Assessment of the critically ill patient

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Flashcards on Assessment of the critically ill patient, created by Elizabeth Then on 07/23/2018.
Elizabeth Then
Flashcards by Elizabeth Then, updated more than 1 year ago
Elizabeth Then
Created by Elizabeth Then almost 6 years ago
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Question Answer
Rationale Thorough health assessment is fundamental Structured framework used to assess physio, emotional, spiritual and social states of patients
Physical assessment framework important data identify patient needs systematic plan of care
Initial assessment framework History functional capability of patient baseline physiological data Continuous, evaluate response to interventions determine achievement of goals
2 levels of assessment 1- brief initial assessment the primary survey 2- secondary comprehensive assessment the detailed information
Australasian Triage Scale ATS 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
Decision making based upon determine urgency allocate resources initiate interventions manage incidents control patient flow
Triage decision making based upon primary - 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
Emergency assessment based upon used for triage, resuscitation, initial evaluation in treatment area consists of primary and secondary survey
Primary and secondary survey detect 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
Primary survey - a systematic linear approach Rapid and accurate provision of resuscitation and stabilisation on a priority basis early determination of need of transfer ensure optimal care is provided
Primary survey overview A irway and C- spine (patency) B reathing assess effory, patterns, sounds C irculation pulse, quality, skin refil, colour, temp D isability assess consciousness
Airway and C - Spine Must 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
Actions if airway totally or partially obstructed position 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
Breathing - inspect, ausculate, percuss inspect - 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
Breathing interventions breathing 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
Circulation assessment inspect - colour, LOC, haemorrhage auscultate - heart sounds palpate - pulses, quality, rate, rhythm severe limb injury - is it threatening the viability of the limb, nv obs
Rapid assessment of blood volume loss skin 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)
Ineffective circulation control external haemorrhage via direct or arterial pressure two large bore intravenous catheters - pressure devices, surgical cut down, warmed fluids, o neg blood transfusion
Absent circulation CPR, give bloods, do surgery
ABC actions A - find and remove obstruction and protect C - spine B - assist O2, bag and mask, intubation C - stop bleeding, chest compressions, medications, IV fluid
Disability assessment inspect - LOC, pupil size and reactions, fractures, pain, facial expressions auscultate - complaints, NandV palpate - Feel for muscle tone AVPU and pupils
ABC OK if no life threatening condition identified identify chief complaint vital signs medications allergies secondary survey
Secondary survey to detect all significant probelms
Exposure assess a patient and expose area to be examined, and note any findings
Temperature exposed, long period immobile, spinal injury poikilothermia, establigh baseline observations
Gadgets and gather pathology assess patients pain score ensure analgesia or appropriate interventions ie splinting reassess pain score following intervention determine bedside monitoring and investigations are required
Head to toe history max fax traume implies c-spine injury chest - palpation, brath sounds, heart sounds abdomen - palpation most important pelvis, perineal area, extremities
History - MIST M - mechanism of injury I - injuries sustained and suspected S - signs and symptoms T - treatment intiated
History - SAMPLE S - symptoms A - allergies M - medications P - past medical history L - last meal and drink E - events immediately proceeding illness
Inspect the back roll patient, look, listen feel
Document main complaint, history of main complaint, signs and symptoms, all sources of information
Critical Care Assessment Trauma - examine all systems Non Trauma - focus on affected systems Guided by primary and secondary survey Cardiovascular, Resp, Neuro, GI, skin, Endo, Haem, Immune
Cardiovascular cardiac history, current cardiac status, potential complications, heart sounds, ECG
Cardiovascular diagnostic procedures labs - 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
Respiratory and cardiovascular lab chest x ray ECG Echo MRI angio haem monitoring
Respiratory diagnostic procedures ABG sputum bronchoscopy, thoracentesis, ventilation/perfusion scanning, chest radiography beside monitoring, pulse oximetry, capnography
Chest X ray anterior Posterior exposure check rotation - clavicles centred over spinous processes adequate inspiration
Capnography the 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
Neurologic LOC pupils, RR, muscle reflexes GCS
Unconsciousness cocktail naloxone, thiamine, 50% dextrose
Head, Ears, Eyes, Nose, Throat inspected, palpated, otoscope for TM (indicative of brain injury), visual acuity
Neurological Sytem Assessment history, physical assessment, LOC, motor function, pupillary function and eye movement, resp pattern, vital signs
Neurologic system diagnostic procedures radiologic procedures EEG, LP, lab studies
Cerebro- spinal Fluid LP 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
Gastrointestinal history - subjective inspect - symmetry, distension, masses, scars bowel sounds - 4 quadrants palpate - painful area last, rectum stool for blood
Gastrointestinal sytem diagnostic procedure lab studies - stool, liver enzymes, bilirubin, serum protein, coags diagnostics - CT, MRI, Biopsies, x-rays
Genitourinary history - change in urine, output, pattern, pain smaple consider pregnancy
Renal system assessment history, physical examination, additional parameters weight, intake and output
Renal system diagnostic procedures lab assessment, BUN, renal biopsies, MRI, CT
Musculoskeletal mostly related to trauma consider infection, degeneration, nutrition, neurologic, cardiac
Integumentary integrity, temperature, turgor, rashes, perspiration
Endocrine target specific complaint e.g. polydipsia
Haematologic bruising, spontaneous bleeding, anaemia
Immune system exposure to infection, immunisations, fever, lymph nodes
HIRAID Assessment History Identify red flags Assessment (clinical examination) Interventions Diagnostics
Additional to primary survey presenting probelm, drugs and diagnostic tests, equipment, allergies, ISBAR
Assessment purpose ongoing, trends established, determine response to treatments, identify new probelms, frequency of assessment
Frequency of assessment stability of patient condition Before and after any patient movement in or out of critical care unit
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