Circulation interventions
- Chest compressions
- Control of bleeding
- IV access
- Fluids, medications, blood transfusion
Disability interventions
- Attempt to elicit a response – verbal, painful
- If unresponsive, obtain help and check breathing and pulses, repeat vital signs
- Administer glucose as needed
- Treat pain
Exposure interventions
- Control bleeding – apply pressure, tourniquet
- Maintain a normal temperature
- Investigate unusual markings or signs of abuse
- Remove wet/soiled pad or linens
Appropriate VS ranges
- HR < 50 or > 90
- RR < 8
- BP systolic < 90 or >180
- Temp < 36.0 or > 38.0
- O2 saturation < 95%
4 checks of Exposure
- Uncover and assess face & head, torso (front and back), extremities for unusual markings
- Skin color and temperature
- Uncontrolled bleeding
- Incontinence
4 checks of Disability
- AVPU/GCS
- Blood glucose/dextrose
- Pupil response
- Pain
ABPP
7 checks of Circulation
- Heart rate and rhythm
- Quality of pulses
- Skin color, temperature, cap refill
- Blood pressure
- Signs of bleeding
- Intravenous access – lines, site to source
- Output - urine
HQOSBIS
4 checks of breathing
- Respiratory rate and effort
- Depth and symmetry of chest rise
- Breath sounds - auscultate
- Oxygen saturation
3 checks of the Airway
- Listen for air movement
- Feel for air movement at nose and mouth
- Look at position of head and trachea
Neuro Qs
Tremors
Difficulty speaking
One-sided weakness
Head/brain history
cardio Qs
SOB
Chest pain
Cardiac risk factors (high BP, high cholesterol, obesity)
Respiratory Qs
SOB (OE)
Hx of infection
Resp. related habits (smoking)
Environmental exposure
Integumentary Qs
Hx of skin disease
Change in moles/skin pigment
Rashes
Healing delay or bruising
Neuro focused assessment MAIN Tasks
Inspect pupils
Inspect GCS
Motor Assessment
Sensation
Neuro motor assessment
Symmetry
Grip
Pronator drift
Flexion of legs
Sensation
Cardio focused assessment
Qs:
1. Any chest pain or tightness?
2. Any shortness of breath? (SOB)
5. Do you seem to tire easily?
9. Any past history of heart disease?
10. Any family history of heart disease?
11. Assess cardiac risk factors
Inspect
* CWMS and capillary refill
* PMI and JVD and carotid pulse
Auscultate
- PMI for 1 min
- HR, rythym + extra heart sounds
* right 2nd intercostal space (ICS), (aortic)
* left 2nd ICS, (pulmonic)
* left 3rd ICS space, (Erb’s)
* left 5th ICS, (tricuspid)
* PMI (mitral)
- radial pulse match apical pulse??
Inspect ARMS and legs
Check radial pulse
* CWMS
* Edema
* Hair distribution
* Varicose veins
* Wound healing
* Check feet pulses (DP, PT)
- Cap refill
Respiratory focused assessment
Qs:
2. SOB? SOBOE?
3. Chest pain with breathing?
4. Hx of respiratory infections
5. Smoking hx?
6. Environmental exposure?
Inspect
- symmetry
-RR + Pattern
- Effort of breaths (uses of accessory muscles)
- Face &mouth and Extremity skin colour
Palpate
- symmetrical expansion
- Skin massess
- Temperature
- Pain
- Tactile fremitus (vibration of chest walls during speaking certain words)
Auscultate anterior and posterior back
- Verbalize adventitious lung sounds
Integ focused assessment
Inspect
- Colour
- Irregularities
- Wounds/dressings
Airway interventions
- Reposition – head tilt/chin lift/jaw thrust
- Suction – secretion, emesis
- Airway – adjunct, endotracheal intubation
Breathing interventions
- Elevate head of bed or position of comfort
- Apply oxygen – nasal prongs, face mask
- Assist ventilation – bag-valve mask
Examples of adventitious lung sounds
crackles,
wheezes,(musical on expiration)
stridor (whistle on inspiration),
pleural rub (bumping, with inflammation)
GU/GI Focused assessment
- Food intolerance
- Abdominal pain?
- Nausea or vomiting
- Bowel habits
- Abdominal history – diseases, surgeries
Urinary symptoms for males
Menstrual history for females
- Contact with STIs for both
GI inspection
- Contour (Distension
- Symmetry
- * Skin
* Pulsation or Movement
* (comfort)
Auscultate
- Quadrants (Verbalize findings hypo/hyper/normal)
Palpate the abdomen last
- For lumps or tenderness
- * palpate symphysis pubis for bladder distention
* verbalize examine tender areas last
GU
* Check urine for color, sediment, hematuria, odor
* Record amount - verbalize normal is > 30 ml/hr
* Assess fluid status – weight, edema, neck vein distension, skin moisture and elasticity, eyes sunken, BP
* Genitalia – visualize only if indicated
Integ. Focused Assessment
Qs
- Previous hx of skin disease? Diabetes? CV disease?
- Excessive dryness or moisture?
- Rashes or lesions? (Be able to ask LOTTAARRPP)
- Medications?
- Hair loss?
- Changes in nails?
Inspect skin
* Color
* Irregularities
- Wounds/dressings
Verbalize for the areas to check for pressure ulcers for immobile patients
Head, Scapulae, Ribs, Elbows, Coccyx, Hips, Ankles and Heels.
Palpate
Texture
Turgor
Temp
Mositure
Edema
Inspect hair and nails
Colour
Texture
Distribution
Lesions
Nails
- Shape, contour, consitency
- Clubbing?
- Cap refill in fingers and toes
Neuro Focusedd assessment
Qs:
Headinaches, dizziness, nausea?
Hx of head injury
One sided weakness or general weakness
Numbness or tingling
Hx of stroke or any brain event?
Inspect
PERRLA
GCS Scoring
- EYES - assess for spontaneous eye opening
- VERBAL Response – assess orientation (A+Ox3)
- MOTOR Response – assess if able to follow commands
Motor assessment
- * Facial symmetry
* Hand grip
* Pronator drift
* Leg raise
* Dorsiflexion & plantarflexion
Sensation (Numbness or tingling)
* touch feet, legs, hands, and arms
