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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.

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Assessing the Acutely Ill

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  1. Assessing the Acutely Ill M.Lynch BSc(Hons).PGCertEd.RM.RN Lecturer/Practitioner Critical Care &Surgery.

  2. 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)

  3. 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, • .

  4. 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)

  5. Assessment.con • Norman and Cook (2000) • What nurses know • What nurses see • What nurses find a quick physical assessment.

  6. Mini assessment

  7. Airway Assessment • Determine patency of the airway. • Look. Listen. Feel.Count the Resp. Rate.

  8. 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

  9. 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

  10. BREATHING • LOOK • LISTEN • FEEL

  11. Circulation • Look : skin colour. CRT. Dehydration • drug chart.electrolytes.signs of • haemorrhage/fluid loss • Listen : accurate assessment of the heart • rate,pulse blood pressure

  12. Circulation • Feel : pulse why? What can it tell us?

  13. Disability • Neurological assessment

  14. 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

  15. 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

  16. 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.

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