Lesson Notebook:

Patient Assessment

Emergency Nursing Orientation 3.0

Lesson Notebook: Patient Assessment

Copyright © 2022 by Emergency Nurses Association. Published by Elsevier, Inc. All rights reserved. 1
 Lesson Notebook:
Patient Assessment

Lesson Outline
Data Collection
• Subjective data are pieces of information that the patient, family, significant other, or caregiver
provides verbally. It reflects the person’s perception of the problem and is information that the
patient or family member has chosen to impart.

• Objective data are factual findings that can be observed or measured. They may be obtained
through physical assessment, physiologic measurements, and laboratory and diagnostic tests.

Components of the Initial Patient Assessment

• The primary survey aims to immediately identify and address life-threatening conditions by
sequentially evaluating the patient’s airway, breathing, circulation, disability, and exposure, using
the ABCDEFG portion of the A-J mnemonic. It focuses mainly on objective data. The amount of
subjective data obtained during the primary assessment, such as the chief concern or reason for
presentation, is often minimal.
o In the first seconds, form a general impression based on an adult patient’s general
appearance, posture, motor activity, speech, affect, mood, and degree of distress.
o For a pediatric patient, observe the Pediatric Assessment Triangle: general
appearance, work of breathing, and circulation to the skin.
o Airway and alertness – Assess airway patency, noting quality of speech and abnormal
airway sounds. Remove any airway obstruction, position the airway for patency, insert an
airway adjunct, and protect the cervical spine.
o Breathing and ventilation – Determine respiratory effectiveness and identify breathing
abnormalities. Auscultate for breath sounds bilaterally. Assist breathing with oxygen
therapy, mouth-to-mouth ventilation, or bag-mask ventilation. Assist with endotracheal
intubation, if needed.
o Circulation and control of hemorrhage – Evaluate pulses, capillary refill, skin color,
temperature, and moisture. Initiate chest compressions, defibrillation, synchronized
cardioversion, and medications, as indicated. Treat dysrhythmias. Control visible bleeding
by applying manual pressure or a tourniques. Establish intravenous access and replenish
intravascular volume with warmed intravenous fluids, as ordered.
o Disability – Assess the level of consciousness and pupil size and reactivity. To conduct
a brief neurologic assessment, use the Glasgow Coma Scale. Identify the possible
cause of a decreased level of consciousness. Consider bedside glucose.
o Exposure and environmental control – Identify signs of underlying illness or injury.
Expose the entire body and cover it to prevent heat loss. Preserve clothing for evidence,
if needed
o Full set of vital signs – Measure the patient’s temperature, pulse, respirations, and
blood pressure with the patient in two or three positions. Also measure (or estimate)
body weight and height. Perform serial measurements to detect subtle and serious vital
sign alterations.
o Family presence – Facilitate the family’s presence in the treatment area and support
their involvement in patient care. Provide explanations about care and procedures and
use resources to support their emotional and spiritual needs.

Copyright © 2022 by Emergency Nurses Association. Published by Elsevier, Inc. All rights reserved. 2
 Lesson Notebook:
Patient Assessment
o Get monitoring devices and give comfort
▪ L: Obtain laboratory studies
▪ M: Monitor cardiac rate and rhythm
▪ N: Consider nasogastric or orogastric tube insertion
▪ O: Assess oxygenation and ventilation
▪ P: Assess and manage pain

• After addressing emergent threats, the secondary survey aims to identify all clinical
indications of illness or injury using the HIJ portion of the mnemonic.
o History – Collect history data while performing a head-to-toe assessment. Discuss the
patient’s chief complaint, history of current illness or injury, medical history, current
medications, and allergies. To help organize and obtain an adequate history, use the
SAMPLE mnemonic: symptoms, allergies, medications, past medical and surgical
history, last oral intake/last output, and events and environmental factors related to the
illness or injury. As time permits, elicit a family and social history. Be sure to identify and
address communication needs related to vision, hearing, language, or developmental
delays.
o Head-to-toe examination – Inspect and palpate the head and face, including the skin,
bones, eyes, ears, nose, and mouth. Assess level of consciousness using a standardized
tool, such as the Glasgow Coma Scale. If the patient has a decreased level of
consciousness, use the AEIOU-TIPPS mnemonic as a guide to possible causes: Alcohol,
Epilepsy or electrolytes, Insulin (hypoglycemia or hyperglycemia), Opiates, Uremia,
Trauma, Infection, Poison, Psychosis, and Syncope.
▪ Assess the oral mucosa for color, hydration status, inflammation, swelling and
bleeding. Note malocclusion and loose or missing teeth.
▪ Inspect and palpate the neck to detect jugular vein changes, tracheal deviation,
point tenderness, dysphagia, and other abnormalities. Auscultate for bruits.
▪ For the chest, record respirations, observe the anterior and lateral chest walls,
palpate for bony deformity and other changes, auscultate breath sounds and
heart sounds. Perform more detailed assessments for patients with dyspnea,
abnormal breath sounds, or chest pain.
▪ To assess the abdomen, inspect it thoroughly, auscultate bowel sounds, gently
palpate all four quadrants, test emesis or stool for blood, and fully investigate
gastrointestinal complaints.
▪ To evaluate the pelvis and perineum, observe for lacerations, other skin
changes, and bleeding; assess genital concerns, vaginal bleeding, priapism, and
urinary complaints; palpate the pelvis bone; assess anal sphincter tone (if
indicated); inspect for labial or scrotal hematoma; consider pregnancy; and if the
patient is pregnant, assess fetal heart tones.
▪ Inspect all four extremities. Note pulses, limb movement, and sensation. Inspect
and palpate for pain, tenderness, deformities, and other problems. Assess
neurovascular status distal to any injury site.
o Inspection of posterior surfaces – Evaluate the patient’s back and posterior aspects of
the arms and legs. Observe for patterned injuries or other injuries that suggest abuse.
Palpate the vertebral column for tenderness and deformity. If needed, perform a rectal
examination.

Copyright © 2022 by Emergency Nurses Association. Published by Elsevier, Inc. All rights reserved. 3
 Lesson Notebook:
Patient Assessment

o Just keep reevaluating – Vital signs, injuries sustained and interventions performed,
primary survey, and level of pain

Special Patient Populations

• Because of their extremes in age, pediatric and older adult patients have unique anatomic
and physiologic characteristics. Obstetric and bariatric patients have changes in body
habitus. Patients from all four populations exhibit assessment-related differences in airway,
breathing, circulation, disability (neurologic status), vital signs, and other areas.

• Examples of variations in pediatric patients - Airways are narrower and shorter than in adults,
which means that obstruction can develop quickly. The head is large in proportion to body.
Flexion of the airway can cause obstruction when the pediatric patient is supine. The chest wall is
thin and the thorax is small; breath sounds are not easily differentiated. The circulating volume is
proportionally greater. The Pediatric Glasgow Coma Scale is used. Heart and respiratory rates
decrease with age. You need to assess immunization status and developmental stage.

• Examples of variations in older adult patients - Loose dentures may obstruct airways.
Changes may include limited chest excursion, decreased cardiac output at rest, gait and
ambulation changes, decreased respiratory rate, and increased blood pressure. Comorbidities
and polypharmacy are likely.

• Examples of variations in obstetric patients - Changes may include predisposition to

nosebleeds and airway obstruction, decreased pulmonary reserve, increased oxygen
consumption, hypervolemia, hypercoagulability, increased heart rate, and blood pressure
variations based on trimester. Obstetric patients require fetal heart tone assessment (after 10 to
12 weeks’ gestation, as part of maternal vital signs), fundal height measurement (which is most
accurate between 20 and 32 weeks’ gestation and correlates in centimeters with gestational age
in weeks), and perineal assessment.

• Examples of variations in bariatric patients - Bag-mask ventilation and endotracheal intubation

may pose difficulties. Changes may include increased work of breathing, diminished breath
sounds, hypervolemia, muffled heart tones, increased risk of stroke, and increased heart and
respiratory rates. Comorbidities are likely.

Ongoing Assessment
• Perform ongoing assessments to identify the patient’s response to interventions and detect
improvement or deterioration in the patient’s status. Follow facility protocols, which may require
you to repeat:
o The trauma score calculation on arrival and 1 hour afterward
o Vital sign measurements and the neurologic assessment every 15 minutes for a
patient receiving fibrinolytic therapy
o The pain rating 30 minutes after administering parenteral opioids

Copyright © 2022 by Emergency Nurses Association. Published by Elsevier, Inc. All rights reserved. 4
 Lesson Notebook:
Patient Assessment

Notes

Copyright © 2022 by Emergency Nurses Association. Published by Elsevier, Inc. All rights reserved. 5