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Discussion

Question.

13 year old boy is admitted to A&E (ED), following a closed head injury. He is accompaned by his mother who states her son was unconscious for about 30 seconds.

List the essential observations the nurse must make ?

1. Airway obstruction? is there any airway obstruction. ?

2. breathing? It the pt breathing, if so what is the reps rate.?

3. circulation. What is the heart rate?

4. Assess child using Glasgow coma scale, to determine level of conscious.

My question is is this the right order & have I missed something?

thank you for your help.

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    • Featured Replies

    You answer is right in front of you. A B C

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    In the ED setting, you will (almost always) follow the ABC order for prioritizing your assessment. First, check to ensure that his airway is patent, unobstructed, and free from any fluids or materials. Next, assess his respiratory rate, pattern, depth, oxygen saturation, etc. Finally, put him on the cardiac monitor, assess his pulse, capillary refill, blood pressure, ECG rhythm, etc. After you have done all of this, and ensured that the boy isn't critically ill or unstable, move on to assess his GCS.

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    it's level of consciousness, and the gcs has been criticized for being less than useful in a lot of populations. google "level of consciousness scales" and read up.

    airway is always first, no matter what. the rest is fine.

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    After ABC...I was taught to use AVPU for level of consciousness over GCS first. (Pt is responsive to Alert (awake) Verbal (perhaps eyes closed but easily aroused/responsive when name called or to other verbal stimulus) P (only responsive to painful or noxious stimulus) or Unresponsive (response to nothing--motion, verbal, pain, noxious stimulus). It's a quick assessment useful in emergent situations

    AVPU Scale

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