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.

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🧑‍⚕️ 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:

  • Monitor LOC changes.

  • Protect airway if reduced consciousness.

  • Check blood glucose.

🅴 Exposure/Environment

• Expose the patient to assess for other injuries or abnormalities.

• Prevent hypothermia: Cover the patient as soon as possible after exposure.

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🔄 Reassessment

After the ABCDE assessment:

• Stabilize the patient.

• Perform a secondary survey (head-to-toe exam, history taking).

• Continuously monitor ABCs and vital signs.

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📌 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.