Final Flashcards
Circulation interventions
- Chest compressions
- Control of bleeding
- IV access
- Fluids, medications, blood transfusion
Disability interventions
- Attempt to elicit a response – verbal, painful
- If unresponsive, obtain help and check breathing and pulses, repeat vital signs
- Administer glucose as needed
- Treat pain
Exposure interventions
- Control bleeding – apply pressure, tourniquet
- Maintain a normal temperature
- Investigate unusual markings or signs of abuse
- Remove wet/soiled pad or linens
Appropriate VS ranges
- HR < 50 or > 90
- RR < 8
- BP systolic < 90 or >180
- Temp < 36.0 or > 38.0
- O2 saturation < 95%
4 checks of Exposure
- Uncover and assess face & head, torso (front and back), extremities for unusual markings
- Skin color and temperature
- Uncontrolled bleeding
- Incontinence
4 checks of Disability
- AVPU/GCS
- Blood glucose/dextrose
- Pupil response
- Pain
ABPP
7 checks of Circulation
- Heart rate and rhythm
- Quality of pulses
- Skin color, temperature, cap refill
- Blood pressure
- Signs of bleeding
- Intravenous access – lines, site to source
- Output - urine
HQOSBIS
4 checks of breathing
- Respiratory rate and effort
- Depth and symmetry of chest rise
- Breath sounds - auscultate
- Oxygen saturation
3 checks of the Airway
- Listen for air movement
- Feel for air movement at nose and mouth
- Look at position of head and trachea
Neuro Qs
Tremors
Difficulty speaking
One-sided weakness
Head/brain history
cardio Qs
SOB
Chest pain
Cardiac risk factors (high BP, high cholesterol, obesity)
Respiratory Qs
SOB (OE)
Hx of infection
Resp. related habits (smoking)
Environmental exposure
Integumentary Qs
Hx of skin disease
Change in moles/skin pigment
Rashes
Healing delay or bruising
Neuro focused assessment MAIN Tasks
Inspect pupils
Inspect GCS
Motor Assessment
Sensation
Neuro motor assessment
Symmetry
Grip
Pronator drift
Flexion of legs
Sensation