When a patient enters the Emergency Department (ED), immediate and accurate assessment is mandatory to ensure prompt medical diagnosis and appropriate care. In the case of Mrs. Baker, a 73-year-old female who collapsed in her backyard, this assessment will assist in determining the reason for her collapse as well as identifying underlying medical problems that may have led to this incident. Upon her arrival at the ED, Mrs. Baker gives her previous medical history, states her primary symptoms, and lists her current medications. Luckily, the nurse is able to get this information before Mrs.
Baker becomes unresponsive with more labored breathing. Once the patient becomes unresponsive, prompt action is necessary. Several interventions and assessment steps will happen simultaneously by the nurse, paramedics and patient care techs. First, the nurse will ensure a patent airway through auscultation of breath sounds and observing chest rise while also applying oxygen via nasal cannula or mask using pulse ox readings to titrate the oxygen, maintaining adequate saturation. The nurse will then attach telemetry leads to the patient’s chest and abdomen so that the electrical conductivity of the heart can be visualized.
These tasks can be accomplished while a sphygmomanometer, wrist watch and thermometer are used by other staff to obtain the blood pressure, respirations per minute and temperature of the patient for comparison to those taken en route. The nurse will also instruct trained staff to check the patient’s blood sugar with a glucometer, since the patient listed diabetic medications. The nurse assessment will begin with the lungs, since oxygen is mandatory for homeostasis. The nurse must ensure that there is air movement in the lungs to support life.
To do so, using a stethoscope, the nurse auscultates breath sounds, listening for abnormalities during inspiration and expiration in all lung fields. If abnormalities exist, they may indicate an excessive fluid volume (crackles), tightness in the airways (wheezes) or a diminished capacity for air exchange (diminished air movement in the lung fields). As she listens, she is also watching for equal chest expansion; for, unequal expansion could indicate injury to the underlying tissues or atelectasis. After the respiratory assessment is complete, the nurse focuses on the heart, as its unction circulates oxygen throughout the body.
To assess the heart, the nurse auscultates in four areas of the anterior chest to verify the pulse regularity and pace shown on the monitor, while listening for possible heart valve function abnormalities (murmur or extra heart sounds), or inflammation (friction rub), all indicators of cardiac output. Once it is established that there are no immediate cardiac issues to address, the nurse will inspect the abdomen, noting its shape, abnormalities in the skin, masses and movement with respiration, then auscultate for bowel sounds in all four abdominal quadrants (Ferguson, 1990).
Bowel sounds indicate a bowel peristalsis, while those sounding distant indicate a buildup of gas or fluid in the abdomen. After the auscultation, the nurse palpates the abdomen for tenderness or masses. Since the patient is unresponsive, the nurse will pay special attention to the patient’s body language during palpation—facial grimacing, physical guarding or flinching—to identify pain or discomfort. The nurse will then move on to explore the rest of the patient’s body, palpating for broken bones, enlarged lymph nodes, possible masses or other abnormalities.
Because the patient is a diabetic, the nurse will also inspect the patient’s skin for signs of injury, as well as noting the temperature and color of the extremities and nail beds, which are indicators of circulation and perfusion. While the nurse is finishing her assessment, other members of the medical team will prepare to gather additional information.
Another nurse or paramedic will initiate an intravenous site while collecting blood samples for diagnostic testing (such as a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Magnesium (Mg) and Phosphorus (Phos) levels and more). Respiratory techs may also collect a sample from the patient’s wrist for Arterial Blood Gas (ABG) testing and set up to perform a 12-step EKG to rule out an acute cardiac event. Additionally, radiology staff will prepare to obtain a chest x-ray or CT to better visualize the heart and lungs, looking for signs of infection, masses or other abnormalities.
If there are signs of injury, such as brusing, on the patient’s body, additional x-rays may be ordered. And, the clerk or unit secretary will call the patient’s primary physician to obtain previous medical records. These records will be used to compare the findings of today’s visit, identifying changes in the functioning of the patient’s body systems and, therefore, homeostasis. As seen above, several tools are used in assessing and collecting patient data. These range from handheld devices to large pieces of equipment.
Yet each provides the medical team with vital information: • The pulse ox allows the nurse to monitor oxygenation to the body’s tissues, and titrate the oxygen supply via nasal cannula or mask to maintain adequate saturation. This is important because the body’s organs and tissues need oxygen to maintain function, tissue health and, as a result, homeostasis. • Telemetry monitoring allows the medical team to see how the heart works and the moment any changes occur—such as, a change in where each beat originates or a delay in the conduction to the ventricles, all which can impact cardiac output. It can also show changes in some instances of acute coronary episodes. Having this information readily available drastically cuts down on the time it takes to diagnose and treat the patient.
• Vital signs (gathered with the sphygmomanometer, thermometer and wristwatch) can often indicate pain or other changes in a patient’s condition—often before other signs or symptoms of a decline in homeostasis occur. For example, if blood pressure suddenly drops, it indicates a decrease in cardiac output, or excessive fluid loss. Vital signs can also indicate an increase in patient discomfort, even when the patient is not able to verbalize the need for pain medication. • The glucometer gives the nurse a quick estimate of the patient’s blood glucose. Extreme high or low blood sugars require quick interventions to prevent injury to body organs and return the patient to homeostasis.
• The stethoscope allows the nurse to hear what is happening inside the patient’s body and the opportunity to immediately gather information. This information will then be used to decide further diagnostic testing and then, in conjuction with those diagnostic results, plan treatment. Lab equipment provides vital analysis of the smallest cells in the body to provide various results the doctor will then interpret. A CBC can indicate infection through elevated white blood cell counts as well as the level of immunity response. The CBC can also show anemia, improper coagulation and improper blood cell production (American Association for Clinical Chemistry [AACC], 2001-2011). The CMP, Mg, and Phos tests show various electrolyte and protein levels as well as other values that indicate kidney and liver function.
The ABG results indicate lung function and gas exchange in the body and includes the level of acid-base balance present in the body. Using these results together, doctors can further develop diagnoses, prescribe treatments and adjust medication dosages to ensure safety for the patient. • Equipment in radiology has perhaps become the most vital tools used in diagnosing patients. Allowing for a look inside the patient, x-ray, CT and MRI machines show everything that cannot be seen with the naked eye, identifying broken bones, collection of fluids, masses and even blood flow.
From the time the patient enters the ED, the nurse will continuously assess and manage pain in the patient. When the patient is alert, the nurse will ask the patient to self-report pain, because pain is subjective and cannot be seen by a third party. However, the nurse knows that elderly patients often refrain from using the word “pain,” often underreporting their discomfort, resulting in poor pain management (Mauk, 2010). So, the nurse will adjust her questions, asking the patient if she is “comfortable,” or having any “discomfort. S/He will also rely on non-verbal indicators of pain: facial expression, positioning of extremities, the level of activity in the body (stillness, squirming or rigidity), crying and consolability.
The FLACC scale measures each of these areas, assigning a numeric value to each. This helps to guide medical professionals in identifying changes, as s/he can establish a baseline FLACC score and then continue to compare the patient’s FLACC to her reported level of pain or discomfort. If the patient’s FLACC seems higher than the patient’s report of discomfort, the nurse may offer an intervention, such as a dose of Tylenol.
There are times when patients say they have no pain, but will accept the intervention because they are experiencing discomfort. The FLACC score can continue to be used when the patient is unresponsive. Since the patient is no longer able to report pain, the FLACC takes on more importance. In addition to the FLACC scale, the nurse can utilize other non-verbal indicators of pain or discomfort: diaphoresis or tearing, physical movement or increased muscle tone and even changes in blood pressure and pulse can indicate pain in an unresponsive patient (American Society for Pain Management Nursing [ASPMN], 2006).
In addition the aforementioned FLACC scale, there are other tools the nurse can utilize, each looking at non-verbal indicators for pain. The nurse should use any of these checklists or tools in conjunction with her own assessment of the patient, and identification of activities inducing discomfort in the patient. The nurse needs to be vigilant about preventing or minimizing discomfort in the unresponsive patient through positioning as well as predicting those activities that may cause discomfort (dressing changes, incisions, treatments, equipment) (ASPMN, 2006).
When the patient is showing signs of pain or discomfort, the nurse will intervene by providing medication. In the event of Mrs. Baker, who is now unresponsive, the nurse will administer pain medication via IV, such as a low dose of morphine. As IV medications have a quick onset of action, the nurse will reassess the patient’s pain within 20 minutes of pushing the medication. Should the reassessment show a decrease in indicators of pain, the nurse will recognize the medication has been effective, and reassess the patient’s pain again in a short interval of time (perhaps 30 minutes, if not sooner) to ensure the patient’s pain is still managed.
Should the reassessment show no change in nonverbal indicators of pain, the nurse may consider a second dose of morphine while also looking for other causes of discomfort, such as positioning of the body and pieces of equipment attached. Should there be no obvious cause of discomfort, the nurse may administer the second dose of medication while reassessing the patient through auscultation and palpation to identify any changes that may have occurred since the initial assessment. It is important to note that the assessment and reassessment of pain needs to continue throughout the patient’s visit to ensure adequate pain control.
In conclusion, the quick work in assessing and gathering data on a patient in the emergency department requires quick-thinking and response by the patient’s nurse, as well as several tools to use in gathering further information. The nurse works with members of an interdisciplinary team that includes staff from radiology, cardiopulmonary, laboratory services, and ambulance personnel. The patient becomes the priority, requiring frequent reassessment, especially when the patient is unresponsive and exhibiting signs of pain or discomfort.