Airway
What is the aim of the AIRWAY ASSESSMENT?
To assess patency!
What is the acronym we use to assess breathing?
RATES
Listen 5 aspects we assess in the "LOOK" aspect of the circulation assessment
1. cyanosis/ skin pallor
2. diaphoresis
3. oedema
4. Does the patient have IV access?
5. bleeding
6. jugular vein distention
What does the "PQRST" acronym stand for and why do we use it?
P- Provocation or Palliation. What provokes or relieves the pain
Q- Quality. What does the pain feel like?
R- Region/Radiation
S- Severity. What is the pain score out of 10.
T- Times. When did the pain start? duration
True or false, "LUB DUB" is an abnormal heart sound
FALSE
List 5 causes of an airway obstruction
1.Foreign Body
2. vomit
3. laryngospasm
4. depressed CNS
5. Mass
6. Infection or swelling
7. Blocked tracheostomy
8. direct trauma
State what each letter or RATES stands for
R- Respiratory rate
A- Auscultate
T- Trachea position
E- Effort of breathing
S- Saturation rate
Listen 3 aspects we assess in the "LISTEN" aspect of the circulation assessment
1. Manual BP
2. Auscultate the heart for "normal heart sounds"
3. Pain assessment
list 5 assessments completed in the "DISABILITY" stage
1. AVPU
2. PEARL
3. GCS
4. BGL
5. Temp
6. Documentation
The airway is the most important component to be established and maintained to prevent hypoxia and death?
TRUE
List 3 noises that wound suggest a compromised airway
1. Snoring
2. audible wheeze
3. Stridor
4. Quincy
List 3 signs we assess when we "LOOK" during this stage
1. Rhythm and depth of breathing
2. Trachea position
3. Trauma/ physical deformity
4. Respiratory effort/ WOB
5. Skin pallor/ cyanosis
List 5 causes of circulation abnormalities
1. fluid or blood loss
2. Acute coronary syndrome
3. RDH
4. IHD
5. Emboli
6. Pneumothorax
7. tamponade
8. septic shock
9. anaphylaxis
10. drugs and toxins
11. hypoxia
12. electrolyte imbalances
List 3 causes of compromise in the "DISABILITY" stage
1. Hypoxia
2. Hypo/hyperthermia
3. Head trauma
4. Hypo/hyperglycaemia
5. Intercranial haemorrhage/stroke
6. Drugs or toxins
We do not reassess after intervention at a compromised stage of the A-E assessment as it a waste time and compromises patient safety
FALSE
It is critical to reassess the effect on the intervention to ensure effective escalation and treatment
State 2 methods of assessing an airway
1. head lift and chin tilt
2. jaw thrust
3. Ask patient to open their mouth
List 3 signs we assess when we "FEEL" during this stage
1. Rise and fall (MINIMUM 2 breaths in seconds)
2. Trachea position
3. surgical emphysema
4. Bilateral vs absent expansion
5. deformity/trauma
Listen 3 aspects we assess in the "FEEL" aspect of the circulation assessment
2. Radial, brachial or carotid pulse
3. Skin temperature
What do you assess in the "EXPOSURE" stage?
Head to toe assessment, looking for bruising, rashes, wounds, bleeding, invasive devices for infection or abnormal output, cellulitis, wounds, tenderness/deformity/oedema
The patient has been admitted for chest pain for investigation. He is now febrile, tachycardic, complaining of central chest pain and has a productive cough.
What bloods need to be collected and what two investigations can be completed for this patient?
Bloods:
1. VBG
2. Blood cultures
3. LFTs
4. FBC
5. CRP
6. U&Es
Investigations:
1. CXR
2. resp swabs
3. CTPA
List 5 nursing interventions for a compromised airway
1. suction
2. head lift, chin tilt
3. jaw thrust
4. Simple airway adjuncts (NPA, OPA)
5. Advanced airway adjuncts (LMA, ETT)
List 3 signs we assess when we "LISTEN" during the breathing assessment
1. audible noisy breathing eg. Wheeze, stridor
2. Auscultate chest for breath sounds eg, crepes, wheeze, crackles, clear
3. Auscultate for air entry
3. Listen for 2 breaths in seconds
List 5 nursing interventions for circulation compromise
1. Gain IV access
2. IVT
3. Bloods
4.CCM and ECG
5. IDC? or bladder scan
6. Postural or bilateral BPs
7. Blood or blood product administration
The patient BGL is 2.8, what are the relevant nursing interventions?
1. If patent is unresponsive or P in AVPU call a MET
2. If patient is alert give 60ml oral glucose
3. inform doctor immediately
4. Give long acting carbohydrate as per hypoglycaemia pathway
5. recheck BGL in 15 mins AND reassess
What type and volume of bolus fluids are administered to an ADULT patient who has a compromised circulation?
500ml N/S, followed by a review, then another 500ml bolus if ineffective