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 very slightly, but the prioritization sequence for assessment and intervention is the same. If you receive pre-hospital notification about the patient, you have a few minutes to activate the team, prepare the room and any equipment, and don personal protective equipment while considering potential safety threats. Pre-hospital providers have valuable information to share about on-scene findings to better understand the mechanism of injury for trauma patients. Setting the expectation for silence and attention to the pre-hospital report upon patient arrival helps ensure this data is not lost. You can listen to the verbal pre-hospital report while looking at the patient. Use your first look at the patient to form a general impression of the patient's condition. Determine if there is any need to reprioritize to C, A, B, C 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 personal protective equipment before approaching the patient and while forming the general impression. Alertness 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. Each letter must be assessed in order, making them double-starred steps of the pediatric or trauma nursing process. Performing these steps out of order can easily result in missing a life-threatening condition. If any abnormalities are noted, the learner intervenes and may need to reassess prior to moving on to the next letter. Interventions may include but are not limited to insertion of an airway, oxygen administration, intravenous line insertion, the consideration of goal-directed therapy for shock, assessment of a blood glucose, and applying a warming method. Pre-hospital transport devices are removed at E. Reassessment of primary survey interventions are considered single-start items. You do not need to wait until a fluid bolus is complete prior to moving to the next assessment, but you need to reassess the effectiveness of the fluid bolus at some point. You will need to confirm endotracheal tube placement immediately. We appreciate that in real life, these assessments take seconds, and interventions may occur simultaneously with multiple team members present. It is feasible that there may come a time when you are the only person available to manage the initial assessment and will need to prioritize in exactly this order. But 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 adjuncts to the primary survey. If the patient is agreeable and family does not interfere with care or pose a threat to the team, now is the time to assign a support person to facilitate family presence. Assessing respiratory effort and the quality of pulses was sufficient to determine the need for lifesaving interventions initially. We can now get a full set of vital signs and attach monitoring devices. Consider the need for labs if they were not already drawn when the intravenous line was inserted, and a gastric tube to decompress the stomach. Oxygen may be weaned to prevent hyperoxia, and capnography can be used for early identification of decreased respiratory effort or extubation. Addressing pain includes an assessment using an appropriate pain scale and managing pain with non-pharmacologic and pharmacologic measures. Pain assessment is another single-starred step. This must be done before the completion of the scenario, but can be done at any time. Sequence is not as vital as it was for the lifesaving primary survey assessments and interventions. The secondary survey is designed to identify all abnormalities. This is accomplished with a thorough history and head-to-toe exams. Medical findings can be missed if this exam does not include the back, so inspect the posterior is an important reminder. Before turning 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 can worsen cord injury with an unstable spine or cause hemorrhage with an unstable pelvis. The nurse will now anticipate interventions or diagnostics based on the patient 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 condition. We hope 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 you cannot see it just yet. Keep studying your provider manual and your instructors will help you apply this process in class to make it more meaningful. Teaching scenarios will be used in class to reinforce this systematic assessment process. We'll now show you an example of what this looks like in real time. Follow along with your pediatric or trauma nursing process reference and PNP or TNP for students. Are you ready? I am. Okay. So, your ambulance is in route with an adult patient involved in a motor vehicle collision. The patient is alert and complaining of a headache. Vital signs are BP 112 over 70, heart rate 100, and respiratory rate is 20. The patient is on a backboard and 2 liters of oxygen by nasal cannula. One large caliber intravenous catheter has been established with isotonic crystalloid solution infusing at a controlled rate. The patient is expected in 5 minutes. Please begin your initial assessment. All right. I'd like to go ahead and activate the trauma team. I'd like to prepare my room, and I'm thinking I might put in a rapid infuser, extra IV supplies, maybe some airway supplies as well. Okay. The team has been activated and roles assigned. Your room is prepared. Okay. I'd like for my team to don their PPE, and I would like to make sure it's full PPE, including gloves, a mask, goggles, et cetera, and then I'd like to determine if there's any safety concerns for our team. There are no safety threats. PPE has been done, and your patient has just arrived. Okay. Then I'm going to do my general impression, and I'd like to know if there's any uncontrolled external hemorrhage, if the patient is unresponsive or apneic. There is no uncontrolled external hemorrhage, and the patient is responsive and does not have apnea. Okay. Then we can move on, and I'd like to start my alertness and airway. Starting with alertness, what's the patient's AFPU? The patient is alert. Patient is alert. Okay. For airway, then I will ask him to open his mouth. The patient is able to open their mouth. Okay. Then I'd like to know if there is any blood monitor secretions. Are there any bony deformities? Is there tongue obstruction, airway swelling, or abnormal sounds? There's no bony deformity, and all of these are no. There's no burns, edema, blood, vomit, or secretions for an object, signs of inhalation injury, loose or missing teeth, snoring, gurgling, or stridor, tongue obstruction, or vocalization abnormalities. Okay. The airway is patent. All right. Then I can move on to breathing and ventilation. I'd like to know if my patient is breathing. What are the breath sounds? What is the skin color? What is the rate, depth, and pattern of the respirations, please? Breath sounds are present bilaterally. The respirations are of normal depth, regular, and slightly rapid. There is no increased work of breathing, no open wounds or deformities. The color is pale. Breathing is spontaneous. There's no subcutaneous emphysema. There's equal rise and fall of the chest, and there's no tracheal deviation or jugular venous distension. All right. It sounds like our breathing ventilation is intact. I'm going to continue the oxygen at two liters per cannula. So I'd like to move on to circulation and control of hemorrhage. I'd like to know if they have the quality of their pulse and what the skin color, temperature, and moisture is, please. The pulse is strong and at a normal rate, and the skin color and temperature is pale, warm, and dry. All right. I'd like to know if my pre-hospital IV is patent. It is patent. Okay. I'd like to start a second IV, and I'll draw my trauma panel labs at this time as well. Okay. So your second IV site is obtained, and your labs are collected. Okay. Because of the circulatory assessment, I'd like to continue his IV fluids of warmed isotonic crystalloids at a controlled rate. And warmed isotonic crystalloid fluids are being administered at a controlled rate. Okay. Let's move on to disability. I would like to get my Glasgow Coma Scale, and I'd like to check his pupils, please. Glasgow Coma Scale is 15, and your pupils are equal, round, and reactive to light bilaterally. Okay. Since he's alert, his Glasgow is 15, I'm not going to get glucose at this time, but I could consider it at this point. Okay. All right. Let's move on to environment and exposure. So the first thing I would like to do is make sure that I have removed all of the clothing, and I've looked for any additional injuries. Okay. And there's an abrasion to his left forehead. Okay. And nothing else? Nope. That is it. Okay. Then let's go ahead and make sure that we keep him warm. So I'm going to give him some warm blankets while I turn up the temperature in the room to prevent any hypothermia issues. Okay. And a warming method has been applied. Okay. All right. Let's move on to full set of vital signs and family presence. I'd like to get blood pressure and heart rate. Okay. So the family has been notified, and they're in route. Your vital signs are BP 116 over 88 with a MAP of 97, heart rate is 98, respiratory rate is 18, temperature is 97.8 Fahrenheit, and your SpO2 is 99% on your oxygen. Okay. Okay. And family's in route? Yes. Then I can move on to get adjuncts and give comfort. Getting adjuncts, I'd like to make sure that that lab got sent, type and cross, lactic acid, CBC, BMP, a typical panel. Then I'm going to move on to the cardiac monitor. So let's put him on the monitor at this point, and I can consider getting an EKG if it were indicated. Okay. Okay. So 98% your cardiac monitor says sinus rhythm. Okay. Let's move on. NG or OG is not indicated for this patient. Okay. Then I would like to think about his oxygenation. What was the pulse oximetry, please? His pulse oximeter is 98% on oxygen. Okay. So we'll keep him on the 2 liters for now, and his end tidal capnography? It's 36 millimeters of mercury. Okay. That sounds like we're in a good spot. Let's go ahead and move on to his pain assessment using an appropriate pain scale. His pain is 3 using an appropriate scale. Okay. 3, we could talk to the physician about maybe considering some analgesics. Otherwise, I'm going to do non-pharmacological interventions such as comfort measures. If he had something that needed to be splinted, I could splint the extremity if it were necessary. Okay. So your non-pharmacologic interventions have been implemented, and analgesia has been ordered and administered. Okay. At this time, is there a need to consider transfer to a trauma center, surgery, or to critical care? Based on what we know at this point, no, there is not. Okay. Go ahead and continue. Okay. I'd like to do my head-to-toe and my history. Do we have any additional pre-hospital report? The pre-hospital provider's report, the patient was a restrained driver of a 2-vehicle collision. Okay. And the airbag did deploy. Okay. And the patient denies any relevant medical history. All right. Not much to do with that report, so we'll go ahead to our head-to-toe. And I would like to start with my head. I'm going to inspect, and then I'm going to palpate all surfaces. I'd like to know if there's any abnormalities, swelling, contusions, abrasions, those sorts of things. There are no abnormalities. Okay. How about the face? I'm going to inspect and palpate the face as well. And there's an abrasion to the left side of the forehead. Okay. All right. Nothing else? No. That's it. Then I would like to assess his neck. I need a second person to help maintain C-spine stabilization. Someone will assist you. So I have a person maintaining that positioning. I'm going to inspect. I'm going to palpate the posterior for any type of step-offs or any other abnormalities while I replace the C-collar. And there's no abnormalities. Okay. Now I'm going to move on to the chest. I would like to inspect, palpate, and auscultate. So I'm going to inspect first. Do I see anything? There's no abnormalities. Okay. I'm going to take a listen to the heart and the lungs. Okay. Breast sounds are clear and equal and heart sounds are within normal limits. Okay. And what about to palpation? Do I have any issues? There's no abnormalities. Okay. Then let's go ahead and move on to the abdomen. And I'm going to inspect, auscultate, and palpate. So do I see anything on inspection? No. There are no abnormalities on inspection. And your bowel sounds are present in all four quadrants. Anything with palpation? There are no abnormalities on palpation. Alright. How about the flanks? I'd like to inspect and palpate the flanks. And there are no abnormalities. Okay. Good. Let's move on to the pelvis then. Let me inspect the pelvis please. And there are no abnormalities noted on inspection. Then I'm going to check for pelvic stability by using gentle downward-inward motion or medially on the iliac crest. Okay. No instability noted. Okay. No instability. So I can go ahead and palpate the symphysis pubis as well. Any issues with that? There's no instability on the symphysis pubis either. And I'm going to inspect the perineum. And there's no abnormalities noted. Okay. At this point we could consider a urinary catheter but it's not indicated in this patient. We will just continue to measure urinary output. Okay. And so it's deferred at this time. Alright. Let's move on to the extremities. I'm going to start with my upper extremities. I'm going to palpate. Look for any kind of deformities or abnormalities. I'm going to check neurovascular status. And then I'm going to do the same for my legs. Okay. What do I find? The extremities have normal color, temperature, and strong pulses in all four extremities. Okay. So we're good there. Okay. So imaging is not indicated at this time so it is safe to turn your patient. Okay. Let's go ahead and log roll the patient. Okay. We have the appropriate number of people here. Okay. And we're going to log roll on my count because I'm at the head. Then I'm going to inspect and palpate the back. Looking for any abnormalities. I'm going to remove the backboard at this time. And there were no abnormalities noted on palpation and inspection. Alright. Good. So what interventions or diagnostics can you anticipate for this patient? I could anticipate potentially a specialty consult. At this point it is not indicated but I'm going to think about that. I could also clean and dress this wound and I would do a tetanus update. Okay. What findings will you continue to re-evaluate while the patient is in your care? That would be our VIP. The vital signs, injuries and interventions, primary assessment, and pain. Okay. What is the definitive care for this patient? This patient could potentially be discharged or possibly admitted as an observation. Okay. Is there anything else you would like to add at this time? No. Okay. Thank you very much.

Pediatric Nursing Process

Trauma Nursing Process

patient assessment

lifesaving interventions

ENPC and TNCC manuals