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Initiating a clinical assessment

Part 2 AIMS to discuss 1. Physical Assessment – what you can learn

2. Primary Assessment

3. Secondary Assessment

Preparation: Rapid visual assessment - ABC

You walk into the patient’s room and ask them how they are and they respond appropriately. What have you learnt?

1.Their airway is patient

2.They are breathing

3.Their brain is still perfused

Thus indicating no life-threatening emergency

You need to do a more in-depth

assessment

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Before commencing a physical assessment: Discuss assessment process and obtain verbal consent; privacy; correct ID (legal considerations) ; and, if possible, allow adequate time. PPE; standard precautions; safe environment (infection control considerations)

Stooped

posture

Tremour

Mask-like face

Rigidity Arms flexed

at elbows

and wrists

Tremour

Hips and

knees

slightly

flexed

Short, shuffling steps

Parkinsonism: •Bradykinesia, rigidity, tremour •May be an extrapyramidal side effect of medication

What can you tell

from the way a

patient walks?

Ataxic gait in cerebellar ataxia. Poor balance and a broad based - lurching and staggering and exaggeration in all movements. Because the patient can’t feel the feet they slap them down and look down while walking

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What can you tell by shaking hands with someone?

Eg Perfusion Hydration Strength Pain Disfigured hands/wrists Finger nails / abnormal

When dealing with debilitated patients Consider:

Nutrition Dentition Podiatry Eyesight and hearing

Primary Survey, also called primary care and primary assessment Followed by precise reporting and documentation Information is conveyed using common terminology

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Dangers (check for hazards, risks, safety) Depending upon the circumstances safety must be considered: If outside the hospital is the scene secure e.g., shooting scene, fire, contamination Occasionally it may be necessary to delay treatment When this is completed then the assessment/treatment can commence

RESPONSIVE

CARE: Patient may startle or act aggressively, approach from feet. Squeeze the patient’s hand and gently squeeze the patient’s shoulders. If no response CALL FOR HELP In hospital this means pressing the red emergency button which automatically calls the Medical Emergency Team (MET) The hospital also has an emergency number *** Out of hospital call an ambulance on 000 (or 112 if using a mobile)

Send for help

If no response SEND FOR HELP In hospital this means pressing the red emergency button which automatically calls the Medical Emergency Team (MET) The hospital also has an emergency number *** Out of hospital call an ambulance on 000 (or 112 if using a mobile)

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AIRWAY “In an unconscious victim, care of the airway takes precedence over any injury” ARC Guideline 4 2006

Step 1 Clear the airway Step 2 Ensure airway patency

If breathing commences the victim can be left on the side with appropriate head tilt. If not the victim should be rolled onto their back and resuscitation commenced

•Determine whether the airway is patent. Are there any gurgles, snoring or obvious bronchospasm?

•Does air appear to be going in and out?

Trauma: If the patient has been subjected to trauma that may have damaged the cervical spine care should be taken not to hyperextend the neck. In this case the ‘jaw thrust’ manoeuvre may be used

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Children (1 to 8 years) and Infants (younger than one year)

“…in infants the head should be kept in neutral and maximum head tilt should not be used”

Head position for children

Airway obstruction Can be partial or complete; typical causes include:

•Relaxation of the airway muscles due to unconsciousness •Inhaled foreign body •Trauma to the airway •Anaphylactic reaction

BREATHING - Normal

•Assessment of Breathing

•Infection Control issues – discuss

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Determine the presence or absence of effective breathing by assessing:

•Rate (approximate)

•Regularity

•Pattern (e.g. abdominal, Cheyne-Stokes)

•Depth

•Symmetrical paradoxical chest rise

•Accessory muscle use

•Skin colour

Expired air delivers a concentration of 15-18% oxygen

Methods of delivery: •Mouth to mouth •Mouth to nose •Mouth to mouth and nose •Mouth to mask

CPR - Start The ARC Guidelines since 2006 does not state feeling for a major pulse (carotid) but states that if there are no “signs of life” to commence external cardiac compressions. However as health professionals one should be able to correctly palpate for a carotid pulse. If there is no palpable pulse in the adult immediately commence compressions.

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Touch the patient’s wrist and evaluate

•Pulse presence

•Rate (approximate)

•Volume

•Regularity

•Skin temperature

•Diaphoresis (clamminess)

•Capillary refill

•Skin / nail-bed colour

If in an emergency setting assess the cardiac rhythm and any ecg abnormalities

Attach Defibrillator

Post resuscitation

SBP >100 mmHg

SaO2 94-98

BGL 6-8 mmol/L

Control seizures

Treatable causes of cardiac arrest are:

Hypoxaemia

Hypovolaemia

Hyop/Hyperkalaemia (other metabolic disorders include acidosis disturbances Mg and Ca

Tension pneumothorax

Tamponade: pericardial

Toxins/poisons/drugs

Thrombosis

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The Secondary Assessment / Survey

Exposure / Environment Can I see everything? What environment has the patient come from? Too hot / cold / are they comfortable? General observations

Appearance Any obvious problems/injuries Behaviour Walk

Pain (the fifth vital sign) assessment (PQRST)

P = Provokes What provokes the pain? What makes it feel worse/better? What was the patient doing when the pain began?

Q = Quality What does the pain feel like? Have the patient describe it. Words commonly used are dull / sharp / pressure / tearing

R = Radiates In what direction does the pain radiate? Is it located in one area? Does it move?

Pain assessment (PQRST)

S = Severity How severe is the pain? On a scale of 0 -10

T = Time When did it start? How long did it last? Has the patient had it before? Is it constant or intermittent?

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Head to toe examination

What is happening for the patient? Has anything been missed any other injuries or problems the patient may not have mentioned

Skin colour pallor/cyanosis/flushed Posture stiff neck/abnormal position Ears / nose Discharges / ‘Battle’s sign’ Eyes ‘rocoon’s eyes/deviation/pupils Odour alcohol / ketones Hydration fever, tachycardia, skin turgor Face symmetry

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I = Investigations Are any of the patient’s reports or results available? J = jot it down Has everything been documented accurately?