Primary Assessments
Focused Assessments
Mental Health
Model of Care
Alerts and Calls
100
What are the steps of a primary assessment
DR(s) ABCDE
100
What are the subheadings of a focused assessment?
Neurological (CNS), Cardiovascular (CVS), Respiratory (Resp), Gastrointestinal (GIT), Genital/Renal/Urinary, Gynaecological/Obstetric, Skin/Integumentary, Musculoskeletal (MSK), Pain Assessment (PQRST), Trauma (Head to toe)
100
What does the WASP acronym stand for?
Wellbeing, Appearance, Safety, Plan
100
What does the green tick on the tracker stand for?
Ready to go - the patient meets criteria to be ready to go for the ward. E.g. not in MET criteria, handover note done, bed request done, all appropriate scans and bloods done
100
What phone number do we use to activate emergency calls e.g. STEMI call, Stroke call and Trauma Call
2222 - state the code and location e.g. Stroke call, ED acute 22
200
What is involved in the breathing (B) primary assessment?
Spontaneous
Regular, tachypnoea or bradypnea
Shortness of breath
Work of breathing or description
Oxygen requirements
200
What is involved in a respiratory assessment?
Look: Exposure, Work of breathing and accessory muscles, RR and rhythm, Symmetry of chest wall movement (what could this indicate?), Speaking full sentences, short sentences, or single words, Positioning, SpO2
Listen: Auscultate chest – wheeze, crackles etc, Cough,
Feel: Chest symmetry, Chest trauma
200
Name five (5) common ED MH presentations
Anxiety, Personality Disorders, Psychosis, Mood Disorder, Eating Disorder, Psychological Distress, Substance use, Self-harm, Suicide or Homicide Risk
200
What does the pink colour represent on the tracker?
Fast track/Paediatric stream
200
As a nursing staff member what are your priorities with a sepsis call?
Complete the 6 steps:
Fluid resuscitation, lactate, IV antibiotics, 2 x sets of blood cultures, O2 administration, ongoing monitoring
300
What are we looking for in the circulation (C) part of the primary assessment?
Colour – pink, pale
Warm or cool peripheries
Is there cyanosis
Strong regular pulses?
IV access
Capillary refill (central and peripheral)
Does the patient need a cardiac monitor/ECG
300
Name five (5) common presentations that you would do an ECG on
Chest pain (young or old) with CP, SOB, back pain, arm pain, Epigastric pain, Syncope, Dizziness, Overdose or poisons, Altered conscious state, Trauma
300
Define Behaviours of Concern
Actions (or reactions) which are disruptive, harmful or challenging for an individual and those around them, especially in specific contexts which include healthcare settings
300
How do we know that the bed on the ward is ready?
The bed request icon will turn green 
300
What is the difference between a trauma call and a trauma alert
Key difference is to activate a trauma call you need to have abnormal vital signs.
Call 2222 and external trauma team arrives to aid in management of this patient for trauma call. Trauma alert is managed internally within ED
400
What does the D stand for in primary assessment and what is involved in this assessment?
Disability
GCS
Pain score
BSL
Neurological deficits
Pupils
400
What blood pressure are we concerned about in pregnant women?
Greater than 140 systolic (sign of pre-eclampsia)
400
What is an Assessment order?
An order under the MHWA. The patient must be seen by an authorised psychiatrist to determine if a treatment order applies. Assessment order ends if: the CTO criteria does not apply, a TTO is made for the person or the AO expires
400
What time do the teams change colour?
0700, 1400, 2200
400
Who can activate a stroke call?
Anyone can call a stroke code in consultation with a senior nursing staff member (e.g. triage trained, CCRN, ANUM) or the consultant in charge
500
What is involved in the Exposure (E) part of a primary assessment?
Expose your patients!
Change into hospital gowns
Ensure warmth and dignity
Monitor for the following- Medical devices, dressings, injuries, stomas
Skin conditions
Temperature
500
What are five (5) common presentations that we should be completing a neurological assessment on?
LOC, Stroke, Head Injury, Visual Disturbance, Unwitnessed fall, Overdose, Toxins, Seizure, Altered Conscious state, Confusion, Severe Headache, Envenomation (snake or spider bite), Inflammatory brain conditions (e.g. encephalopathy), Sepsis
500
What is the difference between physical restraint and mechanical restraint?
Physical Restraint:
The use by a person of their body to prevent or restrict another persons movement. Physical restraint does not include the giving of physical support or assistance to a person in the least restrictive way necessary to enable to person to be supported or assisted to carry out their daily activities; or to redirect the person because they are disorientated
Mechanical Restraint:
The use of a device to prevent or restrict a persons movement
500
What is our nursing chain of escalation?
Team leader, Area ANUM, NUMs, Operations Director (within office hours), Patient Services Manager (PSM) outside of office hours
500
Name five (5) high risk mechanisms that would trigger a trauma call/alert
High Speed MVA >60km/hr, Ejection from vehicle, Vehicle rollover, Fatality in same vehicle, Prolonged Extraction