NUR 3263 (Primary Medical Care) ........................................................ Ruamsook .S. (Community Health Nurse Practitioner) ng and Health, Suan Sunandha Ratjabhat University SSRU ........................................................
SSRU Situations Situations 1 Situations 2 SSRU
- / (Body substance - isolation) (Mechanism of injuries) - safety) -(Scene (Number of patients)
- (Additional resource) SSRU (Initial assessment) Triage Dead Field Triage Minor / mmediate Delayed :
walking around SSRU (Initial assessment) Triage 1st Emergency Severity Index suscitation Emergency Urgent
2nd (.) mergency Urgent Semi-urgent Non-urgen Non-urgent : - ( SSRU Emergency
Urgent - - - - - - - / - - - - - - Emergency Severity Inde
SSRU () ial assessment / d trauma assessment
(C-spine stabilization)C-spine stabilization) head to toe SSRU DCAP-BTLS D = Deformities
C-spine stabilization C = Contusion Assess the head A = Abrasion Assess the neck P = Puncture Apply cervical spinal immobilization Assess the chest B = Burns Assess the pelvic T = Tenderness L = Lacerations Assess all four extremities Assess posterior S = Swelling Assess vital signs and SAMPLE his
SSRU Focused assessment / SAMPLE S = Signs and symptoms A = Allergies M = Medication
P = Past history / L = Last oral intake SSRU ABCDE assessment SSRU
Initial assessment Is the airway patient?, No airway obstruction from Can the patients talk ? Clear - Bleeding airway - Secretion - Suction - Foreign body Naso/orophary ngeal airway
SSRU 14 Head tilt chin lift maneuver Jaw thrust maneuver * C-spine injury SSRU
Initial assessment Is the Hypoxia / Hypoxemia, breathing - Accessory Cyanosis, sufficient? muscles 15 Respiration - Breathing depth and rhythm - Tracheal position - Symmetrical chest expansion SSRU
Initial assessment Acti on Is the Bleeding circulation Skin : . sufficient? - Color(pale, red, mottled) Capillary Stop Cool/warm/dry/s refill time Vitals signs :
bleed, weaty Pulse, IV/IO/ Blood SSRU Initial assessment What is the level of AVPU andconsciousness? Glasgow Coma Scale/Score : 17 AVPU assessment
A = Alert V = Verbal stimuli P = Painful stimuli SSRU Initial assessment Glasgow Coma Scale/Score : GCS 18 13 15 = Mild 9 12 = Mode 3 8 = Severe
Decorticate 19 VS Decerebrate Initial assessment Any clues to explain the patients Completely undress condition? but prevent Head - to - toe 20
hypothermia assessment : - Trauma, Fracture, Wounds, Lesions - Infection, Petechiae, rash SSRU Glasgow Coma Scale/Score : GCS 54
SSRU SSRU
SSRU 1 / 2 3
SSRU 38 1. (C-spine stabilization)Cardiopulmonary arrest) 2. (C-spine stabilization)Unconscious) 7.
(C-spine stabilization)Stroke, Cerebrovascular disease) 3. (C-spine stabilization)Shock) 8. (C-spine stabilization)Drowning and Near drowning) SSRU () 38
13. (C-spine stabilization)Fracture) 19. (C-spine stabilization)Head injury) (C-spine stabilization)) 14. (C-spine stabilization)Eye emergency) 20. (C-spine stabilization)Chest injury) 15. (C-spine stabilization)Ear emergency) 21. (C-spine stabilization)Abdominal injury) 16. emergency) 22. SSRU (C-spine stabilization)Throat ()
38 26. (C-spine stabilization)Human bite) 32. (C-spine stabilization)Jellyfish dermatitis) 27. (C-spine stabilization)Snake bite) 33. (C-spine stabilization)Suicide attempt) 28. (C-spine stabilization)Animal bite) 34. (C-spine stabilization)Rape) (C-spine stabilization)) 29. (C-spine stabilization)Bee/Wasp/hornet sting) 35. SSRU
1 7 1. 7 7. 13. /. 2. 8. 14. 3. 9. 15. 4. 10. 16. SSRU
1 7 19. 22. 24. 20. 23. (C-spine stabilization)//) 25. (C-spine stabilization)Condyloma) 21. /
SSRU 38 1. 3. - / - 2. 4. / SSRU
38 6. - / / 7. /// - ////
SSRU . (C-spine stabilization)2557). . (C-spine stabilization) 3). : . . (C-spine stabilization)2552). . (C-spine stabilization) 12). : . (C-spine stabilization)2551). .(C-spine stabilization) 4). : ...
. (C-spine stabilization)2541). .(C-spine stabilization) 1). : ... SSRU
