14446744
Beschreibung
Karteikarten von Elizabeth Then, aktualisiert more than 1 year ago
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Erstellt von Elizabeth Then
vor mehr als 6 Jahre
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| Frage | Antworten |
| 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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