week 3 Flashcards
Clinical approach and systematic patient assessment
SAMPLE
Signs + symptoms Allergies Medications Past medical history Last meal or GP visit Events leading up to incident
Pulse
60 –100 sines rhythm
Above 100 - Tachycardia
Below 60 - Bradycardia
Rate (per minute)
Regularity
Strength
Blood pressure
80 - 120 mmHg
Systolic pressure (1st)/ diastolic pressure (2nd)
Hypertension - high blood pressure over 120
Hypotension - low blood pressure under 80
Respiratory rate
12-20 breaths per minute
Tachypnea - above 20
Brandypnea - below 12
Oxygen oximetry (Sp02)
Measure the oxygen saturation of arterial blood
94-100% oxygen saturation
Skin assessment
Skin Temperature
Colour
Hydration/ dehyration
Moisture
Glasgow Coma Scale
Severe: GCS 3-8
Moderate: GCS 9-12
Mild: GCS 13-15
Eye opening: (scored out of 4)
Verbal: response (scored out of 5)
Motor response: (scored out of 6)
Blood sugar levels
Hypoglycaemia < 4.0 mmol/L
Normal 4.0-8.0 mmol/L
Hyperglycaemia > 8.0 mmol/L
Temperature
Normal: 37.5 C
Hypothermia: <35.0 °C
Hyperthermia: >37.5 or 38.3 °C
Electrocardiograph (ECG)
ECG is a trace of the hearts electrical activity. The heart rate, rhythm and other important information can be interpreted from the ECG.
Pupils
Assessment of the pupils is undertaken to identify changes in intracranial pressure
Pupil size prior to light
Pupil size immediately post light
Responsiveness of pupils
Normal pupil function can be notes as PEARL -> Pupils Equal And Reactive To Light