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Med-Surg · chapter 33 · Emergency Care

Triage and Assessment

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 4 practice questions with the reasoning.

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Key points

  1. Recognizing ED cues

    It is important for the nurse to identify the cues from the patient assessment, such as the chest pain, BP, and HR, that indicate there is a problem and then analyze those cues to determine the next steps.

  2. Triage assessment actions

    The first is to complete an assessment to determine immediate concerns. This involves asking questions, using clinical judgment to recognize cues, analyzing cues, and prioritizing findings.

  3. Patient privacy during triage

    While conducting triage, the nurse should remember to ensure that the patient’s privacy is protected.

  4. ABCDE triage method

    One of the most utilized method for triaging patients in emergency situations is the airway, breathing, circulation, disability, and exposure (ABCDE) triage assessment (Althobity et al., 2024).

  5. Airway priority

    When using the ABCDE triage method, the airway is assessed first regardless of underlying cause or patient age (Althobity et al., 2024). Emergency airway conditions are always treated first before moving to other areas or body systems.

  6. Airway patency check

    When assessing the airway, the nurse first checks for patency. This can be done by asking the patient questions and listening to their response.

  7. Breathing assessment signs

    The nurse should assess whether the patient’s chest rises symmetrically and whether the trachea is midline. The nurse will also determine how much effort it takes for the patient to breathe.

  8. Compromised breathing interventions

    Recommendations for compromised breathing include positioning the patient, providing supplemental oxygenation, and implementing an artificial airway, such as an endotracheal tube for airway management (Raveendra et al., 2020).

  9. Circulation assessment

    Once the patient’s airway and breathing are stable, assessing for circulation to determine adequate perfusion is critical.

  10. Disability assessment tool

    The Glasgow Coma Scale (GCS) is the most widely used assessment tool for assessing level of consciousness in emergency cases.

  11. Exposure assessment

    The nurse needs to assess for signs of underlying bleeding or trauma and skin abnormalities. Make sure to inspect the whole body, including the back and groin for any injuries or rashes.

  12. Acute symptom priority

    Acute symptoms (those that are current/recent) take precedence over chronic, long-term symptoms or health conditions.

  13. Documentation importance

    Documenting timely, accurate, and complete assessments ensures that the information shared among health-care professionals is factual. Many decisions among the interdisciplinary team are based on documentation of every patient encounter.

  14. Minor emergency treatment

    If the minor needs immediate medical attention and the provider cannot obtain consent from a parent or legal guardian, then they can proceed with treatment.

Terms to know

triage
The term triage refers to the process of assessing and prioritizing patients’ care based on initial assessment findings.
disability
In this triage method, disability refers to a patient’s level of consciousness.
subjective assessment findings
Symptoms, or subjective assessment findings, are those findings that the nurse does not directly observe and are only reported by the patient.
objective assessment findings
By contrast, objective assessment findings, or signs, are aspects that the nurse directly observes and that can be measured.
consent
When patients come into the emergency room and are able to sign documents, the first document they sign is a consent, which gives medical professionals the authority to treat the patient with the most competent and highest quality of care.
implied consent
If a patient is brought to the emergency room and is unable to sign at that time, life-sustaining measures are still provided under implied consent, which means approval is presumed though not obtained during an emergent situation due to the life-threatening nature of the situation.
Minors
Minors, or those under eighteen years of age, are often brought in by parents or legal guardians to be seen in the emergency department.

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

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Every question here, with the answer

  1. At ED intake, a patient reports chest pain radiating to the left arm and rates it 8/10. You observe diaphoresis and measure a heart rate of 111 bpm. Which entry most accurately documents these findings without adding assumptions?

    1. Chest pain 8/10, objectively confirmed by diaphoresis and HR 111 bpm.
    2. Patient reports chest pain radiating to the left arm, rated 8/10; patient is diaphoretic; HR 111 bpm.
    3. Chest pain with tachycardia and diaphoresis, likely myocardial infarction.
    4. Patient reports chest pain, sweating, and a rapid heartbeat; pain rated 8/10.

    Answer: Patient reports chest pain radiating to the left arm, rated 8/10; patient is diaphoretic; HR 111 bpm.

    The correct entry identifies pain as the patient's report and preserves the nurse's observed and measured findings. The other entries infer an unconfirmed diagnosis, attribute observed findings to the patient, or present a subjective pain rating as objectively confirmed.

  2. At 14:00, you complete an ED assessment and have an opportunity to document without delaying patient care. The patient will have additional encounters during the visit. Which documentation approach best follows the section?

    1. Save the assessment findings for an end-of-shift entry so the full course of care can be summarized.
    2. Wait for the next assessment and document only the latest findings to avoid duplicate information.
    3. Wait until the care plan is finalized so the assessment and plan can be entered together.
    4. Document this assessment now, then document later encounters near their occurrence and in chronological order.

    Answer: Document this assessment now, then document later encounters near their occurrence and in chronological order.

    Documentation should follow the order of encounters and be completed as close as possible to when they occur. Waiting for shift end or a finalized plan unnecessarily delays documentation, while recording only the latest assessment leaves a gap in the encounter record.

  3. At 15:00, you finish providing nursing education, discussing advance directives, and confirming the patient's language preference. You also complete medication reconciliation. Your draft note contains only assessment findings. Which revisions are appropriate? Select all that apply.

    1. Document that medication reconciliation was performed.
    2. Add the nursing education provided during the encounter.
    3. Add the patient's language preference and the discussion of advance directives.
    4. Include the advance-directive discussion only if the patient completed a signed directive.
    5. Include medication reconciliation only if it resulted in a medication change.

    Answer: Document that medication reconciliation was performed., Add the nursing education provided during the encounter., Add the patient's language preference and the discussion of advance directives.

    The section includes nursing education, advance-directive discussions, language preference, and medication reconciliation among the communications and activities nurses should document. It does not make documentation of the discussion dependent on a signed directive or documentation of reconciliation dependent on a medication change.

  4. At 16:20, a minor needs emergency care, and the parent is available only by telephone. You are arranging verbal consent and its documentation. Which actions meet the telephone-consent process described in the section? Select all that apply.

    1. Use a nursing narrative describing the call instead of obtaining witness signatures on the consent form.
    2. Have the two witnesses obtain matching consent statements from the parent in separate calls.
    3. Arrange for two witnesses to listen to the parent's consent simultaneously.
    4. Have both witnesses sign the consent form indicating that consent was received by telephone.
    5. Have one witness hear the call and a second witness verify the first witness's written account afterward.

    Answer: Arrange for two witnesses to listen to the parent's consent simultaneously., Have both witnesses sign the consent form indicating that consent was received by telephone.

    The section requires two witnesses to hear telephone consent simultaneously and sign the consent form indicating how consent was received. Reviewing another witness's account or making separate calls does not meet the simultaneous-listening requirement, and a narrative alone does not replace the required signatures.

Where every quote comes from

Section 33.1 Triage and Assessment of Medical-Surgical Nursing by Christy Bowen, Bridget Carey, Jessica Palozie, Maren Reinholdt, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.