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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
Assessment is the first step in caring for a patient.
Careful assessment is fundamental in order to recognise when a patient is becoming compromised,
A AIRWAY (with c spine protection in trauma)
D disability (central nervous system function)
E exposure (with temp. control)
Norman and Cook (2000)
What nurses know
What nurses see
What nurses find a quick physical assessment.
Determine patency of the airway.
Look. Listen. Feel.Count the Resp. Rate.
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
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
Look : skin colour. CRT. Dehydration
drug chart.electrolytes.signs of
Listen : accurate assessment of the heart
rate,pulse blood pressure
Feel : pulse why? What can it tell us?
HALF A ML.X KG. X 24HRS.
OLIGURIA. Production of between 100 –
400mls x 24hrs.
ANURIA. Below 100mls in 24hrs
ABSOLUTE ANURIA NO URINE
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
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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