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Basic clinical observations
- 2. 2 Creating safer working environments with people who care
- 3. 3 Aim To introduce healthcare support workers and adult social care workers to the basic techniques used to observe and monitor the condition of patients and individuals using services, including pain and discomfort levels
- 4. 4 Learning Outcomes The levels of response and the ‘Glasgow Coma Score’ system Eye and pupil responses and how to assess breathing How to monitor and read a person’s pulse and what to look out for How to measure blood pressure and what the readings mean Methods for taking temperature How to assess skin How to record observations An overview of advanced monitoring techniques
- 5. 5 Responsiveness Does the casualty open their eyes and hold a conversation Voice: Obey simple commands Pain: Eye opening or signs of response when stimulated by pain Unresponsive: The casualty is unresponsive Answer simple questions Alert: U P V A
- 6. 6 Glasgow Coma Score Eye Opening: 4 – Spontaneous Eyes open without stimulus 3 – Opening to speech Use your voice and see if their eyes open 2 – Opening to pain Exert a small amount of pressure on the nail bed 1 – No eye opening Neither eye opens to speech or pain stimulus
- 7. 7 Glasgow Coma Score Verbal Response: 5 – Orientated Ask them a question – what is the date? 4 – Confused Can they complete meaningful sentences or phrases 3 – Inappropriate words Only using one or two words (often swear words) 2 – Incomprehensive sounds Groans, moans or mumbling 1 – No verbal response No response with speech or pain stimulus
- 8. 8 Glasgow Coma Score Motor Response: 6 – Obeys commands Will respond to instructions 5 – Localises pain Will locate pain with their hand and try to remove it 4 – Withdraw from pain Pulls away from pain stimulus 3 – Abnormal flexion When pain to fingers arms bends at elbow 2 – Extensor response When pain to fingers elbow straightens 1 – No response to pain With repeated pain stimulus there is no motor response
- 9. 9 Revised Trauma Score Revised Trauma Score 4 3 2 1 0 Score Systolic BP >89 76-89 50-75 1-49 0 Respiratory Rate 10-29 >29 6-9 1-5 0 GCS 13-15 9-12 6-8 4-5 3 Total Trauma Score:
- 10. 10 Revised Trauma Score Total score will range from 0-12: 0 Moribund 12 Normal <9 Significanttrauma
- 11. 12 Eye and Pupil Response
- 12. 13 Examine closely for: Size Equality Reaction to light Pupils represent a window into the brain Assessment of Pupils
- 14. 15 Respiratory Assessment Summary: General appearance Speech Rate Rhythm Breathing effort Pulse rate Skin colour Skin temperature Responsive state Chest examination Peak flow reading Capillary refill time
- 15. 16 Examination of the Chest Examination Techniques: Inspection Palpation Auscultation Percussion
- 16. 17 Abnormal Breathing Sounds Stridor: Harsh, high pitched sound Associated with the upper airway Wheezes: Produced on expiration High pitched, whistling sounds Associated with the lower airway
- 17. 18 Abnormal Breathing Sounds Rhonchi: Course rattling sound Associated with secretions in the bronchi Rales: Soft crackling and popping Abnormal breath sounds produced by fluid filled small airways
- 18. 19 Patterns of Respiration Pattern Rate Rhythm Depth Eupnoea Normal Normal Normal Tachypnoea Increased Regular or irregular Shallow Hyperventilation Rapid Regular or irregular Deep Bradypnoea Decreased Regular Variable Cheyne-Stokes Increased then decreasing Irregular Increased then decreasing Kussmaul’s Rapid Irregular Deep
- 19. 20 Pulse
- 22. Peak Flow Metre 25 30 35 40 45 50 55 60 65 70 MALE 5’3’’ 572 560 548 536 524 512 500 488 476 464 5’6’’ 597 584 572 559 547 534 522 509 496 484 5’9’’ 625 612 599 586 573 560 547 533 520 507 6’0’’ 654 640 626 613 599 585 572 558 544 530 6’3’’ 679 665 650 636 622 608 593 579 565 551 FEMALE 4’9’’ 377 366 356 345 335 324 314 303 293 282 5’0’’ 403 392 382 371 362 350 340 329 319 308 5’3’’ 433 422 412 401 391 380 370 359 349 338 5’6’’ 459 448 438 427 417 406 396 385 375 364 5’9’’ 489 478 468 457 447 436 426 415 405 394 Used primarily to monitor asthma
- 23. Peak Flow Metre Results are recorded on a chart 3 breaths should be taken and the highest reading recorded Reading should be taken twice a day or if they become wheezy or breathless in the day
- 24. Blood Pressure
- 25. Measuring Blood Pressure Sphygmomanometer and stethoscope Sphygmomanometer and palpation of radial pulse Non-invasive blood pressure monitors Estimation of blood pressure by presence of palpable pulse
- 26. Measuring Blood Pressure Estimating Systolic Blood Pressure: Radial 88mmHg Femoral 70mmHg Carotid 60mmHg
- 27. Temperature
- 28. Temperature taking Methods Estimating Systolic Blood Pressure: Oral Rectal Axilla Forehead Tympanic NEVER mix oral and rectal thermometers
- 29. Skin
- 30. Assessment of Skin Skin Colour Possible Causes Red Fever Allergic reactions Carbon monoxide poisoning Pallor Excessive blood loss (Hypovolemia) Fright Cyanosis Hypoxia Airway obstruction Exposure Heart conditions Shock Yellow (Jaundice) Chronic illness
- 31. Assessment of Skin Skin Temperature Possible Causes Hot and Dry Excessive body heat Hot and Wet Reaction to increased internal or external temperature Cool and Dry Exposure to cold Cold and Clammy Shock
- 32. Assessment of Skin – Pressure Areas STAGE 1 Skin is not broken but is red and discoloured. The redness or change in colour does not fade within 30 minutes after pressure is removed STAGE 2 The epidermis or topmost layer of the skin is broken, creating a shallow open sore. Drainage may or may not be present STAGE 3 The break in the skin extends through the dermis (second layer of skin) into the subcutaneous and fat tissue. The wound is deeper than Stage Two STAGE 4 The breakdown extends into the muscle and can extend as far as the bone, usually lots of dead tissue and drainage are present
- 34. Introduction to Advanced Monitoring Techniques
- 35. Glucose Testing Tablet or dietary controlled Diabetes: Before breakfast and 2 hours after lunch or dinner Once or twice a week Used primarily to monitor diabetes
- 36. Glucose Testing Insulin controlled Diabetes: Before meals and/or before insulin injections 1 test at a different rime of day, each day If it is felt that sugar is low If levels are repeatedly more than 11-19mmol During illness On advice of doctor or nurse
- 37. Ideal Glucose Levels 4-7 mmol before a meal 7-9 mmol after a meal
- 38. Pulse Oximetry Pulse Oximeters measure: % of oxygen saturation of arterial haemoglobin (SaO2) Pulse rate
- 39. Pulse Oximetry It can be used to: Assess the adequacy of oxygenation and tissue perfusion Monitor the value of treatment Assess the viability of a limb
- 40. Pulse Oximetry Normal range 97-100% Mild hypoxia 90-96% Moderate hypoxia 85-90% Severe hypoxia Less than 85%