Zusammenfassung der Ressource
Flussdiagrammknoten
- Collect objective Data
•‘collect information’
•- Vital signs
•- assess urine output, quality…
•- ABCDE
•- ECG & bloods
•- BGLs
•- bladder scan
•- Weight
•-Fluid balance (+ve or –ve?). What is the progressive total?
•-Neurological obs
•-Neurovascular obs
•-Skin assessments
•-bowel function
•- Wound assessment
•- Lung and Bowel sounds
- Visual assessment
•‘Look at your patient’
•- Respiratory effort – is your patient breathing? Is their respiratory effort laboured? Shallow? Rapid?
•- Look for pallor, cyanosis
•- Look for a flushed appearance
•- Look for diaphoresis
•- LOC: Are they awake? Drowsy? Unconscious?
•-Is your patient coughing? What is the colour and quantity of the sputum?
•-Is your patient vomiting? Dry retching?
•- Can you see any pressure injuries?
•- Observe characteristics of wounds or injuries
•- Is the skin discoloured, or paper thin? Are there any skin tears?
•- Can you see any deformities?
•- Does the patient appear to be well kept?
•- Does the patient have any lines or drains? (IVCs, ICC/UWSDs, NGTs, PICCs, Infusions, IDCs…)
•- Is the patient having rigors?
- Listen for clues
•- Listen for a cough (dry? Moist?)
•- Listen for a stridor, wheeze, course crackles
•- Audible bowel sounds
•- Laboured, purse lipped breathing
•- Is there evidence of dysphasia? (Impairment of production of language)
•- Is there evidence of dysphagia ( can you hear coughing or choking immediately after attempted swallowing?)
•- Flatulence
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‘Palpate’
•- Skin temperature – cool or warm?
•- Is the skin clammy? Dry?
•- Assess degree of peripheral oedema
•- Is there abdominal distension?
•-Is the abdomen firm? Soft?
•- Is there a palpable bladder (urinary retention?)
- ‘Smell’
•- Foul smelling odour from sputum, wound beds, urine, stool, that may be indicative of an infection
•- Fruity ‘acetone’ breath (DKA)
•- Is there evidence that the patient is not attending to hygiene cares?
•- Halitosis
- Enquire’
•Asking questions to obtain information, is one of the most important part of your assessment.
•for example…
•- When did the symptoms start?
•- How do you feel?
•- Do you have any pain?.....(PQRST)
•- Do you have any shortness of breath?
•- Are you feeling cold/hot? (Pts with fevers)
•- Have you been coughing? Is your cough productive? What colour is your sputum? How much sputum are you producing?
•- Are you feeling dizzy?
•- Are you sleeping well?
•- Do you have any concerns?
•- Do you understand you treatments/ investigations?
•- Do you experience any pain on urination?
•- Have you been taking all of your medications?
•- How is your appetite?
•- Have you had any falls?