Patient Assessment Flashcards
What are signs of an unwell patient
Obvious pale/sweaty
Obvious SOB
Altered conscious state
Unconscious
What are the components of the paediatric assessment triangle?
Appearance, circulation, work of breathing
What are you assessing for paediatric appearance?
Tone Interactiveness Consolability Look/gaze Speech/cry
What are you assessing for paediatric work of breathing?
Abnormal breath sounds
Abnormal positioning
Retractions
Nasal flaring
What are you assessing for paediatric circulation?
Pallor
Mottling
Cyanosis
What actions follow the primary survey?
Rest and reassurance Positioning Airway management Oxygen if required Refusal or limitation of treatment documentation Consider extra resources/MICA
Adequate perfusion
Skin: warm, pink, dry
Pulse: 60-100
BP: >100
Conscious state: alert and oriented
Borderline perfusion
Skin: cool, pale, clammy
Pulse: 50-100
BP: 80-100
Conscious state: alert and oriented
Inadequate perfusion
Skin: cool, pale, clammy
Pulse: <50 or >100
BP: 60-80
Conscious state: either alert and oriented or altered
Extremely poor perfusion
Skin: cool, pale, clammy
Pulse: <50 or >100
BP: <60
Conscious state: altered or unconscious
No perfusion
Skin: cool, pale, clammy
Pulse: no palpable pulse
BP: unrecordable
Conscious state: unconscious
What are the observe components of the mental status assessment?
Safety
Appearance
Behaviour
Affect
What are the listen components of the mental status assessment?
Speech
Thought process
Cognition
What are the discuss components of the mental status assessment?
Thought content
Self-harm
Perceptions
Environment
What are the components of the stroke assessment?
Facial droop
Speech
Hand grip
Blood glucose
What does AEIOUTIPS stand for?
Alcohol/abuse of substances/acidosis Epilepsy/electrolyte/environmental Infection Overdose/oxygen deficiency Underdose Trauma/Tumour Insulin Psychogenic/poisons Stroke/shock
Stroke mimics (10)
Intoxication drug/alcohol Hypo/hyperglycaemia Seizures Brain tumour Syncope Middle ear disorder Migraine Subdural haematoma Sepsis Electrolyte disturbance
Secondary survey head to toe order
Pupils Vision Head Neck Chest Abdo Pelvis Back Legs Arms
Red clinical flags (12)
HR>120 RR>30 Spo2<92% SBP<90 GCS<13 (or <15 if aged 12-15) First presentation seizure ACS Anaphylaxis Ectopic pregnancy Primary obstetric issue Stroke/TIA Sudden onset headache
Yellow clinical flags (9)
Age <5 Complex medical Hx/multiple comorbidities/5+ meds Recent medical/surgical procedure Frailty Communication difficulties Current drug/alcohol intoxication Hx mental health problems Past Hx stroke/falls/TIA Significant unexplained pain
