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Assessing the Acutely Ill - M.Lynch BSc(Hons).PGCertEd.RM.RNLecturer/Practi...


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.

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Assessing the Acutely Ill

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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.


Mini assessment

Mini 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.