Repository STIKes Patria Husada Blitar

Smith, Kani

  
Shortness of Breath Management 
(Ambulatory) - CE 
Copyright © 2020, Elsevier, Inc. All rights reserved.             1 of 7 
ALERT 
Don appropriate personal protective equipment (PPE) based on the patient’s signs 
and symptoms and indications for isolation precautions. 
  
Take extra care with a patient whose airway patency cannot be maintained. These 
patients are not appropriate for the ambulatory care setting and must be managed 
in an emergency care setting.5 
 
OVERVIEW 
Shortness of breath, also known as dyspnea, is defined as a subjective feeling of difficulty 
breathing or breathlessness.5 Shortness of breath may be caused by many different 
conditions such as acute respiratory failure (ARF), chronic obstructive pulmonary disease 
(COPD), acute respiratory distress syndrome (ARDS), pulmonary embolism (PE), 
pneumonia, or asthma. This skill discusses shortness of breath as a whole and how to 
evaluate, monitor, and manage patients with shortness of breath in an ambulatory setting.  
 
Shortness of breath may be diagnosed based on patient presentation along with a detailed 
history and physical. Symptoms the patient may present with, in addition to shortness of 
breath, include tachypnea, tachycardia, abnormal breath sounds, restlessness, decreased 
oxygen saturation, anxiety, chest pain, diaphoresis, pursed-lip breathing, increased work of 
breathing, use of accessory muscles, and cough. A cough in conjunction with shortness of 
breath may be considered normal if it occurs as a lung defense mechanism.5 Some patients 
may even present with difficulty speaking in full sentences. This symptom is more common 
in patients suffering from asthma.5 
 
A detailed history needs to be collected during the patient evaluation. Social habits, travel 
history, and work atmosphere are important portions of the history for every patient 
presenting with shortness of breath. During the physical evaluation, baseline vital signs, 
such as respiratory rate or oxygen saturation, may be abnormal or decreased. Oxygen 
saturation levels are considered normal for any patient on room air at or above 95%.4 Lung 
sounds and skin condition should also be a key portion of the physical examination. 
Abnormal or adventitious lung sounds can help determine a diagnosis. Skin conditions such 
as cyanosis, a blue or gray discoloration of the skin, should be documented and reported to 
the clinical team leader promptly; however, cyanosis may be normal or baseline for patients 
with chronic lung disease. Cyanosis is easily recognized in the areas around the eyes, lips, 
and nail beds.  
 
Causative factors for shortness of breath may be diagnosed in the ambulatory setting with 
diagnostic tools such as x-ray, ultrasonography, and laboratory blood specimen collection. 
Chest x-rays precede all other studies in determining the cause of the patient’s shortness of 
breath.5 In many cases, chest x-rays can help guide a more accurate patient diagnosis, 
depending on the etiology of the shortness of breath. Ultrasonography of a lower limb may 
be ordered if a PE is suspected. Laboratory blood tests associated with patients experiencing 
shortness of breath depend on the patient’s presentation and history and include the d-
dimer; cardiac enzymes; prothrombin time (PT) and international normalized ratio (INR), if 
the patient is taking an antiplatelet medication; and complete blood count (CBC).  
Common risk factors for shortness of breath include tobacco inhalation (e.g., cigarettes, 
vaping), environmental pollution or occupational exposure, respiratory infection, allergic 
  
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reaction, emotional stress, exercise, reflux esophagitis, inhaled irritants, and medications 
such as non-selective beta-blocking agents.5 
 
The patient’s respiratory and cardiovascular status should be evaluated when he or she is 
experiencing shortness of breath. The patient’s quality, quantity, and effort of respiration 
should be noted. 
• Eupnea: normal quite respirations 
• Bradypnea: abnormally slow rate of breathing 
• Tachypnea: rapid rate of breathing 
• Hyperpnea: increased depth and rate of breathing 
• Apnea: complete or intermittent cessation of breathing 
• Biot breathing: two or three alternating short or long breaths with periods of apnea 
• Cheyne-Stokes: repeating patterns of increased breathing followed by more shallow 
breaths with apnea occurring  
• Kussmaul breathing: deep and labored breathing 
 
Cheyne-Stokes may be seen in sleeping individuals who have conditions such as central 
nervous system disease, heart failure, or sleep apnea. 
 
In an ambulatory setting, noninvasive treatments to manage a patient experiencing 
shortness of breath include increasing oxygenation with an oxygen delivery device (e.g., 
nasal cannula, simple mask, partial nonrebreather mask). The goal of oxygen therapy is to 
keep the patient’s arterial oxygen saturation above 90%;1 however, depending on the 
patient’s history of chronic lung disease, the patient’s arterial oxygen saturation may be 
below 90%. If the patient’s respiratory status deteriorates, the health care team member 
should anticipate the need for more aggressive measures, such as invasive treatments 
(e.g., intubation, mechanical ventilation). If invasive treatments are needed, then the 
patient needs to be stabilized and transferred to a higher level of care.  
 
Oxygen delivery devices include nasal cannulas, simple face masks, and partial rebreather 
and nonrebreather face masks. A nasal cannula is the most common device used for oxygen 
administration.1 A nasal cannula is a simple method that still gives the patient freedom to 
move, speak, and eat without being encumbered. A nasal cannula is ideal for patients 
requiring lower concentrations of oxygen ranging from 1 to 6 L.1 A simple face mask is, 
ideally, used for patients that only need oxygen for short periods of time because it covers 
the patient’s nose and mouth, limiting freedom and the ability to conduct daily tasks such as 
eating. A simple face mask allows for 6 to 12 L of oxygen to be administered.1 A partial 
nonrebreather mask is ideal for short-term use as well but is intended for use with patients 
who require higher levels of oxygen concentrations, ranging from 10 to 15 L.1 For both 
partial rebreather and nonrebreather face masks, an attached bag allows the patient 
improved inhalation of exhaled oxygen-rich air along with flowing oxygen. Depending on the 
cause of shortness of breath, pharmacologic agents (e.g., bronchodilators, steroids, 
antibiotics, pain medications) may be prescribed as part of the patient’s treatments.5 
 
EDUCATION 
• Provide developmentally and culturally appropriate education based on the desire for 
knowledge, readiness to learn, and overall neurologic and psychosocial state.  
  
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• Teach the patient the signs and symptoms of shortness of breath (e.g., breathlessness, 
coughing, restlessness, anxiety or increased work of breathing) and instruct him or her 
on when to seek additional care. 
• Encourage the patient to decrease risk factors and triggering events by avoiding tobacco 
inhalation, inhaled irritants, and environmental allergens. 
• Educate the patient on prescribed medications, such as bronchodilators, steroids, 
antibiotics, and pain medications. 
• Explain to the patient that because ease of respiration is of the utmost importance, he or 
she should assume a position of comfort that facilitates breathing. 
• Encourage questions and answer them as they arise.  
 
PROCEDURE 
1. Perform hand hygiene and don appropriate PPE based on the patient’s signs and 
symptoms and indications for isolation precautions. 
2. Introduce yourself to the patient.  
3. Verify the correct patient using two identifiers.  
 
Positioning a patient with shortness of breath must be performed 
immediately in a life-threatening situation. Verify the correct patient 
only if it does not delay the procedure. 
 
4. Explain the procedure to the patient and ensure that he or she agrees to treatment.  
5. Ensure that evaluation findings and laboratory results are communicated to the clinical 
team leader per the organization’s practice. 
6. Follow the organization’s process for activating an emergency response if the patient is 
having difficulty speaking, is breathless, dizzy, or loses consciousness. 
7. Obtain the patient’s actual weight in kilograms. Stated, estimated, or historical weight 
should not be used.2 
8. Obtain the patient’s vital signs, including oxygen saturation.  
 
Rational: Signs and symptoms of shortness of breath and hypoxia may 
include breathlessness, increased anxiety, pursed-lip breathing, increased 
work of breathing, or use of accessory muscles. 
 
9. Obtain a detailed history from the patient. Ask the patient about these items that may be 
related to his or her shortness of breath: 
 
a. How often do you smoke cigars, cigarettes, or vape? 
b. What is your occupational history?  
c. Have you had a chemical exposure? 
d. What is your recent travel history? 
e. Have you had a recent upper respiratory tract infection? 
f. What medications are you taking? 
g. Is the shortness of breath worse with exertion? 
 
10. Evaluate the patient’s cardiovascular status.  
11. Evaluate the patient’s respiratory status. Evaluate for dyspnea or hypoxia. Pay specific 
attention to the quality, quantity, and effort of respiration. Listen for abnormal lung sounds 
  
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during auscultation such as the absence of breath sounds or rhonchi, wheezing, rales, or 
pleural rub. 
12. Inspect the patient’s skin for signs of cyanosis, a blue or gray discoloration of the skin. 
13. Place the patient in a position of comfort.  
 
a. High-Fowler position 
 
i. Raise the head of the bed to an upright position.  
ii. Consider using pillows on the bed to maintain the patient’s position, or elevate the foot of 
the bed slightly while keeping the head of the bed elevated, if the patient can tolerate this 
position.  
 
Rationale: These techniques help prevent the patient from sliding toward the 
foot of the bed. 
 
Use pillows for only a limited time because of pressure created on the 
popliteal vessels. Observe for leg edema as indicated. 
 
b. Orthopnea position (also known as the tripod position) 
 
i. Seat the patient on the edge of the bed with his or her feet dangling, or seat the patient 
in the bed with an over-bed table placed across his or her lap and raised to a comfortable 
level.  
ii. Pad the patient’s arms by allowing them to rest on a pillow or blankets.  
 
Rationale: This position helps patients with respiratory distress related to 
COPD. It also may help relieve dyspnea related to pulmonary edema. 
 
14. Administer oxygen per the practitioner’s orders. 
  
a. Ensure that an appropriate-size face mask or nasal cannula is used for the patient. 
 
Rationale: An improperly fitting mask may not provide adequate oxygen 
administration.  
 
b. Ensure that the lowest fraction of inspired oxygen (FIO2) that produces adequate 
oxygenation is used.5 
 
15. Obtain laboratory blood specimens (e.g., PT and INR if the patient is taking an 
antiplatelet medication, CBC) if ordered.  
 
Rationale: Laboratory tests for shortness of breath include d-dimer and 
cardiac enzymes. 
 
16. In the presence of the patient, label the specimen per the organization’s practice.3  
17. Place the labeled specimen in a biohazard bag and transport it to the laboratory 
immediately per the organization’s practice.  
18. Administer medications per the practitioner’s orders. 
19. Reevaluate the patient’s oxygenation status. 
 
  
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Rationale: Reevaluating the patient’s oxygen status determines whether the 
level of oxygenation is appropriate or if the plan of treatment needs to be 
adjusted. 
  
20. Observe the patient for continued improvements in oxygenation and reduction of signs 
and symptoms of shortness of breath. If the patient’s respiratory status deteriorates, 
anticipate the need for more aggressive measures. 
21. Ensure that oropharyngeal suction and emergency airway equipment are readily 
available. 
22. Monitor the patient for adverse and allergic reactions to the medication. Recognize and 
immediately treat respiratory distress and circulatory collapse, which are signs of a severe 
anaphylactic reaction. Follow the organization’s practice for emergency response. 
23. Discard supplies, remove PPE, and perform hand hygiene. 
24. Document the procedure in the patient’s record. 
 
EXPECTED OUTCOMES 
• Oxygenation improves. 
• Patient’s respiratory status improves or returns to his or her baseline. 
• Patient tolerates the face mask or nasal cannula without difficulty. 
• Partial or nonrebreather face mask fits the patient properly. 
• Patient’s breathing patterns and respiratory rate are normal for his or her age. 
• Patient’s anxiety is decreased. 
 
UNEXPECTED OUTCOMES 
• Patient experiences hyperoxia, leading to impaired gas exchange, pulmonary edema, or 
vasoconstriction with possible extension of a myocardial infarction. 
• Partial or nonrebreather face mask is uncomfortable or does not fit properly. 
• Patient’s respiratory status does not improve or worsens. 
• Patient does not tolerate the face mask or nasal cannula. 
• Patient’s breathing patterns and respiratory rate continue to be abnormal for his or her 
age. 
• Patient’s anxiety is increased. 
 
DOCUMENTATION 
• Patient’s response to procedure 
• Unexpected outcomes and related interventions 
• Education 
• Evaluation findings communicated to the clinical team leader per the organization’s 
practice 
• Amount of oxygen administered and per oxygen delivery device 
• Laboratory specimens collected 
• Position that offers patient the most relief from shortness of breath 
• Evaluations of the patient’s respiratory status, including quality, quantity and effort of 
respiration; abnormal lung sounds during auscultation 
• Transport to a higher level of care (if applicable) 
• Evaluation for the patient’s cardiovascular status 
• Evaluation of the patient’s skin 
• Patient’s vital signs, including oxygen saturation 
• Patient’s weight in kilograms per the organization’s practice 
  
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• Patient’s response to the medication, including any adverse reactions 
 
PEDIATRIC CONSIDERATIONS 
• A family member should be allowed to hold their child and participate in the history and 
physical for their child’s comfort and to encourage their child’s participation. 
• An appropriate-size mask should be used for pediatric patients who cannot tolerate a 
nasal cannula or if higher levels of oxygen delivery are required. The mask should be 
large enough to cover the nose and mouth. 
• If age-appropriate, pediatric patients should be encouraged to assist in the placement of 
the mask.  
 
REFERENCES 
1. Hagler, D. and others. (2020). Oxygen therapy. In Clinical companion to Lewis’s medical-
surgical nursing: Assessment and management of clinical problems (11th ed., pp. 697-707). 
St. Louis: Elsevier. 
2. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication 
safety best practices for hospitals. Retrieved April 13, 2020, from 
https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-
%20FINAL_1.pdf (Level VII)  
3. Joint Commission, The. (2020). National patient safety goals. Ambulatory health care 
accreditation program. Retrieved April 13, 2020, from https://www.jointcommission.org/-
/media/tjc/documents/standards/national-patient-safety-
goals/npsg_chapter_ahc_jan2020.pdf (Level VII)  
4. Maiden, J.M. (2018). Chapter 18: Pulmonary diagnostic procedures. In L.D. Urden, K.M. 
Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (8th ed., pp. 
445-455). Maryland Heights, MO: Elsevier. 
5. Storzer, D.N. (2018). Chapter 2: Pulmonary system. In T.M. Hartjes (Ed.), AACN core 
curriculum for high acuity, progressive, and critical care nursing (7th ed., pp. 34-141). St. 
Louis: Elsevier. 
 
ADDITIONAL READINGS 
Clinical Overview. (2019). Acute respiratory distress syndrome in adults. Retrieved April 13, 
2020, from https://www.clinicalkey.com 
 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
 
Supplies  
• Gloves and PPE, as indicated 
• Nasal cannula 
• Simple face mask 
  
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Copyright © 2020, Elsevier, Inc. All rights reserved.             7 of 7 
• Partial nonrebreather mask 
• Pulse oximeter and sensor 
• Laboratory blood specimen supplies and equipment  
• Bed with adjustable head and foot 
• Pillows (optional) 
• Over-bed table (for orthopnea position) 
• Oropharyngeal suction setup 
• Emergency airway equipment 
• Vital signs equipment (e.g., stethoscope, watch, thermometer, noninvasive BP machine, 
blood pressure cuff) 
 
  
Author: Kani Smith, MSN, FNP-BC 
 
Published: April 2020 
  


English

Shortness of Breath Management

(Ambulatory)

Slivinski, Andrea

Bokholdt, Marlene L

   
 
Emergency Primary Assessment – CE  
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                                                                    Page 1 of 8 
ALERT 
The presence of an environmental hazard (e.g., fire, noxious fumes, potential for explosion, 
active shooter) that mandates immediate evacuation of the area takes priority over the 
primary assessment. 
 
Stabilize the cervical spine throughout the procedure if injury is suspected. 
 
Do not proceed to the next assessment step until interventions for life-threatening 
conditions have been implemented. 
 
Don appropriate personal protective equipment based on the patient’s signs and symptoms 
and indications for isolation precautions. 
 
OVERVIEW 
The primary assessment is intended to assess and intervene rapidly for life-threatening conditions 
in critically ill or injured patients. The primary assessment is done at the initial point of patient 
contact and may be done again after the patient is transferred from the care of one team to 
another (e.g., when the emergency medical services team hands off the patient to the emergency 
department [ED] team members). To ensure that the primary assessment is thorough, a 
systematic approach should be taken, for example, following the widely used A-B-C-D-E 
mnemonic outlined in the procedure steps. 
 
PATIENT AND FAMILY EDUCATION 
• If the patient has been injured, instruct him or her to avoid moving until a spinal cord injury 
has been ruled out. 
• Explain the procedure to the patient and family, and why it is being performed, as time and 
the patient’s condition allow. 
• Encourage questions and answer them as they arise. 
 
PROCEDURE 
1. If the primary assessment will take place at the scene of the incident, assess the scene for 
environmental hazards. If the scene is potentially unsafe, alert the proper authorities to secure the 
scene so the patient may be safely approached. 
2. Perform hand hygiene and don gloves. As indicated by the situation, don mask, eye protection, 
and fluid-resistant gown. 
3. Perform an across-the-room assessment upon the patient’s arrival to quickly identify any life-
threatening conditions such as uncontrolled hemorrhage. If a massive hemorrhage is present, 
apply direct pressure or a tourniquet as needed to control bleeding. 
4. Perform the primary assessment using a systematic approach to ensure that no step is 
forgotten. The steps below follow the widely used mnemonic A-B-C-D-E:4  
 
A = airway and alertness with simultaneous cervical spine (c-spine) protection 
B = breathing and ventilation 
C = circulation and control of hemorrhage 
D = disability (neurologic status) 
   
 
Emergency Primary Assessment – CE  
 
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E = exposure and environmental control 
 
A = Airway and Alertness with Simultaneous C-spine Restriction 
1. Assess the patient’s level of alertness using the AVPU scale to indicate whether the patient is 
alert (A), responds to verbal stimuli (V), responds to painful stimuli (P), or is unresponsive to all 
stimuli (U). 
2. Maintain c-spine protection, if indicated, either manually or with an appropriate-size cervical 
collar. 
3. If the patient is alert or responsive to verbal stimuli, have the patient open his or her mouth to 
assess the airway. 
4. If the patient is not able to open his or her mouth and responds only to pain or is unresponsive, 
manually open the airway with either the jaw thrust (trauma) or the head tilt–chin lift (no 
trauma).  
5. Inspect for potential airway obstructions (e.g., tongue, loose or missing teeth, blood, emesis, 
edema, foreign objects). If a definitive airway is in place, assess for proper placement of the 
airway. 
6. If the airway is partially or completely obstructed, intervene as needed. Potential interventions 
include: 
 
a. Airway positioning  
b. Airway foreign object removal 
c. Oropharyngeal suctioning 
d. Oropharyngeal airway insertion 
e. Nasopharyngeal airway insertion 
f. Endotracheal intubation 
g. Supraglottic airway insertion (laryngeal mask airway) 
h. Retroglottic airway insertion (laryngeal tube airway) 
i. Needle cricothyroidotomy 
j. Surgical cricothyroidotomy  
 
7. If the patient is at risk for a c-spine injury, have an assistant manually stabilize the patient’s 
head until the primary and secondary assessments are complete and c-spine injury has been ruled 
out by radiograph or clinical examination, or until more definitive stabilization can be instituted. 
In the absence of an assistant, place towel rolls or foam blocks alongside the patient’s head to 
help maintain alignment and remind a conscious patient to avoid moving. 
 
B = Breathing and Ventilation 
1. Observe for spontaneous breathing, respiratory rate and depth, the rise and fall of the chest for 
symmetry, the use of accessory muscles, and any open chest wounds, such as an open 
pneumothorax. Note any signs of respiratory distress. 
2. Briefly auscultate breath sounds bilaterally. 
3. If spontaneous respirations are present, and the patient is alert, intervene as needed. Potential 
interventions include: 
 
a. Patient positioning 
   
 
Emergency Primary Assessment – CE  
 
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b. Supplemental oxygen as indicated 
c. Bilevel continuous positive airway pressure (BiPAP) 
 
4. If respirations are absent or abnormal, intervene as needed. Potential interventions include: 
 
a. Bag-mask ventilation 
b. Endotracheal intubation 
c. Emergency needle thoracentesis 
d. Chest tube insertion 
e. Use of a flutter valve or occlusive dressing with one corner untaped for open pneumothorax 
(sucking chest wound) 
 
C = Circulation and Control of Hemorrhage 
1. Evaluate a central pulse (carotid or femoral) for rate and strength. 
2. Observe and palpate the skin for warmth, color, and moisture. 
3. Check for exsanguinating external hemorrhage, and, if present, apply direct pressure to the 
site. If bleeding of the extremities is not controlled by direct pressure, consider applying a 
tourniquet. 
4. If circulation is absent or altered, intervene as needed. Potential interventions include: 
 
a. Chest compressions 
b. Patient positioning 
c. Vascular access and crystalloid fluid or blood administration 
d. Defibrillation 
e. Synchronized cardioversion 
f. Transcutaneous cardiac pacing 
g. Pericardiocentesis 
h. Emergency thoracotomy and internal defibrillation 
 
D = Disability (Neurologic Status) 
1. Evaluate neurologic status using the Glasgow Coma Scale (GCS), or, if the patient is 
intubated, the Full Outline of UnResponsiveness (FOUR) score. 
 
a. The GCS is a universally accepted scoring system to obtain baseline measurements and to 
ensure that subsequent assessment changes will be apparent through the continuum of care. GCS 
scoring quantifies the level of impaired consciousness based on three components: 
 
best motor response + best verbal response + eye opening = GCS score 
 
The final score ranges from 3 to 15 points. A score of 3 means no response in any component. A 
score of 15 means the patient is awake, alert and oriented, verbal, moving all extremities, and 
following commands. A score of less than 8 indicates significant impairment in the level of 
consciousness. If one or more patient responses cannot be tested because an endotracheal tube 
has been placed or a paralytic medication has been administered, then those components are not 
   
 
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scored and are indicated as not testable (NT); for example, an intubated patient who has 
decerebrate posturing (2) and opens eyes only to pain (2) receives a score of 4NT.1,3 
 
Intubate a patient with a GCS score of 8 or less to protect the airway. 
 
Determine GCS component scores by noting the patient’s best response in each category: 
 
Best Motor Response1,3 
6 - Obeys commands  
5 - Localizing 
4 - Normal flexion 
3 - Abnormal flexion  
2 - Extension 
1 - None 
NT 
 
Best Verbal Response1,3 
5 - Oriented 
4 - Confused 
3 - Words 
2 - Sounds 
1 - None 
NT 
 
Eye Opening1,3 
4 - Spontaneous  
3 - To sound 
2 - To pressure 
1 - None 
NT 
 
b. FOUR score5: This scale assesses four components: best eye response, best motor response, 
best brainstem reflexes, and respiratory pattern. Each component has a maximum value of 4, 
with a total score ranging from 0 to 16.5 The FOUR score is a reliable scale that includes 
assessments not addressed by the GCS: brainstem reflexes, eye movements, and complex motor 
responses in patients with altered levels of consciousness. It also scores respiratory pattern 
instead of verbal response, which makes it especially helpful for patients who are intubated. 
 
Best Eye Response 
E4 = eyelids open or opened, tracking, or blinking to command 
E3 = eyelids open but not tracking 
E2 = eyelids closed but open to loud voice 
E1 = eyelids closed but open to pain 
E0 = eyelids remain closed with pain 
 
   
 
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Best Motor Response 
M4 = thumbs-up, fist, or peace sign 
M3 = localizing to pain 
M2 = flexion response to pain 
M1 = extension response to pain 
M0 = no response to pain or generalized myoclonus status 
 
Best Brainstem Reflexes 
B4 = pupil and corneal reflexes present 
B3 = one pupil wide and fixed 
B2 = pupil or corneal reflexes absent 
B1 = pupil and corneal reflexes absent 
B0 = absent pupil, corneal, and cough reflex 
 
Respiration 
R4 = not intubated, regular breathing pattern 
R3 = not intubated, Cheyne-Stokes breathing pattern 
R2 = not intubated, irregular breathing 
R1 = breathes above ventilator rate 
R0 = breathes at ventilator rate or apnea 
 
2. Assess pupil size, equality, and reaction to light. 
 
E = Exposure and Environmental Control 
1. Remove the patient’s clothing to allow for quick identification of all obvious injuries, other 
signs of illness, and any uncontrolled bleeding. 
2. Keep the patient warm by covering with a warm blanket, using warming lights, keeping the 
room temperature warm, or using other commercial warming devices. 
 
When removing clothing, take care to avoid injury from unseen objects within the 
clothing, such as weapons, needles, or glass. For victims of crime, be sure not to 
cut through openings in clothing related to the violence (stabbing, gunshot wound) 
because doing so could destroy evidence; follow the organization’s policy for 
evidence collection. 
 
Completing the Procedure 
1. After completing the primary assessment and addressing any life-threatening conditions as 
they are identified, evaluate whether the patient should be transferred elsewhere. Then proceed to 
the secondary assessment. 
 
MONITORING AND CARE 
1. Monitor the patient for changes in: 
 
a. Airway patency 
b. Breathing effectiveness 
c. Pulse, skin temperature, and color 
   
 
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d. Neurologic status 
 
EXPECTED OUTCOMES 
• Recognition of and appropriate intervention for life-threatening conditions 
 
UNEXPECTED OUTCOMES 
• Failure to recognize and intervene appropriately for life-threatening conditions before 
progressing to the next assessment step, possibly resulting in deterioration of the patient 
• Intervening for noncritical conditions, such as extremity fractures, before correcting life-
threatening conditions, possibly resulting in deterioration of the patient 
 
DOCUMENTATION 
• Conditions found in the primary assessment 
• Vital signs and coma score 
• Interventions performed (including name and dosage of medications administered) to address 
life-threatening conditions 
• Unexpected outcomes and related nursing interventions 
• Patient’s response to interventions 
• Patient and family education 
 
PEDIATRIC CONSIDERATIONS 
• A = Airway and alertness with simultaneous c-spine motion restriction 
o Nasal suctioning is a high-priority intervention in an infant with nasal secretions. 
o Infants have a proportionately larger tongue, which may obstruct their airway. 
o Infants and young children have a prominent occiput. If they are laid on a firm, flat 
surface, the head may flex forward, occluding the airway or worsening a c-spine injury. 
Consider placing a towel roll under the shoulders so that the external auditory canal 
aligns with the shoulder. 
• B = Breathing and ventilation 
o Young infants are preferential nose breathers. Nasal flaring is an indication of respiratory 
distress. 
o The ribs and sternum are more cartilaginous in children than in adults; therefore, 
retractions are common during respiratory distress. 
o Infants rely heavily on diaphragmatic breathing because of poorly developed intercostal 
muscles. For this reason, an upright posture is preferred for children in respiratory 
distress who do not require spinal motion restriction. 
o Because the chest wall of infants and small children is thin, auscultation of breath sounds 
may be misleading; that is, breath sounds may be transmitted from the opposite side, 
leading to “equal breath sounds,” even in the presence of right main stem intubation or 
pneumothorax. Breath sounds should be auscultated bilaterally at the axillae. 
o Avoid aggressively ventilating children; they are more susceptible to barotrauma. 
o Gastric distention may result from crying or excessive bag-mask ventilation, raising the 
diaphragm and restricting ventilation. 
• C = Circulation and control of hemorrhage 
   
 
Emergency Primary Assessment – CE  
 
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o Assess central and peripheral pulses in infants and young children. Capillary refill is an 
important circulatory assessment in infants and young children. 
o Assess for capillary refill in a central area, such as the child’s forehead, chest, or knee. 
Normal capillary refill is less than 2 seconds. 
o Initiate chest compressions if the pulse rate is less than or equal to 60 bpm with evidence 
of poor perfusion or circulation.2 
• D = Disability (neurologic status) 
o In infants and preverbal children, the level of consciousness is more difficult to assess 
than in adults. During the primary assessment, observe the child’s response to handling or 
painful procedures and the presence of spontaneous movements. At the completion of the 
secondary assessment, assess neurologic status using an appropriate pediatric coma scale. 
o The anterior fontanel does not close until 12 to 18 months of age. A bulging anterior 
fontanel may indicate increased cranial pressure. 
• E = Exposure and environmental control: Infants and young children have immature 
thermoregulatory capability and are susceptible to iatrogenic hypothermia. Keep children 
covered and provide warming as indicated. 
 
GERONTOLOGICAL CONSIDERATIONS 
• A = Airway and alertness with c-spine motion restriction: Displaced dentures may cause 
airway obstruction. 
• B = Breathing and ventilation: A supine position may be poorly tolerated and cause 
respiratory distress in older adults, especially those with significant preexisting pulmonary or 
cardiac disease. 
• C = Circulation and control of hemorrhage 
o Capillary refill time increases as part of the aging process and is not a reliable indicator of 
systemic perfusion in adults. 
o In older adults, the decreased sensitivity of baroreceptors, decreased response to beta 
stimulation, and medications may prevent a compensatory tachycardia in response to 
decreased systemic perfusion. 
• D = Disability (neurologic status) 
o Altered mental status in older adults should be assumed to be a new finding unless a 
history of dementia is known. 
o Older adults who are hard of hearing may appear to be confused if they attempt to 
respond to a question that they did not hear correctly. 
• E = Exposure and environmental control: Older adults may have less subcutaneous fat and 
lose body heat easily. Keep them covered and provide warming as indicated. 
 
 
REFERENCES 
1. American College of Surgeons (ACS). (2018). Chapter 6: Head trauma. In Advanced trauma 
life support: Student course manual (10th ed., pp. 102-126). Chicago: ACS. (Level VII) 
2. American Heart Association. (AHA). (2016). Part 5: BLS for infants and children. In Basic 
life support: Provider manual (pp. 45-56). Dallas, TX: AHA. (Level VII) 
   
 
Emergency Primary Assessment – CE  
 
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3. Institute of Neurological Sciences. (2015). GCS: Eyes, Motor, Verbal. Glasgow coma scale: 
Do it this way. Retrieved March 10, 2020, from 
https://www.glasgowcomascale.org/downloads/GCS-Assessment-Aid-English.pdf?v=3 
4. Powers-Jarvis, R. (2020). Initial assessment. In TNCC™: Trauma nursing core course—
provider manual (8th ed., pp. 25-43). Schaumburg, IL: Emergency Nurses Association. (Level 
VII) 
5. Wijdicks, E.F. and others. (2005). Validation of a new coma scale: The FOUR score. Annals 
of Neurology, 58(4), 585-593. doi:10.1002/ana.20611 (classic reference)* (Level VI) 
 
ADDITIONAL READINGS 
Teasdale, G., Jennett, B. (1974). Assessment of coma and impaired consciousness: A practical 
scale. The Lancet, 2(7872), 81-84. doi:10.1016/S0140-6736(74)91639-0 (classic reference)* 
 
*In these skills, a “classic” reference is a widely cited, standard work of established excellence 
that significantly affects current practice and may also represent the foundational research for 
practice. 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
 
SUPPLIES 
• PPE (gloves; mask, eye protection, and fluid-resistant gown if indicated) 
• Flashlight 
• Towel rolls, foam blocks, or other head support devices (for trauma patients) 
• Stethoscope 
• Other equipment as indicated for resuscitative procedures 
• Blanket 
 
 
Clinical Review: Andrea Slivinski, DNP, RN, ACNS-BC, CEN, CPEN 
Revised: Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CEN 
Published: September 2019 
Revised: March 2020 
 


Emergency Primary Assessment

  
 
Emergency Primary Assessment (Pediatric) - CE 
 
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ALERT 
Stabilize the cervical spine throughout the procedure if injury is suspected. 
 
Do not proceed to the next step in the primary assessment or on to the secondary 
assessment stage until interventions for life-threatening conditions have been implemented. 
 
Don appropriate personal protective equipment based on the patient’s signs and symptoms 
and indications for isolation precautions. 
 
OVERVIEW 
The primary assessment is a rapid assessment and simultaneous intervention for life-threatening 
conditions in critically ill or injured children. The primary assessment, a systematic process that 
establishes a prioritized sequence of care, uses an ABCDE approach: 
• Airway and alertness with simultaneous cervical spinal motion restriction if trauma is 
suspected 
• Breathing and ventilation 
• Circulation 
• Disability or neurologic status 
• Exposure and environmental control 
 
CHILD AND FAMILY EDUCATION 
• Provide individualized, developmentally appropriate education to the family and child based 
on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state. 
• Explain the purpose of the primary assessment. 
• If the child is at risk for cervical spinal injury, emphasize to the child and family the 
importance of not moving and that cervical spinal motion restriction will be implemented 
until a spinal cord injury has been ruled out. 
• Address the child by name. Speak in a calm voice, addressing both the child and family. 
• Use developmentally appropriate explanations and allow the child to make simple, 
developmentally appropriate decisions and participate in his or her care. 
• Reassure the family that any pain the child is experiencing will be managed. 
• Encourage the family to interact with the child and assist in any way possible in the care of 
the child. 
• Encourage questions and answer them as they arise.  
 
ASSESSMENT AND PREPARATION 
Child and Family Assessment 
1. Perform hand hygiene before patient contact. 
2. Introduce yourself to the child and family. 
3. Verify the correct child using two identifiers, if time allows. 
4. Assess the child’s and family’s understanding of the reasons for and the risks and benefits of 
the procedure. 
5. With young children or children with chronic neurologic impairment, ask the family for the 
child’s baseline status and what to expect for the child’s typical response. 
  
 
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Preparation 
1. Encourage the family to remain with the child when possible. If the child’s condition requires 
invasive or resuscitative measures, assign a staff member or support person to provide the family 
with support and explanations about what is occurring. 
 
PROCEDURE 
1. Perform hand hygiene and don gloves. Don a fluid-resistant gown, mask, and eye protection, 
as needed. 
2. Verify the correct child using two identifiers, if time allows. 
3. Explain the procedure to the child and family and ensure that they agree to treatment. 
4. When approaching the child, perform a rapid, across-the-room assessment using the pediatric 
assessment triangle (PAT). 
 
Rationale: The pediatric assessment triangle is intended to be a quick visual 
analysis to determine if the child needs immediate intervention.5 
 
a. General appearance: Assess for poor muscle tone, decreased interactivity, crying that cannot 
be consoled, an unfocused gaze, and abnormal speech or crying. 
b. Work of breathing: Assess for retractions, nasal flaring, stridor, grunting, snoring, preferred 
position (e.g. tripod), apnea, or gasping. 
c. Circulation to the skin: Assess for pallor, mottling, cyanosis, or uncontrolled external 
hemorrhage. 
 
If uncontrolled external hemorrhage is identified, take steps to control the 
hemorrhage, including direct pressure and tourniquet. 
 
A = Airway and Alertness with Simultaneous Cervical Spinal Motion Restriction 
5. Using the AVPU scale, determine whether the child is alert (A), responds to verbal stimuli 
(V), responds to painful stimuli (P), or is unresponsive to all stimuli (U). 
6. Assess airway patency while maintaining cervical spinal motion restriction with manual 
stabilization. 
 
a. Open the airway 
 
i. If the child is alert, ask him or her to open the mouth. 
ii. If the child is not alert or cannot follow directions, manually open the mouth. 
 
If there is a possibility of a spinal cord injury, use a jaw thrust maneuver, taking 
care to avoid cervical spinal motion. 
 
b. Assess for vocalization, blood, secretions, vomitus, loose teeth, foreign objects, edema, and 
tongue obstruction. 
c. Assess for signs of upper-airway obstruction, including abnormal inspiratory sounds (e.g., 
snoring, gurgling, stridor, grunting), drooling, dysphagia, or assumption of a preferred position 
(e.g., tripod). 
  
 
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7. If the airway is partially or completely obstructed, clear it of any foreign objects or debris, 
such as teeth, blood, vomit, or secretions, and implement or prepare for one or more appropriate 
interventions, which may include: 
 
a. Airway positioning (e.g., head tilt chin lift, jaw thrust) 
 
Infants also have a proportionately larger tongue, which may obstruct the airway. 
 
b. Nasopharyngeal or oropharyngeal airway insertion 
c. Supraglottic airway insertion (i.e., laryngeal mask airway) 
d. Endotracheal intubation 
e. Cricothyroidotomy 
f. Oropharyngeal or nasopharyngeal suctioning 
 
Nasal flaring is an indication of respiratory distress in infants, who are obligate 
nose breathers.  
 
Perform nasal suctioning in an infant with nasal secretions.  
 
g. Foreign body removal 
 
8. If the child has assumed a position of comfort, allow him or her to maintain this position.6 
9. If the child’s mechanism of injury indicates a suspicion for cervical spinal injury, initiate 
cervical spinal motion restriction per the organization’s practice. 
 
Current recommendations are to use a long backboard only as an extrication or 
transportation device, limit its use as much as possible, and remove it as quickly 
as possible.3 
 
B = Breathing and Ventilation 
10. Assess breathing adequacy. 
 
a. Observe respiratory rate, depth, and effort.  
b. Assess for symmetrical chest rise and fall. 
c. Observe skin color for pallor, mottling, or cyanosis. 
d. Assess for signs of increased work of breathing, such as nasal flaring, chest retractions, 
grunting, use of accessory muscles, head bobbing, or seesaw breathing. 
 
Rationale: The ribs and sternum are more cartilaginous in children; therefore, 
retractions are common during respiratory distress. 
 
e. Briefly auscultate breath sounds bilaterally.  
 
i. If the child is crying and cannot be consoled, listen for breath sounds when the child inhales 
between cries.  
  
 
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ii. Listen for abnormal breath sounds (e.g., wheezing, crackles) or decreased, absent, or unequal 
breath sounds. 
iii. For accuracy, auscultate breath sounds over the midaxillary areas on both sides. 
 
Rationale: Because the chest walls of infants and small children are thin, breath 
sounds may be transmitted from the opposite side. Breath sounds may be 
auscultated equally even when there is right main stem intubation or 
pneumothorax.  
 
11. If a weight is needed for medication administration (e.g., before intubation), obtain the 
child’s weight in kilograms, using a scale if the child’s condition permits or using a length-based 
resuscitation tape if it does not. 
12. If spontaneous respirations are present, support the child with appropriate interventions, 
which may include: 
 
a. Positioning of the child 
 
An upright or semi-Fowler position is preferred for infants and children in 
respiratory distress.  
 
Rationale: Infants primarily rely on diaphragmatic breathing because of poorly 
developed intercostal muscles. 
 
b. Supplemental oxygen therapy (via a nonrebreather mask, nasal cannula, continuous positive 
airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) 
 
13. If respirations are absent or abnormal, implement or prepare for appropriate interventions, 
which may include: 
 
a. Bag-mask ventilation 
b. Endotracheal intubation or insertion of a laryngeal mask airway 
 
Decompress the stomach following manual ventilation with a gastric tube to 
prevent limited ventilation from pressure on the diaphragm from air in the 
stomach. 
 
c. Needle thoracentesis or thoracotomy 
d. Chest tube insertion 
e. Medication administration 
 
C = Circulation and Control of Hemorrhage 
14. Assess circulation. 
 
a. Assess skin color, moisture, and temperature. 
b. Assess capillary refill. 
 
  
 
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Rationale: Capillary refill is an important circulatory assessment in infants and 
young children. Normal capillary refill is less than 2 seconds.4 Capillary refill is 
affected by cold environmental temperatures, which can cause peripheral 
vasoconstriction and produce cool skin and delayed capillary refill.4 
 
c. Evaluate the quality of central and peripheral pulses. Use the carotid pulse in older children, 
the brachial pulse in infants, or the femoral pulse in a child of any age to assess the central 
pulse.2 
 
Rationale: Children have a limited ability to alter stroke volume to increase 
cardiac output; therefore, they compensate for shock by increasing the heart rate. 
An increased heart rate is an early sign of shock. A decreased heart rate, 
associated with poor signs of perfusion, is a late sign of decompensated shock.2 
 
15. If there is no pulse, or if the pulse rate is inadequate and signs of poor perfusion are present, 
immediately begin cardiac compressions.1 
16. If perfusion is poor or ineffective, begin or assist with appropriate interventions. 
 
a. Vascular access 
b. Fluid resuscitation 
c. Blood product administration 
d. Medication administration 
e. Pericardiocentesis 
f. Synchronized cardioversion 
g. Defibrillation 
h. Transcutaneous cardiac pacing 
i. Advanced cardiac life support measures 
 
17. Check for uncontrolled external hemorrhage and, if present, apply direct pressure to the site 
or apply a tourniquet . 
 
D = Disability (Neurologic Status) 
18. Evaluate the child’s neurologic status (disability). 
 
a. Assess and assign a Glasgow Coma Scale score (Table 1). Use the developmentally 
appropriate scale. 
 
Table 1 Modified Glasgow Coma Scale for Infants and Children 
Table 4 Modified Glasgow Coma Scale for Infants and Children 
 Child Infant Score 
Eye opening Spontaneous Spontaneous 4 
To verbal stimuli To verbal stimuli 3 
To pain only To pain only 2 
No response No response 1 
Verbal response Oriented, appropriate Coos and babbles 5 
  
 
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Confused Irritable cries 4 
Inappropriate words Cries to pain 3 
Incomprehensible words or 
nonspecific sounds 
Moans to pain 2 
No response No response 1 
Motor response Obeys commands (e.g., child holds 
up two fingers, wiggles toes, or 
sticks out tongue)* 
Moves spontaneously 
and purposefully 
6 
Localizes painful stimulus (e.g., 
child reaches for hand that is 
starting IV) 
Withdraws to touch 5 
Withdraws in response to pain  Withdraws in response to 
pain 
4 
Abnormal flexion in response to 
pain  
 Abnormal flexion 
(decorticate posturing) in 
response to pain 
3 
Abnormal extension in response to 
pain  
Abnormal extension 
(decerebrate posturing) in 
response to pain 
2 
No response (flaccid) No response (flaccid) 1 
TOTAL   3–15 
*Note: These modifications were added to the scale by the chapter 11 authors (Milonovich, L.M., Eichler, V.F.) and 
book editor (Hazinski, M.F.). Hazinski, M.F. [Ed.]. (2013). Nursing care of the critically ill child (3rd ed.). St. 
Louis: Mosby. 
 
(From Morray, J.P. and others. [1984]. Coma scale for use in brain-injured children. Critical Care Medicine, 12[12], 
1018-1020.)  
 
b. Assess pupil size, shape, equality, and reaction to light. 
 
E = Exposure and Environmental Control 
19. To facilitate a complete assessment, remove the child’s clothing.  
 
a. Assess skin for signs of rash, injury, or maltreatment 
b. Cover the child to maintain normothermia and privacy.  
c. If needed, provide warming measures, such as warm blankets, warm ambient room 
temperature, overhead warming lights, warmed oxygen, or warmed IV fluids. 
 
Infants and young children have immature thermoregulatory capabilities and are 
susceptible to iatrogenic hypothermia, which can complicate resuscitation efforts 
by increasing metabolic demands and exacerbate the effects of hypoxia and 
hypoglycemia.2 
 
Completing the Procedure 
20. Discard supplies, remove personal protective equipment (PPE), and perform hand hygiene. 
  
 
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21. Verify the correct child using two identifiers before documenting the results of the primary 
assessment. 
 
Rationale: The primary assessment should never be delayed to obtain this 
information. A temporary alias (e.g., John Doe, Baby Girl Doe) may be assigned 
if needed to begin an electronic health record for the child. 
 
22. Document the procedure in the child’s record. 
23. After completing the primary assessment and addressing any life-threatening conditions, 
proceed to the secondary assessment. 
 
EXPECTED OUTCOMES 
• Recognition of and appropriate intervention for life-threatening conditions 
 
UNEXPECTED OUTCOMES 
• Failure to recognize and intervene appropriately for life-threatening conditions before 
progressing to the next assessment step 
• Intervention for noncritical conditions, such as extremity fractures and minor burns, before 
correcting life-threatening conditions 
• Injury to the spinal cord from head or neck movement in a child with cervical spine injuries 
 
DOCUMENTATION 
• Conditions found in the primary assessment 
• Interventions made based on the primary assessment for life-threatening conditions 
• Child’s response to interventions for life-threatening conditions 
• Child’s weight in kilograms, if obtained 
• Child and family education 
• Unexpected outcomes and related nursing interventions 
 
REFERENCES 
1. American Heart Association (AHA). (2016). Part 2: Review of BLS and AED for infants and 
children. In Pediatric advanced life support: Provider manual (pp. 15-28). Dallas: AHA. (Level 
VII) 
2. American Heart Association (AHA). (2016). Part 3: Systematic approach to the seriously ill or 
injured child. In Pediatric advanced life support: Provider manual (pp. 29-67). Dallas: AHA. 
(Level VII) 
3. Emergency Nurses Association (ENA). (2015). Long backboard use for spinal motion 
restriction. Retrieved March 12, 2020, from https://www.ena.org/docs/default-source/resource-
library/practice-resources/translation-into-practice/longbackboardusespinalmotionrestriction 
(Level VII)  
4. Fleming, S. and others. (2015). Validity and reliability of measurement of capillary refill time 
in children: A systematic review. Archives of Disease in Childhood, 100(3), 239-249. 
doi:10.1136/archdischild-2014-307079 (Level I) 
  
 
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5. Forseman-Capuzzi, J.R. (2020). Chapter 11: Triage and prioritization. In Emergency nursing 
pediatric course: Provider manual (5th ed., pp. 109-116). Burlington, MA: Jones and Bartlett 
Learning. 
6. Steinman, R.A. (2020). Chapter 6: Initial assessment. In Emergency nursing pediatric course: 
Provider manual (5th ed., pp. 45-58). Burlington, MA: Jones and Bartlett Learning. 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
SUPPLIES 
• PPE (gloves, plus fluid-resistant gown, mask, and eye protection as needed) 
• Blanket 
• Towel rolls or other head-support devices 
• Cardiopulmonary monitor 
• Cardiac leads, pulse oximeter, and blood pressure cuff (size appropriate) 
• Cloth adhesive tape 
• Backboard (optional) 
• Size-appropriate cervical collar (optional) 
• Stethoscope 
• Flashlight or penlight 
• Length-based resuscitation tape  
• Warming lights (optional) 
• IV fluid warmer (optional) 
• Suction to be available as needed 
• Bag and mask to be available as needed 
• Other equipment, as indicated, for resuscitative procedures with a range of sizes appropriate 
for children of all ages 
 
 
Clinical Review: Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CEN 
Published: October 2019 
Revised: March 2020 


Emergency Primary Assessment (Pediatric)

   
 
Emergency Secondary Assessment – CE 
 
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ALERT 
Do not begin the secondary assessment until the primary assessment is complete and 
resuscitation procedures have been initiated as indicated. 
 
Continue to monitor airway, breathing, circulatory, and neurologic status during 
the secondary assessment. If any life-threatening problems arise, return to the 
primary assessment and intervene as indicated. 
 
Prioritize and initiate interventions for injuries or conditions discovered in the 
secondary assessment after the entire head-to-toe examination is complete. 
 
Don appropriate personal protective equipment based on the patient’s signs and 
symptoms and indications for isolation precautions. 
 
OVERVIEW 
The purpose of the secondary assessment is to rapidly and systematically assess injured 
patients from head to toe to identify all injuries and to rapidly and systematically assess 
critically ill patients when the cause of their signs and symptoms is unclear. Interventions 
for injuries or conditions discovered in the secondary assessment should be prioritized 
and initiated after the entire secondary assessment is complete. 
 
PATIENT AND FAMILY EDUCATION 
• If the patient has been injured, instruct him or her to avoid moving until a spinal 
injury has been ruled out. 
• Explain the procedure to the patient and family and why it is being performed, as time 
and the patient’s condition allow. 
• Encourage questions and answer them as they arise. 
 
ASSESSMENT AND PREPARATION 
Assessment 
1. Ensure that the primary assessment is complete and interventions have been initiated 
for life-threatening conditions. 
2. Proceed immediately to the next step if already wearing personal protective equipment 
(PPE), including gloves and—if indicated—a mask, eye protection, and fluid-resistant 
gown. Otherwise, perform hand hygiene and don appropriate PPE before proceeding with 
the secondary assessment. 
3. Assess for risk factors for spinal injury. 
 
Preparation 
1. If the patient is at risk for spinal injury, ensure that spinal alignment is maintained 
throughout each step of the primary and secondary assessments. 
 
   
 
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PROCEDURE 
1. Perform the secondary assessment using a systematic approach to ensure that no step is 
forgotten. The steps below follow the mnemonic F-G-H-I-J (to continue the primary 
assessment mnemonic, A-B-C-D-E):5 
 
F = full set of vital signs and family presence 
G = get monitoring devices and give comfort (using the mnemonic L-M-N-O-P) 
H = history and head-to-toe assessment (using the mnemonics M-I-S-T and S-A-M-P-L-
E) 
I = inspect posterior surfaces 
J = just keep reevaluating 
 
F = Full Set of Vital Signs and Family Presence 
1. Obtain and trend readings for blood pressure, pulse, respiratory rate, peripheral oxygen 
saturation (SpO2), and temperature at regular intervals. 
2. Offer the family the opportunity to be with the patient in the treatment area if 
appropriate. Provide a support person to be with them to answer questions and explain 
procedures. 
 
Rationale: Evidence shows that family presence during trauma 
resuscitation helps the family cope and supports the patient. 
 
G = Get Monitoring Devices and Give Comfort 
1. Follow the mnemonic L-M-N-O-P when obtaining resuscitation monitoring devices 
and supports. 
 
L = Laboratory Studies 
1. Obtain appropriate laboratory tests, such as arterial blood gas (ABG) analysis, lactic 
acid level, and type and crossmatch if indicated. 
2. In the presence of the patient, label the specimen(s) per the organization’s practice.4  
3. Prepare each specimen for transport. 
 
a. Place the labeled specimen in a biohazard bag. 
b. If the specimen requires ice for transport, place the specimen in a biohazard bag, then 
place the bag with the specimen into a second biohazard bag filled with ice slurry. 
 
Rationale: Placing the specimen in a separate bag protects the label from 
being damaged. 
 
4. Immediately transport the specimen(s) to the laboratory. 
 
M = Monitoring (Cardiac) 
1. Monitor cardiac rate and rhythm. Arrhythmias, such as premature ventricular 
contractions (PVCs), atrial fibrillation, or S-T segment changes, may indicate a blunt 
   
 
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cardiac injury. Pulseless electrical activity may suggest cardiac tamponade, tension 
pneumothorax, or profound hypovolemia. 
 
N = Nasogastric or Orogastric Tube 
1. Insert a nasogastric or orogastric tube if indicated or prescribed to relieve gastric 
distention, which helps optimize lung inflation, and to prevent vomiting and aspiration. 
 
Avoid the nasogastric route in patients with a suspected head injury or 
mid-face fractures. 
 
O = Oxygenation and Ventilation (SpO2, End-Tidal Carbon Dioxide [ETCO2]) 
1. Monitor oxygenation by implementing pulse oximetry (if not performed previously). 
Remember that pulse oximetry is a measurement of SpO2 and is not evidence of 
ventilation. An SpO2 of 94% or greater is considered adequate oxygenation.6 
 
Do not rely on pulse oximetry readings in a patient with poor perfusion; 
they may not be accurate. Assess the quality of the plethysmographic 
waveform if there is any doubt. 
 
2. Assess ventilation by monitoring ETCO2 levels via capnography. Normal values range 
from 35 to 45 mm Hg. 
 
P = Pain Assessment and Management 
1. Assess and treat pain with pharmacologic and nonpharmacologic interventions as 
indicated. 
 
H = History and Head-to-Toe Assessment 
1. Obtain a prehospital report of the incident or illness. A helpful mnemonic is M-I-S-T: 
 
M = mechanism of injury 
I = injuries sustained 
S = signs and symptoms before arrival 
T = treatment before arrival 
 
2. Obtain the patient’s history. A helpful mnemonic is S-A-M-P-L-E. 
 
S = symptoms associated with the injury or illness 
A = allergies and tetanus status 
M = medications currently used, especially anticoagulants 
P = past medical history (including hospitalizations and surgeries) 
L = last oral intake and output (last menstrual period if female of childbearing age) 
E = events and environmental factors related to the injury or illness 
 
3. Assess the patient from head to toe. 
 
   
 
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Head and Face 
1. Inspect the head and face for wounds, deformities, discolorations, or bloody or serous 
drainage from the nose or ears. Palpate the entire head and face for wounds, deformities, 
or tenderness. 
2. In the conscious and cooperative patient, evaluate extraocular movements, gross 
vision, and dental occlusion. 
3. Note any unusual odors, for example, gasoline, fruity breath, or ethanol. 
 
Neck 
1. If necessary, remove the anterior portion of the cervical collar while another person 
maintains manual stabilization of the head and neck. 
2. Inspect the anterior neck for wounds, jugular venous distention, discolorations, or 
deformities. Palpate the anterior neck for deformities, crepitus, tenderness, or tracheal 
deviation (best palpated in the notch above the manubrium). 
3. Gently palpate the posterior neck from the base of the skull to the upper back for 
wounds, deformities, tenderness, or muscle spasms. 
 
Chest 
1. Inspect the anterior and lateral chest for wounds, deformities, discolorations, 
respiratory expansion, symmetry, and paradoxical movement. Palpate the anterior and 
lateral chest for deformities, tenderness, or crepitus. 
2. Auscultate breath sounds to determine whether they are present and equal bilaterally 
and note any abnormal sounds, such as crackles and wheezes. 
3. Auscultate heart sounds to determine whether they are clear or muffled. 
 
Abdomen and Flanks 
1. Inspect the abdomen and flanks for wounds, discolorations, or distention. 
2. Auscultate all quadrants for the presence of bowel sounds. 
3. Gently palpate the abdomen and flanks for tenderness, guarding, rigidity, or masses. 
 
To facilitate patient cooperation, palpate known painful areas last. 
 
Pelvis and Perineum 
1. Inspect the pelvic area and perineum for wounds, deformities, discolorations, or 
bleeding from the urinary meatus, vagina, or rectum. 
2. Palpate for pelvic tenderness, crepitus, or instability by gently pressing in on the 
anterosuperior iliac crests bilaterally and pushing down on the pubic symphysis. 
3. Consider placement of an indwelling urinary catheter. 
 
Placement of an indwelling urinary catheter is contraindicated if there is 
blood at the urinary meatus, perianal ecchymosis, or scrotal ecchymosis. 
 
Extremities 
1. Inspect all extremities for wounds, deformities, or discolorations. 
2. Palpate all extremities for tenderness, deformities, muscle spasms, skin temperature 
and moisture, and distal pulses. 
   
 
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3. If the patient is conscious, determine gross motor and sensory function by having the 
patient wiggle the toes and fingers and asking whether he or she can feel your touch. 
 
I = Inspect Posterior Surfaces 
1. In the injured patient, obtain assistance to maintain cervical spine alignment and 
support injured extremities while log rolling the patient to the side. 
 
Avoid rolling the patient onto an injured extremity or side if possible. If 
necessary for adequate assessment of posterior surfaces, roll the patient 
to both sides.  
 
There is evidence that the log roll maneuver can result in spinal movement. 
Carefully consider the risks and benefits of performing this maneuver, 
especially if the potential for spinal cord injury is significant.3  
 
When spinal or pelvic injuries are suspected, radiographs are 
recommended before logrolling the patient.5  
 
2. Inspect the posterior surfaces for wounds, deformities, or discolorations. Palpate all 
posterior surfaces for wounds, deformities, or muscle spasms. 
3. At this point, the practitioner may perform a rectal examination to assess sphincter 
tone, presence of injury to the pelvis or rectal mucosa,1 and the presence of gross or 
occult blood. 
 
Prostate position as determined by rectal examination is not a reliable  
indicator of urethral injury.1 
  
4. Remove the backboard or transferring device as indicated. 
 
J = Just Keep Reevaluating 
1. Continue ongoing monitoring and evaluation of the patient. Reevaluation should 
include the primary survey, vital signs, level of pain and any injuries identified. A helpful 
mnemonic is V-I-P-P: 
 
V = vital signs 
I = injuries sustained and interventions 
P = primary survey 
P = level of pain 
 
Completing the Procedure 
1. Take the patient’s temperature, if not done earlier. 
2. Perform a focused assessment of any injuries or abnormalities found. 
3. Obtain more detailed information about the patient’s medical history, including 
pertinent immunizations, current medications (prescription, over-the-counter, and herbal), 
and past medical and surgical history. 
4. Discard supplies, remove PPE, and perform hand hygiene. 
5. Document the procedure in the patient’s record. 
   
 
Emergency Secondary Assessment – CE 
 
  Copyright © 2020, Elsevier, Inc. All rights reserved.                           Page 6 of 9 
 
MONITORING AND CARE 
1. Evaluate the patient’s evolving condition by monitoring these indicators (and any 
others that apply) and intervene as needed: 
 
a. Airway patency 
b. Breathing effectiveness 
c. Pulse, skin temperature, capillary refill, and color 
d. Neurologic status 
e. Vital signs 
f. Urine output 
 
2. Assess, treat, and reassess pain. 
3. Implement spinal protection measures and other interventions as indicated by 
examination findings. 
4. Obtain diagnostic tests as indicated. 
5. If the family is not already in the treatment area, offer them the opportunity to be with 
the patient now. Provide a support person to answer questions and explain procedures. 
 
EXPECTED OUTCOMES 
• Complete systematic assessment of a critically ill or injured patient in whom the 
cause of signs and symptoms is unclear 
• Identification of all injuries and abnormalities 
 
UNEXPECTED OUTCOMES 
• Patient deterioration may result from a failure to recognize and intervene 
appropriately for life-threatening conditions that develop or worsen during the 
secondary assessment. 
• In the injured patient, trauma to the spinal cord may result from a failure to maintain 
spinal alignment and stabilization throughout the secondary assessment. 
• Patient deterioration may result from a failure to complete the secondary assessment 
and prioritize interventions before initiating them. 
• Patient deterioration may result from intervening for noncritical problems, such as 
extremity fractures, before correcting life-threatening conditions. 
 
DOCUMENTATION 
• Vital signs 
• Injuries and conditions found in the secondary assessment 
• Mechanism of injury or history of present illness, if known 
• Interventions performed (including name and dosage of medications administered) 
• Unexpected outcomes and related interventions 
• Patient’s response to interventions 
• Collection of evidence and chain of custody for evidence handoffs, if applicable 
• Patient and family education 
   
 
Emergency Secondary Assessment – CE 
 
  Copyright © 2020, Elsevier, Inc. All rights reserved.                           Page 7 of 9 
 
PEDIATRIC CONSIDERATIONS 
• Infants and young children have immature thermoregulatory capability and are 
susceptible to iatrogenic hypothermia. Keep children covered and provide warming as 
indicated. 
• Unlike adults and older children, the infant’s skull can accommodate blood loss 
significant enough to cause hypotension and shock. The infant’s anterior fontanels 
should be observed for bulging. 
• Children should be weighed as soon as possible because medication doses, fluid 
resuscitation, and other interventions are influenced by the child’s size. If obtaining a 
weight is not feasible, a length-based resuscitation tape can be used to estimate 
weight. 
• The normal range for vital signs in children varies by age.  
Table 1 Normal Vital Signs According to Age 
Age Heart rate 
(beats/min) 
Blood pressure 
(mm Hg) 
Respiratory rate 
(breaths/min) 
Premature 120-170* 55-75/35-45† 40-70‡ 
0-3 mo 100-150* 65-85/45-55 35-55 
3-6 mo 90-120 70-90/50-65 30-45 
6-12 mo 80-120 80-100/55-65 25-40 
1-3 yr 70-110 90-105/55-70 20-30 
3-6 yr 65-110 95-110/60-75 20-25 
6-12 yr 60-95 100-120/60-75 14-22 
12+ yr 55-85 110-135/65-85 12-18 
* In sleep, infant heart rates may drop significantly lower, but if perfusion is maintained; no intervention is 
required. 
† A blood pressure cuff should cover approximately two thirds of the arm; too small a cuff yields 
spuriously high-pressure readings, and too large a cuff yields spuriously low-pressure readings. 
‡ Many premature infants require mechanical ventilatory support, making their spontaneous respiratory rate 
less relevant. 
(Reprinted with permission from Kliegman, R.M. and others. [2020]. Nelson textbook of pediatrics [21st 
ed.]. Philadelphia: Elsevier.) 
 
• The heart and respiratory rates may be altered by fear, pain, and anxiety, in addition 
to physiologic problems, such as hypoxia and hypovolemia. In children, blood 
pressure may be maintained in the presence of significant hypovolemia. Therefore, 
other assessments of circulatory status (heart rate, capillary refill, skin color, and so 
forth) should be monitored closely. Hypotension is defined as a systolic blood 
pressure less than the fifth percentile for the child’s age.2 
   
 
Emergency Secondary Assessment – CE 
 
  Copyright © 2020, Elsevier, Inc. All rights reserved.                           Page 8 of 9 
 
GERONTOLOGICAL CONSIDERATIONS 
• A supine position may be poorly tolerated and cause respiratory distress in older 
adults, especially those with significant preexisting pulmonary or cardiac disease. 
• Older adults with kyphosis may require additional support under the head to maintain 
their normal (baseline) head and neck position for spinal stabilization. 
• In older adults, the decreased sensitivity of baroreceptors, decreased response to beta 
stimulation, and medications may prevent a compensatory tachycardia in response to 
decreased systemic perfusion. 
• Older adults may have less subcutaneous fat and lose body heat easily. Keep them 
covered and provide warming as indicated. 
• Older adults are at increased risk for pressure ulcers. Pad bony prominences when 
immobilizing older adults and remove them from backboards as soon as possible. 
 
 
REFERENCES 
1. American College of Surgeons (ACS). (2018). Chapter 5: Abdominal and pelvic 
trauma. In Advanced trauma life support: Student course manual (10th ed., pp. 82-101). 
Chicago: ACS. (Level VII) 
2. American Heart Association (AHA). (2016). Part 3: Systematic approach to the 
seriously ill or injured child. In Pediatric advanced life support: Provider manual (pp. 
29-67). Dallas, TX: AHA. (Level VII) 
3. Emergency Nurses Association (ENA). (2016). ENA topic brief—Avoiding the log 
roll maneuver: Alternative methods for safe patient handling. Retrieved March 10, 2020, 
from https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-
briefs/avoiding-the-log-roll-maneuver.pdf?sfvrsn=78887c44_8 (Level VII)  
4. Joint Commission, The. (2020). National patient safety goals: Hospital accreditation 
program. Retrieved March 10, 2020, from https://www.jointcommission.org/-
/media/tjc/documents/standards/national-patient-safety-
goals/npsg_chapter_hap_jan2020.pdf(Level VII)  
5. Powers-Jarvis, R. (2020). Initial assessment. In TNCC™: Trauma nursing core 
course—provider manual (8th ed., pp. 25-43). Schaumburg, IL: Emergency Nurses 
Association. (Level VII) 
6. Siemieniuk, R.A.C. and others. (2018). Oxygen therapy for acutely ill medical 
patients: A clinical practice guideline. BMJ, 363, k4169. doi:10.1136/bmj.k4169 (Level 
VII) 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
   
 
Emergency Secondary Assessment – CE 
 
  Copyright © 2020, Elsevier, Inc. All rights reserved.                           Page 9 of 9 
 
 
SUPPLIES 
• PPE (gloves, mask, eye protection, and fluid-resistant gown if indicated) 
• Trauma scissors to cut clothing, if necessary 
• Stethoscope 
• Pulse oximeter 
• Capnometer 
• Cardiac monitor 
• Appropriate-size blood pressure cuff or noninvasive blood pressure monitor 
• Temperature measuring device (e.g., thermometer, temperature sensing urinary 
catheter) 
• Blanket or other warming device 
 
 
Clinical Review: Andrea Slivinski, DNP, RN, ACNS-BC, CEN, CPEN 
Revised: Marlene L. Bokholdt, MS, RN, CPEN, TCRN, CEN 
Published: September 2019 
Revised: March 2020 
 


Emergency Secondary Assessment

Karaban, Karen

Liddy, Mary Ann

  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                       1 of 8 
ALERT 
Do not attempt to collect a throat specimen swab if acute epiglottitis is 
suspected because trauma from the swab may cause increased edema, 
resulting in airway occlusion.4 
 
Collect oropharyngeal and nasopharyngeal specimens within 3 days of 
symptom onset if possible but no later than 7 days of symptom onset and 
before the start of antimicrobial therapy.1 
 
Don appropriate personal protective equipment (PPE) based on the patient’s 
signs and symptoms and indications for isolation precautions. 
 
OVERVIEW 
A nose-throat swab specimen is used to detect pathogenic microorganisms in the 
nose and throat. To determine the degree of infection, the specimen is placed on a 
culture or transport media in the laboratory to determine if pathogenic organisms 
grow. 
 
Pathogenic organisms that may be identified by this specimen include group A beta-
hemolytic streptococci, Bordetella pertussis, Corynebacterium diphtheriae, and 
Staphylococcus aureus. Other organisms, including Haemophilus influenzae, 
Streptococcus pneumoniae, and Candida albicans, are considered abnormal if found 
in large amounts. The test results help determine which antibiotic therapy or 
treatment is appropriate.  
 
A nose-throat swab may cause discomfort to sensitive mucosal membranes. 
Collecting a throat specimen sometimes causes gagging. The patient’s clear 
understanding of the specimen collection technique may minimize his or her anxiety 
or discomfort. Nasal washing may provide an effective, more comfortable alternative 
to swabbing, when necessary. 
 
EDUCATION 
• Explain to the patient that the procedure may cause some discomfort to sensitive 
mucosal membranes that lasts only a few seconds. 
• Explain that obtaining a throat specimen may cause a tickling sensation or 
gagging and that obtaining a nasal specimen may cause an urge to sneeze. 
• Discuss the patient’s role in collecting the specimen. 
• Explain how and why the specimen is being collected. 
• Discuss the relationship between the test results and the medication and 
treatment prescribed. 
• Discuss the reason for the time delay in receiving test results. 
• Encourage questions and answer them as they arise. 
 
PROCEDURE 
1. Perform hand hygiene. 
2. Introduce yourself to the patient. 
3. Verify the correct patient using two identifiers. 
4. Explain the procedure to the patient and ensure that he or she agrees to 
treatment. 
  
Specimen Collection: Nose and Throat 
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5. Ensure that evaluation findings and laboratory results are communicated to the 
clinical team leader per the organization’s practice. 
6. Determine the patient’s understanding of the purpose of the procedure and his or 
her ability to cooperate. 
7. Evaluate the patient’s nasal mucosa, posterior pharynx, and sinuses and observe 
for any drainage. 
8. Check the practitioner’s order for the type of specimen ordered and specifications. 
9. Obtain assistance for collecting the throat specimen as needed. 
 
Collecting a Throat Specimen  
1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s 
signs and symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers. 
3. Explain the procedure to the patient and ensure that he or she agrees to 
treatment. 
4. Instruct the patient to sit erect in a bed or in a chair and face him or her. A 
patient who is acutely ill or a young child may lie back against the bed with the head 
of the bed raised. 
5. Have the swab and the sterile tube or culture tube ready for use. If using a 
prepackaged swab in a tube, loosen the top so the swab can be removed easily. 
 
Rationale: Having the swab and the sterile tube or culture tube ready 
allows the health care team member to grasp the swab easily without 
danger of contamination. 
 
6. Instruct the patient to tilt his or her head back. If the patient is in a bed, place a 
pillow behind his or her shoulders. 
7. Ask the patient to open his or her mouth and say “ah.” 
8. Depress the anterior third of the tongue with a tongue blade and observe for 
inflamed areas of the pharynx or tonsils. Illuminate the area with a penlight as 
needed. 
 
Rationale: Depressing the tongue permits exposure of the pharynx, 
relaxes throat muscles, and minimizes the gag reflex. The area to be 
swabbed should be clearly visible. 
 
Do not place the tongue blade along the back of the tongue; 
doing so is likely to initiate the gag reflex. If the patient gags, 
remove the tongue blade and allow the patient to relax before 
reinserting it. 
 
9. Insert the swab without touching the lips, teeth, tongue, cheeks, or uvula. 
 
Rationale: Touching the lips, teeth, tongue, cheeks, or uvula with the 
swab may cause contamination with organisms from the oral cavity. 
 
10. Gently but quickly swab the tonsillar area from side to side, contacting any 
inflamed or purulent sites. 
 
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
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Rationale: The inflamed or purulent sites in the tonsillar area contain 
the most microorganisms. 
 
11. Carefully withdraw the swab without touching the oral structures. 
12. Insert the swab immediately into the sterile tube or culture tube (Figure 2). and 
push the tip into the liquid medium at the bottom of the tube or follow instructions 
specific to specimen collection per the organization’s practice. 
 
Rationale: Mixing the swab tip with the culture or transport medium 
helps ensure live bacteria or virus for testing. 
 
13. Place the top securely on the tube. 
14. In the presence of the patient, label the specimen per the organization’s 
practice.3 
15. Prepare the specimen for transport. Place the labeled specimen in a biohazard 
bag. 
16. Transport the specimen to the laboratory immediately per the organization’s 
practice. 
17. Discard supplies, remove PPE, and perform hand hygiene. 
18. Document the procedure in the patient’s record. 
 
Collecting a Nasal Specimen  
1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s 
signs and symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers. 
3. Explain the procedure to the patient and ensure that he or she agrees to 
treatment. 
4. Instruct the patient to sit erect in a bed or in a chair, and face him or her. A 
patient who is acutely ill or a young child may lie back against the bed with the head 
of the bed raised. 
5. Have the swab and the sterile tube or culture tube ready for use. If using a 
prepackaged swab in a tube, loosen the top so the swab can be removed easily. 
 
Rationale: Having the swab, sterile tube, or the culture tube ready 
allows the health care team member to grasp the swab easily without 
danger of contamination. 
 
6. Ask the patient to occlude each nostril one at a time and exhale. 
 
Rationale: As the patient breathes through each open nostril, the 
health care team member determines the nostril with the greater 
patency. 
 
7. Position the patient with his or her head tilted back and use a penlight to check 
the nasal passages for patency. If the patient is on a bed, place a pillow behind his 
or her shoulders. 
8. Carefully insert the swab into the nostril until it reaches the portion of mucosa 
that is inflamed or contains exudate. Rotate the swab quickly and gently. 
 
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                       4 of 8 
Rationale: The swab should remain sterile until it reaches the area to 
be tested. Rotating the swab ensures that it touches all surfaces where 
exudate is present. 
 
9. Remove the swab without touching the sides of the nose. 
 
Rationale: Avoiding contact with the sides of the nose prevents 
contaminating the swab with resident bacteria or virus. 
 
10. Offer the patient a facial tissue to blow his or her nose if needed. 
11. Insert the swab into the sterile tube or culture tube and push the tip into the 
liquid medium at the bottom of the tube or follow instructions specific to specimen 
collection per the organization’s practice. 
 
Rationale: Mixing the swab tip with culture or transport medium helps 
ensure live bacteria or virus for testing. 
 
12. Place the top securely on the tube. 
13. In the presence of the patient, label the specimen per the organization’s 
practice.3 
14. Prepare the specimen for transport. Place the labeled specimen in a biohazard 
bag. 
15. Transport the specimen to the laboratory immediately per the organization’s 
practice. 
16. Discard supplies, remove PPE, and perform hand hygiene. 
17. Document the procedure in the patient’s record. 
 
Collecting a Nasopharyngeal Specimen: Swab Method 
1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s 
signs and symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers. 
3. Explain the procedure to the patient and ensure that he or she agrees to 
treatment. 
4. Instruct the patient to sit erect in a bed or in a chair, and face him or her. A 
patient who is acutely ill or a young child may lie back against the bed with the head 
of the bed raised. 
5. Have the nasopharyngeal swab (on flexible wire) and the sterile tube or culture 
tube ready for use. If using a prepackaged swab in a tube, loosen the top so the 
swab can be removed easily. 
 
Rationale: Having the swab and sterile tube or the culture tube ready 
allows the health care team member to grasp the swab easily without 
danger of contamination. Use of a specially designed nasopharyngeal 
swab allows access to the difficult-to-reach nasopharyngeal area. 
 
6. Position the patient with his or her head tilted back and use a penlight to check 
the nasal passages for patency. If the patient is on a bed, place a pillow behind his 
or her shoulders. 
7. Gently advance the swab to the nasopharynx until resistance is met. 
8. Roll the swab and allow it to remain in place for several seconds. 
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                       5 of 8 
 
Rationale: Leaving the swab tip in contact with the nasopharynx 
facilitates absorption of fluid into the swab. 
 
9. Insert the swab into the sterile tube or culture tube and push the tip into the liquid 
medium at the bottom of the tube or follow instructions specific to specimen 
collection per the organization’s practice. 
 
Rationale: Mixing the swab tip with the medium helps ensure live 
bacteria or virus for testing. 
 
10. Place the top securely on the sterile tube or culture tube. 
11. Offer the patient a facial tissue to blow his or her nose if needed. 
12. In the presence of the patient, label the specimen per the organization’s 
practice.3 
13. Prepare the specimen for transport. Place the labeled specimen in a biohazard 
bag. 
14. Transport the specimen to the laboratory immediately per the organization’s 
practice. 
15. Discard supplies, remove PPE, and perform hand hygiene. 
16. Document the procedure in the patient’s record. 
 
Collecting a Nasopharyngeal Specimen: Wash Method with Suction 
1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s 
signs and symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers. 
3. Explain the procedure to the patient and ensure that he or she agrees to 
treatment. 
4. Instruct the patient to sit erect in a bed or in a chair, and face him or her. A 
patient who is acutely ill or a young child may lie back against the bed with the head 
of the bed raised. 
5. Attach the suction catheter to the suction specimen trap. Attach the specimen trap 
to the suction connecting tubing and adjust the suction. 
6. Draw up 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into a 3-
ml syringe.1 
7. Instruct the patient to tilt his or her head back. If the patient is in a bed, place a 
pillow behind his or her shoulders. 
8. Using the syringe, insert 1 to 1.5 ml of sterile nonbacteriostatic 0.9% sodium 
chloride solution into each nostril.1  
9. Insert the suction catheter into one nostril and suction secretions. 
10. Repeat the procedure for the other nostril per the practitioner’s order. 
11. Remove the specimen trap from the suction tubing and secure the ends per the 
manufacturer’s instructions. 
12. Offer the patient a facial tissue to blow his or her nose if needed. 
13. In the presence of the patient, label the specimen per the organization’s 
practice.3  
14. Prepare the specimen for transport. Place the labeled specimen in a biohazard 
bag. 
15. Transport the specimen to the laboratory immediately per the organization’s 
practice.  
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                       6 of 8 
16. Discard supplies, remove PPE, and perform hand hygiene. 
17. Document the procedure in the patient’s record. 
 
EXPECTED OUTCOMES 
• Patient does not experience bleeding of nasal mucosa. 
• Specimen is not contaminated. 
• Patient tolerates procedure without pain or discomfort. 
 
UNEXPECTED OUTCOMES 
• Patient experiences nasal bleeding. 
• Patient complains of pain during procedure. 
• Specimen is contaminated by adjacent skin or tissue. 
 
DOCUMENTATION 
• Type of test ordered 
• Date and time of collection, and name of person who collected specimen 
• Appearance of nasal and oral mucosal structures 
• Patient’s tolerance of procedure 
• Evaluation findings and laboratory results communicated to the clinical team 
leader per the organization’s practice 
• Unexpected outcomes and related interventions 
• Patient education 
 
PEDIATRIC CONSIDERATIONS 
• Take the time to develop rapport and trust with a pediatric patient before 
beginning any invasive procedure. Include the family; if the family demonstrates 
trust, the patient will be less anxious. 
• Take the time to include age appropriate distraction to manage pain and anxiety. 
• Use a developmentally appropriate approach and explanation of the procedure. 
• Encourage the family to remain present during the procedure. 
• Show the tongue blade and penlight to the child and demonstrate how to say 
“ah” to help decrease anxiety. 
• A school-aged and older child may be more cooperative if given an opportunity to 
ask questions about the procedure and results. 
• Acute respiratory infections in infants and children are viral in origin with the 
respiratory syncytial virus (RSV) as a leading cause.2 
• Nasopharyngeal aspiration and nasal washes can be used for the diagnosis of 
respiratory viruses.1 
• Nasopharyngeal flocked swabbing is increasingly recognized as an alternative to 
nasopharyngeal washes and traditional nasopharyngeal aspiration.1 Flocked 
swabs use nylon fibers sprayed onto the tip of the swab while held in an 
electrostatic field. The electrostatic field ensures that the sample stays as close 
as possible to the swab surface for fast and complete transfer.  
• Using a firm, gentle, and kind manner, stabilize the child’s head and arms when 
collecting nose or throat specimens. If necessary, ask another health care team 
member to assist. 
 
OLDER ADULT CONSIDERATIONS 
• Some older adults need help keeping the mouth open during specimen collection. 
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
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• Some older adults have poor dentition. Be careful not to break a tooth. Consider 
denture removal. 
• If the patient is confused, someone may need to hold his or her hands while the 
specimen is collected. 
 
REFERENCES 
1. Centers for Disease Control and Prevention (CDC). (2017). Unexplained 
respiratory disease outbreaks (URDO): Specimen collection & handling. Retrieved 
March 10, 2020, from https://www.cdc.gov/urdo/specimen.html (Level VII)  
2. Gomez, S., Prieto, C., Folgueira, L. (2016). A prospective study to assess the 
diagnostic performance of the Sofia® Immunoassay for Influenza and RSV detection. 
Journal of Clinical Virology, 77, 1-4. doi:10.1016/j.jcv.2016.01.018 (Level VI) 
3. Joint Commission, The. (2020). National patient safety goals: Ambulatory health 
care accreditation program. Retrieved March 10, 2020, from 
https://www.jointcommission.org/-/media/tjc/documents/standards/national-
patient-safety-goals/npsg_chapter_ahc_jan2020.pdf  
4. Sokolovs, D., Tan, K.W. (2017). Ear, nose and throat emergencies. Anaesthesia 
and Intensive Care Medicine, 18(4), 190-194. doi:10.1016/j.mpaic.2017.01.004 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
 
Supplies 
• Gloves and PPE, as indicated 
• Small biohazard plastic bag for delivery of specimen to laboratory (or container 
specified by the organization) 
• Pillow (as needed) 
 
Collecting a Throat Specimen 
• Sterile swab in sterile tube 
• Tongue blade 
• Penlight 
 
Collecting a Nasal Specimen 
• Sterile swab in sterile tube 
• Penlight 
• Facial tissue 
 
Collecting a Nasopharyngeal Specimen: Swab Method 
• Nasopharyngeal swab on a flexible wire swab in a sterile tube 
• Penlight 
• Facial tissue 
  
Specimen Collection: Nose and Throat 
(Ambulatory)- CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.                                       8 of 8 
 
Collecting a Nasopharyngeal Specimen for: Wash Method with Suction 
• Sterile nonbacteriostatic 0.9% sodium chloride solution  
• Facial tissue 
• Suction catheter and suction specimen trap 
• Syringe 
 
 
Author: Karen Karaban, MSN, RN  
Revised: Mary Ann Liddy, MSN/Ed, RNC-OB, RNC-MN 
Published: April 2019 
Revised: March 2020 


Specimen Collection: Nose and Throat

(Ambulatory)

Fleming, Loraine

  
 
Defusing Anger - CE  
 
Copyright © 2020, Elsevier, Inc. All rights reserved.               1 of 6 
ALERT 
Don appropriate personal protective equipment (PPE) based on the patient’s signs 
and symptoms and indications for isolation precautions. 
 
Do not attempt to intervene alone when a patient demonstrates behaviors 
consistent with possible imminent violence or aggression. 
 
OVERVIEW 
Anger can be a normal human response that ranges from irritation to fury. Patients 
experiencing health disorders may have feelings of vulnerability or fears that cause them to 
experience anger. Helping patients learn to manage anger constructively can assist them 
with expressing their needs safely and developing health promotion skills.18 
 
Angry patients may express their anger verbally or physically. They may also be passively 
angry. Health care team members should identify anger and communicate effectively with 
patients to prevent agitation or angry behavior that may compromise patient care or health 
care team member safety. Team members should also engage in self-assessment and 
debriefing to prevent responses that are not therapeutic and do not support respectful and 
positive relationships with patients. 
 
EDUCATION 
• Provide developmentally and culturally appropriate education based on the desire for 
knowledge, readiness to learn, and overall neurologic and psychosocial state. 
• Teach the patient and family how to recognize early warning signs of anger and triggers 
that may precipitate aggression, such as irritability and restlessness brought on by such 
factors as overcrowded rooms or long wait times.2,3 
• Teach the patient and family about ways to maintain a safe environment.  
• Use communication styles that decrease the perception of blame and likelihood of 
defensiveness.  
• Teach the patient and family about positive coping mechanisms and skills to manage 
anger, including strategies such as verbalizing needs in an assertive, nonaggressive 
manner and identifying diversionary activities that can decrease loneliness and 
boredom.4 
• Teach the patient and family about the medications used for agitation and the potential 
risks, precautions, and adverse effects.13 
• Encourage questions and answer them as they arise. 
 
ASSESSMENT 
1. Perform hand hygiene and don PPE as indicated for needed isolation precautions. 
2. Introduce yourself to the patient. 
3. Verify the correct patient using two identifiers.  
4. Assess the patient for signs and symptoms that may precede violence.5,9,10 
 
a. Angry, irritable affect  
b. Impulsivity or hyperactivity (e.g., pacing, restlessness, slamming doors) 
c. Delusions 
d. Increasing anxiety and tension (e.g., clenched jaw or fist, rigid posture, fixed or tense 
facial expression, mumbling to self, shortness of breath, sweating, rapid pulse rate) 
e. Verbal abuse (e.g., profanity, argumentativeness) 
f. Loud voice, change of pitch, or very soft voice that forces others to strain to hear 
  
 
Defusing Anger - CE  
 
Copyright © 2020, Elsevier, Inc. All rights reserved.               2 of 6 
g. Intense eye contact or avoidance of eye contact 
h. Total silence 
i. Suspiciousness or paranoid thinking  
 
5. Assess the patient for signs and symptoms of depression, such as feelings of 
hopelessness, sadness, and lack of pleasure in activities that were formerly pleasurable.11 
 
Rationale: Depression is associated with an increased risk of anger. 
 
6. Assess the patient for alcohol or drug intoxication or withdrawal.  
7. Assess the patient for possession of a weapon or an object that may be used as a 
weapon (e.g., fork, knife, glass bottle). 
8. Assess the patient for a history of violence to self or others. 
9. Explore recent losses (e.g., job loss, divorce, role changes, physical health).  
10. Assess the patient for demographic risk factors, including exposure to domestic violence 
and a history of abuse, neglect, bullying, or being bullied. 
11. Assess the patient for specific allergies and contraindications to receiving medications 
and advise the practitioner accordingly. 
12. Assess the patient’s perceived support systems and ability to access support. 
13. Assess the patient’s previous methods of anger expression and ability to manage anger 
and frustration.  
14. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an 
organization-approved standardized tool for suicide assessment.12 
15. Assess the need for a psychiatric practitioner consult and seek a consult as appropriate. 
 
STRATEGIES 
1. Perform hand hygiene and don appropriate PPE based on the patient’s signs and 
symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers.  
3. Explain the strategies to the patient and ensure that he or she agrees to treatment. 
4. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an 
organization-approved standardized tool for suicide assessment.12 
5. Use a calm, clear tone of voice when addressing the patient. 
 
Rationale: The patient’s ability to process information decreases during 
episodes of agitation.  
 
6. Use assertive “I” statements and active listening to engage the patient in therapeutic 
communications.  
 
Rationale: Engaging in therapeutic communication allows the patient to 
experience care centered at his or her needs and to promote better 
engagement with treatment.7 This can provide an outlet for venting 
frustrations or an opportunity to identify anger triggers. 
 
7. Use a self-assured, empathetic, nonaggressive posture when communicating with the 
patient. 
 
Rationale: Using a self-assured, empathetic, nonaggressive posture conveys 
that the health care team member is calm, controlled, and nonthreatening. 
  
 
Defusing Anger - CE  
 
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8. Maintain adequate eye contact, but avoid excessive eye contact, which can be interpreted 
as challenging.  
 
Rationale: Adequate eye contact communicates to the patient that the health 
care team member is concerned and interested. 
 
9. Remove or secure potential weapons in the environment. 
10. Maintain adequate distance from the patient, respecting his or her personal space. 
 
Rationale: Patients who have the potential for violence need additional space, 
and the health care team member should have a route of retreat in case the 
patient acts out aggressively. 
 
11. Administer antianxiety and antipsychotic agents as needed.  
 
Rationale: Medications may quickly calm the patient so he or she is more 
receptive to psychosocial interventions and teaching. 
 
12. Match anger management coping interventions to the patient’s needs, interests, and 
abilities. 
 
a. Teach problem-solving techniques for a patient who needs to make a decision. 
b. Decrease stimulation for a patient overwhelmed by the environment. 
 
Rationale: Using the correct strategy can effectively defuse anger and prevent 
violence. 
 
13. Focus on the patient’s strengths by identifying areas in which the patient has had 
positive coping skills and success in facing challenges. 
 
Rationale: Focusing on the patient’s strengths can help him or her regain a 
sense of control. 
 
14. Monitor the patient for healthy coping skills and reinforce the use of appropriate 
expressions of anger. 
 
Rationale: Individuals with limited coping skills and lack of assertiveness have 
a higher risk of using violence.14 
 
15. Provide privacy and decrease environmental and emotional stimulation for the patient 
who is angry.  
 
Rationale: Providing privacy for the patient is a method of demonstrating 
caring and respect and helps protect the patient from experiencing 
embarrassment from acting on angry emotions. When patients are adjusting 
to internal turmoil, decreased stimulation from external sources can help 
them regain emotional control.4 
 
16. Communicate frequently with health care team members regarding the patient’s needs 
and anger issues to ensure consistent team member actions and responses.  
  
 
Defusing Anger - CE  
 
Copyright © 2020, Elsevier, Inc. All rights reserved.               4 of 6 
 
Rationale: Consistency in approaches, especially when centered on patient 
preferences, provides the patient with a sense of control and benefits the 
patient and health care team members. 
 
17. Monitor the patient’s behaviors to ensure that he or she demonstrates positive coping 
skills and avoids self-harm. 
 
Rationale: Higher levels of anger are associated with increased risk of self-
harm and suicide.8 
 
18. Remove PPE and perform hand hygiene. 
19. Document the strategies in the patient’s record. 
 
REASSESSMENT 
1. Reassess the patient for:  
 
a. Anxiety 
b. Ability to use assertive, nonaggressive communication to have needs met 
c. Use of healthy coping skills to deal with anger and frustration 
d. Response to medication for agitation, anxiety, or pain  
e. Expressed understanding of anger triggers and methods for managing anger  
 
2. Reassess the patient for continued presence of high-risk symptoms (i.e., impulsivity, 
hyperactivity, irritability, delusions, or violence to self or others). 
3. Assess, treat, and reassess pain. 
 
EXPECTED OUTCOMES 
• Patient abstains from self-harm or striking health care team members or other patients. 
• Patient maintains self-control independently. 
• Patient uses assertive techniques to express anger and frustration. 
• Patient identifies triggers to anger and safe, healthy methods for expression. 
 
UNEXPECTED OUTCOMES 
• Patient physically acts on anger and aggression toward self or others. 
• Patient destroys property. 
• Patient is unable to maintain self-control independently. 
 
DOCUMENTATION 
• Mental status of the patient  
• Patient behaviors that indicate agitation or anxiety 
• Patient threats of self-harm or passive death wish 
• Strategies used to reduce patient anger and their effectiveness 
• Reassessment of the patient after an anger outburst 
• Education 
• Unexpected outcomes and related interventions 
 
ADOLESCENT CONSIDERATIONS 
• Adolescents may not have developed the skills necessary to deal with feelings that 
trigger anger.15 
  
 
Defusing Anger - CE  
 
Copyright © 2020, Elsevier, Inc. All rights reserved.               5 of 6 
• Adolescents who have sustained or explosive episodes should be seen by a mental 
health professional because these episodes may indicate more serious issues.16 
 
OLDER ADULTS CONSIDERATIONS 
• Older patients may experience a paradoxic effect when taking antianxiety medications 
such as alprazolam because disinhibitory actions of the medication may result in 
increased aggression.17 
• Alzheimer disease can result in changes to personality and increase the likelihood of 
violence.1 
• Patients with cognitive deficits such as delirium and dementia are at increased risk for 
agitated or aggressive behaviors. 
• Calming facial cues may decrease agitation and provide comfort for some agitated 
patients with cognitive deficits.6 
 
REFERENCES 
1. Aigbogun, M.S. and others (2019). Treatment patterns and burden of behavioral 
disturbances in patients with dementia in the United States: A claims database analysis. 
BMC Neurology, 19(1). doi:10.1186/s12883-019-1260 
2. Ashton, R.A., Morris, L., Smith, I. (2018) A qualitative meta-synthesis of emergency 
department staff experiences of violence and aggression. International Emergency Nursing, 
39, 13-19. doi:10.1016/j.ienj.2017.12.004. (Level I) 
3. Beattie, J. and others. (2019). Workplace violence perpetrated by clients of health care: 
A need for safety and trauma‐informed care. Journal of Clinical Nursing, 28(1-2), 116-124. 
doi:10.1111/jocn.14683. (Level VI) 
4. Brown, J. and others. (2016). Low stimulus environments: Reducing noise levels in 
continuing care. BMJ Quality Improvement Reports, 5(1). 
doi:10.1136/bmjquality.u207447.w4214. (Level VI) 
5. Calow, N. and others. (2016) Literature synthesis: Patient aggression risk assessment 
tools in the emergency department. Journal of Emergency Nursing, 42(1), 19-24. 
doi:10.1016/j.jen.2015.01.023. 
6. Cameron, N. and others. (2018). How do care staff in residential aged care facilities 
conceptualise their non-verbal interactions with residents with dementia and what relevance 
has this for how residents’ preferences and capacity for decision-making are understood? 
Dementia, 1-17. doi:10.1177/1471301218798422 (Level VI) 
7. Campbell, S.H., Aredes, N.D. (2019). Global interprofessional therapeutic communication 
scale©(GITCS©): Development and validation. Clinical Simulation in Nursing, 34, 30-42. 
doi:10.1016/j.ecns.2019.05.006 (Level VI) 
8. Dillon, K.H., Van Voorhees, E.E., Elbogen, E.B. (2020). Associations between anger and 
suicidal ideation and attempts: A prospective study using the National Epidemiologic Survey 
on Alcohol and Related Conditions. Journal of Psychiatric Research, 122, 17-21. 
doi:10.1016/j.jpsychires.2019.12.011 (Level VI) 
9. Fernandez, E., Johnson, S.L. (2016). Anger in psychological disorders: Prevalence, 
presentation, etiology and prognostic implications. Clinical Psychology Review, 46, 124-135. 
doi:10.1016/j.cpr.2016.04.012 
10. Genovese, T. and others. (2017). Subjective anger and overt aggression in psychiatric 
outpatients. Comprehensive Psychiatry, 73, 23–30. doi:10.1016/j.comppsych.2016.10.008 
(Level VI) 
11. Genichi, M. (2015). Anger and hostility as primary externalizing features of depression 
in college men. International Journal of Men’s Health, 14(2), 113-128. 
doi:10.3149/jmh.1402.113 (Level VI) 
  
 
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12. Joint Commission, The. (2020). National patient safety goals: Hospital accreditation 
program. Retrieved April 1, 2020, https://www.jointcommission.org/-
/media/tjc/documents/standards/national-patient-safety-
goals/npsg_chapter_hap_jan2020.pdf (Level VII) 
13. Karch, A.M. (2015). Preventing medication errors by empowering patients. American 
Nurse Today, 10(9), 18-23. 
14. Lievaart, M. and others. (2017). The impact of angry rumination on anger-primed 
cognitive control. Journal of Behavior Therapy and Experimental Psychiatry, 54, 135-142. 
doi:10.1016/j.jbtep.2016.07.016 (Level VI) 
15. Pailing, A.N., Reniers, R.L.E.P. (2018). Depressive and socially anxious symptoms, 
psychosocial maturity, and risk perception: Associations with risk-taking behaviour. Plos 
One, 13(8), e0202423. doi:10.1371/journal.pone.0202423 (Level VI) 
16. lkPullen, L. and others. (2015). Anger in adolescent communities: How angry are they? 
Pediatric Nursing, 41(3), 135-140. (Level VI) 
17. Soyka, M. (2017). Treatment of benzodiazepine dependence. The New England Journal 
of Medicine, 376(12), 1147-1157. doi:10.1056/NEJMra1611832 
18. Zarshenas, L. and others. (2017). Anger management in substance abuse based on 
cognitive behavioral therapy: An interventional study. BMC Psychiatry, 17(1), 375. 
doi:10.1186/s12888-017-1511-z (Level VI) 
 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
 
Supplies 
• Gloves and PPE, as indicated 
 
Clinical Review: Loraine Fleming, DNP, APRN, PMHNP-BC, PMHCNS-BC 
 
Published: April 2020 
 
 


Defusing Anger

  
 
Depression: Older Adult Patients - CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.             1 of 5 
 
ALERT 
Don appropriate personal protective equipment (PPE) based on the patient’s signs 
and symptoms and indications for isolation precautions. 
 
Screen all adults for depression regularly.9 Older adults have a high risk of 
completing suicide.4,10 If an older adult patient screens positive for being 
depressed, complete an assessment for suicidal risk and consult a psychiatric 
practitioner if suicidal ideation is present. 
 
OVERVIEW 
Depression is the most predominant mood disorder among older adults worldwide,2 and 
evidence indicates that many physical illnesses affecting older adults, including 
cardiovascular disease, diabetes, hip fracture, and illnesses associated with chronic pain, are 
associated with depression.1 Recognizing depression in an older adult with a chronic illness 
can be difficult because the symptoms may be masked by somatic complaints; health care 
professionals may associate depressive symptoms with the medical condition,11 leading to 
lack of diagnosis and treatment opportunities for depression.1 
 
Recognizing the risk factors for depression is therefore important for all practitioners. These 
factors include social isolation, use of sedative medications, limited involvement in leisure 
activities, and a previous history of depression.3 
 
Older adults should be given accurate information about their conditions so they can make 
realistic and appropriate plans related to their health status. Older adults should be 
encouraged to use coping mechanisms that they have used successfully in the past. 
 
Depression involves symptoms of depressed mood, diminished interest or pleasure in 
almost all activities, changes in sleep and appetite, increased fatigue, feelings of 
worthlessness, poor concentration, and suicidal ideation. Depression is not a normal part of 
aging, and, when diagnosed, it can be successfully treated in most people.1 Older adults 
have more expected losses, so grieving and sadness are common; if sadness persists, 
depression should be considered. The onset of depression later in life can contribute to 
functional impairment and worsening of medical conditions.1 In addition, older adults may 
have substance abuse issues, which complicate and worsen the depression.6 Substance 
abuse may be an issue despite the patient’s age, social status, or living conditions. 
 
Depression increases suicide risk. Specific risk factors for older adults include:1 
• Chronic illnesses, including those that cause severe or chronic pain 
• Family history of depression 
• Social isolation, living alone 
• Polypharmacy 
• Substance abuse or dependence 
 
An older adult patient who expresses suicidal ideation needs immediate referral to a 
psychiatric practitioner for evaluation. While waiting for the consult, the patient should be 
kept under continuous observation in a safe environment according to the organization’s 
practice. 
 
EDUCATION 
• Provide developmentally and culturally appropriate education based on the desire for 
knowledge, readiness to learn, and overall neurologic and psychosocial state. 
  
 
Depression: Older Adult Patients - CE 
 
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• Educate the patient and family regarding all treatments. 
• Teach the patient and family about depression. 
• Educate the patient and family regarding realistic expectations. 
• Instruct the family to notify the health care team member if a change in the patient’s 
normal mood or behavior is noticed. 
• Instruct the patient to notify the health care team member of suicidal ideation. 
• Teach the family the steps to take if the patient makes statements indicating suicidal 
ideation or thoughts of feeling worthless. 
• Instruct the patient and family regarding the potential adverse effects of all prescribed 
medications. 
• Encourage questions and answer them as they arise. 
 
ASSESSMENT  
1. Perform hand hygiene and don PPE as indicated for needed isolation precautions. 
2. Introduce yourself to the patient. 
3. Verify the correct patient using two identifiers. 
4. Complete an admission assessment, including a psychiatric–mental health history. 
5. Assess the patient for symptoms of depression. 
6. Assess the patient for suicidal or homicidal ideation or thoughts of self-harm. Use an 
organization-approved standardized tool for suicide assessment.7 Assess for any specific 
plan or history of suicide attempts. 
 
Rationale: A history of suicide attempts places the patient at a higher risk for 
another attempt.8 
 
7. After obtaining the patient’s consent, obtain additional assessment information from the 
patient’s family and other involved persons. 
8. Obtain a complete list of medications from the patient or family during the admission 
process. 
 
Rationale: Polypharmacy is a risk factor for adverse effects and depressive 
symptoms in older adults.1 
 
9. Assess the patient for current or past substance abuse. 
10. Assess the patient for possible signs of abuse or neglect, such as bruising or 
dehydration. 
11. Assess nutrition and hydration status. 
12. Assess discharge needs, such as placement issues, in-home services, and financial 
difficulties. 
13. Assess the need for a psychiatric practitioner consult and seek a consult as appropriate. 
 
STRATEGIES 
1. Perform hand hygiene and don appropriate PPE based on the patient’s signs and 
symptoms and indications for isolation precautions. 
2. Verify the correct patient using two identifiers. 
3. Explain the strategies to the patient and ensure that he or she agrees to treatment. 
4. Use direct, matter-of-fact communication techniques with the patient. 
 
Rationale: Direct questioning with a matter-of-fact attitude provides clear 
communication regarding what is being assessed. 
 
  
 
Depression: Older Adult Patients - CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.             3 of 5 
 
5. Assess the patient daily and as needed for signs of depression, such as feelings of 
worthlessness or hopelessness. 
6. Assess the patient for behavior and mood changes during every shift. 
7. Assess the patient for changes in cognition at each interaction. 
8. Assess the patient for pain. 
 
Rationale: Chronic pain is a risk factor for depression.1 
 
9. Review all medications, including herbal agents, and instruct the patient regarding 
prescribed antidepressant medication and possible interactions with other drugs. 
 
Rationale: Patients should be taught possible adverse effects associated with 
their medications and potential drug-drug interactions. 
 
Encourage the patient to continue taking prescribed medications 
because antidepressant therapy may not be effective for several 
weeks.5 
 
10. Help the patient maintain nutrition and hydration status. 
11. Ensure that discharge plans include assessment of the patient’s living situation, 
including social isolation, increased loneliness, and the need for home care. 
12. Assess the patient’s ability to participate in discharge planning and his or her 
understanding of the patient education provided. 
13. Remove PPE and perform hand hygiene. 
14. Document strategies in the patient’s record. 
 
REASSESSMENT 
1. Perform ongoing assessments for signs and symptoms of depression. 
2. Reassess the patient’s mood daily and determine if it is congruent with behaviors and 
affect. 
3. Reassess the patient for suicidal risk and ideation. 
4. Consult a psychiatric practitioner if the patient expresses suicidal ideation or if symptoms 
of depression increase. 
5. Reassess the patient’s response to the medication regimen, including adverse reactions. 
6. Assess, treat, and reassess pain. 
 
EXPECTED OUTCOMES 
• Mental health history is documented on admission. 
• Risk factors for depression are identified. 
• Mental health referral is made, if indicated. 
• Depression is treated. 
• Safe environment is provided. 
• Patient does not attempt to harm self or others. 
• Patient cooperates with treatment plan. 
 
UNEXPECTED OUTCOMES 
• Patient’s depression does not resolve. 
• Preexisting depression worsens. 
• Medical-surgical complications, injury, or death occur. 
• Inpatient stay is extended. 
• Patient attempts to hurt self or others. 
  
 
Depression: Older Adult Patients - CE 
 
Copyright © 2020, Elsevier, Inc. All rights reserved.             4 of 5 
 
• Patient does not cooperate with treatment plan. 
 
DOCUMENTATION 
• Assessment findings 
• Information from family or significant others regarding patient’s normal mood and 
behaviors compared with current mood and behaviors 
• Patient’s participation level 
• Patient’s expression of depression or suicidal ideation 
• All treatment interventions  
• Patient’s response to interventions 
• Patient’s response to medication, including adverse reactions 
• Referrals or consults 
• Education 
• Unexpected outcomes and related interventions 
 
SPECIAL CONSIDERATIONS 
• Depression can negatively impact recovery after a myocardial infarction (MI).1 Ensure 
that patients recovering from MI are monitored for depression and receive treatment if 
necessary. 
 
REFERENCES 
1. Blackburn, P. and others. (2017). Depression in older adults: Diagnosis and 
management. BCMJ: British Columbia Medical Journal, 59(3), 171-177. Retrieved April 3, 
2020, from https://www.bcmj.org/articles/depression-older-adults-diagnosis-and-
management  
2. da Costa Lane Valiengo, L., Stella, F., Forlenza, O.V. (2016). Mood disorders in the 
elderly: Prevalence, functional impact, and management challenges. Neuropsychiatric 
Disease and Treatment, 12, 2104-2114. doi:10.2147/NDT.S94643 
3. Domènech-Abella, J. and others. (2019). Anxiety, depression, loneliness and social 
network in the elderly: Longitudinal associations from The Irish Longitudinal Study on 
Ageing (TILDA). Journal of Affective Disorders, 246, 82-88. doi:10.1016/j.jad.2018.12.043  
4. Fässberg, M.M. and others. (2016). A systematic review of physical illness, functional 
disability, and suicidal behaviour among older adults. Aging and Mental Health, 20(2), 166-
194. doi:10.1080/13607863.2015.1083945  
5. Gavrilova, S.I. and others. (2017). Optimization of antidepressant therapy in conditions 
of the gerontology psychiatric out-patient clinic. Neuroscience and Behavioral Physiology, 
47(2), 138-147. doi:10.1007/s11055-016-0377-8 
6. Hansen, M.C. and others. (2016). Correlates of depression in self-neglecting older adults: 
A cross-sectional study examining the role of alcohol abuse and pain in increasing 
vulnerability. Journal of Elder Abuse and Neglect, 28(1), 41-56. 
doi:10.1080/08946566.2015.1136252. (Level VI) 
7. Joint Commission, The. (2020). National patient safety goals. Hospital accreditation 
program. Retrieved April 3, 2020, from https://www.jointcommission.org/-
/media/tjc/documents/standards/national-patient-safety-
goals/npsg_chapter_hap_jan2020.pdf  
8. Parra-Uribe, I. and others. (2017). Risk of re-attempts and suicide death after a suicide 
attempt: A survival analysis. BMC Psychiatry, 17(1), 1-11. doi:10.1186/s12888-017-1317-z  
9. Siu, A.L., US Preventive Services Task Force (USPSTF). (2016). Screening for depression 
in adults: US Preventive Services Task Force Recommendation Statement. JAMA, 315(4), 
380-387. doi:10.1001/jama.2015.18392  
  
 
Depression: Older Adult Patients - CE 
 
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10. Wiktorsson, S. and others. (2018). Few sex differences in hospitalized suicide 
attempters aged 70 and above. International Journal of Environmental Research and Public 
Health, 15(1), 141. doi:10.3390/ijerph15010141 
11. Wright, P.P., Thorpe, C.W. (2016). Triple threat among the elderly: Depression, suicide 
risk, and handguns. JEN: Journal of Emergency Nursing, 42(1), 14-18. 
doi:10.1016/j.jen.2015.01.010 
 
ADDITIONAL READINGS 
American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American 
Geriatrics Society 2019 Updated Beers criteria for potentially inappropriate medication use 
in older adults. Journal of the American Geriatrics Society, 64(4), 674-694. 
doi:10.1111/jgs.15767  
 
 
Elsevier Skills Levels of Evidence 
• Level I - Systematic review of all relevant randomized controlled trials 
• Level II - At least one well-designed randomized controlled trial 
• Level III - Well-designed controlled trials without randomization 
• Level IV - Well-designed case-controlled or cohort studies 
• Level V - Descriptive or qualitative studies 
• Level VI - Single descriptive or qualitative study 
• Level VII - Authority opinion or expert committee reports 
 
 
Supplies 
• Gloves and PPE, as indicated 
 
 
Clinical Review: Loraine Fleming, DNP, APRN, PMHNP-BC, PMHCNS-BC 
 
Published: April 2020 


Depression: Older Adult Patients

Anxiety: Adolescent Patients

Smith, Tim

Bushek, Jennifer

LeClaire, Aimée

Prosser, Tony

COVID-19 Drug Therapy

O'Horo, John C







Section A 
Therapeutic Use Table 
Indications Diphenhydramine 
Hydrochloride 
Renal 
Impairment 
Dosing 
Adiustment 
Hepatic Yes 
Impairment 
Dosing 
Adjustment 
circadian 
rhythm 
disruption 
delayed 
sleep 
phase 
syndrome 
irregular 
sleep-wake 
disorder 
jet-lag 
non-24-
hour sleep-
wake 
disorder 
shift work 
sleep 
disorder 
insomnia Yes 
Yes - Labeled 
Yest- Off-label 
Doxepin 
Hydrochloride 
Yes 
Yes 
Doxylamine Eszopiclone Lemborexant Melatonin Ramelteon Suvorexant Tasimelteon Zaleplon Zolpidem 
Succinate Tartrate 
Yes Yes 
Yes Yes Yes Yes Yes Yes Yes Yes Yes 
I 
Yest 
Yest 
I 
Yest 
Yest 
Yest Yes 
Yest 
Yes Yes Yes Yest Yes Yes Yes Yes 




Not a member yet

Shortness of Breath Management (Ambulatory)