Week Five Flashcards
Types of Patient Assessment
Must be systematic to ensure nothing is missed
- Primary & Secondary Survey
- Functional Health Pattern
- Systems Assessment
- Head to Toe
Assessment Techniques
- Inspection → Look
- Auscultation → Listen
- Palpation → Feel
Inspection
Take time to stop and look, what are you looking for?
- Skin colour (Pink, Grey, Cyanosed, Pale, Flushed)
- Injuries (Deformities, Swelling, Bruising, Lacerations, Foreign Bodies)
- Oedema
- Discharge (Ears, Nose, Vagina etc)
- Symmetry (Facial Features, Chest rise and fall)
Auscultation
Ears
- Some sounds are audible to our ears (Gurgling from upper airway congestion)
Stethoscope
- Blocks out extraneous sound and channels sound to your ears
- Slope earpieces towards your nose
- Bell (Soft/low pitched sounds - heart sounds, murmurs. Hold lightly against skin)
- Diaphragm - used most often (High pitched sounds - breath/bowel sounds. Hold firmly against skin)
Pinard
- Listen for Foetal Heart Rate (FHR) through abdominal wall
Doppler
Palpation
Adds and confirms the data already gathered
- Assesses texture, temperature, moisture, organ location, swelling, pulsation, rigidity, crepitation, masses and tenderness (palpate tender areas fast).
- Also determines lie, presentation and attitude of foetus.
Primary Assessment
- Identifies life threatening problems
- As problems are identified they are immediately addressed before continuing with assessment
- Airway, Breathing, Circulation, Disability
Airway
- Assess if airway patent
- Is patient talking, hoard voice (oedema), any obstruction (loose teeth, vomit, rolled back tongue)
Breathing
- Is patient breathing spontaneously
- Chest rise and fall (Symmetry & Depth)
- Skin Colour (Pink, Cyanotic or Grey)
- Respiratory Rate & Rhythm (Normal, Fast or Slow, Regular or Irregular)
- Respiratory Effort (use of accessory and/or abdominal muscles
Circulation
- Assess Pulse (Quality & Rate)
- Assess Skin colour, temperature, and diaphoresis (sweating)
- Inspect for any obvious bleeding
Disability
- Assess patient’s level of consciousness (AVPU Mneumonic)
A - Is patient alert and responsive?
V - Does the patient respond to verbal stimuli?
P - Does the patient respond to pain?
U - Is the patient unresponsive to painful stimuli? - Assess pupil for response to light, size, equality and shape
Head to Toe Assessment
- Take a full set of vital signs
- Observe patient’s general appearance
~ Gait/posture/mobility
~ Hygiene
~ Dress (kept/unkempt)
~ Odour (alcohol, fruity breath, urine, faeces)
~ Colour (pink/grey/pale/flushed/cyanotic) - Work systematically inspecting all areas, palpating for tenderness and deformities and auscultating where applicable
~ Head and face (eyes, ears, nose)
~ Neck
~ Chest (auscultate breath and heart sounds)
~ Abdomen and flanks (auscultate bowel sounds)
~ Pelvis and Perineum
~ Extremities (also assess motor strength, power and sensation) - Finally inspect and palpate the patient’s posterior surfaces
Dating the pregnancy
Naegle’s Rule
- Add 7 days and 9 months to the date of the first day of the Last Normal Menstrual Period (LNMP)
- Presumes a 28 day cycle
When Assessing Pregnant patients, Remember:
- To avoid compression of the aorta from the gravid uterus, pregnant women should not be assessed while laying supine (on their back)
- A wedge should be placed under the right hip to displace the uterus to the left
- Additionally, management of the pregnant woman involves two patients, however assessment is the same as for the non-pregnant person using the primary and secondary surveys
Primary Survey in Pregnant Ladies
ABCD
- Airway
- Breathing & Ventilation
- Circulation & Control of Bleeding
- Disability (Neurological Assessment & Foetal Status)
Secondary Survey in Pregnant Ladies
The primary survey should be followed by a thorough secondary survey with head to toe examination of the woman
- Abdominal Palpation
- Foetal Heart Rate
- Fundal Height
- Foetal Lie
