Module 2 Flashcards
What does LOU stand for?
Level of Urgency
How is LOU determined and is it revisited??
It is determined on arrival of the patient and on a on-going basis
What is CTAS
Canadian triage acuity scale
How many score are there for CTAS?
1-5
What is a CTAS 1?
Conditions that are threats to life of limb (or imminent risk of deterioration) requiring immediate aggressive interventions
When should a patient with a CTAS of 1 be assessed and seen by a MD?
IMMEDIATE
What is a CTAS 2??
Conditions that are potential to threat life, limb or function, requiring rapid medical assessment and intervention
When should a patient with a CTAS of 2 be assessed and seen by the MD?
15 mintues
What are some examples of a CTAS 1?
Code/arrest, major trauma, shock states, unconscious, severe respiratory distress
Patients are typically non responsive and vitals are unstable or absent
What are some examples of a CTAS 2?
Altered mental state, head injury, severe trauma, neonates, eye pain (8-10/10), chest pain with sharp sudden pains, previous MI/PE/angina, suspected overdose, abdominal pain, GI bleed, asthma, CVA, dyspnea, patients on chemo, suspected abuse, drug/alcohol withdrawal
What is a CTAS 2?
Urgent: Conditions that could potentiall progress to a serious problem reuqiring emergency intervention.
May be associated with signifiicant discomfor or affecting ability to function at work or activities of daily living?
When should a CTAS 3 be examined by a MD?
30 minutes
What are some examples of a CTAS 3?
Head injury with aa GCS of 15 and pain less than 8/10, moderate trauma, mild-moderate asthma, vaginal bleeding and pregnancy, acute psychosis, acute pain 8-10/10, vomiting or diarrhoea ages 2 and less, patient is on dialysis or transplant patient
What is a CTAS 4?
Semi-urgent: conditions that related to patients age, distress, or potential for deterioration or complications would benefit from intervention or reassurance within 1-2 hours
When should a patient with a CTAS of 4 be seen by the MD?
1 hour
What are some examples of a CTAS 4?
Minor head injury, minor trauma, abdomial pain 4-7/10, ear ache, chest pain that does not include SOB, previous cardiac history, URI symptoms, vomiting and diarrhoea with no signs of dehydration >2 years
What is a CTAS 5?
Non-urgent: Conditions that may be acute but are non-urgent as well as conditions which may be part of a chronic problem with or without evidence of deterioration
What are some examples of a CTAS 5?
Minor trauma (contusions, abrasions, minor lacerations not needing closure), sore throat, non-severe vaginal bleeding with no evidence of pregnancy, vomiting or diarrhoea alone with no signs of dehydration over the age of 2
What does LOU’s determine?
Stable, potentially unstable, and unstable
What does Stable mean?
Patients present with normal clinical findings and a history leading to admission that is not life or limb threatening
What does unstable mean?
Patients present with abnormal clinical findings and a hisotry that is considered life or limb threatening
What does potentially unstable mean?
Patients may present with normal clinical findings but their history leading to admissions warrants concern and ongoing observation
What entails primary survey?
Airway Breathing Circulation Disability, doctor, dextrose, discomfort Expose Full set of vitals and family presence Go back and reasses
What is a subjective assessment?
History of presenting illness
Subjective data arises from, and is concerned with, an individual. It is information a particular patient gives you and it is specific to that person’s experience of symptoms. For example, a patient may complain of shortness of breath. This is a subjective finding.
What is a objective assessment?
Head to toe!
Objective data is the opposite of subjective. It is data that is observable to others. For example, a patient who describes feeling short of breath might have increased work of breathing (WOB) presented as accessory muscle use. This is an objective finding.
What entails the “A” in the primary assessment?
Checking that the patient has a patent airway, observing chest rise and fall indicates the movement of air in and out, notice the position of the patient, listen to the patient and feel there airway
Cervical spine assessment is also indicated, do they have the potential to have a C-spine injury
How to assess for “A” in the primary assessment?
Watch the patient chest rise and fall
Ask the patient to speak- note clarity and rate, horseness ect
Feel the airway for potential swelling or obstruction
What is B in the primary assessment?
Breathing
What entails “B” in primary assessment
The effectivness of breathing by watching for symmetry and extend of chest expansion, adequacy of air entry into the lungs and the presences of any abnormal lung sounds
Work of breathing- how hard does the patient have to work to catch their breath
Looking for sings of inadequate perfusion such as low SPO2, cyanosis, pallor, LOC of the patient
What is the C in the primary assessment
Circulation
What entails “C” in a primary assessment?
ED handshake- Checking pulse rate, rhythm and strength
Regular vs. Irregualr
Skin color and temp
Cap refill (less than or equal to 3 seconds)
Chest pain- gold standard is to obtain a rapid 12 lead ECG in all patients experiencing cardiac related chest pain
What are some interventions for A?
Jaw thrust, oral airway support, change position, prepare for intubation
What are some interventions for B?
Supplemental oxygen, teaching/distraction to help with breathing patter
What are some interventions for C?
12 lead ECG, IV access, cardiac monitoring
What is D in the primary assessment?
Disability, doctor, dextrose, discomfort
What is the primary assessment for Disability
AVPU assessment for neurological function
A-Alert: is the patient alert and responsive
V-Verbal: Does the patient respond to verbal stimuli
P-Painful: Does the patient respond to only painful stimuli
U-Unresponsive: The patient who does not respond to painful stimuli is considered to be unresponsive
GCS and PERRLA are the best tools to use to help monitor subtle changes in a patients LOC
What is the stroke scale?
It is a tool used to rapidly assess patients who are suspected of having a CVA
Face- is it drooping?
Arms- Can they raise both?
Speech- is it slurred or jumbled?
Time- Call 911 right away and note time of symptom onset
What are the other “D”s in primary assessment?
Dextrose- hypoglycemic patient can present with an altered LOC, check BG levels
Doctor- If the patient is unstable or potentially unstable, contact the MD right away to ensure this patient is seen in a timely manner
Discomfort- Is the patient experience discomfort and needs pain management
What does “E” mean in the primary assessment?
Exposed
What is important about E? And what should the nurse be aware of regarding this?
Patients need a full physical exam which includes examining the skin and all over.
If the patient is young, female or has suffered some type of trauma, keep this in mind
What does F stand for in the primary assessment?
Full set of vitals and family present
What includes a full set of vitals?
Temp, resperations, pulse, blood pressure and SPO2
What is a good way to check patient for volume issues?
Postural BP’s
Why is family important?
Family members and patients benefit from the presence of them being around
This allows family to ask questions and add information
What is “G” in the primary assessment?
Go back and reassess
Why is this step important?
Patient status can change in a moment, determine if your interventions are effective
What must happen before you move onto your secondary assessment?
The primary assessment must be complete and secure
What is clinical reasoning?
Clinical reasoning involves the thinking processes or analytical skills that we use to make sense of a clinical presentation situation.
How is clinical reasoning initiated?
Through the patient’s chief complaint and their story
How do we use clinical reasoning?
Try to figure out what could be happening to the patient
Ruling out other causes
Helping us prepare for the worst case scenario
What is an actual problem vs. a potential problem
A potential problem is something that could be happening to the patient or a possible worst case scenario
An actual problem is something that is occurring to the patient in the moment
What is an subjective assessment?
The story behind what brought the patient into the ED
What are the components of an adult subjective history?
- Biographical information
- Chief concern or presenting problem
- History of the chief complaint or presenting problem or illness
- Review of systems
- Past health history
- Personal history
- family health history
What are the components of biographical information?
Patient’s name, age, ect. Usually collected by the triage nurse and/or the admitting staff
What are the components of the chief complaint/concern?
The major reason the patient has come to the ED
The chief complaint usually directs the majority of the assessment
What are the componet of the history of the presenting problem?
Includes a description of the course of events since the onset of symptoms
Use LOTARP
What does LOTAAARP stand for?
Location of the problem and or pain Onset of the problem Time and type Associated symptoms Aggravating factors Alleviating factors Radiation of the pain Precipitating event
What are the components of the past health history?
Things that would help possibly guide you
Can be lengthy
focus in on childhood illness, immunization, allergies, medications, medical/surgical history, and recent travel
What is the components of personal history
Information regarding the patient’s personal health
Some data may overlap
Substance use/misuse, smoking, and a history of interpersonal violence
What are the components of a family history?
All information regarding illness that have a familial tendencies and first degree relatives
What are the components of the paediatric subjective history?
C- Chief complaint: reason for the childs ED visit, duration of complaint
I- Immuniztions/isolation: current immunization and exposure to any communicable diseases
A- Allergies: Reactions to medication, foods, products or environment
M- Medications: Current and over the counter meds, date and time of last dose
P-past history of illness (acute and chronic) and birth history
P-Parents perception: Length of illness, exposure to others with similar symptoms, treatment prior to ED visit, mechanisms of injury if applicable
E-Events surrounding illness: Length of illness, exposure to others, treatment prior to ED,
D-Diet: Change in eating patterns, last fluid/solid intake, regular diet, special diet
D-Diapers: Frequency or change in voiding/bowel patterns, change in colour or odour in urine
S-Symptoms associated with illness: Review of systems (ROS) to identify symptoms and progression of symptoms
What is a review of systems (ROS)?
The review of systems is an organised approach allowing you to ask questions in order to obtain data to rule in and rule out hypotheses about what might be causing and/or contributing to the chief complaint.
How should you use ROS?
Along with LOTARP and CIAPEDS, particularly when you get to A in adult and S in peds, and are asking about associated symptoms
You need to consider what systems may cause or be impacted by the chief complaint
What assessment follows a secondary assessment?
Head to Toe
What is included in a head to toe assessment?
General appearance, head/neck, chest, abdomen, extremities (bilateral) and vetrebral area
What is included in a general appearance assessment?
affect/attitude behavior level of consciousness hygiene incontinence odors pain/anxiety or level of distress posture speech pattern and articulation
What is included in the head and neck assessment?
Inspect and palpate scalp for wounds, hematomas, bleeding, or painful areas, nose and ears for blood or other drainage, mouth and tongue, facial symmetry and facial bones, trachea for tracheal position, and cervical spine for pain or tenderness.
Assess pupillary reaction including direct response and consensual reaction; test extraocular movements (EOMs).
Chest assessment?
Inspect for signs of trauma, bruising, expansion/retraction, symmetry, work of breathing, accessory muscle use, paradoxical movement.
Palpate clavicles, sternum, and lateral chest wall for deformities, pain or crepitus, and/or subcutaneous emphysema.
Auscultate breath sounds anteriorly or posteriorly, apices and bases bilaterally; determine presence of breath sounds and presence of any adventitious sounds, apex rate, regularity, clarity, and presence of extra heart sounds.
Abdomen assessment?
Inspect for abdominal distension or asymmetry, for signs of trauma or bruising, for peristalsis, pulsations, genitalia bleeding, bruising, or incontinence.
Auscultate RLQ for bowel sounds (present or absent).
Palpate and compress iliac crest for pain, crepitus, or instability; ask client to perform abdominal distension and retraction and note if pain elicited; if client unable to follow instructions, perform light palpation of abdomen by lightly compressing symphysis pubis for pain, crepitus, or instability, femoral pulses bilaterally for presence and equality.
Extremities assessment?
Inspect for deformity, signs of trauma, position of extremities, skin color, and integrity, and client’s ability to perform flexion and extension of arms and legs.
Palpate arms and legs for pain, deformity, or muscle spasm, radial, dorsalis pedis, posterior tibialis pulses, capillary refill, handgrip strength; dorsiflex and plantarflex feet against resistance, noting strength and equality.
Vertebral assessment
Inspect posterior surface; log roll client and maintain spinal immobilization if potential for a spinal injury exists and then inspect spinal column for deformity/trauma; palpate paravertebral/vertebral area for pain or muscle spasm and percuss costovertebral angles (CVA) for pain.
What entails a muscloskeletal/integument assessment?
Insepct and palpate,
What are the specifics in inspect for musculoskeltal assessment?
Note the position of the extremities, deformities, and colour
What are the specifics in palpate for muscloskeltal assessment?
Pain, tenderness, crepitus, pulses, sensation, temperature, movement and strength
What are the specifics in inspect for integument?
Colour, lesions, scars, signs of injury
What are the specifics in palpate for integument?
Moisture, temp, turgor and texture
What are the factors in a neurological assessment?
Eyes open, best verbal response, best motor response, pupillary response, ROMS, limb strength and equality, presence of drift
What entails a cardiovascular assessment?
Inspect, palpate, auscultate
What does “inspect” entail in CV assessment?
Skin color, LOC, postion of patient, level of discomfot, abnormal pulsations over precordium, edema present
What does “palpate” entail in a CV assessment?
Pulses-rate, regularity, quality, equality Skin condition- temp, texture, turgor Edema- location and severity PMI postion and size virbrations/pulsations over precordium JVD measurement
What does “auscultate” entail in a CV assessment?
Blood pressure (bilat if needed) Pulus paradoxus Heart rate and rhythm comparsion of apical and radial puslses Heart sounds- quality, S1 S2, adventitious sounds (S3, S4, rubs, murmurs, gallops)
What is included in a respiratory assessment?
Inspect, palpate and auscultate
What does “Inspect entail in a resp assessment?
mental status/orientation general appearance client position to facilitate breathing color of skin, earlobes, nailbeds, mouth, distal extremities presence of cough and expectorate (color, amount, consistency) rate, rhythm, and depth of breathing effort of breathing and use of accessory muscles deviation or tugging of trachea signs of injury deformities/scars of thorax or spine chest excursion/retraction/bulging symmetry of chest movement
What does “palpate” entail in a resp assessment?
tracheal position
areas of tenderness
crepitus
respiratory excursion
What does “auscultate: in a resp assessment?
presence and depth of breath sounds
normal breath sounds (bronchial, bronchovesicular, vesicular)
adventitious sounds, (crackles, wheezes, pleural friction rub)
diminished or absent breath sounds
pulsus paradoxus (optional)
What does “inspect” entail for an abd assessment?
position client assumes skin turgor, scars, striae, lesions discoloration signs of trauma pulsating masses symmetry abdominal contour/herniations umbilicus contour/herniations visible peristalsis
What does “auscultate” entail for an abd assessment?
bowel sounds (present or absent and character)
bruits over aortic area
fetal heart rate if applicable
What does “percuss” mean for a abd assessment?
costovertebral angle for pain
What does “palpate” entail for a abd assessment?
areas of tenderness over four quadrants
guarding or rigidity
masses/pulsations
What does “journey” mean in the assessment ?
Where the patient will go to next after their intial ED work-up, this could include going home, surgery, more test, or being admitted to a unit
Important to know that the patient may be in a state of shock throughout this
