Assessing the Acutely Ill
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Assessing the Acutely Ill

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Introduction. Healthcare workers should be competent in undertaking a systematic and comprehensive approach to patient assessment to enable early recognition of potential or actual deterioration in the patients condition(DOH, 2001). ASSESSMENT. Assessment is the first step in caring for a patient.
Assessing the Acutely Ill

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1. Assessing the Acutely Ill M.Lynch BSc(Hons).PGCertEd.RM.RN Lecturer/Practitioner Critical Care &Surgery. This session will focus on the assessment of the acutely ill, and aims to introduce assessment tools that enable systematic patient assessment.This session will focus on the assessment of the acutely ill, and aims to introduce assessment tools that enable systematic patient assessment.

2. Introduction Healthcare workers should be competent in undertaking a systematic and comprehensive approach to patient assessment to enable early recognition of potential or actual deterioration in the patients condition (DOH, 2001) The is taken from the DoH doc.(2001) Comprehensive Critical Care : a Strategic Programme of Action. This document was the precursor of DoH Critical Care without walls, which this course is based on the hypothesis that ITU is a patient need not a place And that pt assessment skills should be The is taken from the DoH doc.(2001) Comprehensive Critical Care : a Strategic Programme of Action. This document was the precursor of DoH Critical Care without walls, which this course is based on the hypothesis that ITU is a patient need not a place And that pt assessment skills should be

3. ASSESSMENT Assessment is the first step in caring for a patient. Careful assessment is fundamental in order to recognise when a patient is becoming compromised, . Courses such as the ALS. And ATLS use a structured and prioritised approached to management of the critically ill.Courses such as the ALS. And ATLS use a structured and prioritised approached to management of the critically ill.

4. Structured Assessment A AIRWAY (with c spine protection in trauma) B breathing C circulation D disability (central nervous system function) E exposure (with temp. control) A airway maintenance and cervical spine control. Problems with the airway must be dealt with first. When assessing airway in trauma always assume a cspine injury and therefore the patient will need a hard collar until x-ray clearance. If the patient can talk then they are able to maintain their own airway. If the patient can talk then they are able to maintain their own airway.If the airway is compromised attempt chin lift and try to clear the airway. If a gagrefelex is present then insert a nasopharyngeal airway. No gag then the patient needs intubation. B breathing and ventilation. The position of the trachea is checked, respiratory rate and air entry. If there are any problems with the respiration these are dealt with immediately for example if there is clinical evidence of tension pneumothorax this needs to be relieved immediately. C circulation and control of active bleeding, assess heart rate. D disability : neurological status. GCS. e. Exposure and environment. During the primary survey resuscitation starts. Shock management. Oxygenation.venous accessA airway maintenance and cervical spine control. Problems with the airway must be dealt with first. When assessing airway in trauma always assume a cspine injury and therefore the patient will need a hard collar until x-ray clearance. If the patient can talk then they are able to maintain their own airway. If the patient can talk then they are able to maintain their own airway.If the airway is compromised attempt chin lift and try to clear the airway. If a gagrefelex is present then insert a nasopharyngeal airway. No gag then the patient needs intubation. B breathing and ventilation. The position of the trachea is checked, respiratory rate and air entry. If there are any problems with the respiration these are dealt with immediately for example if there is clinical evidence of tension pneumothorax this needs to be relieved immediately. C circulation and control of active bleeding, assess heart rate. D disability : neurological status. GCS. e. Exposure and environment. During the primary survey resuscitation starts. Shock management. Oxygenation.venous access

5. Assessment.con Norman and Cook (2000) What nurses know What nurses see What nurses find a quick physical assessment. Norman and Cook (2000) suggest that nurse should perform a mini assessment based on the above criteria. This snap-shot will direct the nurses further action. Norman and Cook (2000) suggest that nurse should perform a mini assessment based on the above criteria. This snap-shot will direct the nurses further action.

6. Mini assessment

7. Airway Assessment Determine patency of the airway. Look. Listen. Feel.Count the Resp. Rate. Look to see if there is any obvious obstruction, this could include vomitus,copious secretions,foreign objects and obstruction by a poorly positioned airway. Guedal airways, endotracheal tubes and tracheostomies which are blocked with secretions or incorrectly placed can obstruct an airway. The patients airway maybe partially or completely obstructed and a paradoxical(seesaw) pattern of respiration will present. Look for evidence of gastric secretions, particularly important as aspiration of acide gastric contents can cause severe lung tissue damage, pneumonitis. Listen : assess the patients ability to speak, asking closed questions like how are you, elicits two pieces of information the patients level of consciousness and their ability to vocalise. In complete airway obstruction breath sounds are absent, while in partial airway obstruction there may be a variety of different sounds produced depending on the source of the obstruction. Look to see if there is any obvious obstruction, this could include vomitus,copious secretions,foreign objects and obstruction by a poorly positioned airway. Guedal airways, endotracheal tubes and tracheostomies which are blocked with secretions or incorrectly placed can obstruct an airway. The patients airway maybe partially or completely obstructed and a paradoxical(seesaw) pattern of respiration will present. Look for evidence of gastric secretions, particularly important as aspiration of acide gastric contents can cause severe lung tissue damage, pneumonitis. Listen : assess the patients ability to speak, asking closed questions like how are you, elicits two pieces of information the patients level of consciousness and their ability to vocalise. In complete airway obstruction breath sounds are absent, while in partial airway obstruction there may be a variety of different sounds produced depending on the source of the obstruction.

8. AIRWAY OBSTRUCTION Inspiratory Stridor : a rasping sound heard during inspiration as a result of obstruction above or involving the larnyx Wheeze : is usually heard on expiration as a result of the lower airways collapsing

9. AIRWAY OBSTRUCTION Gurgling occurs when secretions or liquid is present in the upper airways. Snoring occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles and tongue High pitched crowing sounds occur during laryngeal spasm

10. BREATHING LOOK LISTEN FEEL LOOK the patients chest should be observed to assess, rate pattern and ease of respiration. RESPIRATION RATE IS WIDELY ACCEPTED AS BEING THE MOST SENSITIVE BASIC OBSERVATION IN DETECTING PT.DETERIORATION,Goldhill et.al (1999) LISTEN wheezes. Crackles. Pleural sounds. FEEL the trachea should be in a midline positionLOOK the patients chest should be observed to assess, rate pattern and ease of respiration. RESPIRATION RATE IS WIDELY ACCEPTED AS BEING THE MOST SENSITIVE BASIC OBSERVATION IN DETECTING PT.DETERIORATION,Goldhill et.al (1999) LISTEN wheezes. Crackles. Pleural sounds. FEEL the trachea should be in a midline position

11. Circulation Look : skin colour. CRT. Dehydration drug chart.electrolytes.signs of haemorrhage/fluid loss Listen : accurate assessment of the heart rate,pulse blood pressure

12. Circulation Feel : pulse why? What can it tell us? Assess the pulse, not only for presence but for rate,regularity and qualityAssess the pulse, not only for presence but for rate,regularity and quality

13. Disability Neurological assessment

14. Disability URINE OUTUT. HALF A ML.X KG. X 24HRS. OLIGURIA. Production of between 100 ? 400mls x 24hrs. ANURIA. Below 100mls in 24hrs ABSOLUTE ANURIA NO URINE Identify the cause, always always perform a bladder washout before deciding there is no urineIdentify the cause, always always perform a bladder washout before deciding there is no urine

15. EXPOSURE TEMP. Also a top to toe assessment allow us to see any areas that may have been missed in the initial ABCD eg wounds, areas of inflammation

17. Conclusion A B C D E Coupled with the MINI ASSESSMENT TOOL. Provides a structured approach to patient Assessment and a basis for further intervention / treatment.


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