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11 Cards in this Set
- Front
- Back
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Introduction |
-introduced self to patient and gain consent for nursing intervention -confirm pt identity (ask, wristband and system) + allergies - maintain privacy pull curtains and use an appropriate tone and volume of voice - infection control measure : wash hands and wear appropriate PPE |
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Initial assessment |
- check the environment and that it's safe to approach my patient -check how does the patient looks well or unwell - check the emotional status of the patient agitated, uncomfortable, confused, distressed
Mention all the normal parameters |
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Airway |
- Patency (full sentence, verbal consent) talking to me - if not patent look, listen and feel approach - look and check chest movement is symmetrical, see if they are on O2, check for Tracheal deviation (can indicate a lung collapsed or pneumothorax) and for Tracheostomy or laryngectomy - listen for upper airway sounds (stridor) and for Obstructions (full or partial), listen close to face if air is going in and out - put hand on patient to feel if the chest is raising and falling |
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Breathing |
- put sats prob on patient finger check that is working and pt is warm/ 94-98% / anyone below 94% might needs a non-rebreather mask at 15 l O2 (BTS, 2017) / above 96% (News2) / 88-92% COPD - RR /depth (deep, normal, shallow) / regularity of the pattern (regular, irregular) /check by putting a hand on the chest and count them for a full minute. (News2 12-20) - listen resp noise lower airway (wheezing) - use accessory muscles (abdo, shoulder) - simmetry in breathing - check productive cough (send MC&S) - observe for wounds and drains on the chest area |
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Circulation |
- capillary refill time press on pt finger for 5 secs (less than 2 secs) - HR (rhythm, volume, regularity) - radial pulse for a 1 min. Check if volume: thready, regular, bounding / rhythm: regular, irregular) (NEWS 51-90) - BP (right cuff, right position, 2 fingers over Antecubical Fossa ACF, cover 80% of upper arm) - check blood pressure with dinamap (111-219) - MAP (to check perfusion - pressure of the blood to organs) needs to be above 65 - check IV access + VIPs (Visual Infusion Phlebitis) - Fluid status (IV input =if pt needs fluids I will follow NICE guidelines 2020 and give cristalloids (normal saline) 250 to 500 ml - output = 0.5 mls/kg/hr) - assess skin turgor or presence of odeama (dehydration or fluid overload) - consider if my patient needs IV fluids, additional tests or meds prescription |
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Disability |
- check level of consciousness by using ACVPU (where we are, date) - Assess pupil size and reaction to light (neuro assessment, should be same size, shape and react equally to light) - capillary blood glucose as it can affect the neurological conditions (between 4 and 7 mmols) using glucose monitor - pain assessment (0 - 3 WHO scale) , depending on pain we can arrange a prescription for analgesia |
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Exposure |
- check temperature with thermometer (36.1-38) - get permission of uncover for skin head to toe assessment (rashes, bruises wounds, bodily fluids loss, pressure sores etc.) - check if they wear TED stocking (ask for prescription, correct size and fit) -nutritional assessment with MUST tool (eating & drinking, PEG, NBM, etc.) - Bowel movement, frequency and quantitity |
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S = situation |
- name, role, ward - calling about patient that she's been admitted this morning. I took her obs and I'm concerned cause she's scoring 7 on the NEWS chart. Pt is hypotensive, tachycardic, pyrexic and has eleveted RR |
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B = background |
- Patient was admitted following 3 days of diarrhoea and vomiting. She presented feeling quite unwell - no past medical history, no allergies, not on medications that we are aware of -I'm not quite sure what the problem is, but I think she might have sepsis |
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A = assessment |
- clear airway with RR of 22 - SpO2 of 97% on room air - circulation wise, HR 120, BP 97/60, capillary refill time is 3 secs. She looks quite pale and unwell. - urine output if known - disability wise she's alert, her blood glucose is okay, pupils equal and reacting to light. Not complaining of pain. - nothing to note on Exposure, temp of 37 C |
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R = recommendations |
- with a NEWS score of 6 I'm concerned about her, we need an urgent response - can I have an urgent assessment? In the meantime we are continuously monitor her vital signs, prepare a catether trolley, preper IV fluids, attach the pt to cardiac monitor, etc - please can you come to see her now? |
