Learn more about Clinical Skills today! Standardize education and management competency among nurses, therapists and other health professionals to ensure knowledge and skills are current and reflect best practices and the latest clinical guidelines.
Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.
Refer to the American Heart Association (AHA) interim guidelines for resuscitation of the patient with coronavirus disease 2019 (COVID-19) or a person under investigation (PUI) (Box 1).undefined#ref5">5
The presence of an environmental hazard (e.g., fire, noxious fumes, potential for explosion, active shooter) that mandates immediate evacuation of the area takes priority over the primary assessment.
Stabilize the cervical spine throughout the procedure if injury is suspected.
Do not proceed to the next assessment step until interventions for life-threatening conditions have been implemented.
The primary assessment is intended to assess and intervene rapidly for life-threatening conditions in critically ill or injured patients. The primary assessment is done at the initial point of patient contact and may be done again after the patient is transferred from the care of one team to another (e.g., when the emergency medical services team hands off the patient to the emergency department [ED] team members). To ensure that the primary assessment is thorough, a systematic approach should be taken, for example, following the widely used A-B-C-D-E mnemonic outlined in the procedure steps.
A = airway and alertness with simultaneous cervical spine (c-spine) protection
B = breathing and ventilation
C = circulation and control of hemorrhage
D = disability (neurologic status)
E = exposure and environmental control
Avoid noninvasive positive pressure ventilation (NIPPV), such as bag-mask ventilation or BiPAP ventilation, as much as possible to prevent aerosolization in a patient with a known or suspected airborne-transmitted infectious illness.3,4,5
For a patient with a known or suspected airborne-transmitted infectious illness, initiate preoxygenation using non–aerosol-generating approaches, such as elevating the head of the bed, airway maneuvers, and positive end expiratory pressure (PEEP) valves.3,4,5
Avoid high-flow oxygen delivery devices that provide 6 L or more of oxygen per minute (e.g., high-flow nasal cannula) as much as possible to prevent aerosolization in a patient with a known or suspected airborne-transmitted infectious illness. If a high-flow nasal cannula must be used for preoxygenation, place a surgical mask on the patient, over the device.3,4,5
best motor response + best verbal response + eye opening = GCS score
The final score ranges from 3 to 15 points. A score of 3 means no response in any component. A score of 15 means the patient is awake, alert and oriented, verbal, moving all extremities, and following commands. A score of less than 8 indicates significant impairment in the level of consciousness. If one or more patient responses cannot be tested because an endotracheal tube has been placed or a paralytic medication has been administered, then those components are not scored and are indicated as not testable (NT); for example, an intubated patient who has decerebrate posturing (2) and opens eyes only to pain (2) receives a score of 4NT.1,6
Intubate a patient with a GCS score of 8 or less to protect the airway.
Determine GCS component scores by noting the patient's best response in each category:
6 - Obeys commands
5 - Localizing
4 - Normal flexion
3 - Abnormal flexion
2 - Extension
1 - None
5 - Oriented
4 - Confused
3 - Words
2 - Sounds
4 - Spontaneous
3 - To sound
2 - To pressure
E4 = eyelids open or opened, tracking, or blinking to command
E3 = eyelids open but not tracking
E2 = eyelids closed but open to loud voice
E1 = eyelids closed but open to pain
E0 = eyelids remain closed with pain
M4 = thumbs-up, fist, or peace sign
M3 = localizing to pain
M2 = flexion response to pain
M1 = extension response to pain
M0 = no response to pain or generalized myoclonus status
B4 = pupil and corneal reflexes present
B3 = one pupil wide and fixed
B2 = pupil or corneal reflexes absent
B1 = pupil and corneal reflexes absent
B0 = absent pupil, corneal, and cough reflex
R4 = not intubated, regular breathing pattern
R3 = not intubated, Cheyne-Stokes breathing pattern
R2 = not intubated, irregular breathing
R1 = breathes above ventilator rate
R0 = breathes at ventilator rate or apnea
When removing clothing, take care to avoid injury from unseen objects within the clothing, such as weapons, needles, or glass. For victims of crime, be sure not to cut through openings in clothing related to the violence (stabbing, gunshot wound) because doing so could destroy evidence; follow the organization’s practice for evidence collection.
*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.
Cookies are used by this site. To decline or learn more, visit our cookies page.