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Assessing the Acutely Ill. M.Lynch BSc(Hons).PGCertEd.RM.RN Lecturer/Practitioner Critical Care &Surgery. Introduction.

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assessing the acutely ill

Assessing the Acutely Ill

M.Lynch BSc(Hons).PGCertEd.RM.RN

Lecturer/Practitioner

Critical Care &Surgery.

introduction
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
  • Assessment is the first step in caring for a patient.
  • Careful assessment is fundamental in order to recognise when a patient is becoming compromised,
  • .
structured assessment
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)
assessment con
Assessment.con
  • Norman and Cook (2000)
  • What nurses know
  • What nurses see
  • What nurses find a quick physical assessment.
airway assessment
Airway Assessment
  • Determine patency of the airway.
  • Look. Listen. Feel.Count the Resp. Rate.
airway obstruction
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
airway obstruction1
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
breathing
BREATHING
  • LOOK
  • LISTEN
  • FEEL
circulation
Circulation
  • Look : skin colour. CRT. Dehydration
  • drug chart.electrolytes.signs of
  • haemorrhage/fluid loss
  • Listen : accurate assessment of the heart
  • rate,pulse blood pressure
circulation1
Circulation
  • Feel : pulse why? What can it tell us?
disability
Disability
  • Neurological assessment
disability1
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

exposure
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
conclusion
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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