ED nurse initiated Mx - basic assessments

see also:

• EM nursing
• nurse initiated ED treatment
• ED nurse initiated analgesia

• current presentation including:
  • duration of illness
  • symptoms
  • likely diagnosis
  • assessment of possible dehydration, sepsis, meningitis
  • last ate or drank - if surgery if likely in the next 8 hours, keep nil orally
  • pain score
  • assess blood loss
• notable past history
• important comorbities:
  • diabetes - if so, are they acidotic or ketotic?
  • pregnancy status - if so, care with medications, Xrays and consider possible ectopic as cause of any abdominal pain
  • warfarin or other anticoagulation therapy
  • severe organ disease eg. requiring dialysis, liver impairment, severe COPD or obstructive sleep apnoea (issue with opiates)
• allergies
• other important medications, including recent analgesic or antibiotic use

• vital signs as applicable - heart rate, BP, SaO2, temp, resp. rate
• blood sugar level if diabetic
• urinalysis if:
  • possible UTI
  • renal trauma
  • need to exclude pregnancy prior to Xray, medications
  • diabetic to exclude UTI and ketosis
• search for petechial rash or neck stiffness if febrile to ensure timely Mx of possible meningococcal septicaemia or meningitis
• assess for neurovascular compromise in limb injuries

• decreased mental state
• ongoing seizures
• possible meningococcal septicaemia or meningitis
• hypotension
• heart rate > 140
• hypoxia
• air compromise eg. new stridor
• major trauma call
• possible diabetic ketoacidosis
• possible ruptured ectopic pregnancy or other on-going heavy blood loss
• other time-critical surgical conditions - eg. acute scrotal pain
• condition-specific red flags

• ED nurse initiated analgesia
• nurse initiated ED treatment