15)On Going Assessment

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15)On Going Assessment

  1. 1. On Going Assessment
  2. 2. On Going Assessment Background <ul><li>What </li></ul><ul><ul><li>Re evaluation of the pt with repeat of: </li></ul></ul><ul><ul><ul><li>Initial Assessment </li></ul></ul></ul><ul><ul><ul><li>Vital Signs </li></ul></ul></ul><ul><ul><ul><li>Focused Assessments </li></ul></ul></ul><ul><ul><ul><li>Check of effectiveness of interventions </li></ul></ul></ul><ul><li>When </li></ul><ul><ul><li>After detailed physical assessment </li></ul></ul><ul><ul><li>Often en route to hospital or just prior to loading pt </li></ul></ul><ul><ul><li>STABLE PT = 15 MIN </li></ul></ul><ul><ul><li>UNSTABLE PT = 5 MIN </li></ul></ul><ul><li>Who </li></ul><ul><ul><li>All pt </li></ul></ul>
  3. 3. On Going Assessment Rationale <ul><li>Why </li></ul><ul><ul><li>Pt may deteriorate quickly </li></ul></ul><ul><ul><li>Look for changes in condition and effectiveness of interventions </li></ul></ul><ul><ul><li>Performed at frequent intervals you can observe dynamic changes in status of your pt </li></ul></ul><ul><ul><li>Therefore you are continuously aware of pt condition </li></ul></ul><ul><li>Change in condition </li></ul><ul><ul><li>Emergent pt may deteriorate, improve or remain unchanged </li></ul></ul><ul><ul><ul><li>Medical pt with chest pain responded to O2… </li></ul></ul></ul><ul><ul><ul><li>Is there evidence of internal bleeding in the MVA victim with significant MOI </li></ul></ul></ul><ul><ul><ul><li>What does assessment show after the application of a traction splint to a swollen/deformed thigh </li></ul></ul></ul>
  4. 4. On Going Assessment Components <ul><li>Key Components </li></ul><ul><ul><li>Repeat of Initial assessment </li></ul></ul><ul><ul><ul><li>AVPU </li></ul></ul></ul><ul><ul><ul><li>ABCs </li></ul></ul></ul><ul><ul><li>Repeat of Vital Signs </li></ul></ul><ul><ul><li>Repeat of Focused Assessment related to: </li></ul></ul><ul><ul><ul><li>C/C </li></ul></ul></ul><ul><ul><ul><li>MOI/injuries </li></ul></ul></ul><ul><ul><li>Assessment of adequacy of interventions </li></ul></ul><ul><ul><ul><li>Is what you’ve done thus far working </li></ul></ul></ul><ul><ul><ul><li>If not what must be done </li></ul></ul></ul>
  5. 5. Respiratory Evaluation <ul><li>Areas of assessment </li></ul><ul><ul><li>Rate. Rhythm. Depth. Quality. </li></ul></ul><ul><li>Rate </li></ul><ul><ul><li>Adult = 12-20 per minute </li></ul></ul><ul><ul><li>Child = 15-30 per minute </li></ul></ul><ul><ul><li>Infant -= 30-60 per minute </li></ul></ul><ul><li>Rhythm </li></ul><ul><ul><li>Regular or irregular </li></ul></ul><ul><li>Depth </li></ul><ul><ul><li>Tidal volume adequate or inadequate </li></ul></ul><ul><ul><ul><li>Amount of air breathed in/out in one ventilation </li></ul></ul></ul><ul><ul><ul><li>Approx 500 mL </li></ul></ul></ul>
  6. 6. Respiratory Evaluation cont’d. <ul><li>Quality </li></ul><ul><ul><li>Breath sounds </li></ul></ul><ul><ul><ul><li>Midclavicular & Midaxillary lines </li></ul></ul></ul><ul><ul><ul><li>Present or diminished or absent </li></ul></ul></ul><ul><ul><li>Chest expansion </li></ul></ul><ul><ul><ul><li>Unequal or symmetrical </li></ul></ul></ul><ul><ul><li>Increased effort </li></ul></ul><ul><ul><ul><li>Accessory muscles </li></ul></ul></ul><ul><ul><ul><li>“ Seesaw” breathing </li></ul></ul></ul><ul><ul><ul><ul><li>Infants </li></ul></ul></ul></ul><ul><ul><ul><li>Nasal flaring </li></ul></ul></ul><ul><ul><ul><li>Retractions </li></ul></ul></ul><ul><ul><ul><ul><li>Above clavicles, between ribs </li></ul></ul></ul></ul><ul><ul><ul><li>Cyanosis </li></ul></ul></ul><ul><ul><ul><li>Shortness of breath </li></ul></ul></ul><ul><ul><ul><li>Altered mental status </li></ul></ul></ul>
  7. 7. Accessory Muscle Use Nasal Flaring Retractions
  8. 8. Respiratory Evaluation cont’d. <ul><li>Cyanosis </li></ul><ul><ul><li>Blue/pale coloring of skin </li></ul></ul><ul><ul><ul><li>Nail beds </li></ul></ul></ul><ul><ul><ul><li>Lips </li></ul></ul></ul><ul><ul><ul><li>Eyelids </li></ul></ul></ul><ul><ul><li>Why is this seen in these areas first??? </li></ul></ul><ul><ul><li>Indicates poor perfusion </li></ul></ul>
  9. 9. Breathing <ul><li>Look – Listen – Feel </li></ul><ul><li>If pt breathing and responsive </li></ul><ul><ul><li>Oxygen may be dictated by MOI/NOI </li></ul></ul><ul><li>Breathing more than 24 bpm or less than 8 bpm </li></ul><ul><ul><li>Receive high flow oxygen/BVM </li></ul></ul><ul><li>If unresponsive and breathing: </li></ul><ul><ul><li>Maintain airway and provide high flow oxygen </li></ul></ul><ul><li>If breathing is inadequate: </li></ul><ul><ul><li>Open and maintain airway, assist in ventilation, use adjuncts. </li></ul></ul><ul><li>If pt is not breathing: </li></ul><ul><ul><li>Open and maintain airway with adjuncts, assume ventilatory support </li></ul></ul>
  10. 10. Circulation <ul><li>Assess the pt pulse </li></ul><ul><ul><li>Unresponsive </li></ul></ul><ul><ul><ul><li>Carotid </li></ul></ul></ul><ul><ul><li>Responsive </li></ul></ul><ul><ul><ul><li>Radial </li></ul></ul></ul><ul><ul><li>1 y/o or younger </li></ul></ul><ul><ul><ul><li>Brachial </li></ul></ul></ul><ul><ul><li>Absent pulseless </li></ul></ul><ul><ul><ul><li>CPR & AED </li></ul></ul></ul><ul><li>Assess for major bleeding </li></ul><ul><ul><li>If found, Treat it: </li></ul></ul><ul><ul><ul><li>Direct Pressure </li></ul></ul></ul><ul><ul><ul><li>Elevation </li></ul></ul></ul><ul><ul><ul><li>Pressure Points </li></ul></ul></ul><ul><ul><ul><li>Tourniquet </li></ul></ul></ul>
  11. 11. Skin Color <ul><li>Locations of assessment </li></ul><ul><ul><li>Nail beds, oral mucosa, conjunctiva </li></ul></ul><ul><ul><li>Pediatric </li></ul></ul><ul><ul><ul><li>Palms of hand/Sole of feet </li></ul></ul></ul><ul><ul><li>Normal = Pink </li></ul></ul><ul><ul><li>Abnormal </li></ul></ul><ul><ul><ul><li>Pale </li></ul></ul></ul><ul><ul><ul><ul><li>Poor Perfusion </li></ul></ul></ul></ul><ul><ul><ul><li>Cyanotic </li></ul></ul></ul><ul><ul><ul><ul><li>Blue/grey= Poor oxygenation/perfusion </li></ul></ul></ul></ul><ul><ul><ul><li>Flushed </li></ul></ul></ul><ul><ul><ul><ul><li>Heat or CO exposure </li></ul></ul></ul></ul><ul><ul><ul><li>Jaundiced </li></ul></ul></ul><ul><ul><ul><ul><li>Liver/Gallbladder problems </li></ul></ul></ul></ul>
  12. 12. On Going Assessment Components: <ul><li>Re establish Priority of pt </li></ul><ul><ul><li>Load and go </li></ul></ul><ul><ul><li>Stay and play </li></ul></ul><ul><li>Reassess/Record Vitals </li></ul><ul><ul><li>Compare with baseline </li></ul></ul><ul><ul><li>Notice any trends??? </li></ul></ul><ul><ul><ul><li>Increasing pulse rate with decreasing b/p = ??? </li></ul></ul></ul><ul><li>Review SAMPLE Hx </li></ul><ul><li>Repeat Focused Assessment </li></ul><ul><ul><li>NOI, C/C, MOI, and current knowledge of pt </li></ul></ul><ul><ul><li>Include pertinent aspects of focused Hx/physical </li></ul></ul><ul><ul><ul><li>i.e Pt with Chest pain </li></ul></ul></ul><ul><ul><ul><ul><li>“ Do you still have chest pain?” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Asses for JVD, Lung sounds, etc </li></ul></ul></ul></ul>
  13. 13. On Going Assessment Interventions <ul><li>Check Interventions </li></ul><ul><ul><li>Ensure adequacy of oxygenation/ventilation </li></ul></ul><ul><ul><li>Ensure control of major bleeding </li></ul></ul><ul><ul><li>Ensure adequacy of other interventions </li></ul></ul><ul><ul><ul><li>Splinting </li></ul></ul></ul><ul><ul><ul><li>Immobilization </li></ul></ul></ul><ul><ul><ul><li>PMS. etc… </li></ul></ul></ul>
  14. 14. On Going Assessment Priority Patients: <ul><li>Poor General Impression </li></ul><ul><li>Unresponsive (No gag) </li></ul><ul><li>AMS </li></ul><ul><li>SOB </li></ul><ul><li>Shock </li></ul><ul><li>Complicated childbirth </li></ul><ul><li>Chest pain with systolic pressure less than 100mmHg </li></ul><ul><li>Uncontrollable bleeding </li></ul><ul><li>Severe pain </li></ul>
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