Trauma treatment skills for nurses 22 พค.2558

Trauma treatment skills for nurse ผศ.ดร.กรองได อุณหสูต

คณะพยาบาลศาสตร์ มหาวทิยาลยัมหดิล

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Advance Trauma Life Support (ATLS)

ผศ.ดร.กรองได อุณหสูต

Primary survey and resuscitation

Adjuncts to primary survey

and resuscitation

Secondary survey and management

Adjuncts to the secondary

survey

1 2

3 4

Primary Survey and resuscitation

ATLS

Airway control with cervical spine protection

Breathing and ventilation

Circulation and control of hemorrhage

Disorders of the central nervous system

Exposure of the whole body

Skills for Nurse

Airway: airway management and cervical spine protection

Breathing: detect life threatened chest injury

Circulation : control hemorrhage and detect traumatic shock

Disability: assess disability

Exposure: completely undress but prevent hypothermia


• Clear airway • Inserted: oro/nasopharyngeal airway • O2 mask / Hold mask with bag 10 LPM • Monitor V/S, N/S, O2 sat • Prepare definite airway: endotracheal tube • Nursing record

Airway management and C-spine protection

Patent airway

• O2 mask with bag 10 LPM • Monitor V/S, N/S, O2 sat • Nursing record

Obstructed airway

Definite care

• Assess airway compromise • Manual maneuvers; jaw thrust, chin lift • Protect C-spine

Notify

Reassessment

1

2

5 4

3

http://modern-prepper.com/tag/medicine

http://resuscitation-guidelines. articleinmotion.com/article

chin lift

jaw thrust

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Protect C-Spine

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http://static.dme-direct.com/media/wysiwyg

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http://i.ytimg.com/

http://www.google.co.th/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://ged.free-ed.net/FREE-ed/Resources/PubServ/EMS/EMS%20Primer/emsPrimer01a.asp?iNum%3D406&ei=Vo-oVLD-HMKIuASBtYHQCA&bvm=bv.82001339,d.c2E&psig=AFQjCNEZfS7HdyMmckTXIWYRvMS0XOZoog&ust=1420419037219428

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• Airway management • Hold mask with bag 10 LPM • Monitor V/S, N/S, O2 sat • Prepare definite airway • Assess life threatened chest injury • Prepare for CXR, diagnostic tests, decompression • Nursing record

Breathing and ventilation

Effective

• Assess signs & symptoms • Assess associated injury • Nursing record

Definite care

• Assess chest movement, RR • Assess breath sounds, O2 sat

Notify

Reassessment

1 2

5

3

4

Distress Apnea

• Airway management • Hold mask with bag 10 LPM • Assisting in definite airway • Monitor V/S, N/S, O2 sat • Assess life threatened chest injury • Prepare for CXR, diagnostic tests, decompression • Nursing record

• Reassessment

Class I (<15%) • Tachycardia

•Control bleeding • Assess : ABC, signs of shock • HR, V/S, LOC, Capillary refill time, O2 sat • Evaluate mechanism of injury and other injuries

Notify

Class II (15-30%) • Clinical symptoms

Class III (30-40%) • Perfusion alteration

Class IV ( >40%) • Life-threatened conditions

• O2 mask with reservoir bag 10 LPM • Prepared : definite airway • Initiate 2 large-bore IV • G/M, CBC, Hct. • Prepare adjuncts : N-G tube , Foley catheter, ECG, cut down • Prepare for : diagnostic tests, surgical treatment • Prepared: volume resuscitation • fluid challenge test

• O2 mask with reservoir bag 10 LPM • CBC, Hct. • Prepare for : surgical treatment • Prepared : volume replacement

• Prepared : definite airway • Initiate 2 large-bore IV • G/M, CBC, Hct., ABG • Prepare adjuncts : Foley catheter, N-G tube, ECG, cut down • Prepare for : diagnostic tests, surgical treatment • Prepared volume replacement • fluid challenge test

Hemorrhagic shock

Definite care

1

2

3

4

5

• Airway management • O2 mask with reservoir bag 10 LMP • Prepare for: definite airway • Prepare for: cardiocentesis, thoracentesis, ICD, surgical treatment • Prepare for: X-ray, diagnostics tests • Maintain oxygenation • Monitor: V/S, N/S, LOC, O2 sat, EKG. • Nursing record

• Assess : HR, • Assess : V/S, LOC, O2 sat, Capillary refill time • Evaluate mechanism of injury and other injuries

Cardiogenic / Obstructive shock • Distended neck veins • Dypsnea, tachycardia • Decrease breath sounds • Trachea deviation

Spinal Shock • Paresis, paralysis

• Airway management • O2 mask with reservoir bag 10 LMP • Prepare for: definite airway • Prepare for X-ray, diagnostics tests • Maintain normotension • Monitor: V/S, N/S, LOC, O2 sat • Nursing record

Non hemorrhagic shock

Notify

Reassessment

Definite care

1

2

3 4

5

Disability LOC

Alert

Oriented

Confused

Stupor

Semi coma

Coma

AVPU

Alert

Response to verbal

Response to pain

Unresponsiveness


GCS – FOUR Score


Exposure


Secondary survey and management

E: Exposure (remove clothing)

F: Fahrenheit (keep patient warm)

G: Get a complete set of V/S

H: History & head-to-toe assessment

I: Inspect posterior surfaces


History AMPLE

Allergies

Medications

Past illness

Last meal

Events related to injury

MIVT / MIST

Mechanism of injury

Injury sustained

Vital signs / Signs and symptom

Treatments


LOC, Pupils Head Maxillofacial Neck Thorax Abdominal Pelvis Spinal cord Extremities

GCS score, size, shape, reaction Lacerations, fractures Deformity, crepitus Deformity, emphysema Deformity, bruise Pain, tenderness Fracture, tenderness Motor response, pain response Deformity, abnormalities

Head- to - toe


2° survey

AMPLE Allergies Medications, Past illness Last meal, Events related

to injury

Mechanism of injury

Injury sustained

Vital signs Treatment

MIVT Mechanism

of injury Injury

sustained Signs &

symptoms Treatment

MIST


Re-evaluation

Assure life-

threatened conditions

Continuous monitoring

ABCDE

Relief of severe

pain


Trauma Treatment for Nurses followed Advance Trauma Life Support (ATLS)

Airway & C-spine protection

Breathing & ventilation

Circulation & control bleeding

Disability Exposure

• Assess airway • Open airway • Clear airway and inserted airway • immobilize with C-collar • O2 mask with reservoir bag 10-12 LMP • Prepare definite airway

• Assess RR, breath sounds, chest movement, O2 sat • Assist ventilation 100% with self inflating bag • Prepare definite airway • Ventilation support

• Assess HR, V/S, signs of shock • Control bleeding • IV access with warming fluid • Prevent hypothermia • G/M • Trauma lab

• Head to toe, MIVT, AMPLE • Cleansing • Dressing and suture • Stabilize • RICE

• Assess AVPU, GCS, Pupils • Prepare diagnostic tests • Prepare surgical treatments


Life threatening conditions

• A Airway • B Breathing • C Circulation

Life threatening conditions

• Oxygenation • Ventilation • Perfusion

ABC


Trauma Treatment Competency Skill Basic Doing Develop Advance Expert

Assessment รวบรวมได ้ ครบถว้น วเิคราะห์ สรา้งแนวทาง พฒันาแนวทาง

Priority จดัลาํดบัได ้ ถูกตอ้ง คาดการณ์ได ้ วางแผนป้องกนั สรา้งแนวทาง

Care ใตก้ารนิเทศ ไมซ่บัซอ้น ครอบคลุม กาํกบั แนะนํา พฒันาแนวทาง

Resuscitate ใตก้ารนิเทศ ตามแนวทาง รวดเร็ว ถูกตอ้ง รว่มกบัทีม ทบทวนแกไ้ข

Role รูห้น้าที ่ ตามบทบาท ช่วยทีม ประเมนิผล สรา้งแนวทาง

Monitor ใตก้ารนิเทศ ครบถว้น ป้องกนั กาํกบั แนะนํา พฒันาแนวทาง

Evaluation ใตก้ารนิเทศ ครอบคลุม ครบถว้น ใหค้าํแนะนํา สรา้งแนวทาง

Document ครบถว้น ครอบคลุม ใหค้าํแนะนํา เป็นผูต้รวจสอบ สรา้งเกณฑ์

Report ใตก้ารนิเทศ ไมซ่บัซอ้น ครบถว้น กาํกบั แนะนํา พฒันาแนวทาง

Risk manage ระบุได ้ ระวงั ป้องกนั ประเมนิ สรา้งแนวทาง

Teaching ใตก้ารนิเทศ ไมซ่บัซอ้น ตามแนวทาง กาํกบั แนะนํา พ?ันาแนวทาง

Transfer ใตก้ารนิเทศ ตามข ัน้ตอน ประสานงานได ้ กาํกบั แนะนํา พฒันาแนวทาง


/ชมรมพยาบาลศลัยกรรมอบุตัเิหตแุหง่ประเทศไทย [email protected]

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Trauma treatment skills for nurses 22 พค.2558