NUR213 - Unit 4 Exam Study Guide
, Concept Important Information
SALT triage Know the SALT algorithm and how to color code
algorithm victims.
u Sort, Assess, Lifesaving Interventions,
Treatment/Transport
■ Red/Immediate: Life-threatening, treatable
with immediate attention
■ Airway obstruction, MI, hemorrhage,
severe abdominal injury, tension
pneumothorax, shock, head injury,
threatened loss of limb
■ Yellow/Delayed: Potentially serious but
stable enough to wait a short while for
medical treatment
■ Fractures, burns < 20%, soft tissue
injuries min. bleeding, torso wounds w/o
shock, facial injury w/o airway
involvement
■ Green/Minimal: Minor injuries can wait for
longer periods of time
■ Ambulatory, minor burns, sprains,
lacerations
■ Black/Expectant: Dead, No VS,
injuries incompatible with survival
■ Full thickness burns > 50% TBSA, no
pulse or breathing after airway
opened, high SCI, transcranial GSW
,Concept Important Information
Primary A – B – C – D – E: know what you assess during
Survey the primary survey and how you would assess it
when doing a primary survey in the field or in
the hospital setting.
Know some examples of what would be considered
emergencies related to the ABCDE. For example, A
is for airway - - you may see a blocked airway; B is
for breathing - - you may have absent
respirations, etc.
u A-B-C-D-E
u Airway with C-spine
▪ Check for potential injury to
cervical spine
a. Jaw-thrust to open airway if
C- spine not cleared
b. Manually stabilize neck
▪ Inspect for tongue obstruction,
loose teeth, foreign objects,
edema, burns
▪ Auscultate for obstructive
airway sounds (stridor,
wheezing, gurgling)
▪ Hoarseness may indicate
laryngeal injury or inhalation
injury
▪ Palpate for occlusive facial
deformities, subcutaneous
emphysema
▪ Suction blood/secretions to clear
airway
▪ If client cannot maintain will
need endotracheal intubation
u Breathing
▪ Inspect chest/neck for:
a. Spontaneous breathing with
symmetrical rise and fall
b. Depth, pattern and rate
of respirations
c. Any signs of
respiratory difficulty
d. Skin color and O2 saturation
e. Agitation (low O2) vs.
obtunded (high CO2)
f. Open chest wounds
g. Tracheal deviation
, h. Tension pneumothorax
i. Crepitus or crackling
*** Respiratory Distress ***
▪ Tension Pneumothorax:
Diminished breath sounds,
deviated trachea, muffled heart
sounds, decreased CO
and BP
Concept Important Information
, Concept Important Information
SALT triage Know the SALT algorithm and how to color code
algorithm victims.
u Sort, Assess, Lifesaving Interventions,
Treatment/Transport
■ Red/Immediate: Life-threatening, treatable
with immediate attention
■ Airway obstruction, MI, hemorrhage,
severe abdominal injury, tension
pneumothorax, shock, head injury,
threatened loss of limb
■ Yellow/Delayed: Potentially serious but
stable enough to wait a short while for
medical treatment
■ Fractures, burns < 20%, soft tissue
injuries min. bleeding, torso wounds w/o
shock, facial injury w/o airway
involvement
■ Green/Minimal: Minor injuries can wait for
longer periods of time
■ Ambulatory, minor burns, sprains,
lacerations
■ Black/Expectant: Dead, No VS,
injuries incompatible with survival
■ Full thickness burns > 50% TBSA, no
pulse or breathing after airway
opened, high SCI, transcranial GSW
,Concept Important Information
Primary A – B – C – D – E: know what you assess during
Survey the primary survey and how you would assess it
when doing a primary survey in the field or in
the hospital setting.
Know some examples of what would be considered
emergencies related to the ABCDE. For example, A
is for airway - - you may see a blocked airway; B is
for breathing - - you may have absent
respirations, etc.
u A-B-C-D-E
u Airway with C-spine
▪ Check for potential injury to
cervical spine
a. Jaw-thrust to open airway if
C- spine not cleared
b. Manually stabilize neck
▪ Inspect for tongue obstruction,
loose teeth, foreign objects,
edema, burns
▪ Auscultate for obstructive
airway sounds (stridor,
wheezing, gurgling)
▪ Hoarseness may indicate
laryngeal injury or inhalation
injury
▪ Palpate for occlusive facial
deformities, subcutaneous
emphysema
▪ Suction blood/secretions to clear
airway
▪ If client cannot maintain will
need endotracheal intubation
u Breathing
▪ Inspect chest/neck for:
a. Spontaneous breathing with
symmetrical rise and fall
b. Depth, pattern and rate
of respirations
c. Any signs of
respiratory difficulty
d. Skin color and O2 saturation
e. Agitation (low O2) vs.
obtunded (high CO2)
f. Open chest wounds
g. Tracheal deviation
, h. Tension pneumothorax
i. Crepitus or crackling
*** Respiratory Distress ***
▪ Tension Pneumothorax:
Diminished breath sounds,
deviated trachea, muffled heart
sounds, decreased CO
and BP
Concept Important Information
