Angelite Nurses

Airway

1. Assess, establish, and maintain an adequate airway.
1. Do not hyperextend the neck in a client with suspected cervical spine injury.
2. Use jaw thrust instead.
2. Administer artificial resuscitation if necessary.
3. Observe for chest trauma such as open sucking wounds or flail chest (see Chest Trauma).
4. Administer oxygen at 5 liters/minute unless client has history of COPD; lower oxygen levels needed for those with COPD.
5. Draw blood samples for ABGs.

Hemorrhage and Shock

1. Deep wounds with pulsating blood flow
1. Apply firm pressure over the wound with a sterile dressing.
2. If wound is on a limb, elevate the extremity.
3. Apply pressure with three fingers over appropriate pressure point.
4. Once bleeding is controlled, apply a pressure dressing.
5. Tourniquets should be used only when all other methods have failed.
2. Venous bleeding: apply direct pressure to bleeding site.
3. Never remove any foreign object, such as a knife, from the client; immobilize the object with packing.
4. Assess for and treat shock (see Shock).
5. Administer tetanus booster as ordered.

Neurologic Injuries

1. Inspect the scalp, head, face, and neck for abrasions, hematomas, and lacerations.
2. Gently palpate the head for any injuries.
3. Inspect the nose and ears for leakage of cerebrospinal fluid.
4. Assess the level of consciousness.
5. Evaluate pupillary size, shape, equality, and reaction to light.
6. Assess for sensation and motor abilities.
7. Observe for signs of increased intracranial pressure (see Care of the Client with Increased Intracranial Pressure (ICP)).
8. For additional details of care see Head Injury and Spinal Cord Injury.

Abdominal Injuries

1. Keep client NPO.
2. Assist with insertion of nasogastric tube (for assessment of stomach bleeding and aspiration of stomach contents, which prevents vomiting).
3. Inspect abdomen for injuries.
4. Auscultate bowel sounds.
5. Do not palpate the abdomen (could aggravate possible internal injuries).
6. Prepare client for peritoneal lavage if indicated.
7. Insert Foley catheter.
1. Measure urine output every 15 minutes.
2. Assess for hematuria.

Musculoskeletal Injuries

1. Observe for sign of fracture: pain, swelling, tenderness, ecchymosis, crepitation (grating sound), loss of function, exposed bone fragments.
2. Cover open fracture with sterile dressing to prevent infection.
3. Immobilize any suspected fractures by splinting the joint above and below the injury.
4. Perform neurovascular check of area distal to fracture: assess for color, temperature, capillary refill, sensation, movement, pulses.