This guide has been created to assist students in preparing for emergency simulation sessions as part of their training. It is not intended to be relied upon for patient care.
Assessment: General Clinical Nursing Seminar
The list of differentials for chest pain is long. However, a focused history covering cardiac risk factors can help you to determine which patients are more likely to be suffering from ACS. When a patient presents with chest pain, it is impossible to arrive at a diagnosis without further examination and investigation. A comprehensive history of the chest pain using a SOCRATES method see our chest pain history taking guide can help to narrow the differential diagnosis considerably. However, you will still require further investigations such as ECG and serum troponin levels to be confident of the diagnosis.
Silent MIs do not present with these classical symptoms. Females, the elderly and diabetics are at increased risk of suffering ACS with minimal symptoms. Often the only symptom may be shortness of breath. Importantly, ACS can occur in the absence of any physical signs. Perform a quick general inspection of the patient to get a sense of how unwell they are:.
If the patient is unconscious or unresponsive and not breathing start the basic life support BLS algorithm as per resuscitation guidelines. Call for help! If you think your patient has a compromised airway you need help! Put out a crash call immediately as you require urgent anaesthetic input to secure the airway.
You can perform some simple airway manoeuvers in the meantime. If this is still not enough to open up the airway you can consider the use of an airway adjunct:. You want to get an ECG as soon as possible so you can know what you are dealing with:. You must speak to the cardiology team ASAP. We have already covered oxygen in breathing. This allows continual reassessment of the response to treatment and early recognition of deterioration.
Well done! You have successfully implemented the immediate treatment for your patient. There are just a few more things to do….
If possible, it is important to revisit history taking to clarify risk factors for ACS and other relevant medical information. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate. Check out the history taking guides here. It is really important that you document your initial ABCDE findings, any interventions you made and the response the patient had to those interventions.
Also make sure document salient points from the history. If your patient requires Primary Coronary Intervention you will need to speak to Cardiology directly. As a junior doctor it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:. This site uses functional cookies and external scripts to improve your experience.
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2.7 Focused Assessments
We use Google Adsense, which serves personalised advertisements to users based on their browsing activity. The revenue we generate from these adverts allows us to keep the website free. Table of Contents. Initial steps You are likely to be called to see this patient either: On the ward or As a new presentation to ED with chest pain Inspection Perform a quick general inspection of the patient to get a sense of how unwell they are: If the patient is unconscious, check for a pulse and check that the patient is breathing.
What is their breathing like? Are there any clues from around the bedside? Intervention If you think your patient has a compromised airway you need help! Maintaining the airway whilst awaiting senior support 1. Perform a head tilt, chin lift manoeuvre. Determine if patient ambulates independently, with one-person assist PA , two-person assist 2PA , standby, or lift transfer.
Ask relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level e. Inspect, palpate, and test muscle strength and range of motion:. Note strength of handgrip and foot strength for equality bilaterally. It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment Stephen et al. The focused neurological assessment in Checklist 23 outlines the process for gathering objective data.
Spontaneously 4 To speech 3 To pain 2 No response 1 Best motor response to painful stimuli Press at fingernail bed and record best upper-limb response. Oriented x 3 to person, time, and place 5 Conversation — confused 4 Speech — inappropriate 3 Sounds — incomprehensible 2 No response 1 Glasgow Coma Scale adapted from Jarvis et al.
Focused Respiratory System Assessment
Note hygiene, grooming, speech patterns, facial expressions. Unequal pupils may indicate underlying neurological disease or injury.
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Chapter 2. Patient Assessment. Your patient complains of stomach pain during your head-to-toe assessment. What would be your next steps? You notice that your patient seems lethargic during your head-to-toe assessment. Previous: 2. Next: 2. License 2. Share This Book. Safety considerations: Perform hand hygiene. Introduce yourself to patient. Confirm patient ID using two patient identifiers e. Explain process to patient.
Be organized and systematic in your assessment. Use appropriate listening and questioning skills. Listen and attend to patient cues. Additional Information. Assess respiration rate With hypoxemia, cyanosis of the extremities or around the mouth may be noted. Wheezing may indicate asthma, bronchitis, or emphysema.
Low-pitched wheezing rhonchi may indicate pneumonia. Pleural friction rub creaking may indicate pleurisy. Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation. Assess capillary refill Assess bilateral lower legs Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation CWMS may indicate underlying conditions or injury. Auscultate apical pulse at the fifth intercostal space and midclavicular line.
Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses. Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.