CHAPTER 13

Patient assessment and essentials of

care
Belinda Munroe, Claire Hutchinson

Essentials
● Patient assessment should always begin with DRSABCDE (Danger,
Response, Send for help, Airway, Breathing, Circulation, Disability
and Exposure). Once the patient is physiologically safe, a more
comprehensive assessment can be completed, focusing on relevant
body regions and systems.
● If a patient deteriorates, then reassessment should always start again
at DRSABCDE.
● Use an aid such as the SAMPLE mnemonic to ensure that all relevant
history data is obtained.
● ‘Red flags’ may become evident at any stage of the patient assessment
and should never be ignored.
● A set of vital signs comprises respiration rate, oxygen saturation,
blood pressure, pulse rate and temperature.
● When performing a physical assessment, remember to inspect,
auscultate, percuss and palpate. Use a structured handover tool, such
as IMIST-AMBO or ISBAR; this ensures that no vital information is
forgo en. Double-check your documentation for errors.
● Patients should be screened to identify risk of falls, pressure injuries,
poor nutrition and cognitive impairment, and appropriate strategies
put into practice to prevent or minimise complications.

Introduction
Assessment is the ability to observe and interpret any clinical situation,
thereby influencing the decisions of emergency nurses and paramedics.
Accurate patient assessment enables the evaluation of actions and
practices and lies at the core of both professions. How well patients are
cared for has a direct effect on their sense of wellbeing and recovery. This
chapter also discusses the essential elements of nursing care.
Assessment enables emergency clinicians to prioritise care. The triage
nurse or first-responder paramedic will initiate patient assessment, but, as
every patient's condition has the potential to change, there is a need to
recognise the importance of a detailed initial assessment, followed by the
ability to determine how often reassessment should take place. Patient
reassessment in emergency departments (EDs) has never been more
important, given the prevalence of access block, which results in
prolonged length of stay in the ED.1 Different assessment models exist
with their own distinct purpose. The triage assessment is brief with the
aim to sort patients into order of urgency. The medical model focuses on
the underlying cause of the patient's presenting signs and symptoms.2
The primary survey ensures life-threatening conditions are identified and
treated first.3,4 The HIRAID assessment framework provides a systematic
approach to the comprehensive assessment of patients.5 Assessment
models such as these ensure a structured, evidence-based approach to
assessment and is imperative to enhance the clinician's performance and
optimise patient safety.3,6–8
Emergency clinicians make important clinical decisions every day and
these decisions have an effect on the patient's healthcare and the actions of
healthcare professionals. As care provision is becoming increasingly
complex, emergency clinicians have to rely on sound clinical decision-
making skills to maintain up-to-date care and positive outcomes.9–11
The assessment process
Assessment starts from the first moment you see your patient and begins
with a primary survey assessment and collection of details about the
patient's history, followed by a systematic assessment of relevant body
regions and systems. Assessment findings inform the selection and
prioritisation of interventions. Diagnostic and laboratory tests also
contribute to developing a complete picture of the patient's condition.
The primary survey
The primary survey, as the first element of patient assessment, ensures a
consistent, evidence-informed and sequenced approach promoting patient
safety in all clinical se ings.3 The primary survey consists of DRSABCDE
(Danger, Response, Send for help, Airway, Breathing, Circulation,
Disability and Exposure).4 (See Box 13.1.) The patient environment should
always be checked for danger before commencing patient assessment, to
ensure it is safe to approach the patient. Any foreseeable risks should be
removed to prevent injury prior to commencing the assessment. A scan of
the surroundings will inform you of any danger or hazards that need to be
negotiated. These can include a patient who has collapsed in the waiting
room bathroom and is lying in a pool of water, or at a motor vehicle
collision (MVC), where traffic is still passing at speed. As a paramedic
arriving on the scene, assessment can also tell you about the mechanism of
injury, how many casualties there are and what resources you may need.
You will need to note the position of the casualties and any points of
impact, as this is important information to include when handing over
your patient. Once the scene has been assessed and any danger removed,
then an initial patient assessment of ABCDE can take place. See Chapter 9
for a detailed discussion of scene assessment and management.

Box 13.1
Assessment of DRSABCDE
DR—Danger and Check for danger and patient responsiveness
Responsiveness
S—Send for help If patient unresponsive send for help
A—Airway Is the airway patent and protected?
Is there any sign of obstruction?
Is the cervical spine immobilised (for trauma patients)?
B—Breathing Is the chest rising and falling?
Is breathing adequate?
C—Circulation Is the circulation sufficient to meet the needs of the patient?
Is there ongoing bleeding?
D—Disability What is the patient's neurological status? Assess using AVPU. (Alert, responding
to Voice, responding to Pain or Unresponsive) scale
Check pupil response
Don't forget the glucose
E—Exposure Remove clothing and look for immediate threats to life or limb
What is the patient's temperature?

The Australian Resuscitation Council recommends the primary survey

follows DRSABCD to preserve and restore life when resuscitating the
unconscious patient.4 The Advanced Trauma Life Support guidelines also
teach the step called ‘exposure’, which involves the removal of the
patient's clothing to expose and identify any immediate life-threatening
injuries and ensure adequate temperature control is achieved.12
Undressing and exposing all patients is necessary to enable a complete
assessment, particularly once the patient has reached the emergency
department (ED), where privacy may be maintained. Early measurement
of temperature is important to identify hypothermia, hyperthermia and
febrile illnesses in both trauma- and non-trauma-related presentations
such as sepsis, which requires urgent identification and treatment to
reduce morbidity and mortality.13 Exposure is also recommended by the
Australian Resuscitation Council when reassessing the patient after the
return of spontaneous circulation; targeted temperature control as part of
post-resuscitation care has been demonstrated to improve patient
outcomes.4 See Chapter 14 for patient resuscitation and Chapter 42 for a
detailed assessment of the major trauma patient.
During this phase, life-threatening problems are identified and
interventions commenced if required. The clinician should ensure each
step of the primary survey is complete and any identified life-threatening
conditions are treated first, before moving onto the next stage of
assessment. If nothing imminently life-threatening is detected, a further,
more-focused assessment can take place.4,5 It is important to have a
systematic approach to this assessment to ensure that important
information is not missed, particularly when there is uncertainty around
the patient's underlying problem.14

HIRAID: an emergency nursing assessment

framework
The emergency nursing assessment framework HIRAID, adapted from
Curtis and colleagues,14 can ensure that a systematic approach is taken
when performing an initial nursing assessment.15 The HIRAID assessment
process is comprised of seven critical components:

● History
● Identify Red flags
● Assessment (clinical examination)
● Interventions
● Diagnostics
● Reassessment
● Communication.5
Fig. 13.1 illustrates the relationship between the steps. They do not
necessarily occur in this order, as in reality they often happen
simultaneously. The assessment is a cyclic process, supported by ongoing
reassessment and communication.
 FIGURE 13.1 HIRAID: An evidence-informed emergency nursing assessment framework.14

The history is gained from the patient, relative, carer or significant other.
It should include details about the chief complaint and the patient's
individual health history, such as past medical history, medications and
allergies. Identification of red flags involves recognition and response to
clinical indicators of urgency identified during any stage of the assessment
process. The emergency clinician must respond to red flags and escalate
care as required in a timely manner to prevent deterioration and optimise
patient recovery. Assessment involves the clinical examination of the
patient, including skills such as inspection, auscultation, percussion and
palpation. Interventions which may be required include giving first aid,
applying oxygen and giving analgesia. Once the patient has arrived at an
ED and life-threatening conditions are identified and treated, diagnostic
and laboratory testing can take place.
On the patient's arrival to hospital, the triage nurse is initially
responsible for identifying the chief complaint and the ideal location
within the ED. If the patient is moved to a cubicle area, this is where a
more thorough and detailed assessment is performed to ensure that any
life-threatening illnesses or injuries not found initially are detected and
treatment commenced. Emergency clinicians are often responsible for
patients for extended periods and required to commence treatment and
monitor response to therapies prior to medical review. Therefore, it is vital
that every emergency clinician has the ability to perform an accurate
clinical assessment with a view to determining the chief complaint and not
just record a set of vital signs which, taken in isolation, is often
meaningless.

History
Taking a history requires collection of subjective data. This is the
information that you gather from the patient, relative, carer or significant
other. In the pre-hospital se ing this may also be a witness to an accident.
Developing and maintaining rapport are central to good communication
and effective information gathering.16 It is important to take some time at
the beginning of any assessment to explain who you are and what it is you
are planning to do. Ask open-ended questions and let the patient speak for
a minute or two without interruption, and the main problem and any
concerns should become apparent. Examples of open-ended questions are:
‘What's troubling you today?’, ‘Why have you come to hospital?’ or ‘Why
did you call the ambulance?’. Emergency clinicians should then be able to
focus the assessment and gather required additional information, and
allay any immediate anxieties. Asking open-ended questions of
Indigenous people is very important, as they may not respond well to
direct questioning (see Chapter 5 for further discussion of cultural
considerations). When the patient is acutely unwell, the amount of time
spent asking open-ended questions should be limited so that the
assessment can move promptly to the area of concern, allowing quick
evaluation and management.17
It is important to also speak to family, carers or witnesses, as they may
be able to add pertinent information that the patient considers
insignificant or is unable to give due to an altered mental state. If the
patient has an altered level of consciousness, then the nurse or paramedic
has to rely more heavily on other assessment skills, and once the patient
has arrived in the ED the nurse may need to obtain old hospital records or
contact the general practitioner if friends or relatives are not able to help or
are uncontactable. However, such searches can be quite time-consuming.
The emergency nurse responsible for assessing the patient once they have
been allocated to a treatment space should review the ambulance case
sheet and triage form to ensure information has not been omi ed during
the handover process.
When taking a history, it is useful to develop a systematic approach to
ensure that all the important questions are asked. The SAMPLE mnemonic
(Box 13.2) is a way to structure history-taking in a pre-hospital
environment.18 It should not delay transport to a facility and can be
conducted while en route.

Box 13.2
The SAMPLE mnemonic for history-taking
S Signs and symptoms
A Allergies
M Medications
P Pertinent past history
L Last oral intake
E Events leading up to the illness/injury

Once the patient has arrived at an ED, details about the patient's history
can be handed over to the accepting nurse. The patient's condition may
have changed during transportation, so conducting a thorough assessment
on arrival in a more controlled environment is important. See Box 13.3 for
the questions that should be asked and the rationale for these.16,17

Box 13.3
Pertinent questions to obtain a history
Presenting problem
Chief complaint
What is the reason the patient has presented to hospital? It is advisable to
document this using the patient's own words. It is then very clear what
the patient complained of on presentation, as symptoms can change.
Characteristics
It is important to identify the location and characteristics of the chief
complaint and any related symptoms (both ones you may expect and ones
that are absent). For example, centralised abdominal pain associated with
vomiting or diarrhoea.
Pain history
This can be explored using PQRST (see Box 13.4).
Aggravating causes and relieving factors
What exacerbates or relieves the symptoms? This can provide clues as to
the cause. For example, cough started after being commenced on new
medication.
Timing
You need to explore when the symptoms started, and whether they are
continuous or intermi ent. How long do they last?
Medications taken to relieve symptoms and effectiveness
Some patients take multiple pain medications when pain is severe. If one
type over another is more effective, this can also offer clues.
Individual health history
Past medical / surgical history
This is an essential component of your assessment. Patients may not
realise the significance of prior problems and may not think them
relevant. You should prompt your patient to divulge all past medical
history and previous surgeries, however irrelevant it may seem to them.
Current medications (including smoking, alcohol, illicit drugs)
It is important to elicit details of current medications as they may be
linked to the problem. Not only prescription medications, but also over-
the-counter and herbal or homeopathic ones.
Allergies
Information about allergies is important. However, many patients
a ribute adverse reactions or intolerance to allergies. Therefore, the
reaction to any drug should be noted, e.g. ‘Patient states they are allergic
to morphine, but the reaction they suffered was nausea and vomiting.
This is a common side-effect and not a true allergy.’
Relevant family and social history
The patient's problem may be hereditary or genetic. Important diseases to
ask about are cardiovascular, respiratory, cancer, diabetes, renal disease,
allergies and mental health problems. Although family history is not
diagnostic, it allows risk stratification. The social history should be
tailored to the individual, but an understanding of the patient's social
habits helps to determine further risk factors. Recognition of social
supports at home for an elderly person can assist with early identification
of the likelihood of needing admission. It is also important to identify the
carer responsible for paediatric patients and any child protection concerns
that need to be considered.
Tetanus status; last menstrual period
These are asked about only if relevant to the presenting problem.
 When assessing a patient's pain, the mnemonic PQRST can be very
useful. It helps determine the Provoking factors, Quality, Radiation,
Severity and Timing of the pain, and is a useful tool to assist in exploring
all realms of the pain. (See Box 13.4 for full explanation of terms, and
Chapter 18 for discussion of pain management.) The information gathered
while taking the history will guide emergency clinicians as to which body
systems need to be examined, as well as the extent of the investigation.
However, during history-taking it is important not to make assumptions
about the patient's clinical presentation until a comprehensive assessment
has been completed.

Box 13.4
Pain assessment using PQRST
P—Provoking What factors precipitated the patient's discomfort?
factors What were they doing at the onset of pain?
Q—Quality Get the patient to describe the pain/ache/dullness.
Ask them to tell you its characteristics: ‘Describe the pain and how it feels.’
R—Region/radiation Ask the patient to show you where the pain is and where it radiates to, if
applicable.
Ask if there is pain anywhere else.
S—Severity Get the patient to rate their pain/ache/dullness on a pain scale.
T—Time How long has the patient had the pain; or, if it has gone, how long did it last?
Does anything make it worse or be er?

Practice tip
When taking a history, it is useful to develop a systematic approach to
ensure that all the important questions are asked.

Identify red flags

In determining the severity of the patient's illness and how urgent the
need for intervention is, the emergency clinician relies on a combination of
clinical signs and historical data. These may be actual or potential cues
that indicate presence or risk of serious illness or injury, including
abnormal vital signs, a history of pre-existing illness or time-sensitive
presentations (such as chest pain or the onset of acute neurological signs).
These can be referred to as clinical or historical indicators of urgency, also
termed ‘red flags’. They can be identified when listening to the patient's
history or conducting a clinical assessment. See Table 13.1 for examples.
Identification of red flags prompts the clinician to initiate appropriate
management early. Early recognition and response to signs of clinical
deterioration or issues increasing the risk of deterioration improve the
delivery of care and save lives.19 Each patient should be assessed using the
‘worst first’ approach, and no assumptions should be made until all high-
morbidity and high-mortality conditions have been ruled out.14

TABLE 13.1

Historical and clinical red flags

PRESENTING
HISTORICAL RED FLAG CLINICAL RED FLAG
COMPLAINT
Chest pain History of ischaemic heart Abnormal ECG
disease Pale and diaphoretic
Prolonged chest pain Abnormal vital signs
Diabetes or chronic renal failure
Abdominal pain Recent abdominal surgery Pregnancy
Vascular disease Rigid abdomen
Haematemesis or malaena Abnormal vital signs
Fever Prolonged fever Infected wound
Recent surgery Elevated white blood cell
Immunosuppressed count
Abnormal vital signs
Vomiting Elderly or paediatrics Hypo/hyperglycaemia
History of diabetes Haematemesis
Pregnancy Abnormal vital signs
Shortness of breath Sudden onset Abnormal CXR
History of COPD Use of accessory muscles
Productive cough Abnormal vital signs
ECG: electrocardiogram; COPD: Chronic Obstructive Pulmonary Disease; CXR: Chest X-ray.

Practice tip
Red flags can be found at any stage of the assessment process, when
listening to the patient's history or conducting a clinical assessment.
Assessment (clinical examination)
The next step of the assessment process is the clinical examination. Once
life-threatening problems have been identified and stabilised in the
primary survey, the general survey of the patient and collection of vital
signs should be performed. It is advisable to use the ABCDE approach and
reassess for potential or actual threats to the airway, breathing, circulation,
disability (neurological status) and exposure before moving on to a
focused assessment. If any of the ABCs are compromised, then
interventions will need to be performed before moving on with the
assessment. In airway management, this could be as simple as performing
a jaw thrust or chin lift (while maintaining cervical spine precautions),
through to intubating the patient and securing the airway for
transportation. If at any stage during the assessment the patient appears to
deteriorate, you must return to ABC and reassess these again, stopping if
any interventions are required and only moving forward once the patient
is stable.
A head-to-toe review of the relevant body regions and systems should
follow. The examination sequence is then inspection, auscultation,
percussion and palpation. The emergency clinician should also consider
the patient's ability to perform everyday tasks, such as eating, drinking,
mobilising, toileting and personal hygiene.20 A decline in the ability to
perform these tasks can threaten the safety of the patient while in hospital
and once discharged.5 It is also important to screen for specific risk of
harm. Patients should be screened for pressure injuries, falls, poor
nutrition and cognitive impairment to prevent or minimise harm.
Preventing complications is discussed in more detail under ‘Essentials of
care’ later in this chapter.

General survey
Your general survey commences the moment you first see your patient.
This may be as you approach them in their house or at the scene of an
accident, or as they approach you at the triage window. Posture and gait
should be noted. Listening to the patient speak will reveal clues to
neurological and respiratory function. The overall appearance of the
patient can also give clues to mood, altered level of consciousness and
signs of pain and distress.
Practice tip
The overall appearance of the patient can give clues to mood, altered level
of consciousness and signs of pain and distress.

Vital signs
A set of vital signs should be recorded, remembering that red flags may
appear at any stage of the assessment process and there needs to be
flexibility to move about the HIRAID framework.5 The majority of patients
who suffer an in-hospital cardiac arrest or unplanned ICU admission have
abnormal vital signs in the hours prior to the event.21–24 Failure to
recognise and respond to clinical deterioration in a timely manner
increases the incidence of high-mortality adverse events such as cardiac
arrest25 and unplanned admissions to the intensive care unit.26 One
Australian study reported that clinical deterioration goes undetected in as
many as one in seven ED patients (12.9%).27 Monitoring of vital signs, in
addition to other objective data including neurological status, urine output
and blood gas results, have been shown to assist in the early detection of
deterioration and to prevent loss of life.28–30 Taking vital signs and
identifying deterioration are an essential part of the nurse's or paramedic's
role, and they must know the normal limits and perform repeat
observations to observe for trends. The frequency should be determined
by patient condition and individual department protocols. There are times
when seriously ill patients are not recognised because of the staff's busy,
unpredictable workload.31,32 Taking observations or measuring vital signs
is increasingly being seen as a task-orientated activity rather than the
gathering of clinical information. This can pose a threat to patients, as
there is the potential for observations not to be seen as a serious
responsibility.24 A set of vital signs is considered to consist of:33

● respirations (R)
● oxygen saturations (SpO2)
● blood pressure (BP)
● pulse (P)
● temperature (T) and
 ● conscious state.
Patients who present to the ED for the first time do not have any
baseline observations to compare their condition against. It can therefore
be challenging to determine if the patient's vital signs are within normal
limits for them. Normal ranges for vital signs differ in paediatric patients
and adults (see Table 13.2 for normal values). Changes that occur in
pregnancy also affect vital signs; blood pressure decreases and heart rate
increases according to the effects of increased progesterone and increased
circulating blood volume.34 Once the patient has arrived in hospital,
obtaining an accurate history and reviewing hospital records may assist in
determining what is normal for the patient. Most health services have set
guidelines that define normal ranges for vital signs to trigger recognition
of abnormal vital signs indicating clinical deterioration, such as Between
the Flags.35 It should be noted that having normal vital signs does not
necessarily guarantee a stable physiological status. Examples of this
include: failure to detect large blood losses in a fit, healthy person; failure
to identify serious illness in infants, and inability to detect an inadequate
plasma volume in burn injury patients or a patient taking beta-blockers
who cannot mount a tachycardic response to correct hypotension.
Therefore, it should be remembered that although the vital signs may
appear within normal limits, this may be due to compensatory
mechanisms and/or masked by medications; the patient may in fact be
compromised.

TABLE 13.2
Normal values for blood pressure (BP), pulse (P) and
respirations (R) in paedatrics35,40 and adults32

AGE SYSTOLIC BP* P? R‡

< 3 months 60–100 110–160 30–55
3–12 months 70–110 100–160 30–45
1–4 years 90–110 90–140 20–40
5–11 years 90–110 80–120 20–30
12–16 years 90–120 60–100 15–20
Adult (>16 years) 90–120 60–100 12–20
*
mmHg
?
beats per minute
‡
breaths per minute
Practice tip
Vital signs may appear within normal limits, however, this may be due to
compensatory mechanisms and/or may be masked by medications; the
patient may in fact be compromised.

Respirations
The respiratory rate is considered one of the most important vital signs in
determining clinical deterioration.36 Despite this, the respiratory rate, often
called the ‘forgo en vital sign’ is commonly not accurately measured and
is poorly documented.37 Abnormal respiratory rate is a significant
predictor of deterioration, cardiac arrest and/or need for admission to the
intensive care unit (ICU).38,39 Clinical deterioration can be detected early
on by a change in respiratory rate of as few as four breaths per minute
either side of the normal range, which would otherwise go undetected
through monitoring of other vital signs.37,41,42 A rise in respiratory rate
from 24 to 28 breaths per minute in an adult has been reported to increase
mortality by 5%.41 In an adult, a respiratory rate of less than eight breaths
per minute can indicate an impending cardiac arrest due to hypoxia.43
Respiratory rate is normally more rapid in infants and children.44 For
normal ranges of respiratory rates see Table 13.2.
The rate, depth, rhythm and effort of respiration should be assessed and
recorded.44,45 To obtain the most accurate respiratory rate it is
recommended that respirations be counted for a full 60 seconds.37,46 It can
often be difficult to count respirations in paediatric patients, particularly if
they are crying or moving around. Counting respirations in paediatrics
may be made easier by the use of a stethoscope or by placing a hand on
the child's chest. The depth of respiration can be established by watching
the person's chest rise and fall, and is best done at a distance, so that the
patient is not aware of what you are counting. It can be described as
shallow, normal or deep. The chest wall should expand symmetrically.
The rhythm of breathing should be regular, without presence of tracheal
tug, nasal flaring, use of accessory muscles or signs of intercostal,
substernal or suprasternal recession. On auscultation, air entry should be
clear and equal, with no added breath sounds, such as wheeze or crackles.
Practice tip
The depth of respiration can be established by watching the person's chest
rise and fall, and is best done at a distance, so that the patient is not aware
of what you are counting.

Oxygen saturation
Oxygen saturation (SpO2) is measured using a pulse oximeter, which
detects the amount of haemoglobin that is bound to oxygen or another
substance, and is used as an adjunct to assessing respiratory function.
However, pulse oximetry does have limitations. The probe will not work
through nail varnish, dirt or dried blood. Dysrhythmias or poor peripheral
circulation may also cause low readings because of inadequate and
irregular perfusion. Anaemic patients will have a normal SpO2 reading,
but may be hypoxic. The pulse oximeter measures how much
haemoglobin is saturated, but the patient may have insufficient
haemoglobin to a ain tissue perfusion. Following smoke or exhaust
inhalation, SpO2 readings are of no value as carbon monoxide has a
greater affinity to haemoglobin than to oxygen, so saturation levels could
be 99% but the haemoglobin molecule is saturated with carbon monoxide,
not oxygen, placing the patient in a hypoxic state. An arterial blood gas
should be performed in these patients to accurately measure the partial
pressure of oxygen, partial pressure of carboxyhaemoglobin and
saturation levels. The oximetry probe can cause pressure areas on the skin
if left in one position for an extended period of time, so it is recommended
to change and document probe placement regularly, and place a light
source over nails.47,48

Practice tip
The pulse oximeter tells how much haemoglobin is saturated, but the
patient may have insufficient haemoglobin to a ain tissue perfusion.

Blood pressure
Blood pressure (BP) is the force of the blood pushing against the blood
vessel wall. This measurement of force is determined by: (1) cardiac output
(how much blood is pumped by the heart with each contraction); (2) the
ability of the vessels to stretch; (3) the volume of the circulating blood; (4)
the amount of resistance the heart must overcome when it pumps blood;
and (5) blood viscosity (thickness of the blood).44 The systolic pressure is
the pressure within the arterial system when the ventricles contract. The
diastolic pressure is the pressure within the arterial system when the
ventricles relax and fill with blood. The pulse pressure is the difference
between the two; a pulse pressure of between 30 and 50 mmHg is
considered a normal range.
There are several factors that can influence BP, and these need to be
taken into account. These include the patient's age, gender, fitness,
emotional state and medications (see Box 13.5). It is important to
remember that a fit, healthy person has compensatory mechanisms and
may not display signs of depleted circulating volume until late. For
normal ranges of systolic blood pressure according to age see Table 13.2.

Box 13.5
Factors affecting blood pressure
Age
Blood pressure (BP) tends to rise with age—a ributed to arteriosclerosis, a
process whereby the arteries become rigid and lose elasticity, and
atherosclerosis, a narrowing of the arteries caused by cholesterol deposits.
Gender
Women generally have lower BP than men of a similar age.
Fitness
Athletes tend to have BP in the lower ranges.
Emotional state
Strong emotions and pain can cause the BP to rise as a result of
sympathetic nervous system stimulation.
Medications
Consider if the patient is taking antihypertensives. Also drugs such as
nicotine, caffeine and cocaine tend to constrict arteries and raise BP.

Other factors to consider include BP cuff size and equipment. If the BP

cuff is too large, then the result will be a false low reading. If the cuff is too
small, the result will be falsely elevated. If a patient has poor peripheral
circulation or cardiac dysrhythmias, then electronic BP machines become
inaccurate and may not be able to record a reading at all. In this instance,
and with any resuscitation or clinically unwell patient, a manual reading
should be obtained. It is also good practice to double-check any high or
low reading obtained from an electronic BP machine manually.
The position of the body should be considered when measuring blood
pressure as this may affect the accuracy of the reading.49 To obtain the
most accurate BP reading, the patient should be seated, with their back
supported and both feet resting on the ground, and remain resting in this
position for 5 minutes.50 The arm should be supported at heart level as the
position of the arm affects the pressure observed. For every 2.5 cm that the
arm is above the level of the heart, the pressure reading will be 1 mmHg
lower; similarly, if the arm is lower than the level of the heart, the reading
will be too high.49 It may not always be possible to place the patient in a
seated position; the emergency clinician should therefore consider the
effects that the position of the patient has on the blood pressure reading.
While most healthy patients will demonstrate li le difference in their
lying and standing blood pressure, a significant fall (20 mmHg) can occur
in older people, patients with diabetes and those with symptoms
suggestive of postural hypotension, such as dizziness, syncope and falls on
changing position.51 A lying and standing blood pressure should be
recorded for these groups. First, the patient should have been lying down
for 5 minutes, and have their arm supported at heart level. Record the
blood pressure and then get the patient to stand, keeping the cuff in place.
Allow the patient to stand for 3–5 minutes to allow for delayed orthostatic
hypotension, which usually occurs in the first 5 minutes of standing.52
Support the arm at heart level and repeat the reading. If on standing the
patient reports dizziness, faintness or lightheadedness, the procedure
should be aborted for safety reasons. For patients with a side affected by
stroke, mastectomy or renal fistula, the BP should be taken on the opposite
arm. It is important to remove the BP cuff for all patients between readings
to prevent injury from prolonged pressure in one area.

Practice tip
Patients with diabetes and those with symptoms suggestive of postural
hypotension, such as dizziness, syncope and falls on changing position,
should have a lying and standing blood pressure taken.
Pulse
There is more to a pulse than its rate; pulse rhythm and character should
also be noted. The clinician must palpate the pulse to determine its rate,
rhythm and aptitude (strength). In healthy adults the normal pulse rate is
between 60 and 100 beats/minute,32 but this is higher for children and
babies (see Table 13.2). Tachycardia is defined as a pulse rate greater than
100 beats/minute, while bradycardia is a pulse rate less than 60
beats/minute.53 Factors which can affect the pulse rate need to be
considered when obtaining the patient history. A slow pulse rate may be
normal for a fit athlete, but it may also indicate a cardiac dysrhythmia,
metabolic disturbance, hypothermia, hypoxia or neurological issue, or be
caused by certain medications, such as beta-blockers. A fast pulse rate can
be triggered by emotion, exercise, drugs, infection/inflammation, cardiac
dysrhythmias, hypovolaemia or haemorrhage and hypoxia.54,55 The pulse
volume may be described as bounding, normal, weak, thready or absent.
A bounding pulse may indicate sepsis, carbon dioxide retention or liver
failure, and a thready pulse is indicative of shock. A pulse should be felt
for a minimum of 30 seconds to obtain an accurate reading, and a
minimum of 60 seconds if the pulse is irregular.44 In adults, the pulse is
generally taken over the radial artery, but in a patient in shock it may be
difficult to assess the pulse at this site; the carotid or femoral artery can be
used instead. Brachial, carotid and femoral arteries are the preferred sites
in children.4 Apical measurement is also recommended for monitoring
pulses in babies44,56 (see Fig. 13.2). If a patient is found to have an irregular
pulse, an ECG should be performed and cardiac monitoring should be
considered (see Chapter 16).

FIGURE 13.2 Location of apical pulse.62

Practice tip
The rate, regularity and characteristic of the pulse should be assessed
through palpation.

Temperature
Accurate temperature measurement is essential to identify the presence of
illness, as well as enable appropriate and timely treatment to prevent the
negative effects of an abnormal temperature. Historically, the focus of
temperature management has been on monitoring fever and treating
infection; however, recent research has shown the significance of
hypothermia as an indicator of critical illness.57 Temperature measurement
is indicated in all patients to identify hypothermia, hyperthermia and
other febrile illnesses.58,59
A normal core body temperature is defined as 37°C; however, this may
fluctuate by 0.5°C to 1.0°C.60 The core body temperature is regulated
hormonally by the hypothalamus through controlling heat production and
conservation.61 Infants, children and older people are at risk of having
difficulty regulating body temperature. Infants have poor heat
conservation due to having a greater ratio of body surface area to weight
and less subcutaneous fat compared to adults, where it functions as
insulation.61 Elderly people have a poorer response to extreme external
temperature variations, resulting from slow circulation and structural and
functional changes in the skin.61 Maintaining a normal core body
temperature is essential to optimise normal cellular function.63
Hypothermia is defined as a core temperature below 36°C.64 Hypothermia
is commonly caused by prolonged heat loss or exposure to cold
environments, but can also be an indicator of critical illness, such as
sepsis.60,61,64 Hypothermia has been reported in up to 35% of patients with
sepsis and is associated with increased mortality compared with patients
without hypothermia.57 Hypothermia causes changes in circulation,
coagulation and can cause cellular ischaemia.61 Clinicians should take care
to avoid hypothermia in patients as a result of prolonged exposure to cold
environments or to enable assessment and massive intravenous fluid
resuscitation, which can result in hypothermia. However, therapeutic
hypothermia (32°C to 34°C) has been shown to reduce mortality in
patients post-cardiac arrest through preserving ischaemic tissue.65
 Fever is generally defined as a temperature of 38.3°C or above and is
primarily caused by the action of pyrogens on the hypothalamus, such as
bacteria or virus.60 The term fever is often used interchangeably with
pyrexia or hyperthermia. An elevated temperature may also result from
exposure to extreme environmental temperature, drugs, trauma or
autoimmune disease.66 Fever has been reported to aid the body's response
to infection by preventing replication of infective organisms and
increasing antimicrobial activity in many classes of antibiotics and
improves patient outcomes.60 Significant cellular changes occur in
temperatures above 40°C and are associated with higher mortality,
indicating that the harmful effects of fever outweigh the benefits in
fighting infection.60 It is not common for a temperature to exceed the
upper limit of 41°C, as this exceeds the level set by the hypothalamus.66
Temperatures above 41°C are usually drug-related, but can also result
from damage to the hypothalamus caused by trauma, prolonged high
temperatures (heat stroke) or genetic disorders.66 Cell death rapidly occurs
in adults at 41°C, causing seizures which frequently lead to death.60,61
There are a variety of thermometers for use at various sites. The most
common types are tympanic thermometers, digital electronic and single-
use chemical-dot thermometers. Oral and axilla temperature measurement
devices are reported to be the most accurate out of the non-invasive
thermometers in measuring core body temperatures in adults, followed by
temporal artery thermometers.67,68 Both digital electronic and single-use
chemical dots can be used in the oral or axillary site. However, chemical
thermometers have been found to be less precise than digital
thermometers.41,69 The single-use chemical-dot thermometer only has a
range between 35.5°C and 40.4°C, so in patients suspected of having a
temperature outside this range an alternative thermometer should be
used. Temperature strips, which are liquid-crystal strips applied to the
forehead, have been found to be inaccurate and can miss fevers in
children.
When taking an oral temperature, it is vital to ensure the thermometer is
placed correctly—it needs to sit in the posterior sublingual pocket of the
mouth. This method should not be used in children under the age of 5
years due to the difficulty they experience in holding the thermometer in
the correct position. A digital electronic thermometer will beep when
ready; a single-use chemical-dot thermometer should be left in place for 3
minutes.70 Factors that can influence the reading are a respiratory rate of
greater than 18 breaths/minute and eating, drinking or smoking prior to
the reading being taken.71
The axillary site is considered similar to the oral site when measuring
temperature in adults; however, lack of precision may result in failure to
detect low-grade fevers in paediatric patients.69
Temporal artery thermometers have an infrared sensor that measures
the heat radiating from the skin when moved from the forehead to behind
the earlobe.72 Studies have reported the temporal artery thermometers
correlate or are even more accurate than other non-invasive thermometers
when used in the paediatric population.72,73
Tympanic thermometers measure the temperature from the tympanic
membrane. They are quick and easy to use, and in some studies it has been
reported that they are as accurate as oral thermometers in adult patients.74
However, the accuracy of tympanic thermometers can vary significantly.69
The ear canal must be straightened by pulling the pinna slightly up and
back in an adult. It can be inaccurate in people with a small ear canal, a
build-up of cerumen, otitis media and incorrect placement.69,71
In critically ill patients requiring continuous monitoring of temperature,
urinary thermometers can be inserted easily in the bladder via urinary
catheters. Bladder thermometers have been reported to measure core body
temperature more accurately then rectal thermometers.75 While rectal
thermometers are considered more accurate than other less invasive
methods, the temperature probes can be slow to respond to changes in
temperature and the probe needs to be accurately placed to a depth of 4
cm to obtain an accurate reading.71,75 It is not recommended that
temperatures in children be acquired rectally because of the risk of
perforating the bowel.
It should be carefully noted on the patient's documentation which kind
of thermometer and which site was used to record the temperature. It is
not possible to accurately convert the temperature taken at one site to
compare it with a temperature taken at a different site, with or without
using a different kind of thermometer.71 This is also an important
consideration when the paramedic hands over a patient to the accepting
emergency nurse.

Practice tip
In critically ill patients, thermometers can be easily inserted into the
bladder via urinary catheters to accurately measure core temperature.

Inspection
It is important to look at the patient as a whole before undertaking a more
focused assessment. Inspection commences when you first see the patient,
either at the scene or when receiving clinical handover in view of the
patient. Questions to consider are: Does the patient appear unwell or in
pain? Are they unkempt, inappropriately dressed, under- or overweight?
Once a general view of the patient has been obtained, observations should
become specific, focusing on the chief complaint and affected system.
When inspecting as part of your focused assessment you are looking for
discharge, skin integrity, swelling, redness and other abnormalities. You
should also take note of any diaphoresis and document pallor.

Practice tip
Inspection commences when you first see the patient, either at the scene
or when receiving clinical handover in view of the patient.

Auscultation
Auscultation is the process of listening, usually with a stethoscope, to
sounds produced by the movement of gas or liquid within the body. The
heart, lungs and abdomen are the areas most often auscultated. The
diaphragm of the stethoscope is used to hear high-pitched sounds, such as
bronchial sounds, and the bell is used for low-pitched sounds, such as
heart sounds. If too much pressure is applied with the bell, it tightens the
skin and acts as a diaphragm. It is important to auscultate before
percussing or palpating as these techniques may change sounds that are
heard. Discussions of normal and abnormal findings are found below in
the section on head-to-toe assessment.

Practice tip
It is important to auscultate before percussing or palpating as these
techniques may change sounds that are heard.
Percussion
Percussion is the technique of examining part of the body by tapping it
with the fingertips and hearing the resultant vibratory sounds. The quality
of the sound aids in determining the location, size and density of
underlying structures. The sound can be described as flat, dull, resonant,
tympanic or hyperresonant. See Table 13.3 for sound characteristics and
examples of where they can be heard.

TABLE 13.3
Percussion sounds

SOUND INTENSITY QUALITY COMMON LOCATION

Flat Soft Muted Muscle, bone
Dull Medium Thud-like Liver, heart, full bladder
Resonant Loud Hollow Normal lung
Tympanic Loud Cavernous Intestine filled with air
Hyperresonant Very loud Booming Emphysematous lung

Palpation
Palpation is the process of examining parts of the body by careful feeling
with the hands and fingertips. Light palpation is used for feeling the
surface of the skin, structures that lie just beneath the skin, vibrations in
the chest and for the pulsation of peripheral arteries. The examiner uses
the fingertips, or the back or palm of one hand. When examining the
abdomen, deep palpation may also be used to identify organ structures.
This is performed by placing one hand on the other and using the top
hand to apply pressure to depress the abdomen by 2.5 cm. The bo om
hand remains relaxed. Palpation provides information about the
temperature and moisture of the skin, the presence of tenderness, unusual
vibrations, distension and the size, shape, consistency and mobility of
organs or masses.
Analgesia should be administered if required before palpation is
performed to provide comfort during examination. While many patients
have concerns that the use of pain relief before seeing a doctor may mask
important physical symptoms, the early provision of analgesics has been
reported to have no effect on the accuracy of diagnosis,76 but there is
strong evidence to demonstrate it improves comfort76 and should not be
withheld.
Practice tip
Analgesia should be administered before palpation is performed to
provide comfort during physical examination.
Head-to-toe assessment
In the ED and pre-hospital se ing, the history taken will assist you in
determining which systems you should review. For a more in-depth
review of trauma patient assessment using the primary and secondary
survey, refer to Chapter 42.

HEENT (head, ears, eyes, nose and throat)

Inspection of the external surfaces of the head will reveal the presence of
discharge, redness, abrasions, contusions and bleeding. Palpation can be
performed to feel for any unusual lumps or bumps at the same time.
Inspect the face for asymmetry or swelling, as abnormalities could
indicate facial nerve problems or an allergic reaction. Palpation will reveal
step-offs, deformity and tenderness (see Chapters 31 and 44).
Ears are inspected for discharge, foreign bodies, deformities and lumps.
If infection is suspected, the tympanic membrane (TM) and external
auditory canal are viewed with an auroscope. The pinna is pulled up and
back to straighten the ear canal in an adult, and down and back in a child.
The TM should appear pearly-grey; redness is a sign of infection. In head
injury, blood may be seen in the canal or behind the TM.
Common presentations for eyes include foreign bodies, infection and
trauma. The standard examination for eyes is to perform visual acuity
using a Snellen chart. If the patient wears glasses for reading, these should
be worn during testing if available; otherwise, the use of a pinhole is
advised. The smallest line the patient can read with each eye individually
and then together is noted. Acuity is wri en as a fraction, with the
numerator indicating the distance from the chart (usually 6 m, but a 3 m
modified chart can also be used) and the denominator describing the
distance at which a person with normal vision could read the line.
Therefore, 6/6 is a normal finding.77 The eye should be examined for
obvious foreign bodies. Inflammation, pain, discharge, tearing and
changes in appearance should be noted. Further eye assessment is
discussed in Chapter 32.
The mouth can offer several clues as to the wellbeing of the patient.
Assess the tongue for dryness and colour. A dry tongue can mean
dehydration. Do the gums show evidence of bleeding or swelling? If the
patient complains of a sore throat, check for swelling, redness and
ulceration.
Disability (level of consciousness)
Assessing a patient's level of consciousness is an essential component of a
neurological examination, which is usually performed alongside an
assessment of pupil size and reaction, vital signs and focal neurological
signs in the limbs.78 In the pre-hospital se ing and at triage, the AVPU
scale is often used when assessing disability to quickly determine a
patient's level of consciousness. It crudely measures response: are they
Alert, responding to Voice, responding to Pain or Unresponsive? This
should be followed up with a formal assessment of the patient's score on
the Glasgow Coma Scale (see below).

Glasgow Coma Scale

When performing a more focused assessment, a neurological observation
chart incorporating a Glasgow Coma Scale (GCS) is used. The GCS was
first described in the early 1970s as an objective and reliable measure of
conscious state in patients with head injury.79–81 The GCS is an
internationally accepted measure of conscious state in victims with head
trauma,82–84 and is now used extensively in non-trauma populations.82,84,85
The GCS evaluates three key categories of behaviour that most closely
reflect activity in the higher centres of the brain: eye opening, verbal
response and motor response. These behaviours enable us to determine
whether the patient has cerebral dysfunction.86 There are separate scoring
criteria for adults, children and babies, and the appropriate chart should
be selected. The GCS evaluates each of these parameters by allocating a
numerical score (see Tables 13.4 and 13.5). The scores for each parameter
are then added up to give a total out of 15.80 Because the lowest number
that can be given for each part of the assessment is 1, the lowest score that
can be given is a GCS of 3. ‘Coma’ is arbitrarily defined as a GCS score of <
8, and a GCS score ≤ 8 has been used to indicate the need for endotracheal
intubation.82,84,85
TABLE 13.4
Glasgow Coma Scale79,80

SCORE
Eye opening
Spontaneously 4
To speech 3
To pressure 2
None 1
Verbal response
Orientated 5
Confused 4
Words 3
Sounds 2
None 1
Motor response
Obeys command 6
Localising 5
Normal flexion (withdrawal) 4
Abnormal flexion 3
Extension 2
None 1

TABLE 13.5
Paediatric Glasgow Coma Scale89

SCORE
Eye opening
Spontaneously 4
To speech 3
To pain 2
None 1
Verbal response
Coos, babbles 5
Irritable, cries 4
Cries to pain 3
Moans to pain 2
None 1
Motor response
Normal spontaneous movement 6
Withdraws to touch 5
Withdraws to pain 4
Abnormal flexion 3
Abnormal extension 2
None 1

Although widely used in emergency care, research has shown

variability in the reliability of the GCS,81,83,84,87 making consistency of its
application an important aspect of the nursing management of patients
with a neurological emergency.83 It is best if the same emergency clinician
does the assessment each time, so that if there is a drop in score it can be
a ributed to the patient and not the evaluator. At change of shift or
transfer of the patient, the nurse escort or paramedic and receiving nurses
should perform the evaluation together in order to avoid misinterpretation
and to ensure continuity. Sleeping patients must be woken before
commencing the evaluation. A deterioration of one point in the ‘motor
response’ or one point in the ‘verbal response’ or an overall deterioration
of two points is clinically significant and must be reported to medical
staff.78,88
The Paediatric Glasgow Coma Scale (PGCS) is a modification of the
GCS. Assessment of conscious state in infants and young children is
difficult due to developmental issues and lack of verbal response in young
children.46,79 Well children may have decreased responses because of fear,
and crying may be misinterpreted as a normal response in the context of
significant neurological pathology.46,79 If using the adult GCS, it is
expected that a child will have a reduced score. Refer to Chapter 35 for
further details.

GCS assessment80
Assessment of eye-opening tests the function of the arousal mechanisms in
the brain stem. There are four possible responses when assessing eye
opening: spontaneous, to voice, to pain and none. If the patient is unable
to open their eyes due to paralysis, this should be documented as a ‘P’,
and if the patient's eye is swollen shut an ‘S’ should be documented.
Verbal response may be assessed as: orientated (5), confused (4),
inappropriate (3), incomprehensible (2) and no response (1). To be
assessed as orientated, the patient must correctly tell the nurse their name,
location, day, month and year. Do not assume that a patient is orientated
because they are conversing with you in a normal manner; they need to be
able to correctly answer the above questions to be assessed as orientated. If
verbal response is altered by other processes, for example, dysphasia,
aphasia or facial fractures, this should be documented; and if the patient is
intubated, a ‘T’ should be documented.
Motor response may be assessed as: obeys command (6), localises to
pain (5), normal flexion/withdraws from pain (4), abnormal flexion to pain
(3), extension to pain (2) and no response (1). Although responses of all
limbs should be documented as part of neurological observations, only the
best response counts towards GCS.83 To be assessed as ‘obeys commands’,
the patient needs to squeeze and let go of the nurse's hands on command.
The nurse should take care not to place their hands into the patient's
hands: this may elicit a reflex response that may be misinterpreted as
obeying command. If the patient is paralysed, a ‘P’ should be recorded.
There are two types of painful stimuli: central and peripheral painful
stimuli. Use caution when applying stimuli and do not cause injury such
as bruising. It is recommended that when eliciting a response using pain
that supraorbital pressure be used, but this carries a risk of damage to the
eye, so should be used with caution and not used if facial fractures are
suspected. Other recommended methods include jaw margin pressure (the
flat of the thumb is applied to the corner of the maxillary and mandibular
junction and pressure is increasingly applied for up to 60 seconds),
squeezing the trapezius muscle or applying pressure to the earlobe.90
Assessing pupils is not necessarily effective in the sedated or paralysed
patient; however, any changes in pupil reaction, shape or size are a late
sign of raised intracranial pressure. Very small pupils may be a result of
opiates or barbiturate use. Each limb should be assessed. A peripheral
painful stimulus needs to be applied if the patient does not appear to be
able to voluntarily move the limb. This can be done by applying pressure
to the nail bed of a patient's finger. Bilateral responses should be assessed.
A more detailed assessment of the patient with altered consciousness is
discussed in Chapter 23.
As part of the neurological assessment, routine cognitive screening in
older people is recommended to increase detection and management of
cognitive impairment. Studies have reported that cognitive impairment,
commonly resulting from dementia or delirium, occurs in up to 40% of
older people presenting to the ED; however, it often goes undetected.91
Cognitive impairment in hospitalised patients is associated with higher
rates of adverse events, longer length of stay, functional and cognitive
decline and increased medical and surgical complaints.92,93 The presence
of delirium has been reported to be an independent predictor for increased
mortality in ED patients,94 and if discharged from the ED with an
undetected delirium, mortality increases by three-fold.95 Patients with
dementia are almost twice as likely to die in hospital compared to patients
without dementia.96,97
A range of different tools exist to screen for cognitive impairment in the
ED. To exclude delirium and cognitive impairment, the 4AT tool
(Abbreviated Mental Test 4) is recommended as it is quick and easy for
clinicians to use and no special training is required.98 The 4AT tool
 p g q
measures four features: alertness, orientation, a ention and whether there
are any acute change changes or fluctuating course. A score out of 12 is
calculated: a score of 0 excludes delirium and cognitive impairment, a
score of 1 to 3 indicates cognitive impairment and 4 or above is suggestive
of delirium. The Confusion Assessment Method (CAM) is a validated tool
reported to accurately assess for delirium in EDs.92,99 The CAM consists of
four clinical features: 1) acute onset and fluctuating course; 2) ina ention;
3) disorganised thinking; and 4) altered level of consciousness. The
presence of features 1, 2 and either 3 or 4 are required to make a diagnosis
of delirium. It is important to note that a poor score on screening is not a
diagnosis but a trigger for further assessment. While the 4AT screens for
both cognitive impairment and delirium, the CAM does not assess for
general cognitive impairment such as dementia. If the presence of delirium
or cognitive impairment cannot be excluded, then the patient should be
referred to aged care services for further assessment and management. See
Chapter 38 for further information on cognitive impairment in older
persons.

Practice tip
When handing over care of your patient, repeat your GCS score to the
paramedic or nurse receiving the patient to maintain consistency.

Cervical spine and neck

Examine the external neck for swelling and symmetry. Both the front and
the back should be inspected for injuries. Look for enlargement of the
parotid or submandibular glands and note any visible lymph glands.
Palpate for lumps or enlarged lymph nodes. The potential for C-spine
injury in trauma patients should be considered as part of ‘Airway’ in the
primary survey (see Box 13.1). All trauma patients should be presumed to
have a cervical spine injury until proven otherwise; clearance of the
cervical spine is discussed in Chapter 47.

Practice tip
All trauma patients should be presumed to have a cervical spine injury
until proven otherwise.
Thorax
When examining the thorax, both the respiratory and the cardiovascular
systems will be assessed. The respiratory assessment focuses on the
function of the respiratory system to exchange oxygen and carbon dioxide
in the lungs and its role in regulation of the acid–base balance.
Start by looking for signs of respiratory distress, such as
tachy/bradypnoea, dyspnoea, nasal flaring, use of accessory muscles and
cyanosis. The patient's speech, change in voice and drooling are also
important signs. Examine the hands for clubbing, indicative of chronic
illness such as bronchiectasis, endocarditis and empyema. Observe for
evidence of respiratory failure, for example, hypoxia (central cyanosis), or
hypercarbia (drowsiness, confusion, warm hands, bounding pulse, dilated
veins and a coarse tremor). Observe the pa ern of breathing—see Table
13.6.

TABLE 13.6

Patterns of breathing
NAME PATTERN OF RESPIRATION AETIOLOGY
Eupnoea Normal respiration 12–20
breaths/minute
Tachypnoea Rapid respiration > 20 breaths/minute Fever, pneumonia, pleuritic chest pain
Bradypnoea Slow and regular < 12 breaths/minute Drug intoxication, tumour
Cheyne-Stokes Hyperventilation alternating with Left ventricular failure, raised intracranial
apnoea pressure, high altitude
Biot's or ataxic Irregular in depth and rate, with Neurological disorders/disease
periods of apnoea
Kussmaul Deep, rapid respiration Metabolic acidosis
Pursed-lip Expiration against partially closed Chronic obstructive pulmonary disease
breathing lips

Inspect the shape of the chest, and look for deformities or asymmetry.
The posterior and anterior surfaces should both be inspected; this is most
easily done with the patient si ing on the edge of the bed. Note the
position of the trachea and watch for unequal movement of the chest. This
is more easily ascertained by placing both hands on the chest wall and
feeling for movement. Palpation of the chest should identify any tender
areas or crepitus. The clavicles, sternum, ribs, spine and shoulder blades
should be palpated for any abnormalities and to determine if there are any
factors that will restrict the patient's ability to breathe.100 Respiratory
excursion (thoracic expansion) should be measured. This is best assessed
by standing behind the seated patient and placing the thumbs next to each
other along the spinal processes at the level of the tenth rib. As the patient
breathes in, the thumbs will separate. You should watch for a loss of
symmetry, absence or delay in movement. These could indicate complete
or partial obstruction of the airway, or underlying lung or diaphragmatic
dysfunction on the affected side.101
Percuss the chest bilaterally for resonance. Dullness or hyperresonance
indicates an abnormality.90 Hyperresonance occur when there is an
increased amount of air, such as in chronic obstructive pulmonary disease
(COPD). Dull sounds indicate underlying dense tissue, such as pleural
effusion or tumour. Dullness to the anterior lower lung fields is not
conclusive, as the heart is on the left side and the liver on the right.
Next, auscultate the chest. It is recommended that the patient cough first
to remove sputum that could create adventitious sounds. Use the sequence
shown in Fig. 13.3 and always compare one side with the other. Listen for
normal breath sounds (summarised in Table 13.7), no breath sounds and
added sounds, such as wheeze or crackles.77 No breath sounds may be due
to no air movement, due to an obstructed airway or the presence of air or
fluid preventing sound conduction (e.g. pneumothorax or pleural
effusion). Wheeze is heard when air rapidly flows through constricted
airways, which occurs in asthma or pulmonary oedema. Crackles are
caused by either alveoli opening during inspiration or air bubbling
through fluid, such as in heart failure, pulmonary oedema or infection.
Inspect any sputum produced for colour, consistency, quantity and
presence of blood. Fig. 13.4 summarises the clinical findings for certain
respiratory pathologies. See Chapter 21 for a more detailed description of
respiratory assessment.

FIGURE 13.3 Recommended sequence to auscultate the chest102

TABLE 13.7

Normal breath sounds

SOUND LOCATION
Vesicular Lung tissue
Bronchovesicular Near the bronchi
Bronchial Lower part of trachea
Tracheal Upper part of trachea

FIGURE 13.4 Clinical findings of respiratory pathologies103 T: trachea, M: movement, PN:

percussion note, A: ausultation, VR: vocal resonance

The purpose of examining the cardiovascular system is to assess the

function of the heart as a pump, and of the arteries and veins throughout
the body in transporting oxygen and nutrients to the tissues and in
transporting waste products and carbon dioxide from the tissues.104 Refer
to Chapter 22 for the anatomy and physiology of these processes.
Sit the patient at 45° and observe the jugular veins. Distension is
suggestive of cardiac failure. Auscultate over the main areas of the heart
(see Fig. 13.5), listening for normal heart sounds followed by added
sounds and then murmurs. Normal heart sounds consist of two distinct
parts. The first, named S1, is due to the mitral and tricuspid valves closing
at the start of ventricular contraction or systole. It is best heard over the
mitral and tricuspid areas (Fig. 13.5). The second sound, S2, is the closing
of the aortic and pulmonary valves at the end of systole. It is best heard
over the aortic and pulmonary areas (Fig. 13.5).

FIGURE 13.5 Locations for assessing heart sounds.102 M = mitral area, T = tricuspid area,
P = pulmonary area, A = aortic area.

Added sounds are S3 and S4. S3 is the rapid ventricular filling as soon as
the mitral and tricuspid valves open. It is common in children and young
adults, but in the older adult is a sign of left ventricular failure, a fibrosed
ventricle or constrictive pericarditis. S4 is an atrial contraction (also known
as atrial kick), which induces ventricular filling towards the end of
diastole. It may be normal in middle age, but in an older adult it can
indicate hypertensive cardiovascular disease, coronary artery disease,
aortic stenosis, myocardial ischaemia, infarction and congestive heart
failure.101
 Murmurs are produced by turbulent blood flow. Turbulence occurs
when there is high blood flow through a normal valve or normal blood
flow through an abnormal valve or into a dilated chamber. It is also caused
by regurgitation of blood through a leaking valve. A pericardial friction
rub is a high-pitched noise heard most loudly in systole and is due to
inflammation of the pericardial sac. Identifying abnormal heart sounds is a
skill that is generally mastered after the practitioner becomes proficient at
distinguishing between S1 and S2.44

Abdomen
The abdomen can be divided into four quadrants (see Fig. 13.6). It is useful
to consider this when examining the abdomen, as the area of pain or injury
can give clues to the cause and help give consideration to which structures
may have been injured in a trauma patient.

FIGURE 13.6 Distribution of components in the four imaginary quadrants of the abdominal
system.103

The patient is best examined while lying flat with one pillow under the
head and knees slightly bent. This allows the abdomen to become as
relaxed as possible. Inspect the abdomen for scars, bruising, distension,
symmetry, pulsation and masses. Auscultate over each of the four
quadrants. It is important to listen before touching, as palpating can alter
the frequency of bowel sounds. Listen for 10–15 seconds, but for up to 7
minutes if bowel sounds are difficult to hear.104 Normal bowel sounds
occur every 5–20 seconds. Hyperactive sounds indicate increased
peristalsis. They have a loud tinkling sound and can indicate diarrhoea or
an early bowel obstruction. Hypoactive sounds occur infrequently and
signify decreased motility of the bowel, and can indicate inflammation or
late bowel obstruction. Absent bowel sounds indicate paralytic ileus.
Before palpating the abdomen, allow the patient to empty their bladder,
as this makes examination more comfortable. Start away from the pain.
Look for tenderness, rebound tenderness, guarding and rigidity. Rebound
tenderness is identified by pressing slowly and deeply over the painful
area and then quickly releasing. Sharp pain is felt on release. Percussion of
the abdomen should reveal a hollow, tympanic sound due to the presence
of gas. Fluid masses or organs result in an abnormal dull sound.104

Pelvis
The presence of a genitourinary problem is usually elicited when taking a
history. The patient might complain of difficulty passing urine, urgency,
burning on micturition, altered volume and flank pain. A mid-stream
urine sample is obtained for analysis (see Chapter 25). In addition to
performing a urinalysis, colour, clarity and any offensive odour should be
noted.
A menstrual history should be taken in female patients. It should
include the date of the last menstrual period, contraceptive use and past
pregnancy history. In women of childbearing age, a pregnancy test is
indicated if pregnancy status is unclear. Males should be assessed for
problems specific to their genitourinary anatomy. A slow stream or
inability to void may be indicative of a prostate problem. Painful swelling
of the testes could mean a testicular torsion. Presence of any discharge
(penile/vaginal) or lesions may be indicative of a sexually transmi ed
infection (STI) and should prompt an inquiry about the patient's sexual
history. The patient should be questioned about sexual partners and their
health, contraception methods used, previous history of STI or high-risk
behaviour. It may be difficult to get a full history in the presence of a
partner or parents, and so the emergency nurse should a empt to speak to
the patient alone. This may feel awkward, but most patients understand
the necessity of acquiring a full history. Ascertaining sexual practices can
provide a valuable arena for safe-sex education and referral, if
appropriate.
 Genitourinary trauma (saddle injuries) in children can be caused by
non-accidental injury and the nurse should be alert for this possibility
when taking a history (see Chapter 39).

Musculoskeletal and skin

Most presentations concerned with the musculoskeletal system are due to
pain. This can be caused by trauma, infection and vascular, autoimmune
or degenerative disease. Observation and palpation are done
simultaneously and should start on the unaffected side to give a base for
comparison. Inspect for size, symmetry, deformities, swelling and colour.
Palpate for pain, tenderness, swelling and warmth. Compare range of
movement to the unaffected side. Assess active range of movement before
passive movement. A dislocated limb is considered an emergency if distal
circulation and sensation is affected. See Chapter 17 for more information.
Assessment of the skin comprises observation for colour, integrity,
rashes, lesions and perspiration and palpation to feel temperature and
turgor. Skin colour can also give clues to the underlying pathology; for
example, cherry red lips in carbon monoxide poisoning, generalised
yellowness in jaundice or the pallor of anaemia.
The hands and feet should also be inspected for colour, warmth,
movement and sensation. Adequate peripheral perfusion is established by
feeling a strong radial pulse and a capillary refill time of under 3 seconds.
Observe the peripheral limbs for pi ing oedema, as this can be an
indication of heart failure.

Practice tip
Observation and palpation of both sides/limbs are done simultaneously
and should start on the unaffected side to give a base for comparison.

Other considerations
Signs of an endocrine or haematological condition may become obvious
during history-taking. Areas to focus on in the clinical examination are
discussed in brief here.
Symptoms of an endocrine disorder can include changes in weight,
appetite, bowel habits, hair distribution, pigmentation, sweating or
alteration in menstruation, as well as lethargy, weakness, polyuria,
polydipsia, headaches and impotence. Therefore, it is best to focus on the
specific presenting complaint (see Chapter 26).
A haematological disease can affect red blood cells, white blood cells,
platelets and haemostatic mechanisms. Patients may present with anaemia
characterised by weakness, tiredness, dyspnoea, fatigue or postural
dizziness. Platelet or blood clo ing disorders may present with easy
bruising or bleeding problems. Recurrent infections could be an indication
of a disorder of the immune system. Laboratory testing of blood confirms
the diagnosis. See Chapters 27 and 29 for further discussion.

Mental health assessment

A mental health assessment should consist of gathering general
information, then following with more specific questions to clarify
ambiguities and confirm or refute initial impressions. The main areas
looked at are: appearance (cleanliness, posture, gait), behaviour (facial
expression, cooperation, aggression, agitation, activity levels), speech
(form and pa ern, coherent, logical), mood (apathetic, irritable, optimistic
or pessimistic, suicidal), thought (preoccupied, delusional, safety of
patient and others), perception (hallucinations, auditory, visual, smell,
taste, touch), cognition (orientation to time, place, person) and insight
(understanding of their condition). For further information on mental
health emergencies, see Chapter 36.

Practice tip
The main areas looked at when performing a mental health assessment
are: appearance, behaviour, speech, mood, thought, perception, cognition
and insight.
Special considerations
Physiological and anatomical age-specific differences must be taken into
account when collecting the patient's history and performing a clinical
assessment. Paediatric patients are not just ‘small adults’, but have
physical, cognitive and developmental differences as they progress from
infancy and childhood into adulthood. Examination of children can also be
challenging as they can often be uncooperative and are often reliant on
their carer to provide information about their history. The familiar adage
in paediatrics that ‘children are not just small adults’ could be adapted to
the care of geriatric patients. Older people have a higher proportion of
chronic diseases, which can make assessment challenging and places them
at increased risk of acute illnesses.105 Several age-related structural and
physiological changes develop in geriatric patients. See Table 13.8 for a
summary of anatomical and physiological differences in paediatric and
geriatric patients. For more detail on the assessment and care of paediatric
patients and older people see Chapters 35 and 38 respectively.
TABLE 13.8
Age-specific commonalities

SYSTEM PAEDIATRICS GERIATRICS

Cardiovascular S3 Heard in up to a quarter of Coronary A high incidence over age
children artery disease 60
Murmurs Heard in up to 50% of 3- to
7-year-olds
Respiratory Inhaled At risk of obstruction due to Lung function Declines with age
foreign small airway Pneumonia Increased risk of death
object with age
Gastrointestinal Abdominal Appendicitis, Gastric and At greater risk and
pain intussusception duodenal mortality 4–10 times
ulcers greater from GI bleeding
Vomiting Caused by viral infection. Constipation Due to decreased
and Give fluids to prevent mobility and fluid intake
diarrhoea dehydration or as side effect of
medications
Genitourinary Scrotal Generally caused by hernia, Prostatism Enlarged prostate causing
swelling but if acutely painful micturition problems
consider torsion
UTI Requires follow-up due to Acute renal Function declines with
risk of renal scarring failure age, side effects from
medications
UTI Due to increased urinary
stasis, obstruction or
presence of IDC
Neurological Meningitis Common in childhood Dementia
during neonatal period
Convulsions Occur in 20% of children Acute May be the only sign of
under 5 years. Commonly confusional infection
due to fever state secondary
to infection
Head injury Minor trauma can result
in significant head injury
Head, ears, Tonsillitis If chronic may cause upper Decreased Physiological changes
eyes, nose and airway obstruction, sleep vision occur in aged eye
throat apnoea
Otitis media Common until age 7 Ulceration ofEyelids lose elasticity and
cornea turn inwards
Epistaxis Due to anticoagulants,
hypertension
Integumentary Jaundice Common in neonates, but in Paper-thin skin Easily damaged and
older children viral hepatitis difficult to heal
is the commonest cause
Rashes Most likely due to measles, Hypothermia Increased risk due to fat
chickenpox with fever loss
Musculoskeletal Painful limb Septic arthritis. Present with Osteoporosis Makes bones more fragile
in absence fever and hot, swollen joint and can sustain fractures
of trauma from minor trauma
Mental health Depression Common in adolescence Depression Due to social isolation or
and mood loss of independence
swings
Practice tip
Considerations of the patient's age must be taken into account when
performing an assessment.

Changes that occur in pregnancy should also be taken into consideration

when assessing the pregnant woman. The development of the baby, as
well as hormonal changes, affect the anatomical structure and physiology
of the female.34 See Chapter 34 for further details on the assessment and
management of the pregnant patient.

Obese and overweight patients

The prevalence of obesity is increasing globally and presents a number of
challenges for emergency clinicians, both pre-hospital and in the ED.106,107
A number of physiological changes occur in obese patients which
emergency clinicians must be aware of, including chest wall resistance,
increased abdominal pressure, decreased lung capacity, increased airway
resistance, increased subcutaneous tissue and anatomical distortion.108–110
These changes may impact on assessment findings and place patients at
higher risk of chronic diseases, such as hypertension, diabetes and
obstructive sleep apneoa.111 Bariatric surgery is becoming increasingly
popular to assist with weight loss in these patients, resulting in increased
presentations to the ED with postoperative complications.112 The collection
of a complete patient history, in addition to a comprehensive physical
assessment, is key to determining treatment needs and prioritising care for
bariatric patients. To ensure the accurate assessment and safe care of
bariatric patients pre-hospital and in the ED, emergency services must be
equipped with appropriate equipment.111 When measuring blood
pressure, for example, the correct sized cuff is essential to ensure an
accurate measurement is obtained. A range of manual handling
equipment is also available to ensure safe transport of the patient to
hospital and to facilitate safe manual handling once the patient has arrived
at hospital.113

Interventions
During the assessment process, a range of interventions may be initiated.
This includes simple nursing care, such as repositioning the patient,
dressing a wound or the administration of medications such as antibiotics.
Some treatments may be nurse-initiated, or carried out in response to a
medical order. The delivery of interventions should be prioritised in order
of urgency, following the ABCDE approach to ensure all life-threatening
conditions are treated first.
Interventions will occur simultaneously with other aspects of the
assessment. While helping the patient to get onto the trolley you will
already have started to gather historical data, taking note of how the
patient moves and signs of pain. You might note that they have some
difficulty breathing, so commence oxygen therapy, or they may appear to
have severe pain, so analgesia is given. An intravenous cannula may need
to be sited. In the pre-hospital se ing this may be used to administer fluid
resuscitation or drugs. In the ED se ing it could be used to administer
analgesia and to collect blood for laboratory testing.
Before delivering care the emergency clinician should question if the
care they intend to deliver is best practice. While research knowledge is
produced and published at an increasing rate, translation of research into
clinical practice remains inconsistent and delayed.114 Increasing demands
for emergency care, and limited support received to change practice,
restrict the emergency clinician's capacity to access, critique and adopt
research into their clinical practice.115 As a result, patients who present to
the ED frequently do not receive optimal care, with the incidence of
preventable adverse errors ranging from 36% to 71%.116 Clinicians should
refer to clinical practice guidelines and pathways available to assist in the
delivery of evidence-based care.

Practice tip
Clinicians should refer to clinical practice guidelines and pathways
available to assist in the delivery of evidence-based care.

All patients need to be re-evaluated for a response to these interventions

and for any deterioration in general condition. Based on the findings of the
re-evaluation, more interventions may be required or, in an ED se ing,
medical review sought earlier.
Diagnostics/investigations
Diagnostic tests may commence in the pre-hospital se ing, such as the
performance of 12-lead ECGs, which in some se ings are sent to the local
hospital during transport to expedite transfer to the angiogram suite on
arrival to hospital of patients requiring rapid reperfusion. When a patient
arrives in the ED there is then an opportunity to obtain more extensive
diagnostic and laboratory tests. The availability of this will depend on the
facility. Most major metropolitan hospitals will have access to 24-hour
facilities; however, in more rural and remote areas access may be
restricted, particularly after-hours.9,14
While the primary responsibility for determining which diagnostic and
laboratory tests are required remains that of the medical practitioner,
paramedics and ED nurses need to understand why particular tests might
be required and the significance of the results. This will help with the early
identification of sick or complex patients, initiating investigations and
their subsequent reporting to medical staff. Rather than ordering standard
groups of tests for particular sets of presenting symptoms, clinicians need
to consider whether the tests they order are relevant to the patient's
current condition. For example, ordering thyroid function tests can be
fairly common practice for many presentations, yet it is important to think
critically about whether this is clinically indicated. If it is indicated,
findings may not result in clinical intervention in the acute ED se ing, for
reasons such as time delays in receiving results. However, results can be
followed up by the GP if the patient is discharged, or can prevent delay in
inpatient treatment; for example, if blood collection did not occur until the
following day.
There are certain other tests that are performed during an assessment to
either confirm or rule out a diagnosis. Electrocardiograms (ECGs) are
usually performed on any patient presenting with chest pain, jaw pain,
difficulty breathing, nausea and vomiting or collapse. Falls in the elderly
that are not witnessed could be a result of a cardiac cause, and an ECG
should also be recorded in this group. All patients with a suspected
cardiac problem should have continuous cardiac monitoring according to
department protocol (see Chapters 16 and 22 for more detail on ECGs).
Blood glucose levels (BGLs) should be obtained and recorded for all
patients with diabetes and in patients who present with collapse, altered
consciousness level, multiple abscesses or non-healing wounds, dizziness
and nausea and vomiting, and in neonates (see Chapter 16 for more details
on BGL). Nurse-initiated X-rays are also a consideration when a patient
presents with pain over a distal limb from trauma. Nurses will have to
have completed additional training before being assessed as competent to
perform this skill, and it will depend on whether the facility has a policy or
procedure in place to support this practice (see Chapter 16).

Practice tip
Rather than ordering standard groups of tests for particular sets of
presenting symptoms, clinicians need to consider whether the tests they
order are relevant to the patient's current condition.

Reassessment
Reassessment of the patient is essential to monitor patient progress and to
ascertain response to interventions. If at any time the patient's condition
deteriorates it is important to return to the ABCDEs to ensure life-
threatening conditions are identified and treated first. When evaluating
care and monitoring patient groups, a structured approach should be
employed, focusing on relevant body regions, which is repeated at
appropriate intervals according to the condition of the patient.5,117 The
clinician should also review results from any investigations performed (to
gain a complete understanding of the patient's condition) and consider the
priorities and ongoing plan for the patient.
Communication
Working with others effectively in healthcare is a challenge, and
communication and human relationships with all those involved in the
patient's care have an impact on nursing practice, patient care and how
nurses feel about themselves.118,119 As paramedics and nurses, we have a
responsibility to provide safe and high-quality care. As a component of
this, throughout the assessment process it is essential that communication
occurs on several levels: paramedic to paramedic, paramedic to nurse,
paramedic/nurse to patient and family/carers, nurse to nurse, and nurse to
medical staff. Although paramedics and ED nurses are extremely busy, a
large proportion of their time is spent communicating, so good
communication is an essential aspect of care and can either facilitate a
relationship or create barriers. On this note, public surveys, practitioner
accounts, emerging policy and practice-based research are unanimous:
communication determines clinical quality, patient safety, clinicians’
wellbeing and public satisfaction.120

Principles of communication
Communication is a reciprocal process in which messages are sent and
received between two or more people. The interaction is often
interchangeable, with the speaker receiving messages from the person
listening and the listener sending messages while the other is speaking.121
In general, there are two parts to communication: the verbal and non-
verbal expression of the sender's thoughts and feelings. Verbally, cognitive
and affective messages are sent through words, voice inflection and rate of
speech; non-verbally, messages are conveyed by eye movements, facial
expressions and body language (see Box 13.6). Non-verbal communication
can send powerful messages, such as a suspicious glance, a warm smile or
eyes widened with fear. However, when telephones or other electronic
devices are used to communicate, the effect of gestures and other non-
verbal communication is lost.122

Box 13.6
Factors that have an impact on
communication 1 2 1
Type of Jargon, dialect, social linguistics
language used
Paralinguistic Pitch, tone, pace, emphasis and volume
features
Body language Posture, touch, eye contact, proximity, facial expression, gestures
Social Age, gender, ethnicity, power, social status, relationship
Psychological A itudes and beliefs, prejudices, perceptual distortions, defence mechanisms, frame
of mind/mood, stress, trust
Environmental Privacy, layout of room, odours, lighting, colour

There are four basic principles of communication:

1. It is impossible not to communicate. All behaviour has a message of

some sort. As well as the more obvious carriers of messages like
words or gestures, saying or doing nothing is in itself a message.
Once a message has been sent it cannot be retracted.
2. Every communication has a context and relationship aspect.
3. A series of communications can be viewed as an uninterrupted
series of interchanges. There is no clear beginning or ending to a
series of interchanges—communication between two individuals
has a history and a future in itself and is affected by the past
experiences of each individual.
4. All communication relationships are either symmetrical or
complementary, depending on whether they are based on equality
or inequality. With a status or power difference between two
people, such as between a nurse and a doctor, the complementary
relationship will affect any communication between them. In
general, how communication is interpreted depends on the
relationship the sender has with the receiver.123

Communication in the ED
Effective communication, both among clinicians and between clinicians
and patients, is critical in the provision of safe and quality healthcare, yet
EDs are becoming increasingly challenging healthcare environments for
clinician–patient communication.124 Poor communication practices have
consistently been identified as a major cause of adverse events, leading to
avoidable patient harm in hospitals around the world.124 One study
examined the communication load of the nurse in charge in the ED and
concluded that the number of interruptions impacted upon
communication and had implications for patient safety.125 ED is well
known for being an ‘interrupt driven’ area,126 and nurses are interrupted
on average once every 6 minutes.127 Although there have been numerous
studies on interruptions in the ED, no studies consider interventions on
how to effectively manage these interruptions.126
One Australian study124 observed communication across a number of
EDs and found two broad areas of communication that affect the quality
and safety of the patient journey through the department: how medical
knowledge is communicated, and how clinician–patient relationships are
established and maintained. Both of these are crucial for effective
communication and to deliver care effectively.124

Communicating with other health professionals

Clinical handover
Paramedics, nurses and doctors undertake segregated and distinct
preparation for clinical practice, yet are expected to communicate
effectively with each other in the workplace and ensure excellent and
accurate clinical handover. There are three distinct times when handover
occurs: the paramedic handing over to the triage nurse or resuscitation
team on arrival at the ED; nurse-to-nurse handover at change of shift; and
handover by the emergency nurse to the ward nurse (see Chapter 11).
Often the patients are critically unwell and may be unstable at this time.
The aim of handover in all circumstances is to ensure a seamless exchange
of information between care providers.128 It is acknowledged that without
a proper structure to the handover, vital information is likely to be
forgo en and this can lead to adverse outcomes.129–132 There is much work
currently being conducted in the clinical handover forum; with different
tools suited to different practice environments.133 The mnemonic IMIST-
AMBO (Identification of the patient, Mechanism/Medical complaint,
Injuries/information relative to the complaint, Signs vitals and GCS,
Treatment and trends/response to treatment—Allergies, Medications,
Background history and Other (social) information)134—is a recommended
structure used for handovers from paramedics to emergency staff, and is
discussed in detail in Chapter 42. ISBAR (Introduction, Situation,
Background, Assessment/Agreed plan and Recommendations/Read back)
is a demonstrated effective strategy that can be employed to promote good
communication with other in-hospital staff (Box 13.7).135

Box 13.7
The ISBAR communication tool
I Introduction: identify yourself and introduce the patient
S Situation: what is the main problem? What are your observations?
B Background: pertinent information, including past medical history
A Assessment/Agreed plan: include the clinical assessment and the plan of the care
R Recommendation/Read back: outline any outstanding items that need a ending to and clarify and
check for understanding.

Using a communication tool allows accurate and relevant information to

be shared in a structured format. This leads to a be er patient experience,
increases the credibility of the handover and allows the person receiving
the information to be in possession of all the facts.131 This will lead to them
being able to quickly prioritise what they need to do first when taking over
the care of the patient.

Escalation of care/graded assertiveness

The ability to escalate care in an assertive manner is a vital skill,
particularly in the emergency environment when a patient's condition may
be unpredictable. Regardless of how intimidating a situation may be or
how senior other staff are, it is important to articulate concerns in order to
keep the patient safe. This assertive way of communicating is termed
graded assertiveness. Graded assertiveness is a concept adopted from the
airline industry where adverse incidents often occurred, even though staff
knew something wasn't right as they were too afraid to be assertive when
communicating.119 The employment of graded assertiveness aims to assist
the staff member in escalating their concerns through a stepped process
(Table 13.9).119
TABLE 13.9

Levels of graded assertiveness and examples119

LEVEL EXAMPLE
Level one: express concern with an ‘I’ statement I am concerned about …
Level two: make an enquiry and offer a solution Would you like me to …
Level three: ask for an explanation It would help me to understand …
Level four: a definitive challenge demanding a For the safety of the patient you must listen to
response me
© 2011 The Authors. International Nursing Review. © 2011 International Council of Nurses

It is important to emphasise that assertiveness is not the same as

aggression. Aggression is disrespectful and denies the other person from
expressing their opinions, whereas assertiveness is respectful and allows
the expression of opinions.119

Communication with patients

Dialogue is more than sending and receiving messages verbally and non-
verbally, and each patient should be treated as a unique individual.136
Research has shown that patients who come to the unfamiliar territory of
the ED often experience feelings of bewilderment, loss of control, anxiety
and frustration, particularly as they are moved through a number of areas,
experiencing prolonged and often unexplained waiting times.137 If
clinicians are sensitive to the patient's concerns, communication can be
improved.137 Difficulties arise when the patient is unable to communicate
clearly due to their clinical condition, cognitive impairment, treatment
side-effects or language. This can further aggravate feelings of anxiety,
frustration and stress as they lose control over their life and decisions.
There is also evidence to support that patients with communication
problems are more at risk of preventable adverse events.124,138
The AIDET™ (Acknowledge the patient, Introduce your-self, Duration
of procedures/test/interaction, Explanation of procedure/test/procedure,
Thank the patient for their cooperation) mnemonic, developed by the
Studer Group, encapsulates five principles of communication identified to
promote patient satisfaction139 (see Box 13.8 for an explanation of each
principle). These communication strategies assist clinicians in making
patients feel safe and calm, and to gather the key pieces of information
needed to treat patients safely.139
Box 13.8
The AIDET™ communication principles 1 3 9
A—Acknowledge the patient
Greet the patient and other visitors with a smile, maintaining appropriate
eye contact. Demonstrate a warm, receptive a itude. Address the patient
by their name. Ask them what they would like to be called. Acknowledge
others present.
I—Introduce yourself and your role
Introduce yourself by name and role. Indicate your desire to help the
patient by providing them with your full a ention.
D—Duration of the procedure/test/interaction
Provide a brief explanation of how long any procedures/tests will take to
perform or for results to come back. Let them know who they are waiting
for and possible time-frames. Inform them of any delays.
E—Explanation of procedure/test/interaction
Keep the patient informed to enable them to make informed decisions and
reduce any anxieties they have about the care of their condition. Provide
details about tests and procedures, such as why it is being performed,
who will perform it, whether there is pain or discomfort associated with
the test, and what will happen afterwards. Provide them with an
opportunity to ask questions.
T—Thank the patient for their cooperation
Thank the patient for their cooperation and patience. Ask if there is
anything else you can do.
Courtesy Studer Group

Communication can also occur through physical contact: touch may

communicate empathy and demonstrate warmth.122 Language barriers
may necessitate the assistance of an interpreter with knowledge of
healthcare terminology to ensure the content is adequately
translated.122,140
As a result of greater-than-ever access to medical information through
superior communication systems and technology, patients and families
recognise and may understand the basic definition of many medical terms
and jargon. However, there are large variations of comprehension which
may be of clinical significance. Healthcare providers should not assume a
patient or family member's level of understanding, and an a empt should
be made to determine what their level of comprehension is, particularly
when new information is given. Using plain language, a range of
modalities to provide information and remembering to actively listen to
the patient and/or their family member are key strategies.140

Communication and patient outcomes

It is important to discuss the relationship between communication, sub-
optimal care and patient outcomes, as there is a direct correlation.141,142
The most common characteristics of international crisis-prompted
healthcare inquiries are: care is not delivered in multidisciplinary teams;
people do not communicate well across the clinical divides; and care is not
delivered in a coordinated, organised way. The variety of healthcare areas
investigated demonstrates that no one specialty is immune from error if
poor communication exists.141
Positive interpersonal relationships between clinicians and patients
result in a higher degree of patient involvement, which in turn produces
be er clinical outcomes.124 Poor communication can lead to delays in
transfer from the ED, and there is a correlation between increased hospital
length of stay (LOS) and increased LOS in the ED, especially on weekend
shifts when patients are not reviewed by specialist teams and are often
placed on outlying wards, or wards that are not related to the condition of
the patient, because of the unavailability of appropriate beds.143
Poor communication has been related to staff dissatisfaction, stress and
burnout in the nursing profession,144,145 with stress, wellbeing and
burnout linked to patient safety incidents.146,147 In particular, burnout has
been associated with avoidable mistakes, ineffective delivery of care, and
nursing shortages.148 This highlights the need for strategies to be in place
to identify and reflect on the causes of stress and burnout, and how it
impacts on patient care at both an individual and system level.149

Patient experience
There is good evidence to suggest that a patient's positive experience is
directly associated with safety and clinical effectiveness, across a range of
disease areas and population groups.150 Common public expectations of
emergency care include staff communication with patients, appropriate
 g y p pp p
waiting times, the triage process, information management and good
quality of care.151 Often the healthcare system is portrayed negatively by
the media,149 and while the paramedic and emergency nurse cannot
control all of the elements that contribute to this, effective communication
is achievable. The way in which communication is conducted is closely
related to ED patient satisfaction,152,153 and has been linked to the
interpersonal skills of staff.154 Patients and their families need provision of
information/explanation on a consistent basis, especially on arrival.125
Communicating the cause of delays, patient management plans and how
to get to other locations within the hospital are themes that will improve a
patient's satisfaction.152 Studies on the psychology of waiting show that
experiencing uncertain and unexplained waits makes the wait seem
longer.155 Regular communication with patients in the waiting room,
explaining the reasons for any delays, improves satisfaction levels.139,156,157

Open disclosure
Open disclosure means providing an open, consistent approach to
communicating with patients following an adverse event. This includes
expressing regret for what has happened, keeping the patient informed
and providing feedback on investigations, including the steps taken to
prevent an event from recurring. It is also about providing information
that will enable systems of care to be changed to improve patient safety.
The Australian Open Disclosure Framework provides a nationally
consistent basis for open disclosure in Australian healthcare. It was
endorsed in 2013 and replaces the former Open Disclosure Standard.158
Improving healthcare safety begins with ensuring that communication is
open and honest, and immediate. This includes communication between
healthcare professionals and patients and their carers. It also includes
communication between healthcare professionals, healthcare managers
and all staff. It is important that when this framework is put in place
people feel supported and are encouraged to identify and report adverse
events, so that system improvements can be identified and acted on. This
should include the following:

● Providing an environment where patients, their

family and carers:
 ● receive the information they need to
understand what happened
● can contribute about the adverse event
and, where possible and appropriate,
participate in the incident review,
creating a culture where patients, their
family and carers, clinicians and
managers all feel supported.
● Integrating open disclosure with investigative
processes to identify why adverse events occur.
● Implementing the necessary changes in
systems of clinical care based on the lessons
learned.158
Disclosure is required where a patient has suffered some harm (physical
or psychological) as a result of treatment. This may be a recognised
complication or a result of human or systems error. As soon as an event is
noticed, you should ensure patient safety, perform any immediate care
interventions required and inform your manager. If the emergency
clinician notices harm caused under the care of another clinician, they
should always speak first to their manager and the senior clinician of the
team involved. If these members of staff are unwilling to initiate the
disclosure process, refer the ma er to the person responsible for clinical
risk or medical administration.

Disclosure with the patient and family

The individual making the disclosure should be the most senior healthcare
professional involved; for example, the nurse manager, and someone with
experience or training in communication and open disclosure. Effective
communication is pivotal to the open-disclosure process. Patients, their
families and carers, may become upset or angry when they have suffered
an adverse event. This is a natural response, so it is important not to
become angry or react defensively in this situation. An adverse incident is
an emotionally charged event for all parties. Guidelines for
communicating with the patient and family can be found on the Australian
Commission on Safety and Quality in Health Care website,158 and include
the following:

● Arrange a face-to-face meeting that allows

adequate time for detailed discussion as soon as
possible after an adverse outcome has occurred.
● Listen actively and respectfully to the patient.
● Use plain language and avoid jargon.
● Acknowledge the validity of the emotions the
patient and/or carer may feel.
● Where a family member is present, include
them in your dialogue where appropriate.
● In all discussions, avoid defensiveness and
laying blame. Avoid statements that include
terms such as ‘fault’, ‘blame’ or ‘feel
responsible’.158
Support for staff involved
If directly involved in an adverse event, staff have the right to seek
appropriate legal advice and to disclose information to legal advisers in a
manner that ensures it a racts legal professional privilege. The breaking of
bad news can be extremely stressful on staff members.158 They have the
right to be treated fairly by the institution and to receive natural justice
and procedural fairness, and the right not to be defamed.158 Avoid
statements such as:

● ‘I'm sorry—I appear to have made an error in

judgement.’
● ‘I apologise for this mistake.’
 ● ‘It is my fault that this has happened.’
The best approach is to give an honest and factual account of what
happened.
Healthcare professionals who have been involved in an adverse event
may be angry with themselves or someone else for what occurred. They
may feel that they have let the patient down. It is important to make sure
they receive emotional support and advice after the incident, as well as
feedback once the investigation has been finalised.159,160

Needs of the family

The psychosocial care of family who arrive in the ED with a critically ill
relative is stressful for families, as well as complex and challenging for
staff.161 Quite often, staff are focused on stabilising a patient and may
overlook or ignore anxious family members. Research has shown that
communication with family members is the most important need of family
members of critically ill patients within the ED.162 During such stressful
situations, suffering can be exacerbated when there is a lack of information
provided.163 Another important family need is for relatives to be close to
their loved one.162 Often family members may be left out in the waiting
room or be asked to step outside while an assessment or treatment takes
place, yet family consider being close to their loved one very
important.162,164 Staff should invite family members to be with the patient
whenever possible and engage in family-centred care.165
In light of the various definitions of family and the regulations
regarding the release of information, how people define themselves has
implications for clinicians (see Chapter 4). It is important to ask the patient
who they consider to be family, who they wish to receive information and
who should be allowed in the treatment area. When that is not possible,
the clinician must be guided by good judgement, policy and regulations
and ethics.166
Although emergency care clinicians are usually very busy, it can be
crucial to conduct a brief family assessment, and determine if social work
intervention may be required. There are several ways to develop a
dialogue with families and conduct a quick assessment of family strengths
and potential resources.
 ● Introduce yourself to the patient and the
family.
● Ask about people at the bedside and determine
their relationship to the patient.
● Call patients by name, after having asked how
they wish to be addressed.
● Explain procedures and equipment, and be
honest about the anticipated length of the wait.
● Repeat information; the anxiety of being in the
ED, even in non-urgent situations, decreases the
ability to remember what has been said.
● Stop in the patient's doorway or at the foot of
the bed to update them and their family
whenever the situation in the ED changes.
● After any explanation, always ask if anyone has
questions. If the answer is not known, say so,
then find out the answer.
When encountering a family in the initial stages of a life-changing event,
paramedics and ED nurses often interact with and provide support for
family members who feel despair, fear, anger, guilt or helplessness, or
who are in a state of disbelief or denial. Family members present at the
scene, or who come to the ED with a loved one nearing the end of a long
and debilitating illness, may be fatigued, frustrated or ambivalent. The
paramedic or emergency nurse may be the first to recognise a family that
is bordering on crisis because of the drain on their emotional and physical
resources.
Family needs have been extensively researched, and include the need
for information, reassurance, closeness, support and comfort.167 Practical
ways to meet these are presented in Box 13.9.
Box 13.9
Family needs 1 5 2 , 1 6 0
Ways to meet families’ needs include:

• listen compassionately
• compliment the family on how well members are coping
• involve the family early
• communicate regularly
• praise family strengths
• acknowledge how difficult the experience is
• commend patience
• update them on relative progress and prognosis
• answer questions honestly
• give consistent information
• demonstrate caring (offer a chair and a cup of tea/coffee)
• call them at home to update on patient condition or any change
• inform about transfer plans as they are being made.

The Australian Institute for Patient and Family-Centred Care (AIPFCC)

promotes the relationship between the patient, their family members and
the healthcare professional with the aim to ‘ensure safer, more cost
effective and satisfying health care experience for all involved’.168 The core
values of patient and family-centred care are:168

● compassionate care and communication

● collaboration between patients and carers, both
professional and family
● innovation in our practices
● care practices that are sustainable over time
● care that is accessible to both patients and
carers
● respectful communication
 ● ethical behaviour and practice at all times
● openly and honestly sharing information and
our experiences.
Documentation
Documentation should occur regularly and be contemporaneous,
occurring with each intervention rather than once at the end of a shift.
Documentation must also be legible and identify clearly who the author is;
this is becoming easier with the implementation of electronic records.
Treating clinicians should be able to read the patient notes and determine
the patient status (waiting for review, awaiting ward bed), condition,
interventions that have been performed and response to those
interventions. Up-to-date documentation also allows the patient to be
transferred without delay. Documentation is not only a way to
communicate the assessment, findings and the plan of care for the patient
to other clinicians, it is a legal record of the patient's care (Chapter 4).
Essentials of care
How well patients are cared for has a direct effect on their sense of
wellbeing and their recovery. Effective communication is essential to good
patient care and their subsequent outcomes. The time for an ambulance
patient to be offloaded may be delayed until a treatment space becomes
available. The ED length of stay may be prolonged in some patients who
need to wait for results prior to being discharged. This means that
paramedics and ED nurses need to consider other essential aspects of
patient care. Paramedics and ED nurses are expected to work under
pressure to many standards, guidelines and protocols related to patient
care. However, posing the question: ‘How would I want this patient to be
cared for if they were my grandmother/father/child?’ provides an answer
that sets a benchmark for nursing practice.160 A similar approach should
be taken when interacting with the patient's relatives. Aspects of care, such
as culture, pain and infection control, are discussed in detail elsewhere
(Chapters 5, 18 and 27 respectively).
Two key areas of care—reducing risk and providing high-quality care—
are served by a series of principles (see Table 13.10) and are closely related.
Good risk management is an important component of high-quality care; if
patients are assessed thoroughly and on a continuing basis then problems
may be detected and treated early, thus preventing the development of
unnecessary complications.117,169

TABLE 13.10
Principles of practice117,169

PROVISION OF HIGH-QUALITY
REDUCING RISKS TO PATIENTS
CARE
• Recognition of the specific needs of critically ill patients, • Development of knowledge and
particularly those who are unconscious, sedated or immobile skills for practice
• Recognition of specific complications that may require special • Evidence-based practice
observation or treatment • Optimal use of protocol-driven
• Vigilant monitoring and early recognition of signs of therapy
deterioration • Competent practice
• Selection, implementation and evaluation of specific preventive • Efficient and safe practice
measures • Selection and application of
• Management of potentially detrimental environmental factors appropriate nursing interventions
that may affect the patient • Monitoring the effects of nursing
interventions
• Evaluation of nursing practice
Caring
Caring is a core characteristic of healthcare. In emergencies, life-saving
procedures are, of course, the priority, but it is important not to forget to
meet the patient's psychological needs as well.136,160,170 Professional caring
consists of three essential elements: competence, caring and connection.
Competence involves empowering, connecting and educating people,
making clinical judgements and being able to do tasks and take action on
behalf of people. Aspects of caring are outlined below and involve being
dedicated and having the courage to be appropriately involved as a
professional paramedic and nurse. The connection aspects of professional
caring involve initiating professional connection, which requires both the
patient and the clinician to reach out and respond. A bridge is built when
patients realise the connection and feel free to ask for help. Professional
intimacy then occurs when patients begin to trust the clinician. As a result
of the connection and professional intimacy, emergency clinicians work
with patients towards their common goal. Professional boundaries are
discussed in Chapter 3.
An uncaring encounter can consist of incompetence and indifference,
lack of trust, mutual avoidance and disconnection between the nurse and
the patient. The clinician may be perceived as inconsiderate, insensitive,
disrespectful and disinterested.

Aspects of caring in emergencies

● Being open to and perceptive of others: patients are

often affected by the acute event, as they have
abruptly lost control of their own situation and
are in a position of dependence. A caring
emergency clinician has to be sensitive to such
patients and capable of interpreting or predicting
their needs. The caring clinician needs an open
a itude and should communicate openly with
the patient.
 ● Being genuinely concerned for the patient:
paramedics and nurses with this caring quality
display genuine feelings of goodwill towards
patients and a holistic view of caring.
● Being morally responsible: from the patient's
perspective, calling an ambulance and visits to
the ED are not planned. Suddenly, they become
dependent on others to fulfil their needs.
Clinicians have to act to maintain and strengthen
the patient's dignity in this serious situation.
● Being truly present: this means that clinicians
have to be a entive to the present moment, and
be present in dialogue, in listening and
responding. They should be present in the
situation, physically and emotionally. In order to
be truly present in the dialogue, paramedics and
nurses require good communication skills.136
● Meeting the patient's psychological needs could
reduce the risk of developing post-traumatic
stress syndrome. To create an authentic
encounter, paramedics and nurses need to
display several aspects of sensitive and effective
communication, be dedicated and have the
courage to be appropriately involved.136

Care of paramedics
Just as patients require care, so do paramedics. The role of the paramedic
has moved away from its focus of giving first aid and transporting patients
to hospital, to a more dynamic role that encompasses higher levels of
patient care and instigating interventions based on a thorough patient
assessment.171 Furthermore, they are exposed to increasing levels of
physical and verbal aggression. As part of their role, paramedics are
exposed to a range of highly stressful incidents,172 on top of which the
service is ge ing busier and busier with no real downtime between calls in
which to relax or socialise at the station.171 It has been reported that this is
a cause of increasing stress-related illnesses and work dissatisfaction.173 It
is an accepted belief that to do their job well paramedics should appear
‘tough’, but by failing to talk about a traumatic incident the likelihood of
suffering stress is increased. The value of social support from colleagues
cannot be underestimated as it can help to mitigate the impact of traumatic
events.172 Managers in the profession should be aware of the value of
debriefing or offering counselling, and encompass this into the role where
able. One way to achieve this is to promote the use of an employee
assistance program that offers free, confidential counselling to employees.

Care of emergency nurses

ED nurses also require care. Providing thorough and effective care for
emergency patients is emotionally draining and highly demanding of busy
emergency nurses, who often fail to notice or acknowledge their own
needs.174 A certain amount of stress at work can be a motivator, but
repeated exposure to stressful events can have adverse outcomes.175
Nurses have been extensively studied as groups experiencing high levels
of stress, burnout and fatigue.176 Being aware of the signs of stress and
developing and implementing coping mechanisms is essential.177 Nurses
depend on colleagues and friends for support and value debriefing
sessions, whether it be an opportunity to share feelings or a clinical review
of events. The effectiveness of sessions should be evaluated and staff
health and welfare monitored by ED managers and colleagues. An
awareness of colleagues’ needs is a key to providing the support they
require.160 Employee assistance programs should also be made available
for nursing staff.

Privacy and dignity

Respect, autonomy, empowerment and communication have been
identified within the literature as being the defining a ributes of dignity.
In the busy ED, maintenance of dignity may be unintentionally
overlooked. Patients can be nursed in a corridor, or other patients and
relatives may overhear personal information, which does not lend itself to
upholding the dignity, privacy and confidentiality of the patient.178
Discretion should be used if updating relatives in a crowded waiting
room; triage assessment should be conducted in a safe and private
location, and the patient's dignity should be maintained at all times.179
Personal hygiene and preventing
complications
Patients presenting to the ED can be in various states of hygiene as a result
of injury, vomiting, incontinence or neglect. Also, despite the 4-hour
Emergency Treatment Performance target (formerly known as National
Emergency Access Target),180 patients may remain in the ED for an
extended period of time with the inability to maintain their regular
hygiene routine. Personal hygiene is closely related to individual esteem
and sense of wellbeing, and is an important sensory determinant by family
members that influences their perception of the quality of care the patient
is receiving and the confidence they have in the staff. But while personal
hygiene is a basic right for all patients, it should not be placed above the
need for other therapies, forensic requirements and rest.117
As with all aspects of care and treatment, the patient has the right to
refuse personal hygiene measures. Bathing or washing patients provides
opportunities for the emergency nurse to assess the patient's skin and
tissue. Often this enables the nurse to identify tissue damage that requires
treatment, and to identify dressings or wounds that require a ention.
Some patients who are sweating, incontinent or bleeding need to be
washed and their linen changed as often as necessary. Wet, creased sheets
alter skin integrity and may cause pressure on dependent areas, increasing
the risk of pressure-ulcer development. A bed bath can be a major and
painful undertaking, which often requires at least two people to support
and move the patient along with prophylactic pain relief before
commencing.117 The length of time taken to wash a patient, the
environmental temperature and the patient's clinical condition are factors
that affect cooling. Water on exposed skin causes rapid heat loss and
shivering increases metabolism and oxygen consumption, which is
detrimental in a compromised patient (see Chapter 28).
It is essential to maintain patient privacy and avoid interruptions that
affect the dignity of the patient. All necessary equipment should be
prepared prior to performing any procedure with the patient to ensure
interruptions are minimised and dignity is maintained. Careful handling
of patients to reduce skin friction and shear during repositioning and
transfers can prevent skin tears.117 The management of skin tears is
discussed in Chapter 17.
Practice tip
Consider the length of time a patient has spent, or will spend, in the ED
and ensure opportunities are given for a ending to their personal hygiene
needs, which will differ from person to person.

Eye care
Eye care aims to provide comfort and prevent infection, and is an
important aspect of caring for the sedated or unconscious patient.117 There
are a number of physiological processes that protect the eye. The eye is
protected from dryness by frequent lubrication, facilitated by blinking.
Antimicrobial substances in tears help prevent infection, and the tear ducts
provide drainage. When the eye is unable to close properly, tear film
evaporates more quickly.181 If these mechanisms are compromised, the
patient is at risk of eye problems. The blink response may be slowed or
absent in some patients, such as individuals receiving sedatives and
muscle relaxants, which can potentially cause keratopathy, corneal
ulceration and viral or bacterial conjunctivitis. Patients who are exposed to
high flows of air/oxygen may also be vulnerable to its drying effects.117
(See Chapter 32 for assessment and management of eye injury.)
Eye care and the administration of artificial tears should be provided if
required, if the patient complains of sore or dry eyes or if there is visible
evidence of encrustation. If a patient is receiving high-flow oxygen therapy
via a mask, they may benefit from regular 4-hourly administration of
artificial tears to lubricate the eyes and prevent the drying effect of
oxygen.117 Conjunctival oedema is a common problem associated with
positive-pressure ventilation with high positive end-expiratory pressure
(PEEP) (above 5 cmH2O), and prone positioning often results in the
patient's inability to maintain eye closure.182 Eye closure may be
maintained by applying a wide piece of adhesive tape horizontally to the
upper part of the eyelid. This usually anchors the lid in the closed position,
allowing the eyelid to be opened for pupil assessment and access for eye
care.117

Practice tip
Apply 4-hourly artificial tears to lubricate the eyes to prevent the drying
effect of high flow oxygen therapy.

Oral hygiene
Poor oral hygiene is unpleasant, and causes halitosis and discomfort. Oral
care aims to ensure a healthy oral mucosa, maintain a clean and moist oral
cavity, prevent pressure ulcers from devices such as endotracheal tubes
(ETTs), prevent trauma caused by grinding teeth or biting the tongue and
reduce bacterial activity that leads to local and systemic infection.117
Although mouth care is one of the most basic nursing activities, in some
cases lack of oral hygiene can lead to serious complications or increase the
risk of complications, such as ventilator-associated pneumonia (VAP) in
the ventilated patient.117,183 Studies have shown that mouth care decreases
the risk of VAP and that chlorhexidine mouthwash or gel reduces the risk
of developing VAP from 24% to about 18%.184
If the ED patient has had an extended stay, a toothbrush and toothpaste
and assistance to clean teeth should be provided. The use of mouth swabs
only for oral hygiene is ineffective.185 Many oncology and immunology
patients suffer from mouth ulcers and are on oral care regimens at home.
The maintenance of such a regimen is essential for patient comfort and
may require the emergency nurse to organise and obtain prescribed
mouthwashes from the pharmacy department. Regular sips of fluid or
mouthwash with water for those patients who are nil by mouth prevents
drying, coating and subsequent oral discomfort. If the patient is able to
suck and swallow, small pieces of ice can be very refreshing,117,186 yet it is
important to monitor the amount of ice given so not to give excessive
amounts that would equate to numerous glasses of water. The application
of lanolin or petroleum jelly will ease the discomfort of dry lips and
maintain the integrity of the lips.
For patients with crusty build-up on their teeth (commonly seen in the
elderly or dehydrated patient), a single application of warm dilute solution
of sodium bicarbonate powder with a toothbrush is effective in removing
debris and causes mucus to become less sticky, although its use is
sometimes contested as it can cause superficial burns.117 Its use should be
followed immediately by a thorough water rinse of the mouth to return
the oral pH to normal.117,187
In the sedated, intubated or unconscious patient, absence of mastication
leads to a reduction in saliva production. Saliva produces protective
enzymes. An endotracheal tube can cause pressure areas in the mouth
(which may be exacerbated if the patient is oedematous). Once the patient
is in the intensive care unit, an oral care program will be commenced.

Practice tip
Ensure patients who have an extended stay in ED have access to a
toothbrush and toothpaste as using mouth swabs alone is ineffective.
Prevention of deconditioning
Positioning patients correctly and as soon as possible in the ED, while
considering cardiovascular stability, respiratory function and cerebral or
spinal injury, is important to contribute to the prevention of common
short- and long-term complications of immobility.117 The complications of
immobilisation in the critically ill include pressure injuries, venous
thromboembolism and pulmonary dysfunction, such as atelectasis,
retained secretions, pneumonia and aspiration.188 Ideally, the immobile
patient should be positioned with the head raised by 30° or more, as this
prevents the tongue from obstructing the airway, reduces the risk of
aspiration from secretions and saliva and aids cerebral venous drainage,
helping to reduce intracranial pressure.117 It is also important to remember
that Australian healthcare organisations are required to be accredited for
Standard 8: Preventing and Managing Pressure Injuries.189
Provided there are no contraindications, function should be stimulated
by regular passive movements of all limbs and joints to maintain both
flexibility and comfort, as one week of bed rest substantially reduces
skeletal muscle mass.190 Movement of the lower legs, ankles and feet can
be achieved in conjunction with a gentle massage or application of
moisturiser. Family members may wish to undertake this, giving them an
opportunity to provide the patient with care and touch. The emergency
nurse should encourage the able patient to perform exercises, and conduct
an early physiotherapy referral for patients who may have an extended ED
stay awaiting a ward bed.
Within the intensive care se ing, the standard for body repositioning is
2-hourly, although this does not always happen.182,191 Repositioning may
be required more frequently, which will be determined by the nurse,
based on patient factors and the clinical situation.189 When planning to
reposition the patient, check that there are enough staff available so that all
the patient devices (e.g. intravenous lines) are managed and to give the
patient a feeling of security during the positioning. It is advisable to have a
designated leader in such circumstances to avoid injury or dislodgement
of any devices.

Pressure injury prevention

Many ED patients are at risk of pressure injuries due to immobility, lack of
sensory protective mechanisms, excessive moisture, suboptimal tissue
perfusion and environmental factors that cause pressure and friction: these
issues are exacerbated in the critically ill.92,192 The most common locations
for pressure injuries are the bony prominences, such as the sacrum, the
heels and the head.192–194 Significant risk factors include the age of the
patient, malnutrition192 and delays in the use of pressure-relieving
ma resses (see Box 13.10).195,196 Pressure injury risk-assessment tools, such
as the Braden and Waterlow Scales,197 can help nurses identify at-risk
patients early.

Box 13.10
Risk factors for pressure injuries 1 9 4
• Advanced age
• Anaemia
• Contractures
• Diabetes mellitus
• Elevated body temperature
• Immobility
• Impaired circulation
• Incontinence
• Low diastolic blood pressure (< 60 mmHg)
• Mental deterioration
• Neurological disorders
• Obesity
• Pain
• Prolonged surgery
• Vascular disease

Any pressure injuries should be documented and described in relation

to size, grade/stage and treatment and monitored closely. Many facilities
require pressure injuries to be reported. If a patient develops one pressure
injury, there is a good chance they could develop another. While the
pressure injury may not be evident in the ED, the initial reddened areas
give clues to potential locations for development, and any preventative
measures implemented in the ED contribute greatly to prevention.
Simple preventative measures include water-filled gloves under the
heels, removing additional bed linen from under the patient which may
have been transferred from the ambulance trolley, ensuring the patient is
kept clean and dry (particularly those under stiff neck collars and
incontinent patients), the use of foam boots and alternating pressure-relief
ma resses and foam ma resses with adequate thickness and stiffness.
However, none of these are a substitute for regular repositioning and
avoiding pressure on any affected areas.196 It is also important to
document the details of position each time the patient is repositioned and
communicate this on handover, as well as to maintain the patient's
hydration and nutrition to improve tissue perfusion and integrity.
Patients are also at risk of developing pressure injuries and injury from a
number of devices in everyday use, such as endotracheal tubes,
backboards and blood-pressure cuffs (Table 13.11).198 Close a ention to
detail with frequent observation of the patient, the patient's position and
the presence and location of equipment is required to prevent skin
damage.117
TABLE 13.11
Risk of pressure injuries from commonly used equipment198

EQUIPMENT RISKS
Endotracheal Care should be taken when positioning and tying ETT tapes: friction burns may be
(ETT) tubes caused if they are not secure; pressure injuries may be caused if they are too tight
(particularly above the ears and in the nape of the neck).
Moist tapes exacerbate problems and harbour bacteria.
Oxygen saturation Repositioning of oxygen saturation probes 1–2-hourly prevents pressure on
probes potentially poorly perfused skin.
If using ear probes, these must be positioned on the lobe of the ear and not on the
cartilage, as this area is very vulnerable to pressure and heat injury.
Blood-pressure Non-invasive blood-pressure cuffs should be regularly rea ached and repositioned.
cuffs If left in position without rea achment for long periods of time, they can cause
friction and pressure damage to skin.
Care should be taken to ensure that tubing is not caught under the patient,
especially after repositioning.
Urinary catheters, The patient should be checked often to ensure that invasive lines are not trapped
central lines and under the patient. In addition to causing skin injury, they may function
wound drainage ineffectively.
Bed rails Limbs should not press against bed rails; pillows should be used if the patient's
position or size makes this likely.
Oxygen masks Use the correct-size mask and a hydrocolloid protective dressing on the bridge of
the nose to assist with prevention of pressure from non-invasive or CPAP masks,
especially when these are in constant or frequent use.
Splints and Devices such as leg/foot splints and cervical collars can all cause direct pressure
cervical collars when in constant use and friction injury if they are not fi ed properly.
Hard backboards Hard backboards or spine-boards used by ambulance personnel for patient
extrication cause pressure areas and should be removed on patient arrival to the ED
or on initial log roll.
CPAP: continuous positive airway pressure
Nutrition
The impact of adequate nutrition on patient outcomes is well documented.
The intake of nutrients, such as protein, calories, vitamins, minerals and
fluids, provides the energy source required for growth of all body
structures and maintenance of body functions, as well as supporting the
immune function of the bowel.199,200 Patients presenting to the ED are
often in an altered metabolic state due to the stress response to illness,
injury or starvation (when nutrient intake is unable to meet the body's
energy demands). Wounds place increased metabolic and hence oxygen
and nutritional demands on patients.201,202 Patients with poor nutrition,
including malnutrition, are at greater risk of complications, including
pressure injuries, healthcare-associated infections and mortality, both in
hospital and for up to three years following discharge.92 Malnutrition also
increases length of hospital stay and unplanned hospital re-admissions.33
Critically ill patients are usually in a hypermetabolic state, characterised
by rises in oxygen consumption and use of nutritional substitutes such as
amino acids. Malnutrition and starvation increase electrolyte imbalances,
muscle wasting, morbidity and mortality; delay recovery; impede healing
of acute and chronic wounds; interfere with the body's ability to fight
infection; and increase the cost of hospitalisation.203,204 Understanding the
importance of nutrition and its effect on the patient is integral for nurses to
predict and promote successful outcomes and is a priority of care.205
While it is often inappropriate for the ED patient to have oral intake for
a number of reasons (the potential to require emergency surgery, cerebral
insult that compromises swallowing and gag reflexes, or altered level of
consciousness), it is essential to establish nutritional status as soon as
possible. Nutritional status should be assessed early and documented
clearly and communicated to all relevant parties. In particular, stroke/TIA
patients should have their swallow assessed early as this has shown to
improve patient outcomes.206 Since the implementation of tools, such as
the Acute Screening of Swallow in Stroke/TIA (ASSIST), the assessment
can be performed by the emergency nurse.207 Completion of a swallowing
assessment will determine whether the patient can swallow safely and re-
establish normal nutritional status or identify the need for further referral.
The dietetics department should be notified of special requirements and
speech pathology referral and assessment conducted promptly.
 Particular consideration should be given to the diabetic patient and the
monitoring of their blood glucose levels (BGLs), more so if their condition
requires a prolonged fasting status. Alterations to their anti-
hyperglycaemic medications may need to be made in consultation with
medical staff and careful monitoring implemented.
ED patients who are clinically able to tolerate some form of diet should
be encouraged to eat and drink and should be assisted if necessary,
enlisting the aid of family members, if they are present and willing. This
will help prevent the development of a compromised nutritional state.
Elimination
Effective urine and bowel elimination is a basic human need, and adequate
privacy, discretion and dignity is essential. While it can be difficult in a
busy ED, it is important to facilitate prompt toileting and maximise access
to toilets.
More than one million people living in Australia and New Zealand
suffer from urinary incontinence from causes such as poor pelvic floor
tone, central nervous system disorders, spinal cord injury, fistulas and
bladder disorders.208 Also, the normally continent patient may present
having been incontinent following a seizure or traumatic event. The
paramedic and emergency nurse must recognise the physical and
emotional problems associated with urinary incontinence and frequency.
The patient's dignity, privacy and feelings of self-worth must be
maintained. The discreet disposal of soiled pads, patient sponging (wet
skin contributes to pressure-injury development), cleansing of the
perineum, provision of clean incontinence pads and referral to appropriate
continence services, should be done if required. If urinary catheter
insertion is needed, thorough cleansing and aseptic techniques are
essential to prevent the development of urinary tract infections.

Bowel management
Good bowel care promotes patient comfort and reduces the risks of further
associated problems such as nausea, vomiting and abdominal/pelvic
discomfort. Maintaining good bowel care can range from promoting
defecation to containing diarrhoea, due to changing therapies,
medications, nutrition, hydration and mobility of the patient.117 The
consequences of constipation are not well defined, but can include
increased abdominal distension, impedance of lung function, inability to
establish adequate enteral nutrition and increased acquired bacterial
infections.117 Risk factors for constipation include: immobility, medications
such as opiates, sedatives, anticonvulsants, diuretics and calcium channel
blockers, reduced gut motility, a poor dietary intake, dehydration and
older age.117
Interventions that can be commenced in the ED include exercise—even
in the bed-bound patient—as peristaltic movement of the gut is
stimulated. Diet and fluids are also important considerations in
maintaining normal bowel function, ensuring, if clinically appropriate,
that the patient receives adequate administration of fluid and diet in the
ED. Prior to patient transfer to the ward from the ED, if the patient is at
risk of constipation, ensure that oral aperients have been charted, if
clinically appropriate, so that the risk has been handed over to the ward
nursing staff and the patient has been educated on prevention techniques.
Recognising and managing loose stools/diarrhoea is just as important as
it may signify a particular condition or medication side-effect. Potential
complications, such as fluid and electrolyte imbalance, may occur and skin
damage is likely, particularly in the incontinent or immobile patient.
Protection for staff providing care, as well as other patients and relatives,
should be considered and the requirement for isolation discussed with
relevant infection control staff.
Bowel care can be an embarrassing and even quite distressing issue for
patients, particularly for those who may have lost control of their bodily
functions or perhaps have developed particular routines to maintain
regular bowel motions. Coming to the ED can interrupt routines and
highlight embarrassing issues with bowel motions for the patient,
therefore sensitive nursing care that respects the dignity of the patient is
paramount.117
Summary
This chapter has discussed a ‘head-to-toe’ approach to assessment. The
emergency clinician should consider the assessment process as more than
just recording a set of vital signs. Although the process appears to be time-
consuming, with practice and experience the Emergency clinician is able to
automatically and quickly proceed through the process. This is made
easier by adopting an assessment template such as HIRAID. Reassessment
has been highlighted in monitoring dynamic changes in a patient's
condition and comparing them with the baseline. This can help initiate
timely and appropriate measures to maximise patient care and outcomes.
Effective communication between healthcare providers, the patient and
their family, which acknowledges their concerns, is instrumental in patient
outcomes and satisfaction. The emergency clinician conducting or
commencing the discussed aspects of essential nursing care contributes
greatly to reducing the risk of the patient developing complications during
their hospital stay. Simple measures, such as timely toileting of patients,
will assist to maintain comfort and dignity; documentation of nutritional
status will help avoid malnutrition; regular pressure-area and skin care
will help to prevent pressure injury development. While it is easy to be
distracted by performing advanced procedures, it is vital that these basic
but essential elements of patient care are provided and documented for
the health, comfort and dignity of the patient and to prevent
complications.

Case study
Part A: Pre-hospital
You are the treating paramedic of a morbidly obese man in his forties,
who is complaining of shortness of breath. On arrival to his home the
patient is si ing upright in a chair talking in short phrases, but
complaining primarily of severe left leg pain.
Questions

1. Where would you start your assessment?

a. Inspect his leg.
 b. Record a set of vital signs.
c. Check his BGL.
d. Assess DRSABCD.

You assess the scene and identify no immediate dangers to yourself, so

you approach the patient. He responds appropriately and you commence
taking a history while performing your physical assessment.

2. What mnemonic could you use to structure taking the patient's

history?

The patient's wife informs you that she called the ambulance service,
and is worried as she felt his breathing has become more laboured over
the course of the day. You also learn that the patient has a known history
of type 1 diabetes and a chronic ulcer on his left leg, which has become
malodourous.

3. What ‘red flags’ have you already identified in this patient?

While undertaking your physical assessment you identify that the

patient has a respiratory rate of 28 breaths per minute with some mild
accessory muscle use. Oxygen saturations are adequate. On auscultation,
air entry is equal. You inspect the left leg ulcer and find a red sloughy,
odourous wound. There is decreased sensation to the affected limb, but
strong pedal pulses present. You dress the wound to absorb the exudate
and transport the patient to hospital.

4. How would you (the paramedic) structure your handover to the

receiving emergency nurse on arrival to hospital?

Part B: At the ED
You are the emergency nurse receiving care of this patient in the acute
treatment area.
Questions

5. How would you start your assessment?

a. Collect the patient's history.
 b. Identify red flags.
c. Perform a set of vital signs.
d. Apply oxygen.
6. You commence your physical assessment. When a empting to check
his blood pressure the cuff keeps popping off. What do you do?
a. Tape it on with micropore.
b. Not bother, he has just presented with a leg ulcer.
c. Find an appropriate-size cuff.
d. Use the manual syphygmomanometer as you can stop
inflating before the cuff pops open.

After completing the primary survey you perform a head-to-toe

examination, including a focused respiratory assessment. You identify
that the patient is still only able to speak in short sentences and has
moderate accessory muscle use. The respiratory rate is counted at 32
breaths per minute, oxygen saturations measure 92% on room air and
temperature 38.7°C. The patient denies any history of lung disease.

7. What new ‘red flags’ have been identified and how should you
respond to these?
8. What diagnostic test is this patient likely to require?
9. Your patient suddenly becomes very sweaty and disorientated. What
do you do next?
10. After medical review and initial treatment the patient is admi ed
into hospital. There is no access to a bed for several hours. What
factors do you need to consider for his ongoing care?
Useful websites
Australian Institute of Patient and Family Centred Care.
www.aipfcc.org.au/about.html.
Australian Resuscitation Council, Australian Resuscitation
Council Guidelines. h ps://resus.org.au/.
Clinical Excellence Commission, NSW Health Government.
www.cec.health.nsw.gov.au/.
College of Emergency Nursing Australasia, Peak professional
association representing emergency nurses.
www.cena.org.au.
COMPASS ACT Health, website provides information on the
early recognition of the deteriorating patient and provides a
number of learning resources.
www.health.act.gov.au/professionals/compass.
New South Wales Emergency Care Institute, set up to provide
resources and support to emergency clinicians.
www.aci.health.nsw.gov.au/networks/eci.
First2act, interactive online simulation package.
h p://first2act.com/.
National Safety and Quality Health Service Standards.
www.safetyandquality.gov.au/wp-
content/uploads/2011/09/NSQHS-Standards-Sept-
2012.pdf.
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