Victim assessment.pdf

Victim assessment Victim assessment is an important first aid skill. It requires an understanding of each assessment step as well as decision making skills. Components of victim assessment 1. Danger survey. 2. Primary victim survey (initial assessment). 3. Secondary victim survey....

Victim assessment Victim assessment is an important first aid skill. It requires an understanding of each assessment step as well as decision making skills. Components of victim assessment 1. Danger survey. 2. Primary victim survey (initial assessment). 3. Secondary victim survey. 1. Danger survey Danger survey is an assessment of the accident's environment to determine: 1- Hazards. 2- Cause of injury. 3- Number of victims. 2. Primary victim survey The goal of the primary survey is to determine whether there are life threatening problems that require quick care. Components of primary survey 1- Evaluation victim's responsiveness. 2- A- Airway opening/ cervical spine stabilization. 3- B- Breathing. 4- C- Circulation (pulse, hemorrhage, shock). Emergency Nursing Procedure Book Page 2 2nd year - 1st semester 2022 - 2023  Steps of primary survey 1- Check for responsiveness: a) Tap and gentle shake victim and shout,'' are you okay. See figure(1) Fig. (1) Check responsiveness b) If the victim doesn't respond, call for help and activate Emergency Medical Service (EMS, 123). See figure(2) Fig. (2) Activate EMS 2- Airway opening and cervical spine stabilization a) Open airway through head tilt chin lift maneuver or jaw thrust if neck Fig. (3) Head tilt chin lift injury is suspected. See figure (3,4) Fig. (4) Jaw thrust maneuver b) Check and clear the airway from any foreign objects. See figure (5) Fig. (5) Clear the airway Emergency Nursing Procedure Book Page 3 2nd year - 1st semester 2022 - 2023  Breathing  Check breathing by look, listen and feel.  Look for chest movement  Listen for breath sounds  Feel for expired air. See figure (6)  Assess for 10 seconds before Fig. (6) Check breathing deciding breathing is absent. 3- Circulation a) Check pulse for 5-10 second. See figure(7) Fig. (7) Check pulse from carotid artery b) Check the victim from head to toe for severe bleeding and control it if found. See figure(8) Fig. (8) Check bleeding c) Check the victim for shock manifestations and treat it if found. See figure(9) Fig. (9) Elevated legs Emergency Nursing Procedure Book Page 4 2nd year - 1st semester 2022 - 2023  3. Secondary survey Components of secondary survey A- Victim history(SAMPLE) B- Physical examination A) Victim's history Victim history can be taken from victim, victim's family or friends if available or bystanders Components of victim's history (SAMPLE) S- Signs and symptoms A-Allergies M- Medication P- Previous medical history L- Last meal E- Event B) Physical examination Steps of physical examination 1- Check vital observations a) Level of consciousness( AVPU) The victim is: A- Alert. V- Response to verbal stimuli. P- Response to painful stimuli. Fig. (10) level of consciousness U- Unconscious. See figure(10) Emergency Nursing Procedure Book Page 5 2nd year - 1st semester 2022 - 2023  b) Breathing  Determine breathing rate, rhythm, and depth. See figure( 11)  Determine breathing difficulties (pain when breathing) or abnormal breathing Fig. (11) Calculate respiratory rate sounds (e.g. gasping, wheezing or snoring). c) Pulse  Determine pulse rate and rhythm. See figure(12) Fig. (12) Calculate pulse rate d) Skin characteristics  Temperature (through feel the victim forehead with back of your hand. See figure(13)  Color (look at the victim's face and Fig. (13) Check temperature lips).  Moisture.  Capillary refill. See figure(14) Fig. (14) Capillary refill test e) Pain characteristics if present ( PQRST)  P- Precipitating  Q- Quality  R- Region/ Radiation  S- Severity  T- Time Emergency Nursing Procedure Book Page 6 2nd year - 1st semester 2022 - 2023  2- Head to toe examination Check each area for DOTS  D- Deformities. See figure(15) Fig. (15) Deformities  O- Open wound. See figure(16) Fig. (16) Open wound  T- Tenderness. See figure(17) Fig. (17) Tenderness  S- Swelling g. See figure(18) Fig. (18) Swelling Head to toe examination mechanism i. Check head a. Skull. See figure(19) Fig. (19) Skull examination. b. Eyes (check the pupils for equality and reactivity to light). see figure (20) Fig. (20) Eye examination Emergency Nursing Procedure Book Page 7 2nd year - 1st semester 2022 - 2023  c. Nose and ears for CSF or bleeding or discharges d. Mouth for fractured jaw or teeth. See figure(21) Fig. (21) Nose and mouth examination ii. Check neck a. Feel side and back of the neck for numbness or tingling and strength. See figure (22) b. If no suspect cervical spine injuries ask the victim to slowly move the neck from side to side. Fig. (22) Check neck iii. Check shoulders and collarbone.  Ask victim to shrug shoulders. See (figure 23) Fig. (23) Check shoulders and collarbone iv. Check chest (DOTS)  Feel ribs and sternum. see figure(24)  Ask victim to take deep breath and blow air cut.  Look for unequal rise of chest with each breath. Fig. (24) Check chest Emergency Nursing Procedure Book Page 8 2nd year - 1st semester 2022 - 2023  v. Check abdomen( DOTS)  Apply slight pressure to each quadrant of abdomen to determine rigidity or guarding. See figure(25) Fig. (25) check abdomen vi. Check hips  Push downward and inward both sides of hips with your hands. See figure (26) Fig. (26) check hips vii. Check extremities Upper extremities  Assess both side of each arm one at a time for:  DOTS  CSM: Fig. (27) check sensation C-Circulation. S- Sensation. M- Movement. See figure(27) Lower extremities  Assess both side of each leg one at a time for DOTS and CMS. See figure(27) Fig. (27) leg examination Emergency Nursing Procedure Book Page 9 2nd year - 1st semester 2022 - 2023   Babinski reflex test. See figure (28) Fig. (28) Babinski reflex test viii. Check back  Gently reach under victim and feel the back. See figure (29)  If no suspected spinal cord injury apply log roll to victim and assess all areas of back Fig. (29) Check back Emergency Nursing Procedure Book Page 10 2nd year - 1st semester 2022 - 2023