to disability. What is his complete Glasgow Coma score? So there is no eye opening, giving him a 1. There is no verbal response, giving him a 1. There is no motor response, giving him a 1, which is a total GCS of 3 following drug-assisted intubation. OK, I'd also like to check his pupillary response. I'm going to open both eyes and look at his pupils. The left pupil is dilated and non-reactive. The right pupil is sluggishly reactive to light. OK, I have concerns for a significant head injury because of that assessment finding, so I'm going to go ahead and notify CAT scan of the need for a head CT on this patient. OK, so CT has been ordered and radiology has been notified to expect the patient. All right, I'm going to go ahead and move on to exposure and environment control. I'm going to go ahead and take all of his clothing off. I'm going to look for any other signs of uncontrolled hemorrhage. I'm going to look for lacerations, contusions, abrasions, any obvious bony abnormalities on this patient. So your clothing is removed, and no uncontrolled hemorrhage is noted. There are abrasions, though, noted to the left upper and left lower extremities. All right, so I'm going to go ahead and also then cover the patient back up. We will get a warm blanket put onto him. We'll increase the temperature in the room and make sure that the fluids are on a warmer so that we address the environmental concerns. OK, so all your warming methods have been applied. All right, so I would like at this time a full set of bundles, please. Sure. We have a blood pressure of 122 over 76 with a MAP of 91. Heart rate is 92. Respiratory rate is 12 breaths per minute by a mechanical ventilation. There's a temperature of 98.6. And your SpO2 is 97%. OK, I'd also like to facilitate family presence. Have they been notified? Yes, and the family is en route to the hospital. All right, at this point, I'm going to go ahead and get my adjuncts using the LMNOP mnemonic. Labs were obtained when we got the second IV. I'd like to make sure that there is at least a type and screen. I want to get a lactate level and a complete metabolic panel, CBC, and any other trauma labs that the physician would require. OK, so blood samples are sent to the lab, and they are in process. All right, I'd also like to hook the patient up to the cardiac monitor at this time. Your EKG, or ECG, excuse me, shows a normal sinus rhythm without ectopy. All right, and I'd like to either place a nasogastric or orogastric tube. Because of his head injury, is the nasogastric tube contraindicated? Yes, it is at this time due to the possible head injury. All right, then we'll go ahead and place an orogastric tube on this patient. OK, it's been inserted. All right, and then I would like to check his pulse oximetry at this time. Is oxygen level? Sure, it's currently reading 97%, so there is no indication to wean oxygen at this time. All right, and then I'd also like to apply waveform capnography. OK, so your waveform capnography is normal, reading at 40. All right, and then assess his pain as well, using an appropriate pain scale. OK, so the pain scale result is indeterminate due to the drug-assisted intubation, so we're going to assume that there's pain present based on the identified injuries. OK, I'm going to go ahead and provide some non-pharmacological as well as pharmacological interventions for that pain. We're going to apply some ice, padding, possibly elevate some of the extremities that have injuries to them, and then I'll request an analgesia. OK, so your non-pharmacological interventions have been instituted, and we have given an appropriate dose of analgesia. All right, so at this point, I think I am ready to go on to my head-to-toe in history. So at this time, is there a need to consider transfer to a trauma center or preparation for definitive treatment? Because of the significant head injury and neurotrauma, there's a need for consideration to transfer to a trauma center, yes. OK. All right, so I'd like to start with his history. Is there any pre-hospital provider history? The patient's not able to provide us with any history. So there was significant damage to the car per pre-hospital providers. He was the unbelted driver of the car and was ambulatory on the scene. No airbag deployed, but the windshield was cracked. OK, then I would like to start with his head-to-toe. So I'm going to go ahead and start with the head, and I'm going to inspect and palpate, looking for any sort of abrasions, contusions, lacerations, or bony abnormalities. So a laceration is noted to the left forehead with no active bleeding. OK, I'm also going to inspect and palpate the face as well, taking a look at the eyes, the nose, and the ears, also looking for any abrasions, contusions, or lacerations. So he has contusions and abrasions noted to the left side of his face. The left pupil is dilated, non-reactive to light. The right pupil is sluggishly reactive to light. All right, I'm going to have my team maintain spinal stabilization while I remove the collar. And we're going to inspect and palpate the anterior and posterior surfaces of the neck. We're going to look for any sort of abrasions, contusions, lacerations. We're going to palpate for any bony step-offs along the spine. There's no abnormalities noted. All right, and we'll replace the collar then. And we'll move on to the chest. And we're going to inspect and palpate the chest, again, looking for abrasions, contusions, lacerations, any bony deformities or crepitus. So there's a contusion noted to the left chest. Bony crepitus is also noted to the left chest area. OK, I'm going to go ahead and listen to the chest as well. I'm going to listen to breast sounds. Breast sounds are clear and equal bilaterally. As well as heart sounds. Heart sounds are normal. OK, I'm going to go ahead and move on to the abdomen. We're going to inspect the abdomen, looking for any bruising patterns, any lacerations, abrasions, or contusions. There's no abnormalities noted. OK, and then we're going to listen to the abdomen in all four quadrants. All sounds are present in all four of the quadrants. And then we're going to palpate for any deformities, swelling, or edema. No abnormalities are noted. OK, and then we'll take a look and we'll inspect and palpate both flanks as well, again, looking for bruising, lacerations, contusions, or abrasions. No abnormalities are noted. OK, and then we'll move down to the pelvis. We're going to inspect and palpate. We're going to press in and downward on the iliac crest, as well as putting some gentle pressure over the symphysis pubis. We're going to look for abrasions, contusions, and lacerations as well. OK, so there's no abnormalities noted, and there's no instability noted on palpation of the pelvis. OK, and we're going to check the perineum to see if there's any discharge or bleeding. There's no abnormalities noted. OK, then we'll consider placing a Foley catheter at this time because the patient is receiving fluid resuscitation. So there are no contraindications, and the catheter is indicated for monitoring output. And the urinary catheter is placed with clear yellow urine return. OK, I'm going to move to the extremities now, and I am going to inspect and palpate the bilateral lower extremities, looking for abrasions, contusions, lacerations. I'm going to check pulses, motor, sensation, and vasculature to the bilateral lower extremities. And I'm going to do the same for the upper extremities as well, looking for abrasions, contusions, lacerations, and palpating for any bony abnormalities. So your right upper extremity has no abnormalities. The left upper extremity has abrasions and contusions. The right lower extremity has no abnormalities. The left lower extremity has abrasions and contusions. You do have strong distal pulses present in all four extremities, along with color, temperature, or normal in all four extremities as well. Assessment of the sensation and motor function, we're going to defer, though, due to the drug-assisted inhibition. So imaging has been performed, and there's no evidence of spinal or pelvic injury. It is safe to turn the patient. Okay, I'm going to get the team to help me roll the patient over. We'll go ahead and inspect and palpate along the entire spine of the patient. Again, looking for abrasions, contusions, or lacerations, as well as any bony abnormalities. There's no abnormalities noted. Okay, and we'll go ahead and remove the spine board at this time as well. Okay, so the long board has been removed. So the injuries that you have identified are a possible brain injury, laceration to the left forehead, contusions and abrasions to the left face and chest, bony prepotis to the left chest, contusions and abrasions to the left upper and left lower extremities. What interventions or diagnostics can you anticipate for this patient? We've already called for the head CT, but in addition to CAT scan of the head, we'd also like to get the neck, the chest, and the abdomen as well. If we have a FAST exam available, we'd like to do that as well. We're going to clean and dress the wounds, administer a tetanus shot, and that's about it for right now. Okay, what findings will you continue to reevaluate while the patient is in your care? Well, we want to continually monitor the primary assessment of airway, breathing, and circulation. We'll make sure that we continue to monitor the vital signs, any interventions that we've provided for the patient, and continue to reassess the patient's pain. Wonderful. What is the definitive care for this patient? Because of the significant head injury and neuro-trauma, it's probably best that he's transferred to a trauma care center. Is there anything else you'd like to add at this time? No, I think that's it at this time. Thank you.

Pediatric Nursing Process

Trauma Nursing Process

primary survey

secondary survey

patient assessment

prioritized care