Emergency department nursing vascular assessment: a retrospective study

Nursing documentation in any area is essential, but in the patient with severe trauma and vascular injury it may be critical in evaluating change. In vascular trauma the nursing assessment and documentation provides a baseline for comparison of pulses in the emergency department, the intensive care unit, and the general or vascular floor. A retrospective review of vascular trauma charts performed at St. John's Mercy Medical Center in St. Louis, Missouri, revealed serious documentation omissions. In view of this study a new flow sheet for documentation was proposed, inservices were given, and a follow-up study is proposed for 2 years for implementation date. This study underscores the need to assess current documentation in every institution and regular review of records.