PSA, RSA and GCS

Question 1

Define perfusion.

Answer 1

The ability of the cardiovascular system to provide tissues with an adequate oxygenated blood supply to meet their functional demands at that time and to effectively remove associate waste products.

Question 2

What other factors may influence perfusion assessment?

Answer 2

Ambient temp, anxiety, any cause of ALOC.

Question 3

PSA observations need to be taken into context with…?

Answer 3

1. Presenting problem
2. Prescribed meds
3. Repeat obs and trends
4. Response to management

Question 4

____ alone does not determine perfusion status.

Answer 4

BP.

Question 5

List the 4 elements of Adequate Perfusion.

Answer 5

Sk: WPD
CS: AOTP
BP: >100 SBP
HR: 60-100bpm

Question 6

List the 4 elements of Borderline Perfusion.

Answer 6

Sk: CPC
CS: AOTP
BP: 80-100 SBP
HR: 50 -100 bpm

Question 7

List the 4 elements of Inadequate Perfusion.

Answer 7

Sk: CPC
CS: AOTP/ altered
BP: 60 - 80 SBP
HR: <50 or >100 bpm

Question 8

List the 4 elements of Extremely Poor Perfusion.

Answer 8

Sk: CPC
CS: Altered/unconscious
BP: <60 SBP or unrecord.
HR: <50 or >110 bpm

Question 9

List the 4 elements of No Perfusion.

Answer 9

Sk: CPC
CS: Unconscious
BP: Unrecordable
HR: Nil palpable pulse

Question 10

How many elements are there in the RSA?

Answer 10

9 - CAPERRSSS
Conscious state
Appearance
Pulse
Effort/WOB
Rate
Rhythm
Speech
Skin
Sounds

Question 11

What are the three conditions listed that cause altered auscultated sounds?

Answer 11

LVF w/ APO
Asthma
Upper airway obstruction

Question 12

What change to respiratory rhythm could be anticipated in asthma?

Answer 12

Prolonged expiratory phase.

Question 13

List the findings associated with a Normal RSA.

Answer 13

C - Alert
A - Calm, quiet
P - HR 60-100
E - Normal chest movement
R - Even, regular cycles
R - 12-16
S - Speaking in clear, steady sentences 
S - Normal
S –Usually quiet, no wheeze, no crackles or may be some fine scattered basal crackles
eg. postural

Question 14

List the findings associated with a Mild Distress RSA.

Answer 14

C - Alert and orientated
A - Mildly anxious or calm

P – HR 60 - 100
E – Slight increase in normal chest movement
R – 16 - 20
R – May have a slightly prolonged expiratory phase (ASTHMA)
S – Full sentences
S – Normal
S – Able to cough
      Mild expiratory wheeze 
      (ASTHMA)
      Fine basal crackles (LVF)

Question 15

List the findings associated with a Moderate Distress RSA.

Answer 15

C – May be altered
A – Anxious, distressed
P – HR 100-120
E – Marked chest movement +/- use of accessory muscles
R – Prolonged expiratory phase (ASTHMA)
R – >20
S – Short phrases only
S – Sweaty, pale
S – Able to cough
Expiratory wheeze +/- inspiratory wheeze (ASTHMA)
Fine crackles at bases to mid-zone (LVF)

Question 16

List the findings associated with a Severe Distress RSA.

Answer 16

C – Altered, unconscious
A – distressed, fighting to breathe, catatonic
P – HR >120bpm, bradycardia a late sign
E – Marked chest movement with accessory muscle use,
intercostal retractions +/- tracheal tugging
R - <8 or >20
R – Prolonged expiratory phase (ASTHMA)
S - words only or unable to speak
S – Sweat, pale, +/- cyanosis
S – Unable to cough
Expiratory wheeze +/- inspiratory wheeze, maybe no sounds
Fine full-field crackles with possible wheeze (LVF)
Inspiratory stridor (Upper Airway Obstruction)

Question 17

What is the purpose of the GCS?

Answer 17

To provide an objective measure of consciousness.

Question 18

Outline the circumstances in which AVPU is the more appropriate tool.

Answer 18

Aphasia/dysphasia
Facial injuries
Language barriers
Children (where adapting the GCS can be problematic).

Question 19

What general GCS categories align with the AVPU tool?

Answer 19

Alert – 15
Verbal – 14 to 10
Pain – 9 to 7
Unresponsive - <7

Question 20

What are the GCS components of EYES?

Answer 20

Spontaneous
To voice
To pain
None

Question 21

What are the GCS components of VERBAL?

Answer 21

Alert and orientated
Confused
Inappropriate
Incomprehensible
None

Question 22

What are the GCS components of MOTOR?

Answer 22

Obeys
Localises
Withdraws
Abnormal flexion
Abnormal extension
None

Question 23

What pain stimuli should be applied if the patient does not open eyes to voice?

Answer 23

Firm, constant pressure to mid-sternum with a single knuckle.

Question 24

Why should you not place your fingers inside the patients hands to assess motor response?

Answer 24

May elicit a reflex grasp, rather than a purposeful action.

Question 25

If the pt only obeys with one limb, what is the next step?

Answer 25

Assess the non-obeying limb for localisation or withdrawal and record the disparity.

Question 26

How is “Localizes” assessed?

Answer 26

Firm, constant mid-sternal pressure with a single knuckle.

Question 27

How is “Withdraws” assessed?

Answer 27

Apply nail bed pressure to fingers of unresponsive limb/s. Test both limbs if indicated (unresponsive to earlier assessments).

Question 28

A GCS is a measurement of the best/worst score of the findings?

Answer 28

Best score.