Emergency department nurses will be responsible for the acute assessments of patients presenting with trauma. The primary assessment allows for the recognition of potentially life threating conditions and the correct management to be implemented. The acronym ABCDE provides the basis of the primary assessment and it is an easy way to remember the correct order for assessing patients presenting to the emergency department. The components that make up the assessment will be discussed in more detail. The table below outlines causes of life threatening conditions identified during the primary assessment.
Airway
|
Breathing
|
Circulation
|
| Disability |
A= Airway
The airway is the most important to component to be established and maintained to prevent hypoxia and ultimately death.
Nurses must assess:
- Clear open airway
- Assess for obstruction
- Assess for respiratory distress
- Check for loss teeth
- Assess for bleeding, vomitus or oedema
Interventions that the nurse can implement to manage the airway are:
- Suction
- Jaw thrust manoeuvre
- Nasopharyngeal airway insertion
- Cervical spine immobilisation
B= Breathing
Breathing is assessed after the airway. During times of acute injury and stress the respiratory system can be compromised.
Nurses need to:
- Assess ventilation
- Observe and count the respiratory rate
- Assess the trachea positioning
- Auscultate lungs
- Observe chest wall movement
- Assess the use of accessory muscles
- Look for cyanosis
- Listen for wheezing, stridor, or grunting
Interventions that a nurse can implement:
- Have suction available
- Administer oxygen therapy
- Prepare for the possibility for needle thoracostomy
C= Circulation
Adequate circulation is needed to maintain tissue perfusion and cellular oxygenation. This system involves the heart, vessels, and blood volume.
Nurses need to:
- Check for pulses
- Palpate for quality and rate
- Assess the appearance clammy, cool
- Check for peripheral warmth
- Check capillary refill
- Get a BP reading
- Assess for bleeding
Interventions that a nurse can implement:
- Initiate CPR
- Gain intravenous access
- Obtain blood for labs
- Control bleeding
- Prepare fluids or bloods as needed
D=Disability
A neurological assessment to assess for motor or sensory deficits is important as a decrease in level of consciousness can affect ABC.
Nurses need to:
- Assess orientation to time, place, person
- Assess level of consciousness with AVPU or GCS
- Assess pupils size, shape, reaction
- Assess the ability to move limbs
- Assess the response to stimulation eg pain
Interventions the nurse can implement:
- Ongoing neurological assessments
- Observe for signs of increased ICP
- Splint any deformed limbs
- Patient positioning
E=Exposure
Trauma patients should have their clothing removed in order for a full body assessment to be undertaken.
Once the patient is exposed their privacy needs to be respected by providing a gown and blanket.
Due to the heat loss that can occur, heat lamps, bair huggers, warmed blankets and warmed fluids may be appropriate.
As well as decreased temperature being considered, hyperthermia may be present, which will require cooling measure such as ice packs, cooling blankets and reducing circulating air temperature.
Before the secondary assessment is undertaken, it assumed that all life threatening conditions have been found and corrected. The nurse needs to remember that airway, breathing, circulation, and disability will always be monitored and should be in the forefront of the nurse’s clinical reasoning.
The main focus of the secondary assessment is to explore specific medical conditions the patient may have. The secondary assessment should be methodical and involve inspection, palpation, auscultation, and percussion.
The components of the secondary are continuous with the primary assessment A,B,C,D,E,F,G,H,I.
A full set of vital signs, giving comfort, history taking and head to toe assessment and inspection of the posterior side of the body
All aspects of the primary and secondary assessments should be accurately documented.
F=Full set of vital signs
This aspect of the secondary assessment does not just include the vital signs; temperature, respiration rate, heart rate, blood pressure, and pain, but also encompasses further investigations.
Nurses need to:
- Assess vital signs
- Monitor oxygen saturation
- Undertake an ECG
- Gain a MSU sample and urinalysis
- Monitor blood glucose levels
- Get bloods for FBC, LFT, cardiac enzymes, electrolytes and coagulation factors
- Organise xrays, CT, or MRI as requested
- Insert IDC or NG tube as required
During this part of the assessment the nurse should attempt to determine if family member presence for support is required. The adult patient has the right to consent to or refuse family involvement in their care.
| BP | Temp | HR | RR | SpO2 |
| 120/80 | 36.5-37.2 | 60-100 | 12-20 | <95% |
G=Give comfort
For many patients in the emergency department levels of pain may be quite high. The 0-10 rating for pain is a reliable tool to use. Although the vital signs may not be reflected of a patient experiencing severe pain, nurses must remember that pain is subjective and must take the patient at their word.
In the emergency department there are standing orders which allow the nurse to administer analgesics without a prescription from a doctor. Clinical judgment is needed to assess the correct form of analgesic to be administered.
Giving comfort not only means managing pain put it also means providing psychological comfort. Developing a therapeutic relationship with the patient and the family plays a pivotal role in providing comfort. General comfort measures such as offering reassurance, providing adequate information and explanations, and managing anxiety should be provided to all patients. Anxiolytics may be needed if anxiety levels escalate.
H=History
Gathering information of the incident, injury or illness provides important details, especially with trauma patients as knowledge of the mechanism of injury can provide insight into other injuries which may be present. There are key questions that need to be included into history taking:
- What has caused the patient to present to ED?
- What are the patient’s subjective experiences? eg headaches, nausea, pain
- The provoking factors, quality, radiation, severity, and timing of pain
- Is there a medical health history?
The mnemonic AMPLE is a useful tool to guide history taking
Head to toe assessment
Head/neck/face
- Look for lacerations, tenderness
- Look at ears, eyes, nose, and mouth
- Examine the neck for stiffness, bleeding, difficulty swallowing, and bruising
Chest
- Observe rate, depth, and effort of breathing
- Undertake a full respiratory assessment
- Obtain an ECG
- Examine chest for bruising, scars, bleeding
Abdomen
- Palpate for organs and tenderness
- Percuss for dullness and tympanic sounds
- Auscultate for bowel sounds and bruit
- Look for external signs of damage
Pelvis
- Assess genitalia for signs of injury
- Assess for rectal or vaginal bleeding
Extremities
- Assess range of movement in limbs
- Assess sensation in each limb
- Check peripheral pulses
- Assess skin appearance and capillary refill
I=Inspect posterior surfaces
The posterior surface of the patient needs to be inspected for abrasions, lacerations, deformities, and puncture wounds. The spine should be palpate to identify and deformity or misalignment.
The log roll should be used to roll patients in the emergency department when it is unclear what injuries the patient has sustained.
References
Briggs, E. (2010). Assessment and expression of pain. Nursing Standard, 25(2), 35-38. doi: 10.7748/ns2010.09.25.2.35.c7986
Jones. G. (2003) Care of the emergency patient-frameworks for nursing assessment and management. In G. Jones, R. Endacott, & R. Crouch (Eds), Emergency nursing care: Practice and principals (9-26). New York, NY: Greenwich Medical Media.
Kelly, M. (2008). Nursing care in specialised settings. In D. Brown & H. Edwards (Eds.) Lewis’s medical-surgical nursing (2nd ed., pp. 1836-1875). Sydney, Australia: Mosby Elsevier.
Shackell, E., & Gillespie, M. (2009). The Oxygen Supply and Demand Framework: A tool to support integrative learning. The Canadian Journal of Critical Care Nursing, 20(4), 15–19. Retrieved from //www.caccn.ca/en/publications/dynamics/