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WILSON MEMORIAL GENERAL HOSPITAL P.O. BAG ‘W’ MARATHON, ONTARIO POT 2E0 POLICY & PROCEDURE MANUAL DEPARTMENT: POLICY/PROCEDURE NO: Nursing, Emergency Room ER-S-04 Assessment SUBJECT: DATE OF ISSUE: Standards of Practice: Assessment DISTRIBUTION: REVISION DATES: July 24, 2002 Nursing APPROVAL: PAGE: [1] of [5] PURPOSE: To collect systematic and pertinent data about the health status of an individual admitted to the Emergency Department. POLICY: 1. 2. 3. Data is recorded and communicated to appropriate persons. Priority of data collection is determined by the immediate physical and emotional condition of the individual. The detail with which the assessment and intervention is completed depends upon the needs of each individual. Ongoing assessment is made as long as the individual is in the Emergency Department. CRITERIA: ASSESSMENT: 1. A pertinent patient history is obtained: chief complaint history of present illness allergies medications recent medical/surgical history pertinent family history cultural, socioeconomic and environmental conditions pertinent to immediate health care. 2. Pain is assessed: location quantity onset duration chronology associated mechanisms alleviating mechanisms 3. Alterations or deficits in body systems/responses are assessed: Skin: temperature colour moisture level turgor nail beds petechiae scars lesion rash Musculoskeletal: joint swelling deformity inflammation limitation of motion hyperextensions hyper mobility crepitations grating fixation pain curvature of spine Ears: - wax discharge hemorrhage foreign bodies in canal swelling or redness external ear drum appearance - lesions deformities Nose: - exudate bleeding of the nasal mucosa nasal obstruction Mouth and Pharynx: colour of lips missing or loose teeth inflammation drooling exudate lesions asymmetry of oral cavity tonsils uvula odour of breath appearance of tongue Neck: - enlargement and tenderness of glands and lymph nodes distended veins scars degree of neck mobility tracheal position Thorax: - scars abnormalities of contour, symmetry and expansion Lungs: - use of accessory muscles for respiration abnormal rate of rhythm of respiration dyspnea orthopnea cough exudate discrepancies of air entry abnormal expiration abnormal breath sounds Heart: - localize apical impulse abnormal rate abnormal rhythm and quality PERIPHERAL VASCULAR Arms and Hands: characteristics of radial pulses regularities or absence of radial pulses edema colour abnormalities temperature abnormalities clubbing blood pressure Legs and Feet: femoral pulse pedal pulse inequality or absence of pulses edema colour abnormalities temperature abnormalities Abdomen: - scars umbilical abnormalities contour abnormalities hernia presence or absence of bowel sounds distended bladder ascites tenderness Gastrointestinal: nausea and vomiting recent weight loss or weight gain distention tarry stools diarrhea constipation bowel sounds last bowel movement Urinary: dysuria frequency and burning on voiding nocturia haematuria incontinence urine retention Genitals: - inflammation discharge lesions swelling tenderness haemorrhoids Neurological: as per Glasgow Coma Scale - recognize level of consciousness recent and remote memory changes emotional instability aphasia difficulty in comprehending spoken language abnormalities in gain and balance bilateral symmetry of strength headache paralysis lethargic dizziness seizure syncope restlessness DATA COLLECTION: 1. 2. 3. 4. Data is obtained through interview with the patient, family/significant other. Data is obtained through observation. Data is obtained through physical examination - to include palpitation, auscultation and inspection. Data is obtained through review of patient's lab and x-ray reports and previous records. 2002-07-24:jpp
