Karteikarten
Assessment of the critically ill patient
Karten in diesem Stapel (58)
- 1RationaleThorough health assessment is fundamental
Structured framework used to assess physio, emotional, spiritual and social states of patients - 2Physical assessment frameworkimportant data
identify patient needs
systematic
plan of care - 3Initial assessment frameworkHistory
functional capability of patient
baseline physiological data
Continuous, evaluate response to interventions
determine achievement of goals - 42 levels of assessment1- brief initial assessment the primary
survey
2- secondary comprehensive assessment the detailed information - 5Australasian Triage ScaleATS CODE CATEGORY AKA RESPONSE TIME
- immediately like-threatening 1 resuscitation immediate
- imminently life-threatening 2 emergency 10 minutes
- potentially life-threatening or important time-critical treatment or severe pain 3 urgent 30 minutes
- potentially life serious or situational urgency 4 semi-urgent 60 minutes
- less urgent 5 non-urgent 120 minutes - 6Decision making based upondetermine urgency
allocate resources
initiate interventions
manage incidents
control patient flow - 7Triage decision making based uponprimary - identify life threatening probelms
deliver first aid and appropriate interventions, ABC then primary complaint
objective data - inspection and information e.g. x rays
physiological data
subjective data 'why have you come into ED' open ended questions
- secondary triage decisions - 8Emergency assessment based uponused for triage, resuscitation, initial evaluation in treatment area
consists of primary and secondary survey - 9Primary and secondary surveydetect and treat all life threatening probelms
- conscious patient without primary probelms should complete primary survey in seconds
- unconscious patient will take 90 seconds
Secondary survey not commenced until all probelms in primary survey have been managed - 10Primary survey - a systematic linear approachRapid and accurate
provision of resuscitation and stabilisation on a priority basis
early determination of need of transfer
ensure optimal care is provided - 11Primary survey overviewA irway and C- spine (patency)
B reathing assess effory, patterns, sounds
C irculation pulse, quality, skin refil, colour, temp
D isability assess consciousness - 12Airway and C - SpineMust assume all major trauma patients have a injured spine and maintain cervical spine stabilization/ immobilization
observations - conscious or unconscious?
look, listen, feel
inspect, auscultate, palpate
inspect - airway obstruction, injury, bleeding
auscultate - air entry clear and equal, ineffective cough
palpate - expired air, chest symmetry, subcutaneous emphysema - 13Actions if airway totally or partially obstructedposition patient
open and clear airway
jaw thrust and chin lift
remove fbs and suction
insert an airway
stabilise c-spine and consider intubation
consider needle and surgical cricothyriodotomy - 14Breathing - inspect, ausculate, percussinspect - chest, respirations, rate, position, accessory muscle use, tracheal deviation
listen - equal breath sounds, abnormal sounds, cough and voice quality
percuss - dullness associated with fluid
hyper-resonance associated with air
feel - chest movement and air flow, trachea positions, subcutaneous emphysema - 15Breathing interventionsbreathing present and effective - administer O2
Breathing present but ineffective - administer o2 via non-rebreather mask or bag-mask device
breathing absent - ventilate with 100% o2, assist with intubation - 16Circulation assessmentinspect - colour, LOC, haemorrhage
auscultate - heart sounds
palpate - pulses, quality, rate, rhythm
severe limb injury - is it threatening the viability of the limb, nv obs - 17Rapid assessment of blood volume lossskin colour
carotid pulse palpable (sys bp less than 60)
femoral pulse palpable (sys bp less than 70)
radial pulse palpable (sys bp less than 80) - 18Ineffective circulationcontrol external haemorrhage via direct or arterial pressure
two large bore intravenous catheters - pressure devices, surgical cut down, warmed fluids, o neg blood transfusion - 19Absent circulationCPR, give bloods, do surgery
- 20ABC actionsA - find and remove obstruction and protect C - spine
B - assist O2, bag and mask, intubation
C - stop bleeding, chest compressions, medications, IV fluid - 21Disability assessmentinspect - LOC, pupil size and reactions, fractures, pain, facial expressions
auscultate - complaints, NandV
palpate - Feel for muscle tone
AVPU and pupils - 22ABC OKif no life threatening condition identified
identify chief complaint
vital signs
medications
allergies
secondary survey - 23Secondary surveyto detect all significant probelms
- 24Exposureassess a patient and expose area to be examined, and note any findings
- 25Temperatureexposed, long period immobile, spinal injury poikilothermia, establigh baseline observations
- 26Gadgets and gather pathologyassess patients pain score
ensure analgesia or appropriate interventions ie splinting
reassess pain score following intervention
determine bedside monitoring and investigations are required - 27Head to toe historymax fax traume implies c-spine injury
chest - palpation, brath sounds, heart sounds
abdomen - palpation most important
pelvis, perineal area, extremities - 28History - MISTM - mechanism of injury
I - injuries sustained and suspected
S - signs and symptoms
T - treatment intiated - 29History - SAMPLES - symptoms
A - allergies
M - medications
P - past medical history
L - last meal and drink
E - events immediately proceeding illness - 30Inspect the backroll patient, look, listen feel
- 31Documentmain complaint, history of main complaint, signs and symptoms, all sources of information
- 32Critical Care AssessmentTrauma - examine all systems
Non Trauma - focus on affected systems
Guided by primary and secondary survey
Cardiovascular, Resp, Neuro, GI, skin, Endo, Haem, Immune - 33Cardiovascularcardiac history, current cardiac status, potential complications, heart sounds, ECG
- 34Cardiovascular diagnostic procedureslabs - bloods
electrolytes - k, ca, mg
enzyme levels reflect myocardial cell integrity and function, creatine kinase, troponin
haem status, evaluate anaemia and infection
coags - aPTT, PT, INR
serum lipid levels
other organ functions - BUN, CR, Thyroid hormone, liver enzymes - 35Respiratory and cardiovascular labchest x ray
ECG
Echo
MRI
angio
haem monitoring - 36Respiratory diagnostic proceduresABG
sputum
bronchoscopy, thoracentesis, ventilation/perfusion scanning, chest radiography
beside monitoring, pulse oximetry, capnography - 37Chest X rayanterior Posterior
exposure
check rotation - clavicles centred over spinous processes
adequate inspiration - 38Capnographythe monitoring of the concentration or partial pressure of carbon dioxide (CO. 2) in the respiratory gases. It is usually presented as a graph of expiratory CO
- 39NeurologicLOC
pupils, RR, muscle reflexes
GCS - 40Unconsciousness cocktailnaloxone, thiamine, 50% dextrose
- 41Head, Ears, Eyes, Nose, Throatinspected, palpated, otoscope for TM (indicative of brain injury), visual acuity
- 42Neurological Sytem Assessmenthistory, physical assessment, LOC, motor function, pupillary function and eye movement, resp pattern, vital signs
- 43Neurologic system diagnostic proceduresradiologic procedures
EEG, LP, lab studies - 44Cerebro- spinal FluidLP
examined for:
colour, glucose, protein, leukocytes, opening pressure
glucose - 2/3 of normal serum glucose
protein - normal 18 - 58 elevated in diabetes, tumour, MS
CSF - leukocytes normal 5 or less - 45Gastrointestinalhistory - subjective
inspect - symmetry, distension, masses, scars
bowel sounds - 4 quadrants
palpate - painful area last, rectum
stool for blood - 46Gastrointestinal sytem diagnostic procedurelab studies - stool, liver enzymes, bilirubin, serum protein, coags
diagnostics - CT, MRI, Biopsies, x-rays - 47Genitourinaryhistory - change in urine, output, pattern, pain
smaple
consider pregnancy - 48Renal system assessmenthistory, physical examination, additional parameters
weight, intake and output - 49Renal system diagnostic procedureslab assessment, BUN, renal biopsies, MRI, CT
- 50Musculoskeletalmostly related to trauma
consider infection, degeneration, nutrition, neurologic, cardiac - 51Integumentaryintegrity, temperature, turgor, rashes, perspiration
- 52Endocrinetarget specific complaint e.g. polydipsia
- 53Haematologicbruising, spontaneous bleeding, anaemia
- 54Immune systemexposure to infection, immunisations, fever, lymph nodes
- 55HIRAID AssessmentHistory
Identify red flags
Assessment (clinical examination)
Interventions
Diagnostics - 56Additional to primary surveypresenting probelm, drugs and diagnostic tests, equipment, allergies, ISBAR
- 57Assessment purposeongoing, trends established, determine response to treatments, identify new probelms, frequency of assessment
- 58Frequency of assessmentstability of patient condition
Before and after any patient movement in or out of critical care unit
Informationen
- Beschreibung
- Der Nutzer hat seine Fachbereichs-Information gelöscht. Karteikarten am Assessment of the critically ill patient, erstellt von Gelöschter Nutzer am 23/07/2018.
- Erstellt von
- Gelöschter Nutzer · Jul 2018
- Aktualisiert
- 23 Jul 2018
- Aufrufe
- 49
- Verlauf
-
- Erstellt von Elizabeth Then · 23 Jul 2018
- Kopiert von Elizabeth Then · 23 Jul 2018
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