The initial assessment in emergency nursing is critical for identifying and managing life-threatening conditions as quickly as possible. It follows a structured, systematic approach called the Primary Survey, often abbreviated as ABCDE.
🧑⚕️ 1. Primary Survey (ABCDE Approach)
🅰️ Airway (with C-spine control)
Assess: Is the airway open and clear?
Look for: Obstruction, swelling, foreign bodies, altered level of consciousness.
Action:
Perform jaw thrust or head tilt-chin lift (if no C-spine injury suspected).
Suction as needed.
Insert airway adjuncts (e.g., oropharyngeal airway).
🅱️ Breathing
Assess: Is the patient breathing? Rate, rhythm, depth, effort.
Look for: Cyanosis, use of accessory muscles, chest rise, abnormal breath sounds.
Action:
Administer oxygen.
Assist ventilation if necessary (bag-valve mask).
Prepare for intubation if inadequate respiratory effort.
🅲️ Circulation
Assess: Pulse rate and quality, capillary refill, skin color, temperature.
Look for: Active bleeding, signs of shock (e.g., low BP, tachycardia).
Action:
Control bleeding.
Establish IV access (large bore).
Start fluid resuscitation if needed.
Monitor heart rhythm and vital signs.
🅳 Disability (Neurological Status)
Assess: Level of consciousness (LOC) using AVPU or Glasgow Coma Scale.
AVPU: Alert, Verbal, Pain, Unresponsive
Look for: Pupil size/reactivity, limb movement, signs of stroke.
Action:
🅴 Exposure/Environment
Expose the patient to assess for other injuries or abnormalities.
Prevent hypothermia: Cover the patient as soon as possible after exposure.
🔄 Reassessment
After the ABCDE assessment:
Stabilize the patient.
Perform a secondary survey (head-to-toe exam, history taking).
Continuously monitor ABCs and vital signs.
📌 Key Priorities in Emergency Nursing Assessment
Rapid triage to prioritize care based on acuity.
Documentation of all findings.
Communication with the interdisciplinary team.
Patient advocacy, especially if the patient is unconscious or nonverbal.
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