15)On Going Assessment

On Going Assessment

On Going AssessmentBackground

• What• Re evaluation of the pt with repeat of:

• Initial Assessment• Vital Signs• Focused Assessments• Check of effectiveness of interventions

• When• After detailed physical assessment • Often en route to hospital or just prior to loading pt• STABLE PT = 15 MIN• UNSTABLE PT = 5 MIN

• Who• All pt

On Going AssessmentRationale

• Why• Pt may deteriorate quickly• Look for changes in condition and effectiveness of interventions• Performed at frequent intervals you can observe dynamic changes

in status of your pt• Therefore you are continuously aware of pt condition

• Change in condition• Emergent pt may deteriorate, improve or remain unchanged

• Medical pt with chest pain responded to O2…• Is there evidence of internal bleeding in the MVA victim with significant

MOI• What does assessment show after the application of a traction splint to

a swollen/deformed thigh

On Going AssessmentComponents

• Key Components• Repeat of Initial assessment

• AVPU• ABCs

• Repeat of Vital Signs• Repeat of Focused Assessment related to:

• C/C • MOI/injuries

• Assessment of adequacy of interventions• Is what you’ve done thus far working• If not what must be done

Respiratory Evaluation

• Areas of assessment• Rate. Rhythm. Depth. Quality.

• Rate• Adult = 12-20 per minute• Child = 15-30 per minute• Infant -= 30-60 per minute

• Rhythm• Regular or irregular

• Depth• Tidal volume adequate or inadequate

• Amount of air breathed in/out in one ventilation• Approx 500 mL

Respiratory Evaluation cont’d.

• Quality• Breath sounds

• Midclavicular & Midaxillary lines• Present or diminished or absent

• Chest expansion• Unequal or symmetrical

• Increased effort• Accessory muscles • “Seesaw” breathing

• Infants• Nasal flaring • Retractions

• Above clavicles, between ribs• Cyanosis• Shortness of breath• Altered mental status

Accessory Muscle Use

Nasal Flaring

Retractions

Respiratory Evaluation cont’d.

• Cyanosis• Blue/pale coloring of skin

• Nail beds• Lips• Eyelids

• Why is this seen in these areas first???

• Indicates poor perfusion

Breathing

• Look – Listen – Feel• If pt breathing and responsive

• Oxygen may be dictated by MOI/NOI• Breathing more than 24 bpm or less than 8 bpm

• Receive high flow oxygen/BVM• If unresponsive and breathing:

• Maintain airway and provide high flow oxygen• If breathing is inadequate:

• Open and maintain airway, assist in ventilation, use adjuncts. • If pt is not breathing:

• Open and maintain airway with adjuncts, assume ventilatory support

Circulation

• Assess the pt pulse• Unresponsive

• Carotid• Responsive

• Radial• 1 y/o or younger

• Brachial• Absent pulseless

• CPR & AED• Assess for major bleeding

• If found, Treat it:• Direct Pressure• Elevation• Pressure Points• Tourniquet

Skin Color

• Locations of assessment• Nail beds, oral mucosa, conjunctiva• Pediatric

• Palms of hand/Sole of feet• Normal = Pink• Abnormal

• Pale• Poor Perfusion

• Cyanotic• Blue/grey= Poor oxygenation/perfusion

• Flushed• Heat or CO exposure

• Jaundiced • Liver/Gallbladder problems

On Going AssessmentComponents:

• Re establish Priority of pt• Load and go• Stay and play

• Reassess/Record Vitals• Compare with baseline• Notice any trends???

• Increasing pulse rate with decreasing b/p = ???• Review SAMPLE Hx• Repeat Focused Assessment

• NOI, C/C, MOI, and current knowledge of pt • Include pertinent aspects of focused Hx/physical

• i.e Pt with Chest pain• “Do you still have chest pain?”• Asses for JVD, Lung sounds, etc

On Going AssessmentInterventions

• Check Interventions• Ensure adequacy of oxygenation/ventilation• Ensure control of major bleeding• Ensure adequacy of other interventions

• Splinting• Immobilization• PMS. etc…

On Going AssessmentPriority Patients:

• Poor General Impression• Unresponsive (No gag)• AMS• SOB• Shock• Complicated childbirth• Chest pain with systolic pressure less than 100mmHg• Uncontrollable bleeding• Severe pain