Assessment in ER
Initial impression, ABCs, secondary assessment, and focused respiratory, cardiac, neuro and GI assessments.
Patient Assessment and Triage
Patient Arrival: Initial Impression & ABCs
First and foremost, you will be proactive, not reactive. Your rooms will have all the necessary equipment and supplies needed for an emergency. These include: • Bag Valve Masks (adult and pediatric) • Suction and Oxygen Equipment • Supplies needed to connect the patient onto the monitor When your patient arrives: • Obtain an initial impression • Focus on the ABCs (Airway, Breathing, Circulation) • Get your patient on the monitor • Gather pertinent history • Prepare to place an IV if needed.
Initial Impression
The initial impression, or visual assessment, involves quickly scanning the patient to gather easy-to-see visual information about their overall condition. Essentially, at a glance, you are trying to see how sick a patient looks. • General Mentation (Neuro) o Are they awake and alert? o Somnolent, drowsy or easily falling asleep? • Circulation and Perfusion o Skin color? Cool clammy skin? Diaphoretic and pale? Mottled? o Peripheral Edema? • Breathing o Visible respiratory distress? Rapid breathing? o Use of accessory muscles? Audible wheezing or stridor? • Discomfort and Pain o Grimacing or Guarding a specific area? The initial impression is useful because at a glance, it allows you to determine if a patient "looks" sick and if so, they can be prioritized.
Airway Breathing Circulation
A common misconception is that the ABC's are performed one at a time. While the ABCs are approached systematically, many things happen simultaneously. For example, while connecting to the cardiac monitor, you can ask questions regarding their visit. If they are speaking and breathing without issues, you note their 'Airway' and 'Breathing' are intact. If you are having airway or breathing issues, you won't be speaking in nice, calm sentences. On the other hand, when a patient is in respiratory distress, you will place them on oxygen, place them on the cardiac monitor and place an IV, while the provider is moving down the ABC's. Everyone is working as a team to help stabilize the patient. The ABCs systematic method guides healthcare providers, including nurses, in quickly identifying and treating conditions that compromise oxygenation, ventilation, and perfusion. 1) Airway: Assessment and Interventions a) Assessment: Evaluate for Airway Obstruction i) If speaking, the airway is open. ii) Swelling/Edema, Stridor, Gurgling sounds or Hoarseness of the voice iii) Secretions, Vomitus or Foreign Body b) Interventions i) Position Maneuvers (1) Head Tilt Chin Lift (2) If concern for cervical/spinal trauma, Perform Jaw Thrust ii) Airway Adjuncts (1) Oropharyngeal Airway (a) Only if no gag reflex present in a comatose patient (2) Nasopharyngeal Airway (a) Only when there is no facial trauma (3) Suction (4) Oxygen Administration (a) Non-Rebreather Reservoir Mask (NRB) (b) Bag Valve Mask (BVM) (5) Endotracheal Intubation (6) Cricothyrotomy 2) Breathing Assessment and Interventions a) Assessment i) Observe Rate, Depth, and Use of Accessory Muscles ii) Lung Sounds and Symmetry of Chest Rise iii) SpO2 b) Interventions i) Oxygen (1) NRB (2) BVM (a) Ventilating the patient (providing breaths-observe for chest rise) if no spontaneous or ineffective breaths are present ii) High Flow, Noninvasive Ventilation (Bipap/Cpap) iii) Needle Decompression and Chest Tubes iv) Intubation 3) Circulation a) Assessment for adequate perfusion i) Capillary Refill, Pulses, Heart Rate, Skin Color, Blood Pressure, Mentation, ECG ii) Locate Sites of Bleeding b) Interventions i) Fluid Administration, Blood Products, Vasopressors, Medications to help with oncotic pressure such as Albumin ii) Tourniquet, Vessel Ligation iii) CPR and Advanced Life Support Algorithms 4) Disability a) Assessment i) Level of Consciousness, Orientation Status, GCS ii) Pupils and Glucose iii) Motor and Sensory Function b) Interventions i) Radiology to Pinpoint areas of damage ii) Glucose Administration iii) Intubation for airway protection r/t decreased mentation Protect the C-Spine when performing airway maneuvers.
Secondary Assessment
The secondary assessment is a comprehensive evaluation conducted after the initial stabilization to identify injuries or issues that may have been missed. It focuses on obtaining a detailed medical history, performing a head-to-toe physical examination, obtaining diagnostic studies and laboratory tests. 1) Gathering Medical History a) Helps provide insight into the patient's overall health and can help identify causes of the patient's current condition b) SAMPLE Mnemonic i) S: Signs and Symptoms (1) Chief complaint and presenting symptoms. Obtain information about the onset, duration, location, severity, and associated factors of their symptoms. ii) A: Allergies (1) Inquire about any known allergies, including medications, food, environmental, or other allergens. Document the type of reaction. iii) M: Medication Use (1) Ask the patient about their current medications, including prescription, over-the-counter, and herbal supplements. Document the name, dosage, and frequency. Ask about compliance and any recent changes to their medications. iv) P: Past Medical History (1) Diagnosed Conditions (2) Surgeries (3) Drug/Alcohol/Smoking (4) Recent Hospitalizations (5) Pertinent Family History v) L: Last Oral Intake or Last Meal (1) Determine the patient's last oral intake of food, fluids, or medications. Document the time and type of intake, especially if the patient may require sedation, anesthesia, or surgical procedures. vi) Events (1) Ask about the events leading up to their current condition. Gather information about any trauma, environmental exposures, activities, or lifestyle factors that may be relevant to their condition. 2) Repeat Set of Vital Signs a) Repeating vital signs allows nurses to monitor the patient's response to interventions and assess for any changes in their condition. Vital signs provide valuable insights into the patient's physiological status, helping nurses identify signs of improvement, deterioration, or instability. b) Heart Rate, Blood Pressure, Respiratory Rate, SpO2, Temperature and Pain i) Heart Rate: High or Low can cause a patient to become unstable (1) Tachycardia: Can be a sign of pain, fever, shock, or cardiac issues. (2) Bradycardia: May indicate issues such as cardiac conduction issues, hypothermia or medication side effects. Any heart rate <40 should be taken seriously despite a "stable blood pressure." ii) Blood Pressure: High or Low can lead to perfusion issues and organ damage (1) Hypertension: Can indicate underlying cardiovascular disease, renal dysfunction, stress or poor compliance with medications. (2) Hypotension: May signify hypovolemia and shock (different types of shock) iii) Respiratory Rate (1) Tachypnea: May be a sign of respiratory distress, hypoxia, pain, anxiety, or metabolic acidosis. (2) Bradypnea: Can indicate drug overdose, central nervous system depression, or respiratory failure. iv) SpO2 (1) Hypoxemia: Can be due to respiratory failure, pneumonia, asthma, airway obstruction or countless respiratory issues. v) Temperature (1) Hyperthermia: May indicate infection, inflammation, or heat-related illness (2) Hypothermia: Can result from exposure to cold environments, shock, or other issues. 3) Head-to-Toe Examination a) A more thorough examination is necessary to ensure nothing is missed. Ensure you turn the patient and assess everything. Go through each body system: Neuro, Cardiac, Resp, GI and so forth. b) We will go more in-depth on assessments and how to perform them in the later chapters. 4) Diagnostic Studies and Laboratory Tests a) Can help identify underlying medical conditions or injuries that may not be immediately apparent during the initial assessment. b) Can confirm or rule out suspected diagnoses i) For example, imaging studies such as X-rays can help confirm orthopedic issues like fractures and dislocations, while CTs can help confirm internal issues like gallstones and pulmonary embolisms. Laboratory tests can confirm infectious diseases, metabolic imbalances, or organ dysfunction. We will review labs in a later chapter. c) Can help gauge disease severity: how sick are they i) For example, a high lactate is known to be a sign of poor tissue perfusion and poor outcomes if no interventions are performed while an ABG can help assess the severity of respiratory conditions by looking at the PaO2 and PaCO2. 5) Recognition of Abnormal Findings and Prompt Communication a) As the primary nurse, one of your roles is to keep track of assessment findings and results, and promptly communicate/relaying when there is an abnormal finding. b) For example, if on the repeat set of vitals after the initial stabilization you start noticing a trend of the BP going lower and lower, or the heart rate going higher and higher, or if the potassium level is 6.8 or even the patient's mentation is changing. i) You will need to continuously be on the lookout for abnormal findings and promptly communicate. Of course, perform a good assessment so that when you speak to your provider you are able to paint the whole picture of the situation and provide a good SBAR.
Focused Assessments
Why should we be good with our assessments? Well, in the ER, we are trying to rule out or look for diseases that are deadly! Differentiating patients who are sick vs. not sick. As an ER nurse, you are going to be busy, you're going to have many things to do, and you need to figure out who deserves your time the most, aka prioritization. So the goal is to be quick and concise! You should eventually get to the point where you are in and out in 5-10 minutes or less! But of course, in this time you will find out if your patient is "sick," and if they are, you will devote more time to them. One point I want to make is that although we are only talking about the assessment here, it is important to know that you will be performing interventions and treatments while performing the assessment.
Respiratory Assessment
So what are we trying to answer when we are doing a respiratory assessment? We are focusing on the lungs, trying to figure out if adequate gas exchange is occurring, and gas exchange is determined by a fine balance between ventilation (air movement-oxygen) and oxygenation (blood absorbing oxygen).
Initial Assessment
The first part of the assessment is the visual assessment, otherwise known as the first or initial impression. I've heard it called the 'visual vital signs.' Here we are simply looking at the patient and determining if they look sick. Key findings include: • Increased or decreased respiratory rate • Use of accessory muscles • Tripoding • Audible stridor and wheezing • Visible swelling of the lips or tongue • Inability to speak. Again, you can tell all of this from the door of the room, which is why it's known as the visual assessment.
Patient Who is Not Ill-Appearing
If the patient isn't in severe respiratory distress and is able to speak, we'll gather information from them.
Questions
• When did the SOB or difficulty breathing start? • What were they doing? For example, just sitting down vs. strenuous activity? • Was it sudden? (Think of PEs or a spontaneous pneumo) (Side note: I've seen a lot of spontaneous pneumos in tall and skinny patients) • Was the SOB gradual? (perhaps pneumonia or CHF exacerbation?) • Do they experience sob or sensation of drowning with laying down or activity? (Cardiac issue like CHF or anemia, even). • Ask if they have a cough, whether it is productive or not and if so, what color? Ask about fevers and chills? (Infectious sources of symptoms like pneumonia). • Any recent airplane travel or long car rides where the patient is sitting? (DVTs -> PEs). • Has this ever happened before? What was done for it in the past?
Medical Hx and Medications
• Is there a history of lung issues such as COPD or Asthma? • History of cardiac issues? • What current medications are you taking? Keeping note of albuterol and other inhalants and meds like lasix, are they even taking them? Did they run out? Can't afford them? • Do they smoke or used to smoke? Smokers get lung damage so they are more at risk for pulmonary complications.
Physical Assessment:
• Respiratory Rate and Effort • Chest Symmetry and Breathing Pattern • Listen to lung fields: Comparing sides as you go. Assess for air movement (at least they are getting air/oxygen in and CO2 out) • Abnormal Lung Sounds: crackles (CHF, PNA ) or wheezing (perhaps asthma or allergic reaction), or rhonchi (PNA, COPD). • Listen to trachea if needed for stridor: may indicate a partial upper airway obstruction • SpO2
Patient Who is Ill Appearing
Your initial impression tells you that this patient is sick. Your patient may not be able to speak and answer questions. When this occurs, treatments take priority (while simultaneously assessing).
Immediate Actions
• Place on cardiac monitor: SpO2, Respiratory Rate, ECG, Heart Rate, BP • Provide oxygen: Depending on the severity use Nasal Cannula, Non-rebreather (NRB) or bag-valve mask (BVM) • Obtain IV access: Crucial for medications You're part of a team, so it may be your provider assessing while you're focused on the tasks above. If you are working alone, 1) First, place on oxygen and ensure someone is notifying the provider. 2) Second, place the patient on the pulse ox, then listen to their lungs, assessing for air movement. a) If the patient is working really hard to breathe but there isn't air movement, the patient can go into respiratory failure shortly.
Continue Stabilization/Assessment
• Listen to the lungs: crackles, wheezing, stridor • Connect your patient to the rest of the cardiac monitor to obtain vital signs and basic ECG rhythm o As far as vital signs, if the patient is tachy and has one swollen lower extremity then possible PE? Tachy and fever, then pneumonia? If spo2 is not improving on a NRB or with BVM, then does the patient need to go on noninvasive (BPAP,CPAP) or get intubated? Keeping in mind that for BIPAP/CPAP mentation needs to be intact so pt can protect their own airway. • Assess for Respiratory Effort, Retractions, chest wall symmetry (equal chest rise and fall), patient position (e.g., tripoding), skin color and pt alertness/mentation. o If mentation is declining and there is minimal air movement on auscultation, respiratory failure is imminent. • Assess for edema to lower extremities, abdomen and upper extremities, is it possibly CHF or liver failure? Any vomit around face or clothing, signaling perhaps aspiration? Edema or swelling of lips and tongue will lead you to an anaphylactic reaction. • Do they need respiratory medications? Albuterol and Atrovent breathing treatment to open airways? Magnesium to help relax bronchial smooth muscle? Steroids to decrease inflammation in the airways? Prioritize these medications. Then after assessment and interventions are underway you can start on history gathering, whether from EMS, family, patient, or a chart review.
Cardiac Assessment
With the cardiac assessment, we are trying to figure out if the body is getting the perfusion it needs.
Initial Impression
With the Initial Impression, we are looking for: • Mottled skin, diaphoresis, paleness, level of consciousness, patient position, and whether they are guarding or clenching at their chest.
Questions
• Assess Orientation o What is your name? o What year is it? What month is it? o Where are you right now? o What brought you to the ER? o These essentially tell you that the patient has adequate perfusion to the brain at this moment in time and is able to think and recall. • Question Chest Pain Symptoms o Does your chest hurt? Or do you feel pressure or palpitations? ▪ I've found that some patients don't consider pressure pain, and if you just ask about pain they may not bring up palpitations either. You can ask if their heart is racing instead of using the word palpitation. o When did your chest pain start? o What were you doing? Were you up and around doing activities or were you resting or were you eating? o Where is your pain? Does it radiate? Does it go to your shoulders, arms, back, neck or jaw? o What makes it worse? Does activity make it worse? What makes it better? Does rest make it better? o Is the pain constant or does it come and go? o Another important question is whether this type of pain has happened before, how did it go away and if they went to seek medical help, what were they told? • Associated Symptoms o Dizziness, SOB, nausea/vomiting and weakness which can all point to a cardiac etiology.
Medical History and Medications
• Any diagnosed heart problems? Any prior heart attacks? • What medications are they currently on? o Are they on blood thinners? BP meds? Aspirin on a daily basis? • Risk Factors: Smoking, Obesity, HTN, prior MI's. Essentially the more risk factors the likelihood something serious is occurring increases. • Key Point: Diabetic patients and women may present with nonspecific discomforts when having myocardial ischemia, so consider at least an ECG in these patients. • Key Point: This brings me to a very important point, which is that an ECG needs to be completed within 15 minutes of pt arrival, or it at least should be among the top things of your to do list because it can show an MI, arrhythmias, and even give clues for a PE. • Now, what about drug use? Drugs like cocaine and meth can cause chest pain from how hard they make the heart work. It's important to ask because treatment may differ.
Physical Assessment
• Cardiac Monitor o Blood Pressure, Heart Rate, Spo2, Cardiac Rhythm o I always like to repeat my patients blood pressure right off the bat even if the first one is great, especially if they "look" sick. I just don't fully trust the monitors. o Having the rhythm on the monitor is helpful because you can quickly see if your patient is in SVT, or afib RVR, or even in V-tach. o Tachycardia with a low blood pressure is indicative of shock. The heart rate rises to compensate. • Skin color, Pulses and Capillary Refill o A useful rule of thumb is that an SBP of around 70 is needed for carotid and femoral pulses to be palpable, while approximately an SBP of 80 is needed for a radial pulse and an SBP of 100 for pedal pulses. So if you can feel a radial pulse, you know that the BP is at least in the 80s or above. This is useful if the patient is not yet on the monitor or when the monitor is unable to capture a blood pressure. o A cap refill greater than two seconds is considered delayed. • Edema: Is it bilateral or unilateral? Bilateral tends to be a heart issue while unilateral can be a venous issue, perhaps a DVT. Take a quick look assessing for JVD as it can be a quick way of assessing for fluid overload, besides obvious pitting edema in the lower extremities. • Auscultate: Keep it simple. Are heart sounds loud and clear? Or are they distant? Irregular? Do you hear extra heart sounds like S3 S4 or murmurs? Further assessments that can occur at the bedside include a bedside echocardiogram performed by your provider. As far as history, if the patient cannot provide it, you'll do your best to obtain it from friends, family, EMS, and or a chart review if the patient has been at your facility in the past. Keeping it simple, the cardiac assessment will include: • Level of consciousness • ECG • Vitals: BP, HR, RR, SPO2 • Skin color, pulses, cap refill • Symptoms: Chest pain, Chest Pressure, Palpitations, SOB, nausea/vomiting, diaphoresis, dizziness, Pallor
Neuro Assessment
Time is brain! You do not want to be the nurse who missed a code stroke while triaging. You also want to accurately trend your patient's assessment throughout the shift, to ensure you catch changes. As we know, the first sign of deterioration in a neuro patient will be their mentation and level of consciousness. This will happen way before you start noticing vital sign changes or pupil changes. By obtaining a thorough baseline assessment, you can compare down the line when something changes. For example, if your patient is requiring more stimulation to answer your questions or perhaps you start feeling like something is off, you'll be able to compare those findings to your initial assessment and catch changes early. Of course, you won't perform a thorough neuro assessment on every patient, there's no time for that. However, if your patient presents with a neuro complaint like headaches, motor issues, sensory issues or altered mental status, they warrant a more thorough detailed neuro exam.
Initial Assessment
• Awake and alert? o Do they look at you when you come into the room? • Are they purposely using their extremities? Are they on their phone using both hands? • Are they neglecting one side? For example, moving the RUE to assist themselves, but never making an effort to move the left. • Facial Droop • Slurring of their speech • Gaze preference to one side?
Questions
• Orientation Questions o What is their name? o Where are you right now? o What day, month, or year is it? o Why are you in the ER? o These questions are assessing their ability to think and recall information, and if something is off internally, it will not be easy to do. • Speech o While your patient is speaking, is their speech clear? Slurred? • Symptoms o Always ask the when, how, and where questions. o When did the symptoms start? o How does the patient describe it. o Where is the symptom? o What makes it better and what makes it worse. o Specific Neuro symptoms include headaches, dizziness, blurry vision, tingling or numbness, tremors, balance or coordination issues and even bladder and bowel function. o Ask them if this has ever happened before, and if so what happened. Did it go away on its own or were they diagnosed with something? Key Point: For thrombolytics, it is essential to know when patients were last normal or when they were last seen normal. Thrombolytics are given within a specific window of 4.5 hours after initial symptom onset, so you have to know when the patient was last seen normal. • If comatose o You can ask EMS or family if it was sudden, gradual and intermittent mentation. For example if sudden, it can be from a subarachnoid hemorrhage, if gradual perhaps from a tumor inside the brain, or if fluctuating, perhaps from seizures or other pathologies. • Trauma o Your patient has a headache and keeps passing out, but was just recently hit with a bat to the back of their head, well that's important to know right. Or they recently fell from a ladder, and aren't acting normal per the family. • Prior medical problems, drugs alcohol and smoking, and current medications. For example, if the patient is on blood thinners, a head bleed may be anticipated after trauma.
Physical Assessment
• GCS • Pupils o Are they equal, round and reactive to light? Is the reactivity to light brisk or sluggish? Are their pupils pinpoint or dilated? What about symmetry? Are they different shapes or sizes from each other? I'll have them follow my finger in a side to side motion, then up and down. I'm looking for nystagmus and whether the patient can actually do it. I'll have them close one eye, focus with the other on my nose, and place fingers in each of the four quadrants, having them tell me how many fingers I'm holding up. I'll do this with both eyes. • Face o Facial Symmetry: Facial Droop o Ask them to smile, and to show their teeth, which makes it easier to see a droop. I'll ask them to lift both of their eye brows up as well. o Sensation: Test for sensation on both sides of the face, asking if it feels the same, or is one less? Or is there tingling or numbness present. • Upper Extremities o Ask to squeeze your fingers at the same time, noting if strength is equal. Push and pull you, noting symmetry of strength. o Drift: To assess for a drift, I have them close their eyes, lift their arms with palms up, and I'll count to 10 out loud, noting for drift while I'm counting. o Sensation: Touching both sides and asking if it feels the same. o Coordination: Finger to nose test to assess their coordination. • Lower Extremities o Have them lift against resistance o Push against my palm with pedal/plantar flexion and extension. o Drift: Have them lift each extremity separately, and hold for 10 seconds, counting out loud while I note for a drift. o Sensation: Touching both sides and inquiring whether they feel the same or different. If different, how so? Tingling, numb? Key Point: Become NIH Certified. Crucial to have for taking care of stroke patients.
Neuro Assessment for Intubated Patients
Performing a neuro assessment on an intubated patient comes with challenges as sedative medications prevent an accurate assessment. The challenge lies with, are you going to stop sedation every hour? Most likely not. • Although you may not be stopping the sedation hourly, keep track of your patient's neuro status trends • If at any point, you detect a change is occurring, you must stop the sedation to obtain an accurate neuro assessment
Physical Assessment
• Pupils • GCS • Extremity Assessment o Although the patient may not follow commands as a result of the sedation, you can provide a noxious stimulus to assess sensation and motor response • Noxious Stimulus o Withdrawal or localization from the noxious stimuli lets us know sensation is present and movement of the extremity signals that motor function is intact • Facility Protocol: o You need to verify with your own facility what is acceptable as a noxious stimuli, whether nail bed pressure or a trapezius pinch are okay, or whatever your facility finds acceptable.
Key Point
• If you get report from another nurse, do a bedside assessment with them, at least going over the deficits present so you are fully aware of what they are. Anything can happen at any time, and even in the first few minutes after you take report, a patient can stroke out again, and if you don't know what deficits they already had, you may not catch it. • Finally, don't be afraid to ask another nurse or provider for their opinion. If you feel something is off but can't quite figure it out, do not hesitate to ask for assistance. Again, time is brain. The important thing is that you recognized something was off.
Gastrointestinal Assessment
Among GI Emergencies, we need to be very vigilant for anything ruptured or perforated, as it will lead to massive bleeding and infection as GI tissues are very vascular. For example, a ruptured appendix, gallbladder, spleen, or even ectopic pregnancy. Or Perforated bowel from an Ulcer or Severe bowel obstruction. Some of my busiest patients have been severe GI bleeds, where I've had to give 10+ units of RBCs in the ER to keep them alive before getting permanent surgical interventions. Keeping emergencies in mind, a quick tip is that you should give extra attention when assessing elderly patients with abdominal pain, as often, their abdominal pain can be from a life-threatening condition if left unattended.
Visual Inspection
• Is the abdomen round and distended? (Cirrhotic?) • Any bruising around the umbilicus or the flanks? Intraperitoneal or retroperitoneal bleeding • Scars, masses or hernias? o Prior abdominal surgeries increase the risk for Bowel obstructions • Patient Position o For example, if they are in a fetal position, it can be a sign of peritonitis as stretching out causes irritation and pain. • Appearance: Are they pale or jaundiced? Awake and alert or perhaps stuporous or comatose? Again, to reiterate, first begin by looking at your patient and their abdomen. This should take no more than a few seconds.
Questions
• Where is the pain? • Does it radiate? • When did the pain start? • What were you doing when it started? Was it after eating? What did you eat? • What makes it worse? What makes it better? • Describe your pain • Intermittent or constant? • Fever o Although, you will get a temperature as part of your assessment, still ask your patient if they had a fever at home or chills, which can point the team in the direction of a possible infection. • Next, ask if this has ever happened before. o There will be times, when your patient has been diagnosed with something, which might be the reason for their symptoms, but won't tell you until you explicitly ask about it. • Ask about alcohol use? As it puts patients at an increased risk for liver and pancreatic issues, for cancer, ulcers, and a plethora of other issues. • As with any other patient, ask about past medical history, surgical history, drug use, smoking history, and any current medications they may be on. Do remember that chronic NSAID use can place patients at an increased risk for stomach ulcers.
Associated Symptoms
• Nausea, vomiting diarrhea and constipation • For vomiting and diarrhea, ask, how many times per day? What color? Is your patient dehydrated? The color from vomit and stool is important. For example, is it black? Or very dark? Or bright red? These signal the possibility for a GI bleed. Grey stool can be caused by liver and gallbladder issues. Green vomit is bilious in nature, possibly signaling that an obstruction is present. While green or yellowish stool can signal that an infection is present. As for constipation, when was the last bowel movement? And the type of stool? As small lumps signal severe constipation. For example, constipation, nausea and vomiting, combined with abdominal pain, can be caused by an obstruction. Key Point: If your patient is in the ER for any type of infectious complaint, you must get an oral temp. A temporal temp is not sufficient. And for peds, especially those younger than 1 year old, you need to obtain a Rectal temp. Of course, check with your facility if this is protocol there, and also, of course, explain to the parents why it is necessary. Moving on, although we are discussing Gastrointestinal issues, I want to make sure you are also asking about problems with urination. • A kidney infection, or kidney stone, or even a UTI, can manifest as abdominal pain. So ask your patient if there are any issues with urination. Any discharge from their genitalia. Or scrotal pain? As in men, testicular issues can manifest first as lower abdominal pain. For women of child bearing age: • Is there a chance of pregnancy? • Ask about their menstrual cycle, when was the last one? Any issues with it? Are they regular or irregular? You ask to assess for possibility of an ectopic pregnancy, among many other gynecological issues. Of course, you must obtain a pregnancy test on any women of childbearing age who presents with abdominal pain. It's a cardinal ER rule. So here I briefly wanted to talk about how the location of the pain in the abdomen can signal the cause of it. Here, on the right, I have a drawing of an abdomen, which is divided into RUQ, LUQ, RLQ, LLQ, and Epigastric, Right and Left Flank, and suprapubic regions. • RUQ: Pain in the RUQ, can signal the possibility for liver and gallbladder issues, or even pneumonia in the RLL as the pain can radiate down to the abdomen. • Epigastric: Pain in the epigastric region can be as a result of GERD, gastritis, peptic ulcer disease, pancreatitis and even acute coronary syndrome. • Lower Quadrants: Pain as a result of an ectopic pregnancy, ovarian issues like torsion, and even testicular issues can present as pain in the lower abdomen or suprapubic region. • RLQ: Appendicitis is common. • LLQ: Diverticulitis • Flanks: Kidney issues, like infections and stones. One thing to keep in mind, is that the location of the pain will not always correlate with the organs in the area. Due to the innervations of the abdomen, pain is often referred. For example, the source of the pain can be on the Right side, but the pain itself may only be present on the Left. So be thorough with your assessments. There are also conditions that cause diffuse abdominal discomfort, like DKA.
Physical Assessment
You are not a GI attending, so keep it simple and stick to the basics. When palpating, use your whole hand, not just jab with your fingers. • You're simply looking for areas of tenderness, rigidity, masses or abnormalities. • For example, is their abdomen soft, flat, nontender and nondistended, or is it firm and rigid, tender or distended? • While palpating, keep in mind, the location of the discomfort so you can correlate with potential causes. This allows you to ask even more narrow questions and or focus your assessment more. I wanted to briefly touch on the work up of a GI complaint. For potential liver or gallbladder issues, liver function tests will be ordered by the provider, and these include ALT, AST, bilirubin and albumin, among others. An ultrasound is also commonly ordered for patients with RUQ pain to assess the gallbladder. For pancreatic potential issues, a lipase will be ordered. A CBC will help with seeing if an infection is present, or whether the patient has a low hemoglobin. A BMP will give us lab values to assess kidney health, and electrolytes, which if the patient has severe diarrhea or vomiting, must be assessed. Urine tests will often be ordered to assess for possible infections and kidney function, among other things. Pregnancy testing is used to evaluate for an ectopic pregnancy or other gynecological issues. Ultrasound for RUQ pain, and at bedside by providers to quickly visualize bleeding and organs. Ultrasounds often used for women when assessing gynecological pathologies. Ultimately, CTs provide more in-depth imaging.
Nursing Tips
• Obtain a pregnancy test for any women in their child bearing years who presents with abdominal pain. You must also have negative pregnancy test before taking a women to CT. Check with your facility if they allow rapid point of care pregnancy testing done with blood, which can be obtained when you drew their labs or by pricking like you would to check a blood sugar. • Obtain an ECG for patients complaining with upper abdominal pain who have significant risk factors for ACS such as being a women or a diabetic, or those with significant alterations in vital signs. • The last tip I have is to get really good with working a rapid blood transfuser, because when GI bleed patients tank, they tank. So be ready.
Your notes
Updated 30 Aug 2026