Assessment of ill patient

Question 1

How do you assess AIRWAY (patency)?

Answer 1

Look | Listen | Feel for evidence of airway obstruction

LOOK
• ↑ HR
• ↑ RR
• SpO2%
• sweating 
• use of accessory muscles
• see-saw thoraco-abdominal movements
• recession

LISTEN
• gurgling
• stridor (may be absent in severe cases)
•wheeze

FEEL
• chest rise and fall
• symmetry of chest movement
• tracheal deviation

Question 2

How do you assess BREATHING (ventilation)?

Answer 2

tachypnoea, tachycardia, SpO2 (sig desat = late feature of ventilation abnormality)

NB: absence of breathing difficulty in breathless patient = look for sepsis or metabolic acidosis

cyanosis

Question 3

How do you assess CIRCULATION (perfusion)?

Answer 3

Tissue perfusion/BP

hypotension = late feature of CVS dysfx due to compensatory mechanisms

indequate tissue perfusion 
– decreased conscious lvl
- skin mottling
- decreased tissue turgur
- poor capillary refill 
- oliguria
- metabolic acidosis

Question 4

How do you assess DISABILITY (conscious state)?

Answer 4

GCS, pupillary response

marked reduction in conscious lvl indicates either

• overwhelmed compensatory mechanisms
• severe neurological disease

Question 5

What are the clinical features suggestive of imminent severe deterioration (warning signs of severely ill patient)?

Answer 5

SBP <90mmHg or MAP <70mmHg
HR >150bpm or <50bpm
RR >30 or <8
GCS <12
Oliguria <0.5ml/kg/hr
Na <120 or >150mmol
K <2.5 or >6mmol
pH <7.2
Bicarb <18mmol
Concerned experienced nurse

Question 6

Formula for mean arterial pressure (MAP)?

Answer 6

MAP = DBP + 1/3 (SBP - DBP)

MAP = CO x TPR

Question 7

Which groups of patients are more difficult to assess and why?

Answer 7

(1) YOUNG ADULTS: compensatory mechanisms mask signs of severe illness until very advanced ∴ abnormal vitals = severe illness
(2) ELDERLY or IMMUNOCOMPROMISED: inflam response may be dampened ∴ hide signs of compromise
(3) TRAUMA PT: difficult to assess due to multitude of possible injuries + effect of distracting pain making injuries difficult to localise ∴ need to have detailed Hx of mechanism of injury to give clues to likely injury sites

Question 8

What is a good measure of cardiopulmonary reserve?

Answer 8

Exercise tolerance - important to assess both distance and speed

eg: same distance covered in longer time = worse reserve

Question 9

What are some clinical and lab features suggestive of severe illness?

Answer 9

CVS: tachycardia, hypotension, cold peripheries, skin mottling
- bradycardia may indicate a pre-terminal state

RESP: tachypnoea, recession, use of accessory muscles of respiration, low O2 sat.
- low RR may indicated impending respiratory arrest

SPLANCHNIC: haematemesis, coffee-ground vomitus in NGT, melaena, jaundice

RENAL: oliguria

CNS: decreased consciousness, confusion, aggitation, aggression

METABOLIC: acidosis, severe electrolyte abnormalities (esp hyperK, hypoNa), severe anaemia, thrombocytopaenia, coagulopathy, elevated lactate

MISC: sweating