1 emergency, fucosed assessment

Emergency And Focused Assessment

EMERGENCY ASSESSMENT

A systematic approach to the assessment of an emergency patient is essential. The primary and secondary surveys provide the emergency nurse with a methodical approach to help identify and prioritize patient needs.

Primary Assessment

The initial, rapid, ABCD (airway, breathing, and circulation, as well as neurologic disability resulting from spinal cord or head injuries) assessment of the patient is meant to identify life-threatening problems.

If conditions are identified that present an immediate threat to life, appropriate interventions are required before proceeding to the secondary assessment.

STANDARDS OF CARE GUIDELINES

Emergency Assessment and Intervention When a patient presents with a

potentially life-threatening condition, proceed swiftly with the following: Remove the patient from potential source of

danger, such as live electric current, water, or fire.

Determine whether patient is conscious. Assess airway, breathing, and circulation in

systematic manner. continuation


Emergency Assessment and Intervention When a patient presents with a

potentially life-threatening condition, proceed swiftly with the following: Assess pupillary reaction and level of

responsiveness to voice or touch as indicated. If the patient is unconscious or has sustained a

significant head injury, assume there is a spinal cord injury and ensure proper handling.

Undress the patient to assess for wounds and skin lesions as indicated.

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Emergency Assessment and Intervention When a patient presents with a potentially

life-threatening condition, proceed swiftly with the following: Immediate intervention is needed for such

conditions as compromised airway, respiratory arrest, compromised respirations, cardiac arrest, and profuse bleeding. Provide emergency airway management, cardiopulmonary resuscitation, and measures to control hemorrhage as needed.

Call for help as soon as possible. Assist with transport and further assessment

and care as indicated.

Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches.


A—Airway: Does the patient have an open airway? Is the patient able to speak? Check for airway obstructions such as loose teeth, foreign objects, bleeding, vomitus or other secretions. Immediately treat anything that compromises the airway.

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B—Breathing: Is the patient breathing? Assess for equal rise and fall of the chest (check for bilateral breath sounds), respiratory rate and pattern, skin color, use of accessory muscles, adventitious breath sounds, integrity of the chest wall, and position of the trachea. All major trauma patients require supplemental oxygen via a nonrebreather mask.

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C—Circulation: Is circulation in immediate jeopardy? Can you palpate a central pulse? What is the quality (strong, weak, slow, rapid)? Is the skin warm and dry? Is the skin color normal? Obtain a blood pressure ([BP]; in both arms if chest trauma or dissecting aortic aneurysm is suspected).

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D—Disability: Assess level of consciousness and pupils (a more complete neurologic survey will be completed in the secondary survey). Assess level of consciousness using the AVPU scale: A—Is the patient alert? V—Does the patient respond to voice? P—Does the patient respond to painful stimulus? U—The patient is unresponsive even to painful

stimulus.

Secondary Assessment

The secondary assessment is a brief, but thorough, systematic assessment designed to identify all injuries.

The steps include: Expose/environmental control, Full set of vital signs/ Five interventions/ Facilitate family presence, and Give comfort measures.

Expose/environmental control:

It is necessary to remove the patient's clothing in order to identify all injuries. You must then prevent heat loss by using warm blankets, overhead warmers, and warmed I.V. fluids unless induced hypothermia is indicated.

Full set of vital signs:

Obtain a full set of vital signs including BP, heart rate, respiratory rate, and temperature.

As stated previously, obtain BP in both arms if chest trauma or dissecting aortic aneurysm is suspected.

Institute continuous cardiac monitoring.

Assess Glasgow Coma Scale (GCS) and pain score.

Five interventions: Vascular access Pulse oximetry to measure the oxygen saturation;

consider capnography to measure end-tidal carbon dioxide; noninvasive ultrasonic cardiac output monitor ; and electrocardiogram (ECG)

Indwelling urinary catheter (do not insert if you note blood at the meatus, blood in the scrotum, or if you suspect a pelvic fracture)

Gastric tube (if there is evidence of facial fractures, insert the tube orally rather than nasally)

Laboratory studies frequently include type and cross-matching, complete blood count (CBC), urine drug screen, blood alcohol, electrolytes, prothrombin time (PT) and partial thromboplastin time (PTT), arterial blood gas (ABG), and pregnancy test if applicablle

Facilitate family presence:

It is important to assess the family's needs. If any member of the family wishes to be present during the resuscitation, it is imperative to assign a staff member to that person to explain what is being done and offer support.

Give comfort measures:

These include verbal reassurances as well as pain management as appropriate. Do not forget to give comfort measures to the family during the resuscitation process.

History Obtain prehospital information from

emergency personnel, patient, family, or bystanders using the mnemonic MIVT. M—Mechanism of injury I—Injuries sustained or suspected V—Vital signs T—Treatment

Mechanism of Injury

It is helpful to understand the mechanism of injury to anticipate probable injuries. It is particularly helpful in motor vehicle accidents to know such information as external and internal damage to the car and the period of time elapsed before the patient received medical attention.

Injuries Sustained or Suspected

Ask pre-hospital personnel to list any injuries that they have identified.

Vital Signs

What were the prehospital vital signs?

Treatment

What treatment did the patient receive before arriving at the hospital and what was patient's response to those interventions?

History If the patient is conscious, it is essential to

ask him what happened. How did the accident occur? Why did it happen? A fall, for example, may not be a simple fall—perhaps the patient blacked out and then fell. If the patient is conscious and time permits, explore the chief complaint through the PQRST mnemonic.

P—Provokes, Palliates, Precipitates Q—Quality R—Region, Radiates S—Severity, associated Symptoms T—Timing (onset, duration)

History

Obtain past medical history from the patient or a family member or friend, including age, medical/surgical history, current medications, use of any illicit drugs, allergies, last menstrual period, last meal, and last tetanus shot.

Head-to-Toe Assessment

The head-to-toe assessment begins with assessment of the patient's general appearance, including body position or any guarding or posturing. Work from the head down, systematically assessing the patient one body area at a time.


Head and face Inspect for any lacerations, abrasions,

contusions, avulsions, puncture wounds, impaled objects, ecchymosis, or edema.

Palpate for crepitus, crackling, or bony deformities.


Chest Inspect for breathing effectiveness, paradoxical

chest wall movement, disruptions in chest wall integrity.

Auscultate for bilateral breath sounds and adventitious breath sounds.

Palpate for bony crepitus or deformities.


Abdomen/flanks Inspect for lacerations, abrasions, contusions,

avulsions, puncture wounds, impaled objects, ecchymosis, edema, scars, eviscerations, or distention.

Auscultate for the presence of bowel sounds. Palpate for rigidity, guarding, masses, or areas

of tenderness.


Pelvis/perineum Inspect for lacerations, abrasions, contusions,

avulsions, puncture wounds, impaled objects, ecchymosis, edema, or scars. Look for blood at the urinary meatus. Look for priapism (which could indicate spinal cord injury).

Palpate for pelvic instability and anal sphincter tone.


Extremities Inspect skin color and temperature. Look for

signs of injury and bleeding. Does the patient have movement and sensation of all extremities?

Palpate peripheral pulses, any bony crepitus, or areas of tenderness.


Posterior surfaces—utilizing help, logroll the patient in order to: Inspect for possible injuries. Palpate the vertebral column and all areas for

tenderness.

Focused Assessment

Any injuries that were identified during the primary and secondary surveys require a detailed assessment, which will typically include a team approach and radiographic studies.

EMERGENCY TRIAGE Triage is a French verb meaning “to sort.” Emergency triage is a subspecialty of

emergency nursing, which requires specific, comprehensive educational preparation.

Patients entering an emergency department (ED) are greeted by a triage nurse, who will perform a rapid evaluation of the patient to determine a level of acuity or priority of care. .

EMERGENCY TRIAGE

The triage nurse will assess: the patient's chief complaint; general appearance; ABCD; environment; limited history; and comorbidities.

EMERGENCY TRIAGE Thus, the primary role of the triage

nurse is to make acuity and disposition decisions and set priorities while maintaining an awareness for potentially violent or communicable disease situations.

Secondary triage decisions involve the initiation of triage extended practices.

Priorities of Care and Triage Categories Standardized 5-level triage systems

have been developed and proven through research to possess utility, validity, reliability, and safety.

Time frames and are evidence based is a consensus-based algorithm approach, which utilizes longer time frames).

Triage Level 1—Immediately Life-threatening or Resuscitation

Conditions requiring immediate clinician assessment. Any delay in treatment is potentially life- or limb-threatening.

Includes conditions such as: Airway or severe respiratory compromise. Cardiac arrest. Severe shock. Symptomatic cervical spine injury. Multisystem trauma. Altered level of consciousness (LOC) (GCS < 10). Eclampsia. Extremely violent patient.

.Triage Level 2—Imminently Life-threatening or Emergent Conditions requiring clinician assessment

within 10 to 15 minutes of arrival. Conditions include:

Head injuries. Severe trauma. Lethargy or agitation. Conscious overdose. Severe allergic reaction. Chemical exposure to the eyes. Chest pain. Back pain. GI bleed with unstable vital signs.

.Triage Level 2—Imminently Life-threatening or Emergent Conditions requiring clinician assessment

within 10 to 15 minutes of arrival. Conditions include:

Stroke with deficit. Severe asthma. Abdominal pain in patients older than age 50. Vomiting and diarrhea with dehydration. Fever in infants younger than age 3 months. Acute psychotic episode. Severe headache. Any pain greater than 7 on a scale of 10. Any sexual assault. Any neonate age 7 days or younger.

Triage Level 3—Potentially Life-threatening/Time Critical or Urgent

Conditions requiring clinician assessment within 30 minutes of arrival.

Conditions include: Alert head injury with vomiting. Mild to moderate asthma. Moderate trauma. Abuse or neglect. GI bleed with stable vital signs.

History of seizure, alert on arrival

Triage Level 4—Potentially Life-serious/Situational Urgency or Semi-urgent Conditions requiring clinician assessment

within 1 hour of arrival. Conditions include:

Alert head injury without vomiting. Minor trauma. Vomiting and diarrhea in patient older than age 2

without evidence of dehydration. Earache. Minor allergic reaction. Corneal foreign body. Chronic back pain.

Triage Level 5—Less/Non-urgent

Conditions requiring clinician assessment within 2 hours of arrival.

Conditions include: Minor trauma, not acute. Sore throat. Minor symptoms.

Chronic abdominal pain

PSYCHOLOGICAL CONSIDERATIONS

Approach to the Patient Understand and accept the basic anxieties of the

acutely ill or traumatized patient. Be aware of the patient's fear of death, disablement, and isolation. Personalize the situation as much as possible. Speak, react, and

respond in a warm manner. Give explanations on a level that the patient can grasp. An

informed patient can cope with psychological/physiologic stress in a more positive manner.

Accept the rights of the patient and family to have and display their own feelings.

Maintain a calm and reassuring manner—helps the emotionally distressed patient or family to mobilize their psychological resources.

Include the patient's family or significant others.Continuation


Approach to the Patient Understand and support the patient's feelings concerning

loss of control (emotional, physical, and intellectual). Treat the unconscious patient as if conscious. Touch, call

by name, and explain every procedure that is done. Avoid making negative comments about the patient's condition. Orient the patient to person, time, and place as soon as she is conscious;

reinforce by repeating this information. Bring the patient back to reality in a calm and reassuring way. Encourage the family, when possible, to orient the patient to reality.

Be prepared to handle all aspects of acute illness and trauma; know what to expect and what to do. This alleviates the nurse's anxieties and increases the patient's confidence.


Approach to the Family Inform the family where the patient is, and give as

much information as possible about the treatment she is receiving.

Consider allowing a family member to be present during the resuscitation. Assign a staff person to the family member to explain procedures and offer comfort.

Recognize the anxiety of the family and allow them to talk about their feelings. Acknowledge expressions of remorse, anger, guilt, and criticism.

Allow the family to relive the events, actions, and feelings preceding admission to the ED.


Approach to the Family

Deal with reality as gently and quickly as possible; avoid encouraging and supporting denial.

Assist the family to cope with sudden and unexpected death. Some helpful measures include the following: Take the family to a private place. Talk to all of the family together so they can mourn

together. Assure the family that everything possible was done;

inform them of the treatment rendered. Avoid using euphemisms such as “passed on.” Show the

family that you care by touching, offering coffee.


Approach to the Family Allow family to talk about the deceased—permits

ventilation of feelings of loss. Encourage family to talk about events preceding admission to the ED.

Encourage family to support each other and to express emotions freely—grief, loss, anger, helplessness, tears, disbelief.

Avoid volunteering unnecessary information (eg, patient was drinking).

Avoid giving sedation to family members—may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.

Be cognizant of cultural and religious beliefs and needs.


Approach to the Family Encourage family members to view the body if they wish—to

do so helps to integrate the loss (cover mutilated areas).▪ Prepare the family for visual images and explain any legal

requirements.▪ Go with family to see the body.▪ Show acceptance of the body by touching to give family

permission to touch and talk to the body.▪ Spend a few minutes with the family, listening to them.▪ Allow the family some private time with the body, if

appropriate. Encourage the ED staff to discuss among

themselves their reaction to the event to share intense feelings for review and for group support.

PAIN MANAGEMENT Pain is an unpleasant sensory and emotional

experience associated with actual or potential tissue damage and is also associated with significant morbidity.

Pain inhibits immune function and has detrimental effects on cardiovascular, respiratory, GI, and other body systems.

Pain may be somatic or visceral, acute or chronic, or centrally or peripherally generated.

PAIN MANAGEMENT Over 60% of patients report pain on

arrival at ED, making pain the most common patient complaint. It is imperative to adequately assess, monitor, and relieve pain in the ED.

Significant evidence-practice gaps have been identified with underestimation and undertreatment of pain, despite available clinical practice guidelines.

Pain Primary Assessment

ABCD

Evaluate pain using the PQRST mnemonic

Assess pain score using a pain rating tool, such as the verbal rating scale (VRS), numeric rating scale (NRS), visual analogue scale (VAS), Wong-Baker FACES pain scale, FLACC (faces, legs, activity, cry, and consolability) behavioral scale, or Abbey pain scale.

Pain Primary Interventions

Establish a supportive relationship with the patient.

Respect the patient's response to pain and its management.

Educate the patient regarding methods of pain relief, preventive measures, and expectations.

Administer pharmaceutical and nonpharmaceutical pain control.

Monitor the patient's response to and effectiveness of treatment.

NURSING ALERT

Pain relief is a moral, humane, and physiologic imperative.

Health & Medicine

1 emergency, fucosed assessment