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
