A-E + Head to Toe Assessment

Question 1

What are the common signs of airway obstruction?

Answer 1

Paradoxical chest and abdominal movement (see-saw respiration)
Accessory muscle use
Central cyanosis
Added noises: snoring, strider, gurgling, gasping

Question 2

What are the 3 L’s in Airway assessment

Answer 2

Look for visible obstruction in pt mouth, secretions, swelling, see-saw movement

Listen for patient speaking and strider or snoring noises

Feel for airflow and breaths from patient oral and nasal passage

Question 3

What are the Airway management

Answer 3

High flow Oxygen

Airway manoeuvre ( chin lift head tilt and jaw thrust)

Suction

Airway adjunct (Guedel)

Nasopharyngeal and oral pharyngeal airway (ETT, LMA)

Bag valve mask

Question 4

What does RATES stand for in breathing assessment?

Answer 4

Respiratory rate
Auscultation
Trachea position
Effort
Saturation o2

Question 5

What does deviation of Trachea to one side indicate?

Answer 5

Pneumothorax

Question 6

How to detect a surgical emphysema?

Answer 6

Palpating chest produce a crackling sensation (crepitus) as gas bubbles are pushed through the skin

Question 7

What is involved in Breathing Assessment?

Answer 7

Assess changes in depth and rate of breathing

Auscultate bilateral breath sounds, air entry and adventitious sounds

Look for symmetrical and bilateral chest expansion

Assess for accessory muscle use and increase WOB

Question 8

What are the signs of respiratory distress?

Answer 8

Increased RR
Increased HR
Sweat cold & clammy
Accessory muscle use / neck strain
Exhaustion
Central cyanosis
Audible strider and wheeze
Noisy laboured respiration

Question 9

What are the example of accessory muscle use?

Answer 9

Tracheal tug
Tripod positioning
Abdominal see-saw
Nasal flaring
Neck and sternocleidomastoid
Grunting and strider

Question 10

What are the two types of V/Q mismatch?

Answer 10

Shunt perfusion: poor ventilation - Problem getting oxygen supply across alveoli but good perfusion (blood supply) eg. pneumonia

Dead space ventilation: inadequate perfusion - limited blood supply moving past alveoli but good ventilation eg. Asthma COPD

Question 11

What examples signify circulation problem?

Answer 11

Sepsis

Dehydration

Electrolyte imbalance

Blood loss

MI ischaemia

Question 12

What is involved in circulation assessment ?

Answer 12

Vital signs: BP, HR, feel pulse carotid & radial, temp, ECG

Cold and clammy, sweating, pallor

Urine output and blood loss

cap refill time and central

IV access preparation

Reduced LOC

Question 13

Signs of poor cardiac output ?

Answer 13

Decreased urine output

Reduced LOC

Hypotension

Diminished pulse

Question 14

Treatment for circulatory problem

Answer 14

IV Access

Bloods: troponin, FBC, kidney, cultures electrolyte)

Rapid bolus 500mls crystalloid solution (Hartmanns, 0.9% NA)

Oxygen

IDC catheter

Flat position of patient increase BP to vital organs

Sepsis pathway - broad spectrum antibiotics

Question 15

What are the 3 components of GSC?

Answer 15

Eye opening response

Best verbal response

Best motor response

Question 16

What does a score a GCS score 9-12 indicate?

Answer 16

Moderate head injury

Question 17

What does a GCS score 3-8 indicate?

Answer 17

Comatose severe head injury

Question 18

Key components of a Disability assessment

Answer 18

AVPU and GCS - confusion
Pupillary changes (size, equality & reaction to light)
BSL (DKA,HHS)
Check medication chart (insulin, opiate) & medical history
Pain score

Question 19

What does PEARL stand for?

Answer 19

Pupil
Equal
Round
Reactive to Light
Accomodation

Question 20

What does dilated pupils indicate

Answer 20

Heroin, marijuana, amphetamine, Cochin, hallucinogen, opiate overdose

Question 21

What does unequal pupil indicate?

Answer 21

Head trauma

Question 22

What is normal pupil size?

Answer 22

2-6mm

Question 23

What are the components of Exposure assessment?

Answer 23

Examine skin - head to toe - colour, temp, swear, rashes, bites, swelling, oedema, wound cuts

Abdominal distension

Calf swelling and redness

Drains / stoma output

Question 24

What does COLDSPA stand for?

Answer 24

Presenting complaint

Character - describe signs & symptoms ( crushing or sharp pain)
Onset - when did it begin
Location - where is it and does it radiate
Duration - how long does symptoms last? Recurring or constant?
Severity - rate pain out of 10
Pattern - is there anything that makes the symptoms better or worse
Associated factors - other symptoms associated

Question 25

What are abnormal findings in abdominal examination

Answer 25

Less than 5 clicks/gurgle bowel sounds heard in a minute during auscultation

Involuntary guarding reflex and tenderness when palpating abdomen

Deviated umbilicus

Vigorous wide pulsation visible indicate Abdominal Aortic Aneurysm

Question 26

What is Strider

Answer 26

High pitch sound on inspiration due to partial obstruction of larynx or trachea

Question 27

What is wheeze?

Answer 27

High pitch whistle sound cause by air passing through narrow constricted airway

Broncho-constriction or fluid overloaded due to CHF / pulmonary oedema

Question 28

What is rhonchi?

Answer 28

A deep low pitch rumble or coarse wheezing sound, as air moves through larger bronchial or tracheal airways in the presence of mucous secretions - heard during expiration ( Asthma )

Question 29

What is Crackles?

Answer 29

Fine, short, high pitched sounds caused by air passing mucus or fluid. Commonly heard in base of lung lobes during inspiration