Patient Assessment Flashcards
Neurological Assessment
- PE: RASS, GCS, CN Exam (pupils, corneal, cough, gag), CAM-ICU, reflexes, muscle tone, seizure activity.
- L and D: ONSD, CT (Bleed, Hunt/Hess, Fischer).
- L and T: EVD, Bolt, Lycox catheter.
- Quantify LOC with any sedatives/hypnotics being used.
Cranial Nerves I-VI (Name and function/test)
I - Olfactory (smell) II - Optic (reading, PEARL) III - Occulomotor (H test, PEARL) IV - Trochlear (H test, eyes down) V - Trigeminal; V1-3 (3 x bilateral facial dermatones, corneal reflex) VI - Abducens (H test, eyes lateral)
Cranial Nerves VII-XII (name and function/test)
VII - Facial (corneal reflex, shut eyes, puff cheeks, show teeth)
VIII - Vetibulocochlear (rub fingers next to ears)
IX - Glossopharyngeal (throat sensation, gag reflex)
X - Vagus (cough and gag reflex)
XI - Accessory Spinal (shrug shoulders, turn head)
XII - Hypoglossal (stick out tongue)
CVS Assessment
- Heart rate/rhythm, SBP/DBP/MAP, temperature, peripheral pulse strength, pulse pressure, skin, pedal edema, heart sounds, cap refill.
- L and D: 12-18 lead, Echo, CXR, EF, IVC, Troponin/T-HS, BNP, CK, delta down, lactate, urine output, CVP
- L and T: A-line, PIVs, CVC, IABP, ECMO (VA/VV)
- Scores: , NYHA, Forrester, Killip, TIMI, Sanford
- Qualify with any inotropic/vasoactive/chronotropic support
Respiratory Assessment
-PE: Rate, volume, breath sounds, accessory muscle use, effort, subcutaneous air
-Vent settings: (PLAT, PIP, VTe, VE, I:E, flow, MAP, EtCO2
dysynchrony/frequency)
-L and D: ABG, SpO2, A-a gradient, P:F ratio, CXR, US, CT, FEV-1, vital capacity > 20cc/kg
-L and T: ETT depth, size, cuff pressure, view; chest tubes secure, sealed, positioned, drained contents, un-clotted
Scores: GOLD
GI Assessment
PE: Bowel sounds, distension, palpation, N/V/D, discolouration, jaundice, ascites, post-op surgical site (ensure no trapped air pre-flight!).
- L and D: LFTs, liver enzymes, APAP, salicylates, tox scree, lipase, coags, lactate, BG, AXR, CT, IAP
- L and T: OG/NG, Blakemore/Minnesota, paracentesis drain
GU/Reproductive Assessment
- Macroscopic (colour, sediment, odour, blood) , nitrogen content, microscopic, volume in/out, foley insertion site abnormalities, dialysis port, priapism, tampon in situ
- L and D: Urea, creatinine, GFR, pregnancy test, osmolar gap, urine dip
- L and T: Foley size, secured, type; temp probe, pressure cath.
- Scales: AKI, RIFLE
Infectious Disease Assessment
Micro Hx Fever ABx coverage? Cultures? Travel history Other family sick?
6 reasons to do a physical assessment according to Dr. Erik Vu:
- Confirm pathophysiology
- Confirm Dx
- Refute Dx
- Norm setting (compare/contrast normal to abnormal)
- Therapeutic for patient
- Secure lines and tubes
MSK/Derm Assessment
- PE: splints/binders/c-spine, distal circulation, padding for transport, pressure ulcers, rashes, urticaria, edema, bilateral temperature/circulation.
- L and D: X-ray
- Scores: ASIA, Tile, Gustio
It’s certainly not their fucking blood pressure, so how can you tell if a patient is in shock?
- DLOC/agitation
- Acute lung injury (crackles)
- Ischemic chest pain/troponins/ECG changes
- Ileus (listen for bowel sounds)
- Decreased U/O, increased Cr
- Increased ALT/AST/Bilirubin
- Cool peripheries with delayed cap refill
- Increased lactate
Calculate and Define the Delta Ratio
[Measured AG - Normal AG (12)] divided by [Measured HCO3 - Normal HCO3 (24)]
0.4 - NAGMA
0.4 to 1.0 - HAGMA + NAGMA
1.0 to 2.0 - Pure HAGMA
>2.0 - HAGMA + Metabolic Alkalosis
- Metabolic alkalosis can be pre-determined such as in COPD.
- Only calculates metabolic processes, no respiratory compensation.
- Normal ketoacidosis 0.8 - 1.2
Winters Formula
Used to assess for appropriate respiratory compensation in acid/base disturbances:
Suspected PaCO2 = (1.5 x measured HCO3) + 8 (+/- 2)
Delta Gap
Used to determine other acid/base disturbances in ketoacidosis:
Delta Gap = [Measured AG - Normal AG (12)] - [Normal HCO3 (24)] - measured HCO3)
or…
Delta Gap = Na - Cl - 36
-6 = HAGMA + NAGMA
-6 to 6 = Pure HAGMA
+6 = HAGMA + Metabolic Alkalosis
*Doesn’t account for intracellular/bone buffering so more likely to misdiagnose a metabolic alkalosis, especially in a lactic acidosis.
All this talk about Delta Deltas, but what about using base deficit to assess for secondary acid-base disorders?
Unlike the delta ratio, base deficit (BD) measurements takes into account non-bicarbonate buffering. Bicarb is also just calculated, not actually measured so….?
The theory is that an elevated AG should be accompanied by an equal decrease in BD.
An greater AG than the BD = Secondary metabolic alkalosis.
A greater BD than the AG = NAGMA is also present.
