Adult Assessment Flashcards
Adequate Perfusion
Skin: WPD
HR: 60-100
SBP: > 100
CS: Alert & Oriented
Borderline Perfusion
Skin: CPC
HR: 50-100
SBP: 80-100
CS: Alert & Oriented
Inadequate Perfusion
Skin: CPC
HR: < 50 or > 100
SBP: 60-80
CS: Alert or Altered
Extremely Poor Perfusion
Skin: CPC
HR: < 50 or > 110
SBP: < 60
CS: Altered or Unconscious
No Perfusion
Skin: CPC
HR: Nil palp
SBP: Unrecordable
CS: Unconscious
Normal Respiratory
Appearance: Calm, Quiet Speech: Clear, Steady Sounds: Quiet RR: 12-16 Rhythm: Regular WOB: Normal Pulse: 60-100 Skin: Normal CS: Alert
Mild Respiratory Distress
Appearance: Calm or Anxious
Speech: Full Sentence
Sounds: Cough, Mild Wheeze or Basal Crackles
RR: 16-20
Rhythm: Prolonged Expiratory Phase
WOB: Slight ^ Chest Movement
Pulse: 60-100
Skin: Normal
CS: Alert
Moderate Respiratory Distress
Appearance: Distressed, Anxious
Speech: Short Sentences
Sounds: Cough, Insp/Exp Wheeze, Mid-Zone Cckl
RR: > 20
Rhythm: Prolonged Expiratory Phase
WOB: Marked +/ - AM use
Pulse: 100-120
Skin: Pale, Sweaty
CS: Alert or Altered
Severe Respiratory Distress
Appearance: Exhausted, Fighting to Breath
Speech: Word or None
Sounds: No Cough, I/E Whz, FF Cckl, Stridor, No
RR: > 20 or < 8
Rhythm: Prolonged Expiratory Phase
WOB: Marked +/ - AM use, IC retract, +/ - TT
Pulse: > 120 or < 60 (Late)
Skin: Pale, Sweaty, +/- Cyanosis
CS: Altered/ Unconscious
AVPU
Alert
Voice
Pain
Unresponsive
GCS Eyes
Spontaneous: 4
To Voice: 3
To Pain: 2
None: 1
GCS Verbal
Orientated: 5
Confused: 4
Inappropriate Words: 3
Incomprehensible Sounds: 2
None: 1
GCS Motor
Obeys Commands: 6 Localises to Pain: 5 Withdraws to Pain: 4 Flexion to Pain: 3 Extension to Pain: 2 None: 1
Adult Trauma TCG VSS
HR: < 60 or > 120 RR: <10 or > 30 SBP: < 90mmHg SpO2: < 90% GCS >= 16: < 13 GCS < 15: < 15
Adult Trauma TCG Specific Injury
All Penetrating Injuries.
Blunt Injuries:
- Serious Injury to single body region, needing special
care such that life, limb or life quality is at risk
- Significant injuries > 1 body region
Specific Injuries:
- Limb amputation or threat
- Suspected Spinal Cord injury or Spinal #
- Burns > 20% TBSA or Suspected Resp Tract
- High Voltage ( > 1000 volts) burns.
- Serious Crush Injury
- Major Compound # or Open Dislocation
- # to >= 2 of Femur/ Tibia/ Humerus
- # Pelvis
Adult Trauma TCG High Risk
Mechanism of Injury:
- Motor/ Cyclist impact > 30km/h
- High speed MCA > 60km/h
- Pedestrian impact
- Ejection from vehicle
- Prolonged extrication
- Fall from > 3m
- Struck on head by falling object > 3m
- Explosion.
Co-morbidities:
- Age < 12 or > 55
- Pregnant
- Signficant underlying med injury;
- Poorly controlled HTN.
- Obesity
- Controlled or uncontrolled CCF
- Symptomatic COPD
- IHD
- Chronic Renal Failure or Liver disease
MSA Observe
Safety:
Scene safety is 1st priority
Appearance:
Neatness, cleanliness, extraocular monement
Behaviour:
Bizarre or inappropriate, threatening or violent, unsual motor activity, impaired gait, agitation
Affect:
Flat, depressed, agitated, hostile, withdrawn
MSA Listen
Speech:
Rate, volume, quantity, content.
Thought Process:
Vague, jumping btw thoughts
Cognition:
Poorly organised thoughts, poor memory, short attention span, impaired judgement, impaired insight
MSA Discuss
Thought Content:
Delusions, suicidal thoughts, concerned w/ body functions
Self-harm:
Ask pt whether attempted or plan self-harm/ suicide
Perceptions:
Hallucinations
Environment:
Lack of family/social support, substance abuse, recent stressors
Clinical Red Flags VSS
Mandatory Tx
HR: > 120 RR: > 30 SBP: < 90 SpO2: < 90% / UL norm GCS: < 13 / < 15 (age <16)
Clinical Reg Flags
Mandatory Tx
Stridor First Presentation Seizure Anaphylaxis (incl resolved) ACS (incl resolved) Ectopic Pregnancy Primary Obtetric Issue. Stroke/ TIA Sudden Onset Headache Unable to Walk (unusual) Post Tonsillectomy Bleeding
Clinical Yellow Flags
Advise Hosp or GP < 2hrs
Ongoing Pt/ Carer concern
Infection non-responsive to community care
Immunocompromised w/ suspected infection
Surgical procedure within 2/52
Unexplained pain >= 5
Syncope
Abdo pain
AND MUST HAVE:
Capability to attend hosp/GP
Be read Referral Advice Script
Ambulation Risk Assessment
High Risk
Prerfusion:
- Inadequate or extremely
poor.
- Sig postural changes in BP &/or HR.
Baseline Mobility:
- Poor.
Specific Conditions:
- Anaphylaxis.
- Acute Respiratory Presentation.
- Acute Coronary Syndrome/ STEMI.
ACTION = Extricate supine or sitting (as approp 4 pres).
Ambulance Risk Assessment
Increased Risk
Perfusion:
- Borderline.
Baseline Mobility:
- Impaired.
Specific Conditions:
- Drug or alcohol use.
- Medicine admin (eg. Opioids).
- Cognitive impairment.
- Neurological pathology.
- Hx of falls.
- New or pre-existing injury.
- Frail or requires mobility aid.
- Morbid obesity.
ACTION = Aim to extricate supine or sitting.
Ambulation Risk Assessment:
All Patients.
Pause & Plan.
Request Manual Handling if required.
Provide redundancy options in case ambulation fails.
In complex egress situations, if risk to patient is acceptable, consider Sit/ Stand/ Walk test & limit walking/ exertion.
