asessment of the sick patient Flashcards
1
Q
What is the ABCDE approach?
A
A - airway
B - breathing
C - circulation
D - disability
E - exposure
2
Q
What level of consciousness should you expect when assessing a sick patient?
A
The patient may be conscious but can then still become unconscious at some point in your assessment.
3
Q
AIRWAY ASSESSMENT
A
- Are they speaking to you?
- Look for signs of obstruction or swelling:
PARTIAL OBSTRUCTION - inspiratory stridor (upper airway obstruction)
COMPLETE OBSTRUCTION - no breath sounds through mouth or nose EMERGENCY
4
Q
What would an expiratory wheeze be more characteristic of?
A
Asthma or COPD (obstruction of the lower airways)
5
Q
BREATHING ASSESSMENT
A
- Look, listen, feel for signs of respiratory distress (USE OF ACCESSORY MUSCLES).
- Listen to breath sounds - gurgling = secretions, stridor/wheeze = partial obstruction.
- Count the rate: normal is 12-20 for adults, 20-30 for children.
- Oxygen saturation using pulse oximeter.
- Hands on shoulders to see if both sides expand equally and bilaterally, look at trachea position.
- possible PNEUMOTHORAX. - SUPPLEMENTAL OXYGEN using bag valve mask if pt is too slow/not breathing at all or non-rebreathe mask
6
Q
Circulation
A
7
Q
CIRCULATION ASSESSMENT
A
- Count patients pulse - rate and rhythm in radial and central positions.
- if radial pulse is present then it is about 90.
- carotid ONLY = low blood pressure. - Capillary refill time - pressure for 5 secs, longer refill than 2 seconds means poor perfusion.
- Look for signs of cyanosis under tongue, hands (blue, pink, pale, mottled)
8
Q
DISABILITY
A
- Assess consciousness with AVPU:
- A: alert
- V: vocal stimuli
- P: painful stimuli (sternal rub and pinching nail bed
- U: unresponsive to all stumuli - Check GLUCOSE (normal = 4-6)
- Pupils (size, equality and reaction to light).
9
Q
EXPOSURE ASSESSMENT
A
- Respect pt dignity and minimise heat loss.
- Check for rashes (anaphylaxis) or ankle oedema (heart failure)
- Any other wounds or bleeding?
