 Check for patency

 Look; listen; and feel

 Check for decrease level of
consciousness (?)
 Check for debris/foreign material
 Observe for snoring and/or wheezing
 Observe for stridor (75%)
 Observe for coughing
 Observe for the universal sign
 Observe for facial trauma especially
to the jaw
 Observe for neck trauma and
swelling
 Observe for allergic reaction
 Headtilt-Chinliftmaneuver
 Jaw-Thrust maneuver
 Airway insertion
 Oropharyngeal
 Nasopharyngeal
 The above are all independent
nursing actions
 Endotracheal Tube (ETT) Intubation
 Tracheostomy (Surgical)
 Crico-thyrodotomy (Surgical)
 The above are interdependent
nursing actions. The nurse does
not perform the procedure but
makes preparations for and assist
the physician. They are also called
definitive airway management
 Observe for the presence/absence of
spontaneous breathing
 Look; listen; and feel
 Observe rate- 12-20
 Observe depth- rise and fall movement at
the epigastrium (corresponds to
contraction and relaxation of the
diaphragm
 Observe rhythm- regular pattern of
inspiration and expiration
 Observe effort- effortless with no use
of accessory muscles
 Observe for nasal flaring- sign of
severe respiratory distress
 Observe for symmetry- equal rise and
fall of chest (each hemi-thorax should
rise and fall equally)
 Observe for defects to the chest wall-
puncture wounds; fractures, bruising
etc
 Observe for flailing chest wall-
indicates chest wall instability due to
multiple rib fractures
 Observe for paradoxical breathing-
chest wall falls when the person
breathes in and rises when the person
breathes out. Heavy abdominal
breathing might be present
 Observe for cyanosis and decreased
SPO2 readings
 Rescue breaths:
 Mouth to mouth
 Mouth to mask
 Bag-valve mask
 Administer oxygen
 Elevate head of bed
 Teach and encourage deep breathing
 Stabilizechest wall
 Chest tube insertion (Tube Thoracostomy
 ETT and mechanical ventilation
 Pain management
 Assess level of consciousness
 Observe for uncontrolled external
hemorrhage
 Assess pulse
 Rate- 60-100
 Volume- feeble, bounding, normal
 Rhythm- regular
 Assess blood pressure
 Observe for cyanosis:
 Peripheral
 Central
 Observe skin color and temperature
 Observe neck veins
 Hemostasis of any external bleeding
 Administer IV fluids
 Administer prescribed medications
 Trendelenburg position
 Assess level of consciousness:
 Alert
 Voice (responds to)
 Pain (responds to
 Unresponsive
 Observe flexion and extension
 Assess speech
 Coherence
 Comprehension
 Observe pupils
 Size- in adults varies from 2 to 4
mm in diameter in bright light to 4
to 8 mm in the dark
 Reactivity to light
 + reactive
 - non-reactive
 +/- sluggish
 Assess ICP: 1/3 of pulse pressure
 ETT: If clinical evidence of raised
intracranial pressure or ICP > 20mmHg
 Medication:
 Phenytoin load 15mg/kg over 1 hour if
structural abnormality on CT or if
history of fitting
 Mannitol osmotherapy can be
considered (0.25g/kg – 1g/kg) as an
alternative to hypertonic saline
 Prepare for surgery