FORM INITIAL ASSESSMENT FOR EMERGENCY NURSING

NAME : …………………………………

DATE : …………………………………

NO STATEMENT SCORE 1 2 3
PRIMARY SURVEY
1 PREPARE 6
Choice of Leader
Used Self Protection Device
2 ASSESS PATIENT 6
Check response
Call for Help for Emergency System Management
3 AIRWAY 12
Check Cervical Fracture
Check Obstruction of Airway
Open Airway
Management Obstruction of Airway
4 BREATHING 12
Assess for Breathing such as Inspection, Auscultation,
Percussion and Palpation (IAPP).
Giving oxygenation and ventilation
Assess Open Pneumothorax (Open Chest wound), Tension
Pneumothorax, Fail Chest, and Massive Haematothorax.
Management for Open Pneumothorax, Tension
Pneumothorax, Fail Chest, and Massive Haematothorax.
5 CIRCULATION 12
Check bleeding resources and assess sign and symptom of
shock
Stop bleeding
Management fracture
Put in IVFD and take blood samples for laboratory
6 DISABILITY 9
Assess GCS
Pupil Reflect
Check for lateralization
7 EXPOSURE 6
Looking for lacerated and other bleeding resources
Prevent Hypothermia
8 FOLLEY CATHETER 9
Indication
Contra Indication
Volume Urine normal
9 GASTRIC TUBE 9
Indication
Contra Indication
Normal Fluid
10 HEART MONITOR 6
ECG Interpretation
Implementation or Therapy
 11 PULSE OXYMETRI AND X-RAY PHOTO 6
Value normal of Oxymetri
Location for X-Ray photo

SECONDARY SURVEY 9
12 Heat to toe, Vital sign, and Anamnesis
Prepare to Operation Room
Prepare to transfer
TOTAL SCORE 100

TOTAL SCORE FOR STUDENT

Note: Past Examination Scores were 80.

SUPERVISOR,

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