Chapter 16-Assessing ABCs in respiraatory patients Flashcards
What is the first step in assessing the airway?
Assess the airway; air must flow in and out of the chest easily for the airway to be considered patent.
What maneuver should be used to open the airway in nontrauma patients?
Head tilt-chin lift maneuver.
What maneuver should be used to open the airway in patients with suspected spinal trauma?
Jaw-thrust maneuver.
What should be evaluated after confirming the airway is patent?
Evaluate whether the patient’s breathing is adequate.
What factors should be assessed to evaluate the adequacy of breathing?
Rate, rhythm, quality of respirations, use of accessory muscles, retractions, abdominal breathing, depth of breathing, tidal volume, rise and fall of the chest, and skin conditions.
How can cyanosis be observed in dark-skinned individuals?
By examining the palms or the mucous membranes of the lips.
What indicates that respirations are labored?
If the patient can speak only one or two words at a time before gasping for a breath.
What position should a patient in respiratory distress be placed in?
Generally sitting upright in a full or semi-Fowler position.
At what rate should oxygen be administered via nonrebreathing mask?
15 L/min.
If the patient’s breathing has inadequate depth or the rate is too slow, what may be needed?
Assisted ventilations with a bag-mask device.
What three questions should be asked to assess breathing?
- Is air going in and out? * Does the chest rise and fall with each breath? * Is the rate appropriate for the age of the patient?
What should be done if the patient is unconscious?
Reposition the patient’s head and insert an oral airway.
What is the next step after assessing breath sounds?
Assess circulation.
What pulse characteristics should be evaluated?
- Pulse rate * Pulse quality * Pulse rhythm
What indicates potential cardiac problems during pulse assessment?
Irregular beats.
What does abnormal capillary refill indicate in infants and children?
Greater than 2 seconds.
Is capillary refill considered a reliable assessment tool in adults?
No.
What can cause respiratory distress related to red blood cells?
An insufficient number of red blood cells to transport oxygen.
What can produce a life-threatening situation related to oxygen concentration?
An insufficient concentration of oxygen in the blood.
What signs indicate life threats in a patient?
- Problems with the ABCs * Poor initial general impression * Unresponsiveness * Potential hypoperfusion or shock * Chest pain associated with low blood pressure * Severe pain anywhere * Excessive bleeding
What should be done if the patient’s condition is unstable and there is a possible life threat?
Address the life threat and proceed with rapid transport.
When can a thorough secondary assessment be performed?
If the patient’s condition is stable and there are no life threats.
