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Head to Toe: Rapid Response Assessment

Objectives. Summarize the appropriate circumstances for a focused exam vs complete head to toe assessmentDescribe the steps in assessment of the cardio-pulmonary system and other body systemsIdentify appropriate patient interventions/examinations by RT's and RN's in the acute and post acute settin

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Head to Toe: Rapid Response Assessment

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    1. Head to Toe: Rapid Response Assessment Kelly Thelen APRN, FNP, CRRN Madonna Rehabilitation Hospital Lincoln, NE

    2. Objectives Summarize the appropriate circumstances for a focused exam vs complete head to toe assessment Describe the steps in assessment of the cardio-pulmonary system and other body systems Identify appropriate patient interventions/examinations by RT’s and RN’s in the acute and post acute settings

    3. Why assess beyond the obvious? Changes in the patient’s physical and/or mental status Presenting concerns to the team Presenting concerns to the physician, PA, or nurse practitioner Making decisions regarding emergent vs. non-emergent

    4. Patient History Past Medical History Medications Allergies Subjective data from patient Don’t forget the family!! Direct care staff report

    5. General Appearance Vital Signs Affect Dress, Grooming, and personal hygiene Posture, facial expression, manner, and attention span Speech Judgement

    6. HEENT Head Incisional changes S/S of infection Increased swelling New onset of HA’s or change in HA’s Ears Eyes PERRLA, tracking, neglect, visual-perceptual changes, conjunctiva, Sclerae, Nystagmus Nose Throat C/O pain, changes in voice quality

    7. Neck Trach site Supple Cervical Adenopathy Carotid Bruits Jugular distention

    8. Pulmonary Chest diameter Respiratory Rate, Rhythm, and Effort Accessory Muscles Auscultation Crackles (rales) Wheezes Rubs Percussion

    9. Cardiac Carotids and Jugular veins Rate and Rhythm Murmurs Pulses in the extremities Color of the extremities Swelling

    10. Abdomen Contour Bowel Sounds Aortic region Percussion Palpation Rebound tenderness

    11. Genital/Rectal Edema Urine output Concentration Odor Pain Bowel Movements Constipation Diarrhea

    12. Musculoskeletal New pain vs. old pain Location, quality, relieving factors, exacerbating factors Gait Numbness tingling Posture

    13. Skin Turgor Color Temperature Moisture Rashes or lesions Wounds Ecchymosis

    14. Psychological Sleep pattern Personality Affect Delerium Anxiety Depression

    15. Neurological Many components addressed in other areas of evaluation LOC Cognition Orientation Sensation Reflexes Strength Speech Swallow

    16. Diagnostics: When and Why? Labs UA Blood Cultures CBC’s, BMP’s, CMP’s Liver Function Pre-Albumin ABG’s EKG’s X-rays

    17. When do I call the physician, PA, or NP *ERROR ON THE SIDE OF CAUTION* New orders needed More extensive assessment needed Transfer requested Per provider request

    18. How do I determine if it is a Medical Emergency When in doubt, ask the treating provider Significant change in status Requiring services not offered at the current facility

    19. Available Resources Staff members who consistently care for the patient RT’s, Nurses, Therapists, Nursing Assistants Physicians, NP’s, and PA’s Response Team Reference items

    20. Rapid Response in Acute Care Rapid Response Team (RRT) Outline management of patients who have been identified to be in a threatening situation. A threatening situation is defined as a system or multi-system failure that is evidenced by a change in LOC, respiratory distress or cardiac changes.

    21. Rapid Response Criteria RRT Primary Reasons for calling: Staff worried Respiratory Change in VS Change in LOC New onset of pain I&O discrepancy Failure to respond to treatment

    22. Rapid Response Criteria cont… Staff member is worried about the patient Acute ? in HR < 40 or >130 Acute ? in systolic B/P < 90 mmHg Acute ? in RR <8 or >30 bpm Acute ? in SpO2 < 90% despite oxygen Acute ? in concious state Acute ? in UO to < 50 ml in 4 hours

    23. Rapid Response Interventions RRT Suspected problems leading to the call and action plans for the team Stroke-initiate stroke team/orders Sepsis-initiate protocol MI- 12 lead, MONA Hypovolemia-fluid resuscitation Respiratory Distress: identify cause, manage airway, suction and supplement with O2 Oversedation-Narcan and airway management

    24. Rapid Response in Post Acute Care P.A.C.E. Team Presentation, Assessment, Collaboration, Evaluation Madonna Rehabilitation Hospital Benefits Decreases the number of patients returned to acute care and interrupted stays Second assessment for the patient to establish the best plan of care or next steps As a provider, the PACE team provides me with a thorough assessment and evaluation of the patient and situation when I am not at the hospital

    25. P.A.C.E. Response Criteria “Something is just not right” Mental status changes Significant ? in vitals (HR, RR, B/P, T°, Pain) ? O2 needs ? Activity tolerance (= 2 missed therapies in 12-24 hrs) Unrelieved pain Significant weight gain = 1 lb/day Changes in LAB values

    26. Thank you for your participation! Please feel free to contact me with questions! 402-483-9883 Cellular phone: 402-580-0353 E-mail: kthelen@madonna.org

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