A-E + Head to Toe Assessment Flashcards
What are the common signs of airway obstruction?
Paradoxical chest and abdominal movement (see-saw respiration)
Accessory muscle use
Central cyanosis
Added noises: snoring, strider, gurgling, gasping
What are the 3 L’s in Airway assessment
Look for visible obstruction in pt mouth, secretions, swelling, see-saw movement
Listen for patient speaking and strider or snoring noises
Feel for airflow and breaths from patient oral and nasal passage
What are the Airway management
High flow Oxygen
Airway manoeuvre ( chin lift head tilt and jaw thrust)
Suction
Airway adjunct (Guedel)
Nasopharyngeal and oral pharyngeal airway (ETT, LMA)
Bag valve mask
What does RATES stand for in breathing assessment?
Respiratory rate
Auscultation
Trachea position
Effort
Saturation o2
What does deviation of Trachea to one side indicate?
Pneumothorax
How to detect a surgical emphysema?
Palpating chest produce a crackling sensation (crepitus) as gas bubbles are pushed through the skin
What is involved in Breathing Assessment?
Assess changes in depth and rate of breathing
Auscultate bilateral breath sounds, air entry and adventitious sounds
Look for symmetrical and bilateral chest expansion
Assess for accessory muscle use and increase WOB
What are the signs of respiratory distress?
Increased RR
Increased HR
Sweat cold & clammy
Accessory muscle use / neck strain
Exhaustion
Central cyanosis
Audible strider and wheeze
Noisy laboured respiration
What are the example of accessory muscle use?
Tracheal tug
Tripod positioning
Abdominal see-saw
Nasal flaring
Neck and sternocleidomastoid
Grunting and strider
What are the two types of V/Q mismatch?
Shunt perfusion: poor ventilation - Problem getting oxygen supply across alveoli but good perfusion (blood supply) eg. pneumonia
Dead space ventilation: inadequate perfusion - limited blood supply moving past alveoli but good ventilation eg. Asthma COPD
What examples signify circulation problem?
Sepsis
Dehydration
Electrolyte imbalance
Blood loss
MI ischaemia
What is involved in circulation assessment ?
Vital signs: BP, HR, feel pulse carotid & radial, temp, ECG
Cold and clammy, sweating, pallor
Urine output and blood loss
cap refill time and central
IV access preparation
Reduced LOC
Signs of poor cardiac output ?
Decreased urine output
Reduced LOC
Hypotension
Diminished pulse
Treatment for circulatory problem
IV Access
Bloods: troponin, FBC, kidney, cultures electrolyte)
Rapid bolus 500mls crystalloid solution (Hartmanns, 0.9% NA)
Oxygen
IDC catheter
Flat position of patient increase BP to vital organs
Sepsis pathway - broad spectrum antibiotics
What are the 3 components of GSC?
Eye opening response
Best verbal response
Best motor response
What does a score a GCS score 9-12 indicate?
Moderate head injury
What does a GCS score 3-8 indicate?
Comatose severe head injury
Key components of a Disability assessment
AVPU and GCS - confusion
Pupillary changes (size, equality & reaction to light)
BSL (DKA,HHS)
Check medication chart (insulin, opiate) & medical history
Pain score
What does PEARL stand for?
Pupil
Equal
Round
Reactive to Light
Accomodation
What does dilated pupils indicate
Heroin, marijuana, amphetamine, Cochin, hallucinogen, opiate overdose
What does unequal pupil indicate?
Head trauma
What is normal pupil size?
2-6mm
What are the components of Exposure assessment?
Examine skin - head to toe - colour, temp, swear, rashes, bites, swelling, oedema, wound cuts
Abdominal distension
Calf swelling and redness
Drains / stoma output
What does COLDSPA stand for?
Presenting complaint
Character - describe signs & symptoms ( crushing or sharp pain)
Onset - when did it begin
Location - where is it and does it radiate
Duration - how long does symptoms last? Recurring or constant?
Severity - rate pain out of 10
Pattern - is there anything that makes the symptoms better or worse
Associated factors - other symptoms associated
What are abnormal findings in abdominal examination
Less than 5 clicks/gurgle bowel sounds heard in a minute during auscultation
Involuntary guarding reflex and tenderness when palpating abdomen
Deviated umbilicus
Vigorous wide pulsation visible indicate Abdominal Aortic Aneurysm
What is Strider
High pitch sound on inspiration due to partial obstruction of larynx or trachea
What is wheeze?
High pitch whistle sound cause by air passing through narrow constricted airway
Broncho-constriction or fluid overloaded due to CHF / pulmonary oedema
What is rhonchi?
A deep low pitch rumble or coarse wheezing sound, as air moves through larger bronchial or tracheal airways in the presence of mucous secretions - heard during expiration ( Asthma )
What is Crackles?
Fine, short, high pitched sounds caused by air passing mucus or fluid. Commonly heard in base of lung lobes during inspiration