Flashcards in Module 1- Health Assessment Frameworks Deck (24):
What are the two types of assessments and what are they used to do?
- General- to determine a specific pt issue/problem
- Focused- to investigate an identified issue further
What does a general assessment involve?
- Primary survey
- Secondary survey
- Health assessment (physical exam, vitals)
When is the primary survey performed and what does it involve?
- Performed once you confirm the pt has not gone into cardiac arrest
- Involves using the ABCDE approach to rapidly assess an acutely ill or deteriorating pt
When is the secondary survey performed and what does it involve?
- Performed after the primary survey has been completed and pt has been stabilised (vitals normalise) with required treatments.
- Involves a head-to-toe examination and includes a complete history, physical exam, and vitals
What should be done if a patient begins to deteriorate during the secondary survey?
- The secondary survey is stopped and the primary survey is redone
What does a focused assessment involve?
- Involves assessment of a specific organ system related to the pts:
> presenting diagnosis/complaint or
> current complaint
List some indications for assessment?
- Admission assessment- done upon admission to HCF
- Shift assessment- done upon beginning shift or at any time during the shift if pts status changes or deemed necessary
- Focused assessment- done
In what ways is the ABCDE approach strongly evidence based?
- Developed based on evidence collected by:
> The Australian Resuscitation Council (ARC)
> The International Liaison Committee on Resuscitation (ILCOR)
- Guiding principle for assessment frameworks is the Australian Commission of Safety and Quality in Healthcare
Why was the ABCDE approach developed?
- In response to finding by the ACSQHC that pts are at serious risk of adverse events in Australian HCF and that deterioration could be prevented if changes in vitals were detected and acted upon early
How is the ABCDE approach enshrined in professional nursing documents?
- NMBA RN Stds for Practice
1. Thinks critically and analyses clinical practice
4. Comprehensively conducts assessments
6. Provides safe, appropriate, responsive quality nursing practice
- NSQHS Stds
9. Recognising and responding to clinical deterioration in acute health care
List the 7 Standards of Practice for the Registered Nurse as developed by the NMBA
1. Thinks critically and analyses nursing practice
2. Engages in professional and therapeutic relationships
3. Maintains capability for practice
4. Comprehensively conducts assessments
5. Develops a plan for nursing practice
6. Provides safe, appropriate, and responsive quality nursing practice
7. Evaluates outcomes to inform nursing practice
Describe the rationale for using the ABCDE approach
- To provide a predictable framework for rapid clinical assessment which HCP are able to use to break down clinical presentations into managemental parts and identify life-threatening conditions
When can the ABCDE approach be used?
- In any clinical and non-clinical environment
List the stages of the ABCDE assessment
1. Initial Assessment
5. Disability Consciousness
List what must be done during the initial assessment component of the ABCDE approach
1. Perform hand hygiene
2. Greet pt and introduce yourself by name and designation
3. Reassure pt, tell them what you're going to do and why
List what must be done during the airway assessment component of the ABCDE approach and describe normal findings
> Skin colouration - uniform, pink
> Obstruction in mouth/throat - none present
> Chest movement - equal
> Abnormalities in chest/neck/face
2. Auscultate chest (anterior and posterior)
> Breath sounds - present
> Stridor - no
> Wheeze - no
> Gargling - no
3. Palpate chest
> Breath on your hand/cheek - Yes
> Tracheal deviation - No
If during the airway assessment you identify an airway obstruction what should you do?
- Call for help
If during the initial or airway assessment the patient speaks to you in a normal voice, what should you do and why?
- Skip the airway assessment component of the ABCDE approach
- The airway is patent
List what must be done during the breathing assessment component of the ABCDE approach and describe normal findings
> Respiratory distress (shallow/rapid breaths) - no
> Pt mannerism (tripod, clutching throat, propped up etc)- no
> Use of accessory muscles- no
> Abdominal breathing- no
> Colouration- uniform, pink
> Gasping, pursed lips, nasal flaring- no
> Sweating- no
> Thoracic wounds/scars/abnormalities- no
2. Auscultate chest
> Symmetry of breath sounds- equal airway entry
> Adventitious sounds- none
> Symmetry of chest expansion (butterfly) - Yes
> Chest wall for abnormalities - None
> Respiratory rate: 12-20 (or 12-24 if older adult)
> SpO2: greater than 97%
If the patient has increased respirations or low SpO2, what should you do?
- Apply O2 mask
- 5-6 L/min when using nasal prongs (any higher irritates patients nasal cavity)
- 6+ (usually 15 L/min) when using mask
List what must be done during the circulation assessment component of the ABCDE approach and describe normal findings
> Pallor- no
> Visible blood loss- no
> Cyanosis- no
> Sweating- no
> Colouration of hands and fingers- normal
> Audible HR corresponds to pulse rate? - Yes
> Abnormal heart sounds- no
> Peripheral perfusion - hands and toes should be warm
> Peripheral CRT- less than 2 seconds
> Peripheral oedema- No
> Radial pulse rate, character, rhythm, symmetrical- 60-100 bpm, 2+ (normal), regular, bilateral
> Central CRT
> Heart rate
> Blood pressure
> Urine output
> CRT (central and peripheral) - less than 2 seconds
List what must be done during the exposure assessment component of the ABCDE approach and describe normal findings
1. Expose full body, respecting dignity and heat loss
2. Inspect for signs of haemorrhage, bruising, infection, injury, etc
When conducting a secondary survey list the body regions you would inspect and what you would look for
1. Head- integrity of skull, scalp, any evidence of injuries (contusions, haemotomas)
2. Face- integrity of facial bones, bruising, discharge from nose/ears/mouth, swelling, injury
3. Neck- JVP
4. Chest- size/shape of chest, integrity of ribs, bruising, discomfort
5. Abdomen, bruising, tenderness, distension, pulsatile masses
6. Pelvis - integrity of pelvis, evidence of incontinence
7. Upper/lower limbs- integrity of bones, bruising, function, strength,
8. Back- integrity of spine, bruising