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01.01 Prioritizing Assessments

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Overview

  1. Order of ER Nurse’s Assessment
    1. Assess patient using ABCDE
    2. Initiate life saving treatment PRN & notify provider
    3. Then proceed with focused assessment
      1. Chief complaint
      2. Medical History
      3. Medications
      4. System Assessment(s) relevant to chief complaint

Nursing Points

General

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18 pt
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  1. Initial assessment of the patient: ABCDE
    1. AIRWAY
      1. Visual threat to airways
      2. Voice clarity
      3. Audible breath sounds (without stethoscope).
    2. BREATHING
      1. Respiratory rate (12-20)
      2. Work of breathing
      3. Pulse Ox
    3. CIRCULATION
      1. Color
      2. Bleeding
      3. HR & BP
    4. DISABILITY
      1. Level of Consciousness (neuro status)
        1. AVPU
      2. Orientation
    5. EXPOSURE
      1. Temp (blankets)
      2. Clothing (gown)
  2. Results of First Assessment:
    1. Abnormal
      1. Initiate life saving treatment
      2. Notify provider
    2. Normal
      1. Proceed to Focused Assessment
        1. Information about chief complaint
          1. Started when?
          2. Doing what?
          3. Happened before?
          4. Better/worse?
          5. Any other/associated symptoms
        2. Up to date medical history
        3. Up to date medication list
        4. System Assessment(s)
  3.  TIPS
    1. Higher Acuity Patients
      1. More detailed assessments
      2. AFTER ALL life saving interventions completed
    2. Pt w/ Multiple Complaints
      1. Assessment of every system affected
    3. LISTEN to their answers!
      1. Add appropriate assessments!
  4. REASSESS!
    1. Remember to constantly reassess
      1. Add Vital Signs
      2. Before & after interventions
      3. Prior to conclusion of care
        1. Before discharge
        2. Before admission to floor
    2. Facility Requirements

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Assessment

  1. Ankle Pain 
    1.  
    2. Chief complaint questions
      1. Started when?
        1. “After I fell.”
      2. Doing What?
        1. “I tripped”.
          1. How? Abuse?
        2. “I got dizzy” – Syncope
          1. Additonal cardiac, resp, & neuro assessment 
      3. Happened before?
        1. “No”
        2. “Yes”
          1. Social work? Home safety
      4. Better/Worse?
      5. Associated/Additional Sx
        1. Other injuries?
    3. Medical History
    4. Med List
    5. System Assessment
      1. Deformity
      2. Pedal pulse
      3. Color
      4. Sensation
      5. Range of motion
  2. Abdominal Pain
    1. Chief complaint questions
      1. Started when?
        1. “Last night”
      2. Doing what?
        1. Watching TV”
      3. Happened before?
        1. “Yes”
          1. “Seen by MD then?”
      4. Better/worse?
        1. After I eat”
      5. Associated/Additional Sx
        1. Nausea
    2. Medical History
    3. Med List
    4. System Assessment
      1. Inspection of abdomen
      2. Auscultation of bowel sounds
      3. Palpation of abdomen
      4. Last BM
      5. Urinary Complaints
      6. LMP
      7. Sex Hx (new partners)
  3. Chest Pain
    1. Chief complaint questions
      1. Started when?
        1. Three Hours Ago
      2. Doing what?
        1. “Walking to mailbox”
      3. Happened before?
        1. “Yes”
          1. When?
            1. “My last heart attack”
      4. Better/worse?
        1. After walking
      5. Associated/Additonal Sx
        1. Shortness of breath
          1. (repeat chief complaint questions)
        2. Nausea/Vomitting
          1. Add GI assessment
    2. Medical History
      1. Details last MI
      2. Last cardiology visit
    3. Med List
    4. System Assessment
      1. Inspection of chest
      2. Auscultate breath sounds
      3. Auscultate heart sounds
      4. Checking for adequate perfusion of extremities
      5. Pulses
      6. Capillary Refill
      7. Edema

Nursing Concepts

  1. Prioritization
  2. Clinical Judgement

Reference Links

Video Transcript

Hey guys! I’m really excited to talk to you today about assessments in the ER! SO many times, Nursing students will come down and spend some time with us and they’ll be practicing their head to toe assessment and I’ll hear another ER nurse say to them “yeah we don’t do that here, we just look at what they’re here for”. To me that gives off the message that were not as thorough, or don’t look as closely. Guys, that could NOT be further from the truth! ER nurses are responsible for a TON of additional information in our assessment! Today I’m going to show you what the ER nurse assessment looks like, why we do it, and how you can perform this too.

SO! Every single patient, every time. Emergency medicine LOVES “ABC”s. It’s what’s most important, to keep the patient alive.

If there is anything abnormal with that assessment, you’re immediately addressing it and getting the provider involved.

Only if your patient is stable from this standpoint, will you proceed to your focused assessment. And we’ll break that down as well. We’re not going to go into crazy detail about the particular physical assessment skills themselves.

If you guys want to brush up on your physical assessment, we have a TON of videos in both the Fundamentals of Nursing Course and the Health Assessment Course. So make sure to check those out.

And always, SO important to REASSESS. Things are ALWAYS changing. And you want to stay on top of that.

As promised! ABCDE. Guys this is probably the most important part of the assessment, and it takes less than 30 seconds. You can look at all of this by simply looking at your patient and their vital signs. Personally, I do this the moment I walk into the patient’s room while I’m making eye contact with them, and introducing myself to them as their nurse. Keep in mind my patients are always on monitors, so I can see their vital signs simultaneously. If you don’t have that luxury try to make sure you’re grabbing a set of vitals with every assessment.

AIRWAY – Can I see anything threatening their airway? Swelling around their neck?Is their voice clear? Can I hear them breathing by just looking at them, no stethoscope. Guys if you can ever hear your patients breathing without having to use your stethoscope, something is WRONG.

BREATHING – We know normal respiratory rate is 12-20. Are they breathing too fast? Or too slow. How hard are they working for it? What’s their work of breathing? What’s their pulse ox?

CIRCULATION – Are they bleeding from anywhere? Hows their heart rate? BP? Hows their color? Are they pale? Dusky? Beat red in the face?

DISABILITY – often refers to neurological status. Whats their level of consciousness? Are they awake? Lethargic? Unresponsive? Are they alert x oriented x 3? Are they functioning at their baseline? Are they acutely confused or do they have a history of dementia?

EXPOSURE – can mean have slightly different meanings here, especially in trauma, but ultimately it can refer to how exposed the patient is or their temperature. Of course I’d be obtaining that with the vital sign, but I use this here as a reminder to make sure their in a gown, ready for the provider’s assessment as well, and have blankets available to them to keep warm. I try to bring them with me when I go to meet them.

IF any of these things are abnormal we’re immediately intervening. We’re placing them on oxygen. We’re starting IV’s. We have protocols in place in the ER to give us permission to do these things if the patient needs it. And we’re certainly getting the provider to the bedside if needed, or at the very least making sure their aware of the patient and their current status.

We’re not going to proceed with the focused assessment until all this has been addressed.

Okay! So they’re stable! ABCDE is normal. Focused Assessment time.

First we’re investigating the chief complaint! Some patients will voluntarily tell you more than you ever would need to know, and the details of their last 30 years if you let them. Others are more reserved, and you really have to do some detective work.

So you’re going to be asking questions like: When did it start? What were you doing when it started? Has this happened to you before?

Is there anything that makes it better? How about worse? Do you have any other ASSOCIATED symptoms? So has anything else been bothering you, or accompany this complaint.

The patients answers to these questions will tip you off to ask more questions as needed. Its happened before? When did it happen? Were you seen then? What did they say it was?

The answers also might tip you off to add additional body system assessments.

Always make sure the patient’s medical history is updated. I’ll often read them what I have for a list in their chart and verify nothing has changed. And keep in mind you might need to ask for a little more information specific to their age or gender. For instance a young woman, you’re going to ask her last menstrual cycle and so forth.

At this time I will also confirm a medication list. I’ll ask if there is anything new? AND if anything was started recently? You never know if their complaint is related to a new side effect for them. And of course you want to know if they’ve been compliant with their medications as well.

Here I use my physical assessment skills to examine the body systems related to the complaint. I would also add appropriate assessments here if needed based on their answers. That’s why it is SO important to really LISTEN.

 

Keep in mind the higher the acuity of the patient, the more detailed assessments will be. If they have multiple complaints, you need to make sure you assess every body system affected.

You want to reassess as frequently as possible. Before & after every intervention. Including those vital signs. And also at the conclusion. Before that patient is either discharged and goes home, or is transferred and admitted upstairs, you need to know what that patient looked like when they left! Also make sure to know your facilities requirements. Most facilities will tell you exactly how often they want you to be assessing your patients and of course, make sure you’re documenting these assessments.

So let’s look at some examples! Lets pretend we have pretty bad triage notes today, and very limited information. 

43 year old male with ankle pain.

 

Walk in and see the patient. Quickly – ABCDE is normal, vitals stable. 

No need to intervene at this time. 

Proceed with focused assessment.

Chief complaint questions

When did your ankle begin hurting? “When I fell last night.” 

How did you fall? What were you doing?

“I tripped over the carpet” Additional questions might be “Did anyone push you” to determine if abuse was involved.

“I got dizzy” Additional assessments cardiac, neuro, and respiratory

Anything make your ankle feel better or worse? “Hurts to walk on it”

Any other pain or injuries anywhere else? “No”

Medical History. Don’t forget to ask about substance and alcohol use. If the alcohol use is heavy , you might need to add an assessment for alcohol withdrawal. Side note this happens a lot! Many alcoholics will  wait until they sober up to come in an be evaluated inadvertently putting them into withdrawal. This a perfect example of how more assessments might be needed for a simple complaint based on their answers.

Medications. Up to date.

System Assessment. Assessment of the ankle – looking for deformity, pedal pulse, color, sensation, range of motion. But ALSO – based on our questions have perhaps adding an assessment for alcohol withdrawal as well.

REASSESS – Frequent intervals. Before and after pain medications. Before and after splint application if needed. And before discharge. 

Let’s look at another example!

Patient presents with chest pain. 

Patient looks OK from ABCDE standpoint, and all vitals WNL except his Sp 02 is 88% on RA. 

Intervene – yes. I’m going to apply 2L nasal cannula. His sats  improve. He’s now stable from that ABCDE standpoint, but because we have a protocol for chest pain, I will most likely insert his IV and obtaining blood work while proceeding my focused assessment questions.

Now my focused assessment: I’ll start with my chief complaint questions.

When did it start? “It started two hours ago”

What were you doing? “Had just finished mowing the lawn”.

Does anything make it better? Or worse? “Seems to be worse when I’m walking around”

Any other symptoms? “I’m a little short of breath”.

I’m going to make sure I have an up to date medical history, and medication list for sure

This is a higher acuity patient, so more body systems will be involved. I’ll be performing a detailed cardiac and respiratory assessment. I already have my stethoscope on the patient, so I might as well complete the GI portion of the assessment as well. 

Re-assess! Patients of higher acuity need very frequent assessments. Their ACBDE assessment can change on a dime. Just keep this in mind.

So your nursing concepts here are prioritization of the patients needs, using your clinical judgement to guide care.

Again, assess with ABCDE. Intervene at this time if needed. Then proceed to your focused assessment, including questions about chief complaint, medical history, medications and system assessment. And always Re-Assess!

 

 

 

Guys I hope this is starting to give you an idea of what nursing looks like from the ER standpoint, starting with that first step of the nursing process,  the ASSESSMENT. Thanks so much for watching. I hope you all go out and be your best selves today, and as always, Happy Nursing!

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