Ward R
Axone. 1989 Sep;11(1):9-12.
The first priority in any emergency is always an adequate airway. The nurse is involved in clearing the mouth, inserting an oral airway, assisting with intubation, oxygen therapy and assessing continually the patient's respiratory system. The nurse must also monitor the patient's vital signs, administer intravenous fluids appropriately along with medications, insert foley catheters and note urinary output. Simultaneously, the nurse constantly observes the patient's level of consciousness and neurological status. This information must be documented carefully by the nurse amidst all this apparent chaos. This can be done only when good assessment skills, combined with knowledge of diagnosis, treatment and appropriate nursing intervention, aid the Emergency Nurse in setting priorities in the Emergency care of the head injured patient.
在任何紧急情况下，首要任务始终是确保气道通畅。护士要参与清理口腔、插入口咽气道、协助插管、进行氧疗并持续评估患者的呼吸系统。护士还必须监测患者的生命体征，合理给予静脉输液及药物，插入导尿管并记录尿量。同时，护士要持续观察患者的意识水平和神经状态。在这一切看似混乱的情况下，护士必须仔细记录这些信息。只有当良好的评估技能与诊断、治疗知识以及恰当的护理干预相结合时，急诊护士才能在头部受伤患者的急诊护理中确定优先事项。
