ED Assessment Framework
What does the acronym ABCDE stand for in the primary survey?
Airway, Breathing, Circulation, Disability, Exposure/Environment
What does FAST - VAN stand for?
Face
Arms
Speech
Time
Vision
Aphasia
Neglect
What does the PAT acronym stand for & what does it assess?
Pediatric Assessment Triangle: Appearance, Work of Breathing, Circulation to Skin (aka. color)
CTAS 1 patients require what level of care?
Immediate resuscitation
What is relational practice in nursing?
A way of practicing that emphasizes genuine connection, respect, and understanding of each person’s lived experience to support holistic, compassionate care.
In the secondary survey, what does "H" stand for in HIJ?
History & Head to Toe (focused assessment)
What is the time window for IV thrombolytic therapy (tPA or TNK)?
Within 4.5 hours of symptom onset
What is one reliable pediatric pain assessment tool for non-verbal children?
FLACC Scale (Face, Legs, Activity, Cry, Consolability)
How soon should a CTAS 2 patient be reassessed?
Within 15 minutes
Name one principle of trauma-informed care
Safety, trustworthiness, choice, collaboration, or empowerment
What is the purpose of a primary survey in the ED?
To identify and treat life-threatening conditions rapidly
What is one critical nursing priority when a stroke is suspected?
Rapid recognition and activation of stroke protocol/code stroke **TIME IS BRAIN**
When assessing a child, what should you do before touching them?
Observe their appearance and caregiver interaction (from the doorway)
Introduce yourself to parents and child
Smile (show full face, if wearing a mask)
What does CTAS 3 represent in terms of acuity?
Urgent but stable; reassess within 30 minutes
Give one example of how an ED nurse can apply relational practice during a busy shift
Taking a brief moment to make eye contact, listen actively, or validate a patient’s concern before moving on to the next task
Name two key elements of reassessment and why they matter
Ongoing monitoring of VS and interventions; ensures stability and detects deterioration early
Name two components of the NIH Stroke Scale (NIHSS) assessment
Level of consciousness, motor strength (arms and legs), gaze, speech, etc.
Name two relational practice strategies with children/families.
Active listening, empathy, explaining care simply, involving caregivers, game(s)/music included in care, etc
Provide one example of a CTAS 4 or 5 presentation
Minor conditions, ex: sore throat, suture removal, medication refill
How can trauma-informed care help reduce patient distress in the ED environment?
By creating psychological safety, avoiding re-traumatization, and supporting control and choice in care decisions