FUNDAMENTALS OF A-G RAPID ASSESSMENT Flashcards

1
Q

AIRWAY

A

Patent, partially obstructed or obstructed

Noises, secretions, cough, artificial airway

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2
Q

BREATHING

A

respiratory Rate, Regularity (regular, irregular, apnoea)

Breathing effort (spontaneous or supported)

Respiratory distress – work of breathing (nil, mild, moderate or severe)

Breath sounds (clear, absent, decreased, crackles, wheeze, bilateral air entry and movement)

Also see Oxygen delivery device Nursing Guideline.

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3
Q

CIRCULATION

A

Skin temperature peripherally and centrally (warm, cool, cold, hot, diaphoretic)

Skin colour (normal, pink, pale, dusky, mottled, cyanotic, or other) *assess skin, lip, oral mucosa and nail bed colour

Central Capillary refill time ( <2 brisk, 2-3 normal, 3-4 slugglish, >4seconds slow)

Skin Turgor (Quick return, slow return, tenting, other)

Oral mucosa (moist, dry, pale or cyanotic)

Pulses palpated, (location left and right, rate, rhythm and strength)

ECG rate and rhythm if monitored

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4
Q

DISABILITY

A

Level of consciousness (Alert Voice Pain Unconscious score, AVPU score), or

Level of sedation score University Michigan Sedation Score (UMSS)

Gross Motor Function Classification System (GMFCS)

Identify any abnormal movement or gait and any aids required such as mobility aids, transfer requirements, glasses, hearing aids, prosthetics/orthotics required

Seizure activity (yes or no)

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5
Q

EXPOSURE

A

Exposure. In exposure, nurses will assess the patient for skin rashes, wounds, pressure injury, signs of infection, bruises, skin changes (turgor). A tool such as aSSKINg (assessment, skin assessment and skin care, surface, skin, keep, incontinent, nutrition) can be used

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6
Q

FLUIDS

A

monitor input an output

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7
Q

GLUCOSE

A

assessing pt blood glucose levels

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