Guide - Rapid Assessment PDF

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RAPID ASSESSMENT FRAMEWORK: GUIDE A quick primary assessment to rule out immediately life-threatening issues Red parameters covered as significant indicators in Early Warning Score (NzEWS)

How to assess: Airway = Is the patient conscious/alert (A on AVPU)? Is the patient able to speak – airway is patent. Listen to them breathing if no sounds heard from movement of air & there is no rise & fall of chest then complete airway obstruction, this is a clinical emergency. Observe colour of face/lips & responsiveness of patient. Any wheeze, stridor & gurgling could suggest partial airway blockage-investigate immediately. Breathing= Look for movement of the chest and use of accessory muscles? Record the respiratory rate & SpO2, is oxygen in progress? Does the patient appear relaxed in their breathing eg. shoulders down & can they talk in sentences or only in single word sentences? What is patient saying eg. Short of breath/breathlessness? Any audible wheeze or rattling sounds associated with breathing? Circulation = Look at colour pink/flushed/pale/grey? Look for bleeding/wounds or drains. Feel temperature does the patient’s peripheries feel warm? If cool check capillary refill time? Is the patient diaphoretic? Take a tympanic temperature. Palpate a radial pulse & consider rate, rhythm & volume. Record a blood pressure. Consider & ask patient about urine output. Has the patient got intravenous access (IV line)? Disability = Look & consider patient’s level of consciousness are they Alert? Responding to voice (due to being more sedated/sleepy) or only responsive to pain &/OR are they unconscious (AVPU). Listen to the patient are they coherent or disorientated/confused in their mentation? Is the patient complaining of pain – follow up with COLDSPA. Record blood sugar levels (BSL’s) significant if a diabetic &/or deteriorate quickly. Environment = Everything else that should be considered for other potential problems. From the above A to D analysis consider if the patient is in the right place with the right equipment and the right medical/nursing staff attending. Actual Problems/risks: Include here any immediately life-threatening issues, critical assessment findings/first level problems Potential Problems/risks: Decreased respiratory function OR Increased respiratory rate, decreased SpO2. Cardiovascular compromise due to cardiac event, acute chest pain OR increased heart rate, decreased B/P, risk of haemorrhaging, Deteriorating Neurological function OR rousable to voice/pain only, delerium...