Patient Assessment System Flashcards
Hand Hygiene
- soap and water for at least 20 seconds
- sanitizer with at least 60% alcohol
- hands can’t be too dirty for sanitizer
Masks
- N95 filters air intake
- cloth masks on filter air on outtake
ABCDE Assessment Sequence
airway, breathing, circulation, disability, expose
Assess the Airway
- open the airway
- clear obvious obstructions
- observe any labored breathing
Assess for Breathing
- look for chest movement - listen for sound of air passing through the upper airway
- if breathing is labored check for injuries on chest
Assess for Circulation
check pulse
- carotid artery on neck for at least 10 seconds
- next try radial artery in the wrist
look for severe bleeding
Decision on Disability
Deside if further spine protection is needed
- if there is spine injury consider jaw thrust to open airway
Expose
Expose and examine major injuries
- without moving patient search for major injuries that may be hidden under clothing
ABC or CAB?
CAB is more appropriate for cardiac arrest to begin CPR faster.
- still need to complete all letters of alphabet
Secondary Assessment.
- consider the needs of the patient and rescuers
- head to toe physical exam, measurement of vital signs, and a medical history
- see chart for head to toe exam
Head
- check ears and nose for fluid and mouth for injusries that may affect airway
- observe face for symmetry
feel skull for depressions or tenderness - run fingers through hair to detect bleeding/cuts
- check eyes for injuries or pupil abnormalities and ask about vision
Neck
the trachea/windpipe should be in the middle of nect
- feel entire cervical spine from base of skill to top of shoulders to identify pain or issues
shoulders
examine shoulders/collar bones for injury
- if possible touch along entire length of collar bones
arms
- feel arms from armpit to wrist
- check circulation, sensation, and motion (CSM)
- check radial pulse
- ask patient about any unusual sensations
- have patient squeeze your hands and extend their wrist
Chest
- feel chest for deformity or tenderness
- push in from the sides
- ask patient to breathe deeply as you compress the chest
- observe semetry during breathing
Abdomen
- feel abdomen for tenderness or muscle rigidity with light pressure
- look for distension, discoloration, and bruising
Back
- feel each vertebra from the neck to pelvis
- logroll patient if needed
Genitals
check genitals if requested
legs
- check legs from groin to ankle
- check CSM in feet one foot at a time
- check pulse or visually inspect any discoloration and check for warmth
- ask patient about any sensations in legs/feet
- assess sensitivity for light touch on small and big toe
- ask patient to push and pull feet against hand pressure
Vital Signs
Objective indicators of airway, breathing, circulation, brain function, and body temperature.
responsiveness
pulse
respiration
skin
blood pressure
pupils
temperature
measuring vital signs
- general rule measure and record vital signs every 15-20 minutes. (more frequent if patient is bad)
Level of Responsiveness (LOR)
Brain function or mental status. Assess and classify using AVPU
AVPU
- Awake
- Verbal - not awake but responsive to a verbal stimulus (try louder)
- Pain - not awake but responsive to only a painful stimulus.
- Unresponsive
*(to stimulate pain, pinch muscle at back of shoulder or neck, rub the sternum with knuckles, or squeeze a fingernail)
AVPU Awake Scale
A+Ox4 - knows person, place time and event
A+Ox3 knows person, place, time, but not event
A+Ox2 knows person and place, but not time or event
A+Ox1 nows person, but not place, time or event
A+Ox0 - none of above = ‘disoriented’
PPTE - person place time event
A - Awake
O - oriented
