Assesment Flashcards
Scene assessment
-Hazard and environment
-Mechanism of injury (MOI) and chief complaint
-Number of pt’s
- additional resources needed
-forming a general impression
-donning PPE
Forming a general approach
-the pt’s chief complaint
-if the pt is injured or ill
-the pt’s sex and approximate age
Primary assessment
- introducing yourself
-assessing level of responsiveness
-assessing cervical spine ( c spine)
-simultaneously assessing airway, breathing and circulation (ABC) including a pulse check
-preforming a rapid body survey (RBS) including a skin check
Level of responsiveness (AVPU)
A - Alert (eyes open pt is able to verbalize)
V- verbal (pt responds to commands or questions)
P- painful ( pt exhibits facial grimace, flexion, extension or withdrawal of a body part or moan in the groan)
U- unresponsive (or makes no response)
What is dyspnea?
and how long do you assess the person’s breathing for?
Difficulty breathing may have such signs and symptoms
-inadequate rise and fall of the chest
-increased effort on respiration
-very slow or fast respiratory rates
Max of 10 seconds
Agonal respirations
Inadequate pattern of breathing sometimes associated with cardiac arrest states
- they originate from lower brain stem neurons as higher brain centers become increasingly hypoxic
So the diaphragm is receiving intermittent residual impulses from the brain resulting in sporadic, grasping for breaths
These breaths do not provide enough oxygen and require immediate interventions
Checking pulse
Placing 2-3 fingers on a major artery
- carotid (neck) or radial (wrist) for adults
-brachial (bicep area arm between elbow and shoulder) for infants
How often to check ABC’s
5min for unstable/life threatening pt
10 min for stable
Pulse oximetry range
Normal 95-100% -no action needed
Mild hypoxia 91-94% - administer emergency oxygen via nasal cannula or standard oxygen mask
Moderate hypoxia 86-90% - administer emergency oxygen using a non rebreather mask or a bag value mask with oxygen reservoir
Severe hypoxia 85% or lower - administer emergency oxygen using a non rebreather mask or a bag valve mask with an oxygen reservoir
How often should pulse oximetry be taken and recorded with vital signs
Every 5 mins for unstable pt
Every 15 mins for stable pt
Rapid body survey (RBS) should check the pt in the following order,
Head
Neck
Chest
Abdomen
Pelvis
Lower extremities
Upper extremities
Back
Note RBS also includes checking for external hemorrhaging
Common positions
-Lateral (laying on side)
-Supine (laying on back)
-Lateral recumbent “recovery” (pt is laying in semi prone, half way between prone laterally)
-Fowler (laying on back, body elevated to 45- 60 degrees)
-semi Fowler (laying on back body elevated less than 45)
-trendeleburg (laying on back with legs elevated)
Secondary assessment definition
More thorough that primary assessment and focuses on gathering detailed information about the patient’s history and condition
3 steps to the secondary assessment
- Interview pt, bystanders to get info about the chief complaint
2.check pt’s vitals - Do a head to toe physical examination
Acronym SAMPLE
This helps you gather info
S. signs and symptoms (what’s bothering you)
A. Allergies ( what allergies do you have)
M. Medications ( what meds are you currently taking/ have their been recent changes)
P. Past/ present medical history
L. Last oral intake (last eat or drink)
E. Events before incident (what happened to cause the problem)
Is a pt is experiencing pain the
Mnemonic OPQRST
O. Onset - did it start suddenly or develop over days/ hours
P. Provocation - what makes the pain worse or provokes it
Q. Quality - What does the pain feel like, sharp dull stabbing moving
R. Region and radiation - where exactly is the pain located does it radiate to other areas
S. severity - on a scale of 1-10 how bad is the pain
T. Time - when did the pain start
Some examples of vital signs
And when to be assessed/ reassessed
-Level of responsiveness (avpu Glasgow coma scale)
-respiration
-pulse
-skin characteristics
-pupils
-blood pressure
-spo2
-body temp
-blood glucose level
Reassessed and recorded every 5 mins for unstable pt
Reassessed and recorded every 15 mins
Glasgow coma scale
System to determine pt’s level of responsiveness and is a good indicator of eventual outcome for head trauma
The 3 sections are scored individually then added together
- eye opening
-verbal response
Motor response
Respiration rate
Normal for adult 12-20 breaths a min
Count breaths for 15 seconds then x4 to get the # per minute
Pulse rate
Normal pulse rate for adult 60-100 beats a minute
50 for athletes
Skin characteristics
Ex pt with breathing issues might have a flushed pale face
Skin looks red when the body is forced to work harder
If blood is directed away from the skin, skin will loose is underlying red tones becoming pale or bluish and feel cool and moist
When blood below the skin is oxygen deficient it can give the skin a bluish tint this is called cyanosis
Capillary refill
Method for estimating the amount of blood flowing through the capillary beds -ex finger nails
Squeeze nail bed and release. In a healthy person the area below the nail will turn pale as you press and return to pink again in 2 seconds
-if this does not happen this indicates that circulation to the fingertip is impaired
