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ED nurse initiated Mx - basic assessments

basic nursing assessment common to all pathways

document brief history:

  • 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

document targeted examination:

  • 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

escalate medical referral if red flags:

  • decreased mental state
  • ongoing seizures
  • possible meningococcal septicaemia or meningitis
  • hypotension
  • heart rate > 140
  • hypoxia
  • air compromise eg. new stridor
  • 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

commence nurse initiated Mx

nursing/nursingrxbasics.txt · Last modified: 2012/07/19 14:02 (external edit)