WEEK 8 - A - E ASSESSMENT Flashcards
AIRWAY - CAUSES OF AIRWAY OBSTRUCTION
- Foreign bodies –Solid/food bolus –Blood –Vomit
- Trauma
- Infection
- Inflammation
AIRWAY - RECOGNITION OF AIRWAY OBSTRUCTION
- Is the airway obstructed?
· Look, listen and feel - Can the person speak in a usual voice in full sentences?
- Any evidence of:
· Noisy breathing
· Gurgling
· Choking
· Snoring
· Stridor
AIRWAY - TREATMENT OF AIRWAY OBSTRUCTION
- Call for assistance
- First aid steps to safely remove obstruction (where possible)
· e.g. first aid (back blows), Magill forceps, suction
· recovery position - airway manoeuvres
· simple adjuncts - oropharyngeal airways
- nasopharyngeal airways
· advanced techniques
- e.g. supraglottic airway device, intubation, once advanced help arrives - high flow oxygen
BREATHING - CAUSES OF BREATHING PROBLEMS
- Decreased respiratory – Drive
- CNS depression – Effort
- Muscle weakness/tiring
- Pain
- Lung disorders:
· Asthma
BREATHING - RECOGNITION OF BREATHING PROBLEMS
- LOOK - Rate, rhythm, depth, conscious level, cyanosis.
- LISTEN - Noisy breathing, silence is bad
- FEEL - expansion, percussion
BREATHING - TREATMENT OF BREATHING PROBLEMS
- position patient
· High Fowler’s position - reassure
- oxygen
· if no SpO2 recordable – use maximum flow
· guided by SpO2 (94 - 98% if measured) - Support breathing if inadequate
· e.g. bag-valve-mask, non-invasive ventilation - treat/consider underlying cause
CIRCULATION - CAUSES OF CIRCULATION ISSUES
- Shock:
· Hypovolaemia
· Distributive
· Cardiogenic
· Obstructive
CIRCULATION - RECOGNITION OF CIRCULATION ISSUES
- Shortness of breath
- Poor peripheral perfusion – increased capillary refill time
- Heart rate
· tachycardia,
bradycardia, arrhythmias - Blood pressure changes; hypotension, hypertension
· May manifest in other ways, consider confusion, poor urine output, chest pain
CIRCULATION - TREATMENT OF CIRCULATION ISSES
- Reposition in bed; supine with one pillow or semi-Fowler’s
- oxygen, if appropriate
- IV/IO access, take bloods
- point of care blood test
- Venous blood gas
DISABILITY - CAUSES OF REDUCED CONSCIOUS LEVEL
- Drugs
· Prescribed
· Recreational - Hyper or hypoglycaemia
- Hypoxia
- Cerebral hypoperfusion
- Hyper or hypothermia
DISABILITY - RECOGNITION OF REDUCED CONSCIOUS LEVEL
- AVPU and pupils initially
· then GCS later - blood glucose
- core temperature
- check medications, infusions, charts and notes
DISABILITY - TREATMENT OF REDUCED CONSCIOUS LEVEL
- Airway-Breathing-Circulation treatment
- position to facilitate patent airway if needed; lateral or recovery position
- oxygen if appropriate
- treat underlying cause
- achieve normoglycaemia
· Glucose
· Insulin
EXPOSURE
· examination
- surface, orifice, extremity, cavity, drains
- e.g. injuries, bleeding, tenderness, deformities, rashes, bites and stings
· avoid heat loss
- record temperature
· remove clothes to enable examination - maintain dignity
FLUIDS
· Input and output
· Fluid balance chart
· Urine output Drains
· Vomiting
· Diaphoresis
· Thirst, skin turgor
GLUCOSE
· Reduces conscious level
· Polyuria
Polydipsia (thirst)
* Ketonuria
* Glucosuria
