Assessment Flashcards
Adult Adequate Perfusion
Skin: warm, pink, dry Pulse: 60-100 BP: >100 SYS Conscious State: Alert CRT: <2sec
Adult Borderline Perfusion
Skin: cool, pale, clammy Pulse: 50-100 BP: 80-100 SYS Conscious State: Alert CRT: >2sec
Adult Inadequate Perfusion
Skin: cool, pale, clammy Pulse: <50 or >100 BP: 60-80 SYS Conscious State: Either alert or confused CRT: >2sec
Adult Extremely Poor Perfusion
Skin: cool, pale, clammy Pulse: <50 or >110 BP: <60 or unrecordable Conscious State: altered or unconscious CRT: >2sec
Adult No Perfusion
Skin: cool, pale, clammy Pulse: absent BP: unrecordable Conscious State: unconscious CRT: nil
Adult Normal Respiratory
Conscious: Alert Appearance: calm and quiet Pulse: 60-100 Effort: normal chest movement RR: 12-16 Rhythm: regular Sats: >94% Sounds: normal air sounds Speech: calm and steady Skin: normal
Adult Mild Respiratory Distress
Conscious: Alert Appearance: calm or anxious Pulse: 60-100 Effort: slight increase in effort RR: 16-20 Rhythm: (asthma prolonged exp. phase) Sats: >94% Sounds: Asthma: mild exp. wheeze LVF: minor crackles at bases Speech: full sentences Skin: normal
Adult Moderate Respiratory Distress
Conscious: may be altered Appearance: distressed or anxious Pulse: 100-120 Effort: marked chest movement, use of accessory muscles RR: >20 Rhythm: (asthma prolonged exp. phase) Sats: <94% Sounds: Asthma: exp. wheeze +/- insp. LVF: minor crackles at mid and bases Speech: short phrases Skin: pale and sweaty
Adult Severe Respiratory Distress
Conscious: altered conscious state or unconscious
Appearance: distressed, anxious, exhaustion
Pulse: 100-120
Effort: marked chest movement, use of accessory muscles, intercostal recession, tracheal tug
RR: >20 or <8
Rhythm: (asthma prolonged exp. phase)
Sats: <90%
Sounds: Asthma: exp. wheeze +/- insp. LVF: full field crackles Obstruction: Stridor
Speech: single words
Skin: pale and sweaty +/- cyanosis
Mental Health Assessment (9)
(Be SMART and Politically Correct)
Behaviour
Speech
Mood
Appearance
Response
Thought Content
Thought Flow
Perceptions
Concentration
Paediatric Age Groups
Newborn - First few hours
Infant - 0-1 years
Small Child - 1-9 years
Large Child - 10-12 years
Newborn Pulse
120-160
Infant Pulse
100-160
Small Child Pulse
80-120
Large Child Pulse
80-100
Newborn BP
N/A
Infant BP
> 70mmHg
Small Child BP
> 80mmHg
Large Child BP
> 90 mmHg
Newborn RR
40-60
Infant RR
20-50
Small Child RR
20-35
Large Child RR
15-25
Paediatric Respiratory Distress Signs (8)
Tachypnoea Grunting Wheezing Pallor Chest Wall Retraction Use of Accessory Muscles Cyanosis (Late sign) Abdominal Protrusion
Respiratory Distress Assessment
Exertional SoB Cough Pain on coughing Able to swallow Drooling Sleeping Position Nocturnal Dyspnoea Previous hospital or intubation Recent med changes Meds compliance Frequency of use Clot risks (calf pain, surgery, prolonged stasis)
Chest Pain Assessment
Sweating Palpitations Nausea/Vomiting Dizziness/Lightheaded SoB Calf Pain Peripheral Oedema BP L vs R Diarrhea Constipation
Define Perfusion
The ability of the cardiovascular system to provide tissues with an adequate blood supply to meet their functional demands at that time and to effectively remove the associated metabolic waste products.
GCS Scale
Eye
1 Nil
2 Pain
3 Voice
4 Alert
Verbal
1 Nil
2 Incomprehensible Sounds
3 Inappropriate Words
4 Confusion
5 Orientated
Motor
1 Nil
2 Decerebrate
3 Decorticate
4 Withdraws to Pain
5 Purposeful Movement
6 Obeys Commands
