Emergency Nursing Patient Assessment

Emergency Nursing Assessment Framework Overview

• Patient assessment is a key component of emergency nursing practice
• Emergency health personnel cannot limit their approach to a specific disease group because patients seek emergency services for various complaints
• A systematic and uniform approach is demanded due to unanticipated patient presentations
• The most important concept of the course is emergency nursing assessment, explored through a case study of abdominal pain
• Abdominal pain is a common complaint in North American emergency departments, accounting for 10% of visits
• Up to half of abdominal pain cases are discharged without a definitive diagnosis
• Causes of abdominal pain are varied, gastritis, food poisoning, blunt trauma
• Individuals experiencing bullying, domestic violence, and/or unusual stress may present with similar symptoms
• The incidence of abdominal pain will likely continue to rise due to several variables
• A systematic approach to patient assessment is needed, focusing on abdominal pain and pathophysiology
• Mechanism of injury relates to the assessment of a patient with a physical injury
• Documentation in the context of emergency departments is needed

Learning Outcomes:

• Explain common, emergent conditions presenting with the symptom of abdominal pain
• Outline the concept of “level of urgency” in relation to ED nursing practice
• Apply a systematic approach for the primary, subjective, and objective assessment of individuals with abdominal pain
• Use clinical reasoning skills in assessment and treatment of ED patients
• Describe the concept of “mechanism of injury” in specific situations
• Demonstrate a systematic approach to ED documentation: clear, concise, and comprehensive

The McDermott Case

• Cliff senses chaos upon arriving at the unit at 1530, triage desk and resuscitation bays are full
• Cliff works as a float at the triage desk, reassessing patients awaiting placement
• Cliff asks about the "sickest" patient to prioritize
• Placement wait times can cause acuity levels to change
• McDermott is a frequent visitor, with a new complaint of belly pain
• The anatomy and physiology of the GI, GU, and GYNE systems are important to review to re-familiarize
• The abdominal cavity can be thought of as a box with a lid to find the area of discomfort

Types of Visceral Pain:

• Article discusses Assessment and Differential Diagnosis of Abdominal Pain
• Key points are of Types of Visceral Pain from the Document

Tension Pain:

• Results from increased peristaltic contraction from substances like spicy foods/infections
• Can occur from aggressive attempts at moving contents past obstructions like tumors, adhesions, or constipation
• Acute stretching of an organ capsule due to inflammation or fluid accumulation may also lead to tension pain
• Is characterized by vague, deep, and poorly localized pain, patients often change positions to find relief

Inflammatory Pain:

• Begins as vague and poorly localized pain due to visceral peritoneum inflammation, which is innervated by type C fibers
• Pain becomes more severe and localized as inflammation progresses to the parietal peritoneum (innervated by type A delta fibers)
• Appendicitis starts with general abdominal discomfort and progresses to localized pain in the right lower quadrant
• Patients with inflammatory pain tend to lie still to minimize discomfort

Ischemic Pain:

• Least common but most serious type of visceral pain, associated with insufficient blood supply to abdominal organs
• Sudden onset, intense, continuous, and progressively worsening pain
• Common causes include strangulated bowel, progressions, and mesenteric artery infarction
• Ischemic pain is not relieved by analgesia

Frequent Emergency Visits

• ED staff sometimes refer to patients in a non-complementary way who come in regularly
• Called "Frequent Flyers
• pause to consider the implications of the term, when used that way
• Consider staff's thoughts/feeling about patients who stays in the hospital too long
• Consider how this may impact your approach to the patient
• Particular vulnerable group.
• Nurses can become complacement.
• Their index of suspicion goes down
• Things can get missed.
• Patients are marginalized.
• Financial status and chronic illness.
• Be aware of how a person's position might be influencing your nursing practice in unintended ways

Level of Urgency (LOU)

• Level Of Urgency (LOU) Is the classification and prioritization of a patient's health concern
• a measure and judgment about the priority of care.
• Determined initially and on an ongoing basis.
• Useful When you're asked to make decisions about who gets the last available strectcher.
• Nurses should always consider LOU when performing assessments.

Patient's can be stable or unstable

• Stable: patients present with normal and not life/limb threatning
• Unstable: abnormal and considered life/limb threatning.
• Potentially unstable: Normal clinical findings but their history leading to admission warrants concern

Canadian Triage Acuity Scale (CTAS)

• Was developed by ED physicians and nurses in the 1990's
• tested,reasonable, inter-rater reliability.
• Provides a framework for initial patient assessment results and a "score" of 1,2,3,4 or 5.
• Score to "1” patient is critically ill and requires immediate and medical attention and probably resuscitation.
• CTAS Scores provide standard triage classifications.
• Provincial and national statistical analysis of patient numbers and presentations.

Systematic Approach to Assessment

• Nurses assess patient every shift.
• Situation factors make EDs unique and for the reason clear.
• Combat uncertainty and use a systematic approach
• Goals to identify the best assessment
• Baseline data, monitor and trends to get to know the patients
• Using a systematic approach to collect information

Emergency Nursing Assessment Framework Components:

• Primary (ABCs)
• Secondary assessments
• subjective history, objective assessment, focused system assessment

Primary Assessment Breakdown

• C: Identify need for CPR or need to control major bleeding
• A: Airway and C-spines control
• B: Breathing
• C: Circulation
• D: Disability, Doctor, Dextrose, Discomfort
• E: Expose
• F: Full set of vital signs and Family presence
• G: Go back and re-assess

Data collection

• Data is subjective or objective
• So, understand the difference between them to understand their meaning
• Subjective: arises from the patient themseterm-10lves and their experience
• objective: Observable to others
• There are subjective and objective findings for each, with varying data
• Assessment is flexible and like putting together a puzzle
• Data is objective at first but more can be collected given there is no pain or complications.

Primary Assessment

Assessment:

• CAB verses ABC = Need for CPR/ Uncontrolled bleeding
• Airway and C-spine = Look, Listen, Feel for air movement/Clarity of speech/Patency verses/obstruction. Stridor, gasping,wheezing,snoring, drooling, gurgling, AVPU , C-spine injury trauma
• Breathing = Rate, effort, and quality of respirations. Diminished or absent, retractions, accessory, muscle use, nasal flaring,head, Auscultate lungs.
• Breath Sounds. Symmetry of expansion, Respiratory distress Circulation = Skin, color, temperature, moisture. Capillary refill time/Pulses for quality, rate, rhythm/ Chest Pain
• Disability = Reassess AVPU/ GCS

Interventions:

• CAB verses ABC = CPR or Start BLS/ACLS/PALS/control
• Airway and C-spine = Clear oropharynx suctioning thrust chin/Oral and airway
• Breathing = Assist ventilations and supplement by vent
• Circulation = Initiate IV(s) or IO Cardiac monitor,Resuscitative fluids , ECG (12 lead).
• Disability = Pain antiemetic notify emergency

Assess on Primary:

• Mobility, Full range of motion
• Skin colour
• Temperature

Initial Assessment (Primary):

• What we are looking for:
• Safety
• Consciousness level
• Airway
• Breathing
• Circulation
• Hemorrhage.

Disability/Neurological Assessment:

• Check responsiveness
• Verbal ability.
• Assess mental status.
• Check pupils for reaction.
• Is the patient oriented to time, place, person

Primary Interventions:

• Suction
• Oxygenate
• Immobilize.
• Apply direct pressure to sites.
• Warm the patient up!
• IV Access.
• Monitor vital signs frequently
• Support
• Prepare for secondary.

Secondary Assessment:

• Subjective History
• Objective Assessment (Head to Toe)
• Focused System Assessment
• Disposition, movement of labwork
• Imaging (CT/X-Ray/ultra sound)
• Where do they need to be
• Patient gets a Gown & blanket

Assessment and Interventions (Secondary):

• History head to toe +allergies,Medication, Past medical history,Last meal Disposition, movement + imaging, transfer

Primary Assessment is The "ABCs"

• Includes everything from C,A, to G. Assessment of a patient's airway, breathing, circulation, disability, vital signs.

Collecting data

• Collection of objective and subjective data is limited in this phase to assessing and intervening for these major components.
• Primary assessment must be sequential and satisfactory
• Airway must be patent and adequate before proceeding or intervening
• Airway -> Breathing -> Circulation -> disability
• Example of wrong intervention: intubating when you should have gave the patient intravenous

In ABC's: CAB vs ABC

• 2015, Heart and Stroke Foundation, follow guidelines Patient needs pulse, Chest compressions should be started Hemorrhage that can be prevented Survey needs to address

A: Airway and C-spine

• Following the need to start basic life there must be rapid identification of external hemorrhizing