CLINICAL INFORMATION FOR NURSES

               Dearnurses.net is no longer available.

Updated 1/25

Dear nurses,

New links have been added below.

Here are the topics:

IV assessment

Avoiding Medication errors

Neurological Assessment

Chest Pain Assessment

    Chest pain assessment

      The Numerical Pain Scale is a useful tool when
        assessing pain. It is based on a scale of 0-10.

A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

PAIN ASSESSMENT

Updated 6/25

Dear nurses,

It is important to recognize, when a patient
complains of pain, an assessment should be
done by the nurse. Below, examples of pain
assessment, with links, have been added. 

Enjoy learning!

Learn more about : Chest pain assessment 

Learn more about: Pain assessment

Learn more about: The standards of care

Learn more about:
Dehydration on a long flight
Abdominal Aortic Aneurysm

Be cautious, prevent falls!

NEUMERICAL PAIN SCALE ASSESSMENT

 

Scenario: Paul had surgery on his back two days prior.
He is having pain and requests medication. The nurse
does an assessment.

Neumerical pain scale assessment

This a very useful tool when assessing pain. It is 
based on a scale of 0-10 ( 10 being the worst).
A ladder starts from the ground which is the
lowest point. It escalates to the highest point,
so does the pain. Pain scale:

0 = no pain
1-3 = mild pain
4-6 = pain is considered moderate
7-10 = pain is extreme or severe

Helpful hints:

Medication that is given by mouth, takes
longer to be absorbed than when it is given 
IM or IV.

It is important to do a pain assessment after
medication has been given. Documentation 
of the effect it has and any side effects, is 
also helpful. Learn more:
Safe medication administration

Learn more : The Nursing Process

PATIENT ASSESSMENT

Dearnurses.com is no longer available.

New topics with links have been added below.

Patient assessment is a very important tool. 
The patient having chest pain, would have 

an assessment done by the nurse.

A description of the pain, as well as pain
scales assessment ( 1-10) is usually done.

Documentation of intervention is also 
necessary. 

Below are more assessment links:
 Neurological assessment
Abdominal assessment 

Stroke assessment









Updated 2/25

Dear nurses,

Regardless of where you work, assessment is a very important tool. Enjoy learning more about patient assessment( Chapter 15). This is full of helpful information on assessment in the clinical setting. Topics include - Assessment of:

The Patients Responsiveness

Stroke

Cranial Nerves

Spinal

Fall

Pain

& more

CARDIOGENIC SHOCK AND ASSESSMENT

Scenario: Mrs. R is a 48 year-old female who has a history of a previous myocardial infarction. She was admitted 2 days ago with mild chest pain. She was resting comfortably when she suddenly started feeling short of breath. She is anxious and calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment, vital signs, and oxygen saturation. She gives oxygen per protocol.

-The nurse notifies the doctor of what has occurred and her assessment findings. She also mentions the vital signs, low oxygen saturation, and steps that were taken to correct the saturation. The doctor gives further orders, including a transfer to CCU.


Why chest pain assessment?
It must be remembered that a patient with heart damage will also experience chest pain. Assessment of the pain should also be included. This may be sharp, with radiation to shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
 Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

PATIENT ASSESSMENT IS IMPORTANT

Updated 8/25

Scenario: Mrs. R is a 48 year-old female who has a history
of a previous myocardial infarction. She was admitted 2 days
ago with mild chest pain. She was resting comfortably when
she suddenly started feeling short of breath. She is anxious 
and calls the nurse.

What actions did the nurse take?
The nurse reassures Mrs. R. She does an assessment, vital 
signs and oxygen saturation. She gives oxygen per protocol.

-The nurse notifies the doctor of what has occurred and her
assessment findings. She also mentions the vital signs, low
oxygen saturation, and steps that were taken to correct the
saturation. The doctor gives further orders, including a
transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage
 will also experience chest pain. Assessment of the pain
should also be included. This may be sharp, with radiation
 to shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
 Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : ARDS, DVT and PE

ADDRESSING PATIENT ASSESSMENT

Updated 7/25

Scenario: Mrs. R is a 48 year-old female who has
a history of a previous myocardial infarction. She
 was admitted 2 days ago with mild chest pain. 

She was resting comfortably when she suddenly
started feeling short of breath. She is anxious and
 calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment,
 vital signs, and oxygen saturation. She gives oxygen
 per protocol.

-The nurse notifies the doctor of what has occurred
and her assessment findings. She also mentions the
vital signs, low oxygen saturation, and steps that
were taken to correct the saturation. 

The doctor gives further orders, including a transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage will
also experience chest pain. Assessment of the pain should
also be included. This may be sharp, with radiation to shoulder
/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
 Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Scenario: In the image above, Ann is an opera
singer. While on stage, she suddenly starts having
trouble getting her words out. Her right arm also
feels weak. These symptoms are classic of someone
experiencing a stroke.

Signs and stroke symptoms:

- sudden , severe headache
- slurred speech, mental confusion

- nausea and vomiting

- visual disturbances, hearing loss

- facial weakness

- weakness in arm or leg on one side

A CAT scan or MRI or both may be done to 
confirm diagnosis.

ADDRESSING PAIN ASSESSMENT

Updated 8/25

Dear nurses,

As we all know, pain is a common complaint.
It is important to recognize the cause, source
and to do an assessment on a scale of 1-10.

Pain medication is given to the patient complaining
of pain. Medication is usually ordered by the doctor.
The MAR is used for each patient.

Documentation of the pain medication given, the
pain scales from start to finish and the outcomes
of all medication, is also important.

Below are some scenarios associated with pain.

Learn more about: Aortic rupture

PACU

The nurse above is about to make a medication error.
This is very poor judgement on her part.

Here are some helpful pointers for good medication administration:
- Follow MD orders

- Remember the five or more rights
- DO NOT USE COLOR CODING AS YOUR ONLY GUIDELINE.
Remember, many pills may have the same color, but that does not
mean they are of equal strength.
- If you are a new nurse and you are uncertain, consult with a more
 experienced nurse to help you out.

- Always follow your Institution's policies and procedures.

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

Learn more about: Chest pain assessment and

Triage Nurse

CARDIOGENIC SHOCK ASSESSMENT

Updated 7/25

Scenario: Mrs. R is a 48 year-old female who has a
history of a previous myocardial infarction. She was
resting comfortably when she suddenly started feeling
 short of breath. She is anxious and calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment,
 vital signs, and oxygen saturation. She gives oxygen 
  per protocol.

-The nurse notifies the doctor of what has occurred and
 her assessment findings. She also mentions the vital signs,
low oxygen saturation, and steps that were taken to correct
the saturation. The doctor gives further orders, including a
transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage will
also experience chest pain. Assessment of the pain should also
 be included. This may be sharp, with radiation to shoulder/jaw,
or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
 Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : Organizational Skills

CARDIOGENIC SHOCK AND CRITICAL THINKING

Updated 8/25

Scenario: Mrs. R is a 48 year-old female who has a history
of a previous myocardial infarction. She was admitted 2 days
 ago with mild chest pain. She was resting comfortably when
she suddenly started feeling short of breath. She is anxious 
and calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment, vital 
signs, and oxygen saturation. She gives oxygen per protocol.

-The nurse notifies the doctor of what has occurred and her
assessment findings. She also mentions the vital signs, low
oxygen saturation, and steps that were taken to correct the
saturation. The doctor gives further orders, including a
transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage
 will also experience chest pain. Assessment of the pain
should also be included. This may be sharp, with radiation
 to shoulder/jaw, or it may feel like chest pressure.

Helpful Hint:
Chest pain should always be assessed.
 Enjoy learning more about this topic by clicking on the link:
Simplifying Cardiogenic Shock

Learn more about : ARDS, DVT and PE

Learn more about: Aortic Rupture

WHEN CPR IS NEEDED IN THE EMERGENCY ROOM

   Updated 8/25

Dearnurses.net is no longer available.

New information has been added below.

The image above shows a Code blue in progress. This is 
happening in the emergency Room. Always follow your

Institution's policies and procedures for Code Blue. 

The role of the nurse who is assigned to the Code Blue

The nurse has an important role in effective communication.
There are many responsibilities.

- staying calm in a chaotic situation
- giving clear instructions to coworkers
- ensuring that MD orders are conveyed correctly

- proper documentation of vital signs and all treatments /
  interventions that take place ( defibrillation for example)
  - the nurse becomes the " binding force.

Scenario: Mrs. R is a 48 year-old female who has a history
of a previous myocardial infarction. She was admitted 2 days
 ago with mild chest pain. She was resting comfortably when
she suddenly started feeling short of breath. She is anxious 
and calls the nurse.

What actions did the nurse take?
-The nurse reassures Mrs. R. She does an assessment, vital signs
, and oxygen saturation. She gives oxygen per protocol.

The nurse notifies the doctor of what has occurred and her
assessment findings. She also mentions the vital signs, low
oxygen saturation, and steps that were taken to correct the
saturation. The doctor gives further orders, including a
transfer to CCU.

Why chest pain assessment?
It must be remembered that a patient with heart damage
 will also experience chest pain. Assessment of the pain
should also be included. This may be sharp, with radiation
 to the shoulder/jaw, or it may feel like chest pressure.

Learn more about : ARDS, DVT and PE

PAIN MANAGEMENT

Updated 6/25

Dear nurses, 

It is important to remember that pain assessment,
should not be overlooked. Always follow MD orders

for pain management.

Documentation of pain relief is also necessary.

Chest pain is a very common complaint. It may
occur anywhere and anytime, even at rest.
Learn more about : Chest pain

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to|
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

ADDRESSING THE STROKE PATIENT / AN ASSESSMENT

Updated 8/25

Dear nurses,
New topics have been added. 

Enjoy learning!

 Learn more about: Stroke assessment

Learn more about: Cranial nerves and 
Subarachnoid hemorrhage

Learn more about : Stroke prevention

       The Numerical Pain Scale is a useful tool when
        assessing pain. It is based on a scale of 0-10.

A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

THE NUMERICAL PAIN ASSESSMENT

 

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

AVOIDING MEDICATION ERRORS / NUMERICAL PAIN SCALE

Scenario: In the above image, a patient was brought into the 
 Emergency room with complaints of chest pain and a drop in 
 blood pressure. The doctor ordered Morphine for the pain and 
  Dopamine for the hypotension. Both medications were given

     as ordered. The nurse in the green top (left) gave the Morphine
and started the Dopamine infusion.

Next : What went wrong? The nurse forgot to put a label on the
 IV bag and did not document what time both medications were 

 given. It is very important for the nurse to pay close attention to
the time that medications are given. 

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to|
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

Learn more : The Nursing Process

ASSESSMENT OF CHEST PAIN FOR NURSES

Dear nurses,

Updated 3/24

Chest Pain Series is no longer available. Please click on the link:
Chest pain assessment

for more updated information.

Are you having difficulty with your CLINICAL SKILLS? Do you know how to assess and document chest pain? Simply, click on to the link: " CHEST PAIN SERIES"and

your questions will be answered. You will learn how to :

- assess and intervene when there is chest pain.

- document findings and call for help.

You may also enjoy watching the video :

http://www.dearnurses.com/clinical_nursing_videos_called_sessions ( Sessions 12)

PAIN ASSESSMENT FOR NURSES

Updated 1/25

Dear nurses,

Dearnurses.com is no longer available. Please click
on the link for more updated information: 

Pain assessment

Scenario 1: In the image above, the nurse in the green 
top has been enjoying a lengthy conversation with a friend. 
She has no idea one of the patients is having chest pain.

Learn more by clicking on the link below:
Clinical judgement

HELPFUL INFORMATION FOR NURSES IN THE CLINICAL SETTING

Dear nurses,

Here is some helpful information for the clinical nurse:

- Do not forget to document the medications you gave

- Check for a history of allergies prior to administering medications

- Never recap a used needle

- It is advisable not to use a needle disposal that is full

- If the trash can is full, notify Housekeeping!

The Numerical Pain Scale is a useful tool when
assessing pain. It is based on a scale of 0-10.
A ladder starts from the ground and escalates to|
the highest point, so does pain start from 0-10.

It is important to do a pain assessment after pain
medication has been given. See image for more
information.

WHAT IF YOUR PATIENT HAS CHEST PAIN ?

Dear nurses, if your patient was having chest pain, would you
know how to do an assessment?
Chest pain may be the warning signs of a heart attack! 
To learn more about chest pain assessment, the clinical setting ,
simply click on the link:
http://www.dearnurses.com/clinical_nursing_videos_called_sessions
and
http://www.dearnurses.com/chest_pain_series_-_master_your_clinical
and enjoy learning.

IGNORING CHEST PAIN

Updated  8/23

Dear Nurses,

Helpful information on chest pain and assessment can be obtained 
by clicking on the link: 

Chest pain assessment and quiz

If there is chest pain, act fast!