Assessment: Primary Assessment

  1. Perform hand hygiene and apply clean gloves.
  2. Verify patient's identity in accordance with institutional policy.
  3. Assess airway patency while simultaneously maintaining cervical spine alignment with manual stabilization. Airway patency is assessed by observing for chest rise and fall and by listening and feeling for air movement from the nose and mouth. If the airway is partially or completely obstructed, implement the appropriate intervention. Potential interventions include the following:
  4. Airway positioning
  5. Airway foreign object removal
  6. Oropharyngeal airway insertion
  7. Nasopharyngeal airway insertion
  8. Laryngeal mask airway
  9. Endotracheal intubation
  10. Combitube™
  11. Cricothyrotomy
  12. Percutaneous transtracheal ventilation
  13. Tracheostomy
  14. Oropharyngeal suctioning
  15. If the patient is at risk for cervical spine injury, have an assistant manually stabilize the head until the primary and secondary assessments are complete and more definitive immobilization can be instituted. In the absence of an assistant, set towel rolls or foam blocks alongside the head to help maintain alignment and remind a conscious patient not to move. Do not tape down the head and blocks until the patient is fully strapped to a backboard. Maintain cervical spine immobilization until the neck is cleared by radiograph or clinical examination.
  16. Assess breathing adequacy by observing the respiratory rate, depth, and difficulty. Briefly auscultate breath sounds bilaterally. Implement pulse oximetry monitoring for all seriously injured or ill patients. If respirations are absent or abnormal, implement appropriate interventions. Potential interventions include the following:
  17. Positioning the dyspneic patient
  18. Oxygen therapy and delivery
  19. Suctioning
  20. Bag-mask ventilation
  21. Emergency needle thoracentesis
  22. Chest-tube insertion
  23. Using flutter valve or occlusive dressing with one corner untaped for open pneumothorax (sucking chest wound)
  24. Assess circulation by evaluating the radial or carotid pulse for rate and strength. Observe and palpate the skin for warmth, color, and moisture. Check for exsanguinating external hemorrhage, and if present, apply direct pressure to the site. If the circulation is absent or altered, implement appropriate interventions, including chest compressions, as indicated. If an assistant is available, institute electrocardiographic monitoring. Other potential interventions include the following:
  25. Positioning the hypotensive patient
  26. Pericardiocentesis
  27. Emergency thoracotomy and internal defibrillation
  28. Vascular access
  29. Defibrillation
  30. Synchronized cardioversion
  31. Transcutaneous cardiac pacing
  32. Evaluate the neurologic status to determine whether the patient is alert (A), responds to verbal stimuli (V), responds to painful stimuli (P), or is unresponsive to all stimuli (U). Assess pupil size, equality, and reaction to light.
  33. After completing the primary assessment and addressing any life-threatening conditions, proceed to the secondary assessment.
  34. Upon completion of the primary assessment, document any pertinent findings and interventions.