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Patient assessment

Mary Corcoran provides an overview of patient assessment for emergency room nurses. ER nurses must be prepared to assess patients with a wide range of medical, surgical, traumatic, social and behavioral complaints spanning all ages. The initial assessment involves a primary survey of the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) followed by a secondary survey of FGHI (Full set of vitals, pain assessment, history, head-to-toe exam, inspection of posterior surfaces). Special populations like children, elderly, obese, and pregnant women require modification of the standard assessment process. Ongoing reassessment is important for patients with changing conditions or receiving certain treatments.

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Patient Assessment Mary Corcoran RN, BSN, MICN
Emergency Assessment OverviewPatients who present to the ED have every possible complaint from Medical, Surgical, Traumatic, Social, and Behavioral. ER nurses need to be able to handle a broad spectrum of patients spanning all ages from newborn to centenarians. A competent ER nurse must be a “jack-of-all trades” master of “most”, and constantly prepared for EVERY conceivable scenario.
Types of InformationSubjective DataObjective DataInformation verbally provided by the patientIs the patients perception of the problemOften put in “Quotes”And referred to as the Chief ComplaintData considered FactualThings you can see and/or MeasureObtained fromInspectionPalpationAuscultationPercussionSmell Used to validate the patients subjective complaint
Essential Assessment tools for ERInterpersonal SkillsKnowledge of Anatomy and PhysiologyPhysical assessment skillsAnd the ability to apply critical thinking to each patients unique situation
Initial Assessment Primary Phase (ABCDE)Secondary Phase (FGHI)Ensures that potentially life threating conditions are identified and addressedEvaluatesAirwayBreathingCirculationDisabilityExposureDone after primary exam and primary threats addressedMeasurement of VSPain AssessmentHistoryHead to ToePosterior surface inspection
Primary AssessmentDuring Primary Assessment in initial impression of the patient is formed, determining them to be “sick” or “not sick”.
Primary AssessmentAirwayIs pt vocalizing sounds appropriate for age?Check for obstruction or foreign material visible in the oropharynx (blood, emesis, teeth, debris)Look for swelling or edema to lips, mouth, tongue, or neckIs the pt drooling or dysphasic?Listen for stridor or abnormal sounds
Primary Assessment AirwayIf the airway is obstructed what do you do?Head tilt- chin lift (if no trauma)Jaw ThrustSuctionAirway Adjunct (OPA, NPA)Preparation for intubation
Primary Assessment BreathingAssess for the following:Spontaneous breathingRate and Pattern Symmetrical Rise and FallIncreased work of breathing (nasal flaring, retractions)Use of accessory musclesChest wall stability/integritySkin color
Primary Assessment BreathingWhat if breathing is significantly compromised?Assess Lung SoundsBag-mask device assistanceOxygenPosition Airway OpenOcclude Open chest wounds Intervene to relieve PTX if applicableIf not compromised?Assess lung sounds
Primary Assessment CirculationAssess skin for:ColorTemperatureMoistureCap Refill (central-on head or chest)Uncontrolled bleeding or Trauma
Primary Assessment CirculationCompromisedNo PulsePalpate Pulse (central/periph)Rate and QualityPlace on Cardiac MonitorEstablish Vascular AccessBegin ResuscitationBLS, or ACLS
Primary Assessment DisabilityA helpful mnemonic exists to assist in a brief neurologic assessmentA- Alert: Pt is awake, alert, responsive to voice and is oriented to person, time, and placeV- Verbal: Pt responds to voice but is not fully oriented to person, time, or placeP- Pain: Pt does not respond to voice but does respond to painful stimulusU- Unresponsive: Pt does not respond to voice or painful stimulus
Primary Assessment DisabilityWhat if they have ALOC?Check pupils-Size, equality, and reactivity to lightFurther investigate during your secondary assessment
Primary AssessmentExposureRemove the patients clothing to thoroughly examine and identify any underlying cause of illness or injuryCovering the patient maintains privacy and prevents heat loss
Secondary AssessmentOnce emergent threats are addressed, your secondary assessment can be completed (FGHI)
Secondary Assessment Full Set of Vital SignsTemperatureOral, Tympanic, Temporal, Axillary, RectalPulseRate and Rhythm (regular or irregular)Quality (Bounding, Weak, Thready)Respiratory RateRate, Rhythm, Depth, and WOBBlood PressureProper size cuff is importantOxygen SaturationProper placement of probe is keyWeightMust be done on ALL children/infants
Family
Secondary Assessment Give Comfort MeasuresPain- “the 5th vital sign”PQRST (Provoked, Quality, Radiation, Severity, Time)0-10 scaleFACES pain scaleFLACC Infant pain scale*More on pain later
Secondary Assessment HistoryAMPLE mnemonicA- AllergiesRecord severity and type of reactionM- MedicationsRx, OTC, Herbal, Recreational, unprescribedP- Past Health HistoryL- Last Meal EatenE- Events leading to injury/illness
Secondary Assessment Head to ToeHead and FaceInspect Lacerations, abrasions, avulsions, puncture wounds, foreign objects, burns, rash, ecchymosis, edemaOral mucosa for hydration, swelling, bleeding, loose teethEyes, lids, vision status, PalpateFeel for broken bones, crepitus, asymmetry and tendernessPerform Detailed neuro exam if applicable
Secondary AssessmentHead to Toe Neurologic GCS- Glascow Coma Scale (3-15)Common Scale, used to describe patient neurologic status, allows for easy communication between disciplines NIH Stroke Scale (0-60)Used to score stroke patients and in determining need for fibrinolytic therapy, and provides easy method of communication among providers
AEIOUTIPPSCauses of ALOCA- AlcoholE- Epilepsy/electrolytesI- Insulin (hypo/hyperglycemia)O- OpiatesU- UremiaT-TraumaI- InfectionP- PoisonP- PsychosisS- Syncope
Secondary Assessment Head to ToeNeckInspectFor injury, deformity, crepitus, edema, rash, lesions, and massesJugular veinsPalpateTracheal position, for SQ emphysema, and areas of tendernessC-spine for Tenderness, step-off, bony crepitus
Secondary Assessment Head to ToeChest (pulmonary and Cardiac)InspectRate and depth of respirations (paradoxical movement), trauma or rash, lesions, pacemakers, medication patches etc. PalpateBony deformity, crepitus, tenderness etcAuscultateLung sounds, adventitious sounds, heart sounds
Secondary AssessmentHead to ToeAbdomenInspectContour of abd, ascites, trauma, scars, tubes, stomasPalpateAway from the site of any reported painFor any Rebound TendernessAuscultateBowel sounds
Secondary Assessment Head to ToePelvis/PerineumInspectTrauma, edema, lesions, edema, bleeding, drainage or discharge (and quantity)Palpate Pelvis for bony stability, sphincter tone
Secondary Assessment Head to ToeExtremitiesInspectAll 4 (if present) for redness, edema, rash, lesions, trauma, wounds, movementPalpatePulses, pain, tenderness, temperature, cap refill, sensation
Secondary Assessment Inspect Posterior SurfaceInspectBleeding, abrasions, wounds, hematomas, ecchymosis, rash, lesions, and edemaPattern injury, or injury in different stages of healing (indicator of maltreatment-require further follow up)PalpateRectal tone- check character of stool, and for presence of blood
REVIEW A- AirwayB- BreathingC- CirculationD- DisabilityE- Exposure/ EnvironmentF- Full Set of Vitals, Facilitate Family presenceG- Give Comfort MeasuresH- History and Head to ToeI- Inspect posterior Surfaces
Ongoing AssessmentShould be done, if the patient has changes in condition, and upon assuming care of a new patient- other guidelines may apply specific to your facilitySpecial situations may require more frequent monitoring and reassessment Conscious sedation, blood transfusion, fibrinolytic therapy, pain medications, restraints, trauma, stroke etc.
Special Patient PopulationsChildren and the elderly have unique anatomic and physiologic factors that must be considered in the assessment process. OB and Bariatric pts also present assessment challenges due to change in body habitus. Attention to these populations, and modification of assessment process may be necessary.
Questions?