Assessment (As Applicable)
- Assess neurological status, level of alertness, level of consciousness.
- Assess airway, respiratory, and circulatory status (ABCs).
- Palpate radial pulse for rate and rhythm and character.
- If Pt monitored, assess ECG and treat arrhythmias per physician order.
- Obtain SAMPLE history.
- Assess baseline VS (HR, RR, BP, SpO2, temp.).
- Assess pain/symptom characteristics (see OPQRST in ASSESS).
Intervention (As Applicable)
- Establish and maintain ABCs.
- Treat life-threatening emergencies immediately.
- Initiate emergency interventions (e.g., call a code, defibrillation).
- Place Pt in position of comfort and offer reassurance.
- Administer oxygen as indicatesd/ordered and titrate to SpO2 >90%.
- Using SBAR format, notify physician of change in Pt status including pertinent assessment findings and any interventions.
- Obtain IV access as ordered and titrate to SBP >90 mm Hg.
- Obtain labs, ECG, and imaging studies as ordered.
- Document assessments, any interventions, and outcome.