High-Acuity Nursing and Rapid Patient Assessment

Comprehensive vocabulary flashcards covering the foundations of high-acuity nursing, rapid patient assessment, clinical judgment, prioritization (ESI), and communication tools based on lecture notes.

Emergency Nursing

A specialized field of nursing providing immediate care to patients of all ages with undiagnosed, urgent, or life-threatening physical or emotional health conditions requiring rapid assessment and intervention.

Acute Care

Care typically for urgent and often life-threatening conditions, concentrating on immediate stabilization and intervention.

Triage and Prioritization

A core function involving the rapid assessment of patients to determine the urgency of their condition and prioritize care effectively based on severity.

High-Acuity Care

Care for patients with acute, life-threatening, or unstable conditions requiring complex assessments, intensive care interventions, and continuous vigilance.

Physiological Instability

A characteristic of critically ill patients involving rapidly changing vital signs and multi-system organ involvement.

Loss of Compensatory Mechanisms

A condition in critically ill patients where minor stressors can lead to catastrophic physiological collapse.

Vigilant Monitor

A nursing role focused on identifying micro-changes in patient status before they manifest as macro-events.

Interdisciplinary Coordination

The responsibility of leading the resuscitation team and managing rapid information flow.

Initial Impression

The “across-the-room” survey taking note of general appearance, work of breathing, skin color, and level of consciousness.

Primary Survey (ABCDE)

A systematic assessment focusing on Airway, Breathing, Circulation, Disability, and Exposure/Environment to identify life threats.

Airway (Primary Survey)

Assessing patency, checking for stridor, snoring, or foreign bodies, and intubating if compromised.

Breathing (Primary Survey)

Evaluating respiratory rate, effort, breath sounds, and chest expansion; administering oxygen or ventilating.

Circulation (Primary Survey)

Checking central pulses, skin temperature, capillary refill time, and hemorrhage; establishing dual large-bore IV access.

Disability (Primary Survey)

Performing a rapid neurological check using AVPU and pupil response.

Exposure / Environment (Primary Survey)

Removing clothing to find hidden injuries while preventing hypothermia with warm blankets.

Secondary Survey

A head-to-toe examination and diagnostic integration initiated only after all life threats in the Primary Survey are identified and corrected.

SAMPLE History

A mnemonic for gathering patient history: Signs & Symptoms, Allergies, Medications, Past Medical History, Last Oral Intake, and Events leading up to injury/illness.

OPQRST Pain Assessment

A tool for evaluating pain: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, and Timing.

Tanner’s Model Step 1: Noticing Cues

Observing initial patient data, lab results, and trends.

Tanner’s Model Step 2: Interpreting Data

Analyzing and synthesizing collected information.

Early Signs of Deterioration

Acute mental status change, unexplained tachypnea, and subtle tachycardia.

Late Signs of Deterioration

Bradycardia rhythm, hypotension, cyanosis, and a dropping GCS score.

Fundamental Principle of Prioritization

Treat the sickest patients first, regardless of their arrival order.

ESI Level 1: Resuscitation

Patients requiring immediate life-saving intervention, such as cardiac arrest, massive trauma, or active seizures.

ESI Level 2: Emergent

Patients in high-risk situations or with abnormal vital signs who should be seen within $15\,\text{mins}$, such as chest pain or stroke signs.

ESI Level 3: Urgent

Patients requiring multiple resources but with stable vitals, to be seen within $30-60\,\text{mins}$, such as abdominal pain or a mild asthma attack.

ESI Resource

Any procedure, test, or treatment helping establish a diagnosis or manage a condition, excluding routine nursing care or simple physical exams.

AVPU Assessment

A rapid scale to assess level of consciousness: Alert, Verbal, Pain, and Unresponsive.

Glasgow Coma Scale (GCS)

A scoring system for neurological assessment based on Eye opening ($1-4$), Verbal response ($1-5$), and Motor response ($1-6$).

Severe Brain Injury (GCS)

A total GCS score of $3$ to $8$, indicating a comatose state; defined by the rule: “GCS of $8$, intubate!”

SBAR

A critical communication tool consisting of Situation, Background, Assessment, and Recommendation.

Closed-Loop Communication

A verification tool involving a Sender, a Receiver repeating the order, and a final Verification that the action was performed.

Time-Critical Documentation

The practice of recording medication times and critical interventions as they occur to establish an accurate care timeline.