Patient Assessment Katie Good-Opdahl, RN Obj ect ives Following t - - PowerPoint PPT Presentation

Patient Assessment

Katie Good-Opdahl, RN

Obj ect ives

• Following t he present at ion, individuals should be able t o:
• Complet e a t horough head t o t oe assessment of t he ED pat ient
• Wit hhold knowledge for early recognit ion of t he crit ical ED pat ient

“ The compet ent emergency nurse must be a ‘ j ack-of-all-t rades’ , mast er of most ”

• Pat ient s present t o t he ED wit h every possible medical, surgical,

t raumat ic, social and behavioral healt h condit ion.

• S

ubj ect ive vs Obj ect ive Dat a

Back t o t he Basics

• Gown every pat ient , every t ime
• A-I mnemonic for assessment
• Primary vs S

econdary Assessment s

• Bot h can be complet ed wit hin minut es unless resuscit at ive measures are

required.

Primary Assessment

• Ut ilized t o ident ify and address pot ent ially life-t hreat ening

condit ions

• ABCDE
• Airway
• Breat hing
• Circulat ion
• Disabilit y
• Exposure

Secondary Assessment

• Ident ify all clinical indicat ors of illness or inj ury
• FGHI mnemonic
• Full set of vit als
• Give comfort measures
• Hist ory and head-t o-t oe assessment
• Inspect post erior surfaces

Airway

Assessment Act ions include: *Ident ifying and removing any part ial or complet e airway

• bst ruct ion;

*Posit ion airway t o maint ain pat ency Int ervent ions: *Insert oropharyngeal or nasopharyngeal airway *Prot ect cervical spine

Breat hing

• Assessment Act ions include:
• Assist breat hing wit h oxygen t herapy, mout h t o mask vent ilat ions, or bag-

mask vent ilat ion as needed

• Int ubat e when necessary
• Int ervent ions:
• Assist in providing vent ilat ions and supplement al oxygen as needed
• Relieve t ension pneumot horaces may be necessary t o support breat hing

effort s

Circulat ion

• Assessment Act ions include:
• Evaluat e pulse presence and qualit y, charact er, and equalit y
• Assess capillary refill, skin color and t emperat ure
• Assess for diaphoresis and skin t urgor
• Int ervent ions:
• If no palpable pulse is present , init iat e CPR and resuscit at ion effort s

Disabilit y

• Assessment Act ions include:
• Det ermine level of consciousness
• Int ervent ions:
• If alt ered level of consciousness, furt her assessment needs t o be complet ed

in order t o invest igat e cause.

Exposure and Environment al Cont rol

*All pat ient ’s should be in a gown

• Provide a blanket
• Trauma pat ient ’s meet requirement s t o have warmed rooms

Secondary Assessment – Full Set of Vit als

• Temperat ure
• Core t emperat ure recommended
• Rect al
• Urinary cat het er t hermist ors
• Pulse
• Palpat e cent ral pulses
• A change is indicat ory of compensat ory mechanisms
• Respirat ions
• Count respirat ions for a full minut e
• Chest must raise equally on bot h sides
• Oxygen Sat urat ion
• Good plet h
• Observe wit h clinical appearance
• Blood Pressure
• Proper cuff size
• Cardiac monit or vs manual BP

*Weight, Height, and head circumference

Give Comfort Measures

• Pain is referred t o as t he 5t h VS
• Age-appropriat e st andardized t ool
• F

ACES Pain Rat ing S cale

• FLACC – face, legs, act ivit y, cry and consolabilit y
• Comfort measures init iat ed based on chief complaint and obvious

inj ury

Hist ory

• AMPLE
• Allergies
• Medicat ions
• Past healt h hist ory
• Last meal eat en
• Event s leading t o

t he illness/ inj ury

Head-t o-Toe Assessment

• Head and Face
• Neck
• Chest
• Abdomen
• Pelvis/ Perineum
• Ext remit ies
• Post erior S

urfaces