Ba sic Asse ssme nt: a nd Alp ha b e t so up ! Yo u c a n use fo r a ll p a tie nts! T his to p ic will re view the nurse s a sse ssme nt impo r tanc e in the a sse ssme nt o f a ll typ e s o f p a tie nts that p re se nt to E D a nd a lso c a n b e use d o n inp atients.
L e t’ s g e t Sta rte d Wha t d o the a c ro nyms me a n a nd d o the y he lp !! We ll Ye s the y d o F o llow up e ve r y p atie nt eve r y time a nd yo u wo n’ t miss a thing! L e t’ s sta rt :
No w A,B,C, D ( sing a lo ng ) C AND A to ge the r : Ble e d ing( c irc ulatio n Obvious b le eding) Sto p a nd c o ntro l Airway a nd C sp ine : L o o k, into the a irwa y, listen fo r no ise s, b re a thing, F e e l fo r a ir mo vement: Inte r vene : Ho w? Re p o sition, Suc tio n, Ap p ly O2, Sto p a nd Ba g: Is tha t e a sy? Ja w thrust a nd E C T e c hnique
L e t’ s d e sc rib e the BVM
Hig h F lo w Oxyg e n T he ra p y
Ne o na ta l to Ad ult
Are we b re a thing ye t? ? F o r the p a tient Or p a tie nt o n the ir o wn Ho w e ffe c tive a re we o r the y Ra te a nd d e e p o f re sp ir a tio ns E ffe c tive ne ss: Co lor improving Are we tiring o r is the p a tie nt tiring?
B: Bre a thing is it e ffe c tive ? ? Co lo r Ale rt Ra te a nd d e p th Is o ur a d junc t wo rking Ca n we mo ve o n?
C: Circ ula tio n Ble e d ing? Co lo r Ce ntra l a nd p e rip he ral p ulse s If we a k o r d iffe re nt why? Do we ne e d b lo o d , fluid s,Oxyge n, More c a rd iac o utput Wha t is the p a tie nts c hie f c o mplaint?
D: Disa b ility Ne uro sta tus Me ntatio n: BS Pup ils GCS Sc o re
E : E xp o sure a nd E nviro nme nta l Co ntro l Ge t the pa tie nts c lo the s o ff, pla c e in g o wn All pa tie nts g e t na ke d!!! Co ve r, pro te c t mo de sty a nd q uic k a sse ss the skin
F : F ull se t o f Vita l Sig ns T his inc lude s T e mpe ra ture He a rt ra te Re spira to ry ra te Blo o d pre ssure : Ho w to ta ke b lo o d pre ssure : T his is whe n I a usc ulta te o ne if the pa tie nt is sic k”
G: Give c o mfo rt me a sure a nd Ge t Mo nito ring d e vic e s Co mfo rt: Pa in, No n p ha rma c o logic al mea sure s Pa in me d ic a tio ns All mo nitors o n, re a sse ss Vital signs Blo o d suga r L : IV,labsif no t d o ne M: Mo nito r Oxyge na tio n: Re a sse ss, Sa tura tio n wo rk o f b re a thing, Ca p no gra phy? Do we ne e d it? De p e nd s o n p a tie nt
H: Histo ry Why a re the he re Wha t is c hie f c o mp laint to d a y Is it re la te d to p rio r Histo r y: T ha nks to e le c tro nic he alth re c ords we c a n usua lly find so me info rma tion F ind ings to c a use a la rm: Ale rt p rovide r Me dic atio ns: Have the y b e e n ta king the m a nd if so whe n,wha t a nd ho w muc h Dia gno stic s : Wha t d o yo u a ntic ipa te will b e ne e d e d ? He lp yo ur p ro vid er o ut a s yo u se e the p a tie nt first a nd la st in mo st c a se s.
Insp e c t a nd re a sse ss He a d to to e a sse ssme nt a nd d o n’ t fo rge t the b a c k sid e We might no tic e skin c olo r c ha nge s, sta rt o f d e c ub iti's ulc e r, unke mpt hygie ne
With e a c h p a tie nt e a c h time We will ha ve g o o d o ut c o me s Dilige nt b y b e d sid e c are give rs save s p a tients a nd ho p e fully p reve nts d e c line .
Re fe re nc e s E NA.o rg Ame ric a n Assoc iatio n o f Critic al c a re : AACN.o rg E M ra p
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