ASSESSMENT OF THE CRITICALLY Ill PATIENT

I Id de en nt ti if fy y t th he e c co or rr re ec ct t s se eq qu ue en nc ce e o of f p pr ri io or ri it ti ie es s i in n a as ss se es ss si in ng g t th he e c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt t. .
S St ta at te e w wh hy y i it t i is s i im mp po or rt ta an nt t t to o h ha av ve e a a s sy ys st te em ma at ti ic c a ap pp pr ro oa ac ch h t to o a as ss se es ss sm me en nt t a an nd d c ca ar re e, , w wi it th h r ra at ti io on na al l f fo or r e ea ac ch h
s st te ep p. .
I Id de en nt ti if fy y c cl li in ni ic ca al l s si it tu ua at ti io on ns s i in n w wh hi ic ch h a a p pa at ti ie en nt t s s c co on nd di it ti io on n m ma ay y b be ec co om me e c co om mp pr ro om mi is se ed d. .
D De em mo on ns st tr ra at te e s sa af fe e a an nd d e ef ff fe ec ct ti iv ve e a as ss se es ss sm me en nt t a an nd d c ca ar re e o of f t th he e c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt t u us si in ng g a a s sy ys st te em ma at ti ic c
a ap pp pr ro oa ac ch h. .
I In nt tr ro od du uc ct ti io on n
F Fa ac ct ts s
P Pa at ti ie en nt ts s a ad dm mi it tt te ed d f fr ro om m t th he e w wa ar rd ds s t to o I IC CU U w wh he en n c co om mp pa ar re ed d t to o t th ho os se e a ad dm mi it tt te ed d f fr ro om m A A& &E E h ha av ve e a a h hi ig gh he er r
p pe er rc ce en nt ta ag ge e m mo or rt ta al li it ty y ( (G Go ol ld dh hi il ll l, , 2 20 00 01 1) ). .
N Ne ea ar rl ly y 8 80 0% % o of f h ho os sp pi it ta al l i in np pa at ti ie en nt ts s w wh ho o e ex xp pe er ri ie en nc ce e a a c ca ar rd di io or re es sp pi ir ra at to or ry y a ar rr re es st t h ha av ve e d do oc cu um me en nt te ed d
o ob bs se er rv va at ti io on ns s o of f d de et te er ri io or ra at ti io on n i in n t th he e 8 8h ho ou ur rs s b be ef fo or re e t th he e a ar rr re es st t ( (B Br ri is st to ow w e et t a al l 2 20 00 00 0) )
T Th he e 3 3 k ke ey y s st ta ag ge es s o of f r re ec co og gn ni it ti io on n a an nd d t tr re ea at tm me en nt t o of f a a c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt t: :
U Un nd de er rs st ta an nd di in ng g t th ha at t a an n e em me er rg ge en nc cy y e ex xi is st ts s
I Id de en nt ti if fy yi in ng g a an nd d p pr ri io or ri it ti is si in ng g p pr ro ob bl le em ms s. .
A Ac ct ti io on n a an nd d e ev va al lu ua at ti io on n
A As ss se es ss sm me en nt t
A As ss se es ss sm me en nt t i is s t th he e f fi ir rs st t s st te ep p i in n c ca ar ri in ng g f fo or r a a p pa at ti ie en nt t, , a an nd d a as ss se es ss si in ng g t th he e c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt t i is s a an n e es ss se en nt ti ia al l
p pa ar rt t o of f t th he ei ir r c ca ar re e. .
C Ca ar re ef fu ul l a as ss se es ss sm me en nt t i is s f fu un nd da am me en nt ta al l i in n o or rd de er r t to o r re ec co og gn ni is se e w wh he en n a a p pa at ti ie en nt t i is s b be ec co om mi in ng g c co om mp pr ro om mi is se ed d. .
T Th he e n nu ur rs se e a ac ct ts s a as s p pa at ti ie en nt t a ad dv vo oc ca at te e, , m mo on ni it to or ri in ng g, , a an nt ti ic ci ip pa at ti in ng g p po ot te en nt ti ia al l p pr ro ob bl le em ms s, , p pl la an nn ni in ng g, , i im mp pl le em me en nt ti in ng g
a an nd d c co on ns st ta an nt tl ly y e ev va al lu ua at ti in ng g c ca ar re e, , a an nd d c co om mm mu un ni ic ca at ti in ng g w wi it th h o ot th he er r M MD DT T s st ta af ff f i in nv vo ol lv ve ed d i in n t th he e p pa at ti ie en nt t c ca ar re e. .


P Pa at ti ie en nt t A As ss se es ss sm me en nt t S Sy ys st te em ms s
B Ba as si ic c L Li if fe e s su up pp po or rt t ( (B BL LS S) )
A Ad dv va an nc ce ed d L Li if fe e S Su up pp po or rt t ( (A AL LS S) )
A Ac cu ut te e L Li if fe e- -t th hr re ea at te en ni in ng g E Ev ve en nt ts s, , R Re ec co og gn ni it ti io on n a an nd d T Tr re ea at tm me en nt t ( (A AL LE ER RT T) )
T Th he e A Ad dv va an nc ce ed d T Tr ra au um ma a L Li if fe e S Su up pp po or rt t ( (A AT TL LS S) )

A Al ll l o of f t th he es se e a as ss se es ss sm me en nt t s sy ys st te em ms s u us se e a a s sy ys st te em ma at ti ic c a ap pp pr ro oa ac ch h i in n a a s st tr ri ic ct t o or rd de er r: :
A A: : a ai ir rw wa ay y ( (w wi it th h C C- -s sp pi in ne e p pr ro ot te ec ct ti io on n i in n t tr ra au um ma a) )
B B: : b br re ea at th hi in ng g
C C: : c ci ir rc cu ul la at ti io on n
D D: : d de ef fi ic ci it ts s i in n n ne eu ur ro ol lo og gi ic ca al l s st ta at tu us s
E E: : e en nv vi ir ro on nm me en nt t ( (e ex xp po os su ur re e) )



C Cu ur rr re en nt t p pr ra ac ct ti ic ce e i in n c cr ri it ti ic ca al l c ca ar re e s se er rv vi ic ce es s
D De ev ve el lo op pm me en nt t o of f o ou ut tr re ea ac ch h s se er rv vi ic ce es s f fr ro om m c cr ri it ti ic ca al l c ca ar re e s sp pe ec ci ia al li is st ts s t to o s su up pp po or rt t w wa ar rd d s st ta af ff f i in n m ma an na ag gi in ng g p pa at ti ie en nt ts s
a at t r ri is sk k. .
I Im mp pr ro ov ve ed d p pa at ti ie en nt t m mo on ni it to or ri in ng g t th hr ro ou ug gh h t th he e u us se e o of f e ea ar rl ly y w wa ar rn ni in ng g s sc co or re es s ( (E EW WS S) ) o or r m mo od di if fi ie ed d e ea ar rl ly y w wa ar rn ni in ng g
s sc co or re es s ( (M ME EW WS S) )


D De ef fi in ni it ti io on n
C CR RI IT TI IC CA AL LL LY Y I IL LL L

D De ef fi in ne ed d a as s t th ho os se e p pa at ti ie en nt ts s w wh ho o a ar re e h hi ig gh h r ri is sk k f fo or r a ac ct tu ua al l o or r l li if fe e t th hr re ea at te en ni in ng g h he ea al lt th h p pr ro ob bl le em ms s. .




A. General information

1. Critical care nursing deals with human responses to life-threatening problems and includes
the critically ill patient, the critical care nurse, and the critical care environment.
2. It is the field of nursing with a focus on the care of the critically ill or unstable patients.

3. Care is provided to patients of all ages with alterations in physical or emotional health.
4. The critical care nurse coordinates interventions aimed at resolving life-threatening problems.


5. Critical care nurses can be found working in a wide variety of environments and specialties, such as
emergency departments and the intensive care units.
B. Critically Ill Patient

1. Critically ill patients are defined as those patients who are at high risk for actual or potential life-
threatening health problems.


2. The critically ill patient is at high risk for developing life-threatening problems and requires constant,
intensive, multidisciplinary assessment and intervention to restore stability, prevent complications, and
achieve and maintain optimal responses



3. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and
complex, thereby requiring intense and vigilant nursing care.



3. A management and administrative structure is required to ensure effective care through all phases of
the patients hospital stay, from emergency department to discharge


4. Legal, regulatory, social, economic, and political trends must be monitored to promote the early
recognition of problems and a timely response



5. Specialized electronic technology and techniques are used to monitor patient status continuously; these
may create safety hazards for patients, such as possible exposure to electric shock
D. Roles of the critical care nurse
1. Care provider: provides comprehensiveand at times highly technicaldirect care to the patient and
family in response to life-threatening health problems



2. Educator: provides patient and family with education based on their learning needs and the severity of
the situation and allows the patient to assume more responsibility for meeting health care needs as health
condition stabilizes or improves


3. Manager: coordinates the care provided by various health care workers to achieve the specific goal of
providing optimal nursing care to critically ill patients
4. Advocate: protects the patients rights
E. Functions of the critical care nurse

1. Assesses and implements treatment for patient responses to life-threatening health problems
2. Provides direct measures to resuscitate, if necessary
3. Uses independent, dependent, and interdependent interventions to restore stability, prevent
complications, and achieve and maintain optimal patient responses



4. Provides health education to the patient and family
5. Supervises patient care and ancillary personnel



6. Supports patient adaptation, restores health, and preserves the patients rights, including the right to
refuse treatment

F. Legal issues affecting the provision of critical care nursing

1. Negligence
2. MALPRACTICE
3. INFORMED CONSENT
4. Implied consent
5. Advanced directives, including DURABLE POWER OF ATTORNEY and living wills

A Ad dm mi is ss si io on n P Pr ro ot to oc co ol l

P Pa at ti ie en nt ts s w wi it th h r re es sp pi ir ra at to or ry y f fa ai il lu ur re e s su uc ch h a as s p pn ne eu um mo ot th ho or ra ax x a an nd d h he em mo ot th ho or ra ax x. .
S Sh ho oc ck k
C Ch he es st t t tr ra au um ma a, , P Po os st t s su uc cc ce es ss sf fu ul l C CP PR R
P Po os st t m ma aj jo or r s su ur rg ge er ry y
A Ac cu ut te e r re en na al l f fa ai il lu ur re e
S Sp pe ec ci ia al l c co on ns si id de er ra at ti io on ns s i in n a as ss se es ss si in ng g a a c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt t
A As ss se es ss s p pa at ti ie en nt ts s f fl lu ui id d a an nd d e el le ec ct tr ro ol ly yt te es s
A As ss se es ss s h he em mo od dy yn na am mi ic c s st ta ab bi il li it ty y ( (V V/ /S S) )
A As ss se es ss s p pa at ti ie en nt t c cl li in ni ic ca al ll ly y a an nd d l la ab bo or ra at to or ry y
A As ss se es ss s t th he e p pa at ti ie en nt ts s n nu ut tr ri it ti io on na al l s st ta at tu us s
A As ss se es ss s t th he e n ne eu ur ro ol lo og gi ic ca al l f fu un nc ct ti io on n
A As ss se es ss s p pa at ti ie en nt ts s c ca ap pa ab bi il li it ty y t to o d do o a ac ct ti iv vi it ti ie es s
A As ss se es ss s p pa at ti ie en nt ts s p pa ai in n s sc ca al le e

I Im mp po or rt ta an nt t f fa ac ct to or rs s t to o c co on ns si id de er r i in n a as ss se es ss si in ng g a a c cr ri it ti ic ca al ll ly y i il ll l
E Ed du uc ca at te e y yo ou ur rs se el lf f o on n t th he e p pa at ti ie en nt ts s i il ll ln ne es ss s. .
O Ob bs se er rv ve e f fo or r c co on nd di it ti io on n c ch ha an ng ge es s i in n c cr ri it ti ic ca al ll ly y i il ll l p pa at ti ie en nt ts s
L Li is st te en n a an nd d o of ff fe er r e em mo ot ti io on na al l s su up pp po or rt t f fo or r t th he e p pa at ti ie en nt t d de ea al li in ng g w wi it th h c ch hr ro on ni ic c i is ss su ue es s. .
C Co om mp po on ne en nt ts s o of f a a n ne eu ur ro ol lo og gi ic ca al l a as ss se es ss sm me en nt t
I In nt te er rv vi ie ew w
L LO OC C
P Pu up pi il ll la ar ry y a as ss se es ss sm me en nt t
C Cr ra an ni ia al l N Ne er rv ve e t te es st ti in ng g
V V/ /S S
M Mo ot to or r f fu un nc ct ti io on n, ,
C Ce er re eb br ra al l f fu un nc ct ti io on n
S Se en ns so or ry y f fu un nc ct ti io on n
D De ef fi ic ci it ts s i in n n ne eu ur ro ol lo og gi ic ca al l s st ta at tu us s & & e en nv vi ir ro on nm me en nt t ( (e ex xp po os su ur re e) )
H Ho ow w w wi il ll l y yo ou u a as ss se es ss s n ne eu ur ro ol lo og gi ic ca al l s st ta at tu us s a an nd d e en nv vi ir ro on nm me en nt t? ?




L Le ev ve el l o of f C Co on ns sc ci io ou us sn ne es ss s
1 1. .A Al le er rt t a aw wa ak ke e, , l lo oo ok ks s a ab bo ou ut t
- - r re es sp po on nd ds s i in n a a m me ea an ni in ng gf fu ul l m ma an nn ne er r t to o v ve er rb ba al l i in ns st tr ru uc ct ti io on ns s a an nd d g ge es st tu ur re es s. .
R Re ea ad di il ly y a ar ro ou us se ed d, , o or ri ie en nt te ed d, , f fu ul ll ly y a aw wa ar re e o of f e ex xt te er rn na al l a an nd d i in nt te er rn na al l s st ti im mu ul li i
R Re es sp po on nd ds s a ap pp pr ro op pr ri ia at te el ly y, , c co on nd du uc ct ts s m me ea an ni in ng gf fu ul l i in nt te er rp pe er rs so on na al l i in nt te er ra ac ct ti io on n ( (3 3 C C s s- -c co on ns sc ci io ou us s, , c co oh he er re en nt t, , c co og gn ni it ti iv ve e) )

2 2. .D Dr ro ow ws sy y ( (l le et th ha ar rg gi ic c, , s so om mn no ol le en nt t) ) o or ri ie en nt te ed d w wh he en n a aw wa ak ke e b bu ut t i if f l le ef ft t a al lo on ne e w wi il ll l s sl le ee ep p. .
N No ot t f fu ul ll ly y a al le er rt t, , d dr ri if ft ts s o of ff f t to o s sl le ee ep p w wh he en n n no ot t s st ti im mu ul la at te ed d
C Ca an n b be e a ar ro ou us se ed d t to o n na am me e w wh he en n c ca al ll le ed d i in n n no or rm ma al l v vo oi ic ce e b bu ut t l lo oo ok ks s d dr ro ow ws sy y
R Re es sp po on nd ds s a ap pp pr ro op pr ri ia at te el ly y t to o q qu ue es st ti io on ns s o or r c co om mm ma an nd ds s b bu ut t t th hi in nk ki in ng g s se ee em ms s s sl lo ow w, , i in na at tt te en nt ti iv ve e, , l lo os se es s t tr ra ai in n o of f
t th ho ou ug gh ht t, , s sp po on nt ta an ne eo ou us s m mo ov ve em me en nt ts s a ar re e d de ec cr re ea as se ed d


3 3. .C Co on nf fu us se ed d ( (o ob bt tu un nd de ed d) ) T Th hi is s i is s t tr ra an ns si it ti io on na al l s st ta at te e b be et tw we ee en n l le et th ha ar rg gy y a an nd d s st tu up po or r
S Sl le ee ep ps s m mo os st t o of f t th he e t ti im me e, , d di if ff fi ic cu ul lt t t to o a ar ro ou us se ed d- -n ne ee ed ds s l lo ou ud d s sh ho ou ut t o or r v vi ig go or ro ou us s s sh ha ak ke e, , a ac ct ts s c co on nf fu us se ed d w wh he en n i is s
i in nc co oh he er re en nt t, , r re eq qu ui ir re es s c co on ns st ta an nt t s st ti im mu ul la at ti io on n f fo or r e ev ve en n m ma ar rg gi in na al l c co oo op pe er ra at ti io on n d di is so or ri ie en nt te ed d t to o t ti im me e, , p pl la ac ce e o or r
p pe er rs so on n - - m me em mo or ry y d di if ff fi ic cu ul lt ty y i is s c co om mm mo on n
h ha as s d di if ff fi ic cu ul lt ty y w wi it th h c co om mm ma an nd ds s
E Ex xh hi ib bi it ts s a al lt te er ra at ti io on n i in n p pe er rc ce ep pt ti io on n o of f s st ti im mu ul li i, , m ma ay y b be e a ag gi it ta at te ed d

4 4. .S St tu up po or ro ou us s ( (s se em mi i- -c co om ma a) ) g ge en ne er ra al ll ly y u un nr re es sp po on ns si iv ve e e ex xc ce ep pt t t to o v vi ig go or ro ou us s s st ti im mu ul la at ti io on n. .
- - o op pe en ns s e ey ye es s t to o d de ee ep p p pa ai in n
S Sp po on nt ta an ne eo ou us sl ly y u un nc co on ns sc ci io ou us s, , r re es sp po on nd ds s o on nl ly y t to o p pe er rs si is st te en nt t a an nd d v vi ig go or ro ou us s s sh ha ak ke e o or r p pa ai in n, , h ha as s a ap pp pr ro op pr ri ia at te e m mo ot to or r
r re es sp po on ns se e

5 5. . C Co om ma at to os se e u un na ar ro ou us sa ab bl le e a an nd d u un nr re es sp po on ns si iv ve e
- - d do oe es s n no ot t o op pe en n e ey ye es s t to o d de ee ep p p pa ai in n
C Co om mp pl le et te el ly y u un nc co on ns sc ci io ou us s , ,n no o r re es sp po on ns se e t to o p pa ai in n o or r t to o a an ny y e ex xt te er rn na al l o or r i in nt te er rn na al l s st ti im mu ul li i
L Li ig gh ht t c co om ma a h ha as s s so om me e r re ef fl le ex x a ac ct ti iv vi it ty y b bu ut t n no o p pu ur rp po os se ef fu ul l m mo ov ve em me en nt t
D De ee ep p c co om ma a h ha as s n no o m mo ot to or r r re es sp po on ns se e


A Ac cu ut te e c co on nf fu us si io on na al l s st ta at te e ( (d de el li ir ri iu um m) )- - i is s c cl lo ou ud di in ng g o of f c co on ns sc ci io ou us sn ne es ss s; ; i in na at tt te en nt ti iv ve e; ; i in nc co oh he er re en nt t c co on nv ve er rs sa at ti io on n; ;
i im mp pa ai ir re ed d r re ec ce en nt t m me em mo or ry y; ; o of ft te en n a ag gi it ta at te ed d a an nd d h ha av vi in ng g v vi is su ua al l h ha al ll lu uc ci in na at ti io on ns s; ; d di is so or ri ie en nt te ed d , , w wi it th h c co on nf fu us si io on n
w wo or rs se e a at t n ni ig gh ht t w wh he en n e en nv vi ir ro on nm me en nt ta al l s st ti im mu ul li i a ar re e d de ec cr re ea as se ed d
T Th he e d di if ff fe er re en nc ce e b be et tw we ee en n c co om ma a a an nd d s sl le ee ep p
S Sl le ee ep pi in ng g p pe er rs so on ns s r re es sp po on nd d t to o u un na ac cc cu us st to om me ed d s st ti im mu ul li i
S Sl le ee ep pi in ng g p pe er rs so on ns s a ar re e c ca ap pa ab bl le e o of f m me en nt ta al l a ac ct ti iv vi it ty y( (d dr re ea am ms s) )
S Sl le ee ep pi in ng g p pe er rs so on ns s c ca an n b be e r ro ou us se ed d t to o n no or rm ma al l c co on ns sc ci io ou us sn ne es ss s
C Ce er re eb br ra al l o ox xy yg ge en n u up pt ta ak ke e d do oe es s n no ot t d de ec cr re ea as se e d du ur ri in ng g s sl le ee ep p a as s i it t o of ft te en n d do oe es s i in n c co om ma a
S Sp pe ec ci ia al l S St ta at te es s o of f a al lt te er re ed d l le ev ve el l o of f c co on ns sc ci io ou us sn ne es ss s
1 1. .B Br ra ai in n D De ea at th h a an n i ir rr re ev ve er rs si ib bl le e l lo os ss s o of f c co or rt ti ic ca al l a an nd d b br ra ai in n s st te em m a ac ct ti iv vi it ty y. .
2 2. .P Pe er rs si is st te en nt t v ve eg ge et ta at ti iv ve e s st ta at te e a a c co on nd di it ti io on n t th ha at t f fo ol ll lo ow ws s s se ev ve er re e c ce er re eb br ra al l i in nj ju ur ry y i in n w wh hi ic ch h t th he e a al lt te er re ed d s st ta at te e b be ec co om me es s
c ch hr ro on ni ic c o or r p pe er rs si is st te en nt t. .
S Sp pe ec ci ia al l S St ta at te es s o of f a al lt te er re ed d l le ev ve el l o of f c co on ns sc ci io ou us sn ne es ss s
3 3. .L Lo oc ck ke ed d i in n S Sy yn nd dr ro om me e a a s st ta at te e o of f m mu us sc cl le e p pa ar ra al ly ys si is s, , i in nv vo ol lv vi in ng g v vo ol lu un nt ta ar ry y m mu us sc cl le es s, , w wh hi il le e t th he er re e i is s
p pr re es se er rv va at ti io on n o of f f fu ul ll l c co on ns sc ci io ou us sn ne es ss s a an nd d c co og gn ni it ti io on n. .

G GL LA AS SG GO OW W C CO OM MA A S SC CA AL LE E

D DE EV VE EL LO OP PE ED D T TO O A AS SS SE ES SS S T TH HE E S ST TA AT TE E O OF F A A P PE ER RS SO ON N S S C CO ON NS SC CI IO OU US SN NE ES SS S A AF FT TE ER R A A H HE EA AD D I IN NJ JU UR RY Y. .
I IN ND DI IC CA AT TE ES S L LO OC C R RA AN NG GI IN NG G F FR RO OM M D DE EE EP P U UN NC CO ON NS SC CI IO OU US SN NE ES SS S T TO O C CO OM MP PL LE ET TE E C CO ON NS SC CI IO OU US SN NE ES SS S

T Th he e G GC CS S s sc co or re e r re ef fl le ec ct ts s t th he e b br ra ai in n s s f fu un nc ct ti io on na al l l le ev ve el l
A A f fu ul ll ly y a al le er rt t , , n no or rm ma al l p pe er rs so on n h ha as s a a s sc co or re e o of f 1 15 5, , w wh he er re ea as s a a s sc co or re e o of f 7 7 o or r l le es ss s r re ef fl le ec ct ts s c co om ma a

G GL LA AS SG GO OW W C CO OM MA A S SC CA AL LE E

I It t i is s b ba as se ed d o on n t th he e c cl li ie en nt t s s r re es sp po on ns se e i in n t th hr re ee e a ar re ea as s : :
E Ey ye e O Op pe en ni in ng g
M Mo ot to or r R Re es sp po on ns se e
V Ve er rb ba al l R Re es sp po on ns se e



G GL LA AS SG GO OW W C CO OM MA A S SC CA AL LE E
H Ho ow w t to o p pe er rf fo or rm m t th he e G GC CS S
1 1. .A As ss se es ss s t th he e p pa at ti ie en nt ts s e ey ye e o op pe en ni in ng g
4 4 p pt ts s. . g gi iv ve en n t to o p pa at ti ie en nt ts s w wh ho o o op pe en ns s e ey ye es s s sp po on nt ta an ne eo ou us sl ly y. .
3 3 p pt ts s. . I If f t th he e p pa at ti ie en nt t e ey ye es s o op pe en n u up po on n c co om mm ma an nd d
2 2 p pt ts s. . I If f p pa at ti ie en nt t o on nl ly y o op pe en n e ey ye es s o on n p pa ai in nf fu ul l s st ti im mu ul lu us s
1 1 p pt t. . n no o r re es sp po on ns se e



V Ve er rb ba al l r re es sp po on ns se e
. .
. . M Mo ot to or r R Re es sp po on ns se e

6 6 p pt ts s i is s g gi iv ve en n t to o a a p pa at ti ie en nt t w wh ho o m mo ov ve es s a ar rm ms s a an nd d l le eg gs s s sp po on nt ta an ne eo ou us sl ly y o on n c co om mm ma an nd d. .
5 5 p pt ts s i is s g gi iv ve en n t to o a a p pa at ti ie en nt t d di is sp pl la ay ys s p pu ur rp po os se ef fu ul l m mo ov ve em me en nt t w wi it th h a a p pa ai in nf fu ul l o or r u un np pl le ea as sa an nt t s st ti im mu ul lu us s. .
4 4 p pt ts s i is s g gi iv ve en n t to o a a p pa at ti ie en nt t w wh ho o o on nl ly y w wi it th hd dr ra aw ws s a aw wa ay y f fr ro om m p pa ai in n w wi it th h n no o o ot th he er r r re es sp po on ns se e. .



M Mo ot to or r R Re es sp po on ns se e

3 3 p pt ts s i is s g gi iv ve en n t to o a a p pa at ti ie en nt t d de em mo on ns st tr ra at ti in ng g d de ec co or rt ti ic ca at te e p po os st tu ur ri in ng g. .
2 2 p pt ts s i is s g gi iv ve en n t to o a a p pa at ti ie en nt t i in n a a d de ec ce er re eb br ra at te e p po os st tu ur re e. .
1 1 p pt t p pa at ti ie en nt t d do oe es s n no ot t m mo ov ve e a at t a al ll l



G GC CS S S SC CO OR RI IN NG G

C Ca al lc cu ul la at te e t th he e G GC CS S s sc co or re e b by y s su um mm mi in ng g t th he e p po oi in nt ts s f fo or r t th he e e ey ye e, , v ve er rb ba al l a an nd d m mo ot to or r r re es sp po on ns se e s sc co or re es s. .
T Th he e e ey ye e s sc co or re e r ra an ng ge es s f fr ro om m 1 1 t to o 4 4 p po oi in nt ts s
T Th he e v ve er rb ba al l r re es sp po on ns se e s sc co or re e r ra an ng ge es s f fr ro om m 1 1 t to o 5 5
T Th he e m mo ot to or r r re es sp po on ns se e r ra an ng ge es s f fr ro om m 1 1 t to o 6 6
I In nt te er rp pr re et ta at ti io on n o of f t th he e G GC CS S
A A G GC CS S o of f l le es ss s t th ha an n 9 9 r re ep pr re es se en nt ts s s se ev ve er re e b br ra ai in n i in nj ju ur ry y. .
A A G GC CS S s sc co or re e b be et tw we ee en n 9 9 a an nd d 1 12 2 m mo od de er ra at te e b br ra ai in n i in nj ju ur ry y
A A G GC CS S o of f 1 13 3 o or r 1 14 4 i is s a a m mi in no or r b br ra ai in n i in nj ju ur ry y
Pain Assessment with the
010 Numeric

Pain Intensity Scale
The 0 to 10 pain scale is commonly and successfully used with hospitalized and nursing home patients,
even those with mild to moderate dementia.

0-10 NUMERIC PAIN INTENSITY SCALE

This scale asks the person in pain to assign a number, from zero to ten, to the severity of their
pain.
It is important to properly instruct the person in how to rate their pain.

Use the following statements to ask the person to rate their pain
.
1. I would like you to rate your pain on a scale from zero to ten.
2. Zero means you have no pain at all.
3. Ten means the worst possible pain you can image.
4. What number would you give to your pain?

- A common administration error is to describe 10 as the worst pain
- you ever had. For some people, the worst pain they ever had

may have been something minor like a toothache; and remember, persons with dementia may not be able to remember their worst pain


A variation of this technique is to provide the instructions, then ask the
person to point to the number that represents their pain.
The values on the pain scale correspond to pain levels as follows:
1 3 = mild pain
4 6 = moderate pain
7 10 = severe pain




T Ti ip ps s a an nd d W Wa ar rn ni in ng gs s

A An ny y c ch ha an ng ge es s o on n t th he e G GC CS S s sh ho ou ul ld d b be e e ev va al lu ua at te ed d a an nd d r re ep po or rt te ed d t to o t th he e p ph hy ys si ic ci ia an n. .
A A p pa at ti ie en nt t w wh ho o i is s 1 15 5, ,a an nd d b be ec co om me es s c co on nf fu us se ed d o or r d di is sp pl la ay ys s c ch ha an ng ge e i in n m mo ot to or r r re es sp po on ns se e m mu us st t b be e e ev va al lu ua at te ed d i im mm me ed di ia at te el ly y, ,
a an nd d p ph hy ys si ic ci ia an n n no ot ti if fi ie ed d. . T Th hi is s m ma ay y i in nd di ic ca at te e a a m mo or re e s se er ri io ou us s p pr ro ob bl le em m s su uc ch h a as s s st tr ro ok ke e a an nd d r re eq qu ui ir re es s a a f fo ol ll lo ow w u up p t te es st ts s. .

I In nt tu ub ba at te ed d p pa at ti ie en nt ts s a as s w we el ll l a as s t th ho os se e p pa at ti ie en nt ts s w wi it th h s se ev ve er re e f fa ac ci ia al l/ /e ey ye e s sw we el ll li in ng g o or r d da am ma ag ge e i is s i im mp po os ss si ib bl le e t to o t te es s t th he e v ve er rb ba al l a an nd d e ey ye e r re es sp po on ns se e, ,i in n t th he es se e
c ci ir rc cu um ms st ta an nc ce es s t th he e s sc co or re e i is s g gi iv ve en n a as s 1 1

C CR RA AN NI IA AL L N NE ER RV VE E T TE ES ST TI IN NG G


C CR RA AN NI IA AL L N NE ER RV VE ES S



C Cr ra an ni ia al l n ne er rv ve e 1 1

O Ol lf fa ac ct to or ry y s se en ns so or ry y n ne er rv ve e, ,s sm me el ll l . .
A As sk k c cl li ie en nt t t to o c cl lo os se e e ey ye es s a an nd d i id de en nt ti if fy y d di if ff fe er re en nt t a ar ro om ma as s, ,s su uc ch h a as s c co of ff fe ee e, ,o or ra an ng ge e, ,a al lc co oh ho ol l
F Fi ir rs st t a as ss se es ss s p pa at te en nc cy y b by y o oc cc cl lu ud di in ng g o on ne e n no os st tr ri il l a at t a a t ti im me e a an nd d a as sk ki in ng g t th he e p pe er rs so on n t to o s sn ni if ff f
D Do o n no ot t u us se e a al lc co oh ho ol l w wi ip pe es s b be ec ca au us se e t th he ey y a ar re e i ir rr ri it ta at ti in ng g
A Ab bn no or rm ma al l f fi in nd di in ng gs s
A An no os sm mi ia a- - l lo os ss s o of f s se en ns se e o of f s sm me el ll l o oc cc cu ur rs s b bi il la at te er ra al ll ly y w wi it th h t to ob ba ac cc co o, , s sm mo ok ki in ng g, , a al ll le er rg gi ic c r rh hi in ni it ti is s a an nd d c co oc cc ca ai in ne e u us se e
U Un ni il la at te er ra al l l lo os ss s o of f s se en ns se e o of f s sm me el ll l i in n t th he e a ab bs se en nc ce e o of f n na as sa al l d di is se ea as se e i is s n ne eu ur ro og ge en ni ic c a an no os sm mi ia a

C Cr ra an ni ia al l n ne er rv ve e 2 2
O Op pt ti ic c- - s se en ns so or ry y n ne er rv ve e, ,v vi is si io on n a an nd d v vi is su ua al l f fi ie el ld ds s
A As sk k p pa at ti ie en nt t t to o r re ea ad d t th he e s sn ne el ll le en n s s c ch ha ar rt t
T Th hi is s i is s t th he e g gr ro os ss s e em ma as su ur re e o of f p pe er ri ip ph he er ra al l v vi is si io on n
I It t c co om mp pa ar re es s t th he e p pa at ti ie en nt t s s p pe er ri ip ph he er ra al l v vi is si io on n, , a as ss su um mi in ng g t th ha at t t th he e e ex xa am mi in ne er r s s p pe er ri ip ph he er ra al l v vi is si io on n i is s n no or rm ma al l
T Th he e e ex xm ma ai in ne er r p po os si it ti io on ns s h he er rs se el lf f a at t e ey ye e l le ev ve el l w wi it th ht th he e p pa at ti ie en nt t, , a ab bo ou ut t 2 2 f fe ee et t a aw wa ay y
A Ab bn no or rm ma al l f fi in nd di in ng gs s
I If f t th he e p pa at ti ie en nt t i is s u un na ab bl le e t to o s se ee e t th he e t ta ar rg ge et t o or r f fi in ng ge er r o of f t th he e e ex xa am mi in ne er r a as s t th he e e ex xa am mi in ne er r d do oe es s, , t th he e t te es st t i in nd di ic ca at te es s l lo os ss s o of f p pe er ri ip ph he er ra al l v vi is su ua al l f fi ie el ld d. .
P Pa ap pi il le ed de em ma a s su ug gg ge es st ts s i in nc cr re ea as se ed d i in nt tr ra ac cr ra an ni ia al l p pr re es ss su ur re e
C Cr ra an ni ia al l n ne er rv ve e 3 3





O Oc cu ul lo om mo ot to or r- - m mo ot to or r n ne er rv ve e, , e ex xt tr ra a o oc cu ul la ar r e ey ye e m mo ov ve em me en nt t. .
A As ss se es ss s p pu up pi il l r re ea ac ct ti io on n
I In n a ad du ul lt t, , t th he e r re es st ti in ng g s si iz ze e o of f t th he e p pu up pi il l i is s 3 3 t to o 5 5m mm m. .
C Cr ra an ni ia al l n ne er rv ve e 4 4

T Tr ro oc ch hl le ea ar r- - m mo ot to or r n ne er rv ve e, ,E EO OM M, ,s sp pe ec ci if fi ic ca al ll ly y m mo ov ve es s e ey ye eb ba al ll l d do ow wn nw wa ar rd d a an nd d l la at te er ra al ll ly y. .
C Cr ra an ni ia al l n ne er rv ve e 5 5

T Tr ri ig ge em mi in na al l/ /o op pt th ha al lm mi ic c b br ra an nc ch h- - s se en ns so or ry y n ne er rv ve e
S Se en ns sa at ti io on n o of f c co or rn ne ea a a an nd d s si id de e o of f f fa ac ce e. .
A As sk k c cl li ie en nt t t to o l lo oo ok k u up pw wa ar rd d l li ig gh ht tl ly y t to ou uc ch h t th he e l la at te er ra al l s sc cl le er ra a o of f t th he e e ey ye e w wi it th h s st te er ri il le e g ga au uz ze e, ,t to o e el li ic ci it t b bl li in nk k r re ef fl le ex x
A Ab bn no or rm ma al l f fi in nd di in ng gs s
D Di il la at te ed d / /p pi in np po oi in nt t p pu up pi il ls s, , D Di il la at te ed d a an nd d f fi ix xe ed d p pu up pi il ls s
C Co on ns st tr ri ic ct te ed d p pu up pi il ls s
U Un ne eq qu ua al l o or r n no o r re es sp po on ns se e t to o l li ig gh ht t
A Ab bs se en nc ce e o of f c co on ns st tr ri ic ct ti io on n o or r c co on nv ve er rg ge en nc ce e
A As sy ym mm me et tr ri ic c r re es sp po on ns se e
N Ny ys st ta ag gm mu us s o oc cc cu ur rs s w wi it th h d di is se ea as se e o of f t th he e s se em mi ic ci ir rc cu ul la ar r c ca an na al ls s i in n t th he e e ea ar rs s, , m mu ul lt ti ip pl le e s sc cl le er ro os si is s o or r b br ra ai in n l le es si io on ns s, , P Pt to os si is s
S St tr ra ab bi is sm mu us s, ,L Li id d l la ag g

C Cr ra an ni ia al l n ne er rv ve e 5 5

T To o t te es st t l li ig gh ht t s se en ns sa at ti io on n, ,l le et t c cl li ie en nt t c cl lo os se e e ey ye es s a an nd d w wi ip pe e a a w wi is sp p o of f c co ot tt to on n t to o t th he e c cl li ie en nt t s s f fo or re eh he ea ad d
T To o t te es st t f fo or r d de ee ep p s se en ns sa at ti io on n, ,u us se e a al lt te er rn na at ti in ng g b bl lu un nt t a an nd d s sh ha ar rp p e en nd ds s o of f s sa af fe et ty y p pi in n o ov ve er r s sa am me e a ar re ea as s. .
M Ma ax xi il ll la ar ry y b br ra an nc ch h

S Se en ns so or ry y n ne er rv ve e, ,s se en ns sa at ti io on n o of f s sk ki in n o of f f fa ac ce e, ,t to on ng gu ue e a an nd d t te ee et th h. .
A As ss se es ss s s sk ki in n s se en ns sa at ti io on ns s
M Ma an nd di ib bu ul la ar r b br ra an nc ch h
M Mo ot to or r a an nd d s se en ns so or ry y n ne er rv ve e- - m mu us sc cl le es s o of f m ma as st ti ic ca at ti io on n, ,s se en ns sa at ti io on n o of f s sk ki in n a an nd d f fa ac ce e

A As sk k c cl li ie en nt t t to o c cl le en nc ch h t te ee et th h
C Cr ra an ni ia al l n ne er rv ve e 6 6


A Ab bd du uc ce en ns s- - m mo ot to or r n ne er rv ve e, ,E EO OM M, ,m mo ov ve es s e ey ye eb ba al ll l l la at te er ra al ll ly y. .


C Cr ra an ni ia al l n ne er rv ve e 7 7
F Fa ac ci ia al l- -m mo ot to or r a an nd d s se en ns so or ry y n ne er rv ve e. .F Fa ac ci ia al l e ex xp pr re es ss si io on n; ;t ta as st te e
A As sk k c cl li ie en nt t t to o s sm mi il le e, ,r ra ai is se e e ey ye eb br ro ow ws s, ,f fr ro ow wn n, ,p pu uf ff f o ou ut t c ch he ee ek ks s. .
A As sk k c cl li ie en nt t t to o i id de en nt ti if fy y v va ar ri io ou us s t ta as st te e p pl la ac ce ed d o on n t ti ip p a an nd d s si id de es s o of f t to on ng gu ue e
A Ab bn no or rm ma al l f fi in nd di in ng gs s
M Mu us sc cl le e w we ea ak kn ne es ss s i is s s sh ho ow wn n b by y f fl la at tt te en ni in ng g o of f a a n na as so ol la ab bi ia al l f fo ol ld d, , d dr ro oo op pi in ng g o of f o on ne e s si id de e o of f t th he e f fa ac ce e, , s sa ag gg gi in ng g o of f t th he e l lo ow we er r e ey ye el li id d, , a an nd d e es sc ca ap pe e o of f a ai ir r f fr ro om m
o on nl ly y o on ne e c ch he ee ek k t th ha at t i is s p pr re es ss se ed d i in n
L Lo os ss s o of f m mo ov ve em me en nt t a an nd d a as sy ym mm me et tr ry y o of f m mo ov ve em me en nt t o oc cc cu ur r w wi it th h b bo ot th h c ce en nt tr ra al l n ne er rv vo ou us s s sy ys st te em m l le es si io on ns s a an nd d p pe er ri ip ph he er ra al l n ne er rv vo ou us s s sy ys st te em m l le es si io os sn n ( (b be el ll l s s
p pa al ls sy y) )
C Cr ra an ni ia al l n ne er rv ve e 8 8 a ac co ou us st ti ic c ( (v ve es st ti ib bu ul lo oc co oc cc ch hl le ea ar r n ne ea ar rv ve e) )
A Au ud di it to or ry y
- - v ve es st ti ib bu ul la ar r b br ra an nc ch h s se en ns so or ry y n ne er rv ve e, ,f fo or r e eq qu ui il li ib br ri iu um m
- - D Do o t th he e R Ro om mb be er rg g s s t te es st t
- - c co oc ch hl le ea ar r b br ra an nc ch h, ,f fo or r h he ea ar ri in ng g ( (a as ss se es ss s c cl li ie en nt t s s a ab bi il li it ty y t to o h he ea ar r s sp po ok ke en n w wo or rd ds s, ,v vi ib br ra at ti io on ns s) ) w wh hi is sp pe er r t te es st ts s a an nd d t tu un ni in ng g f fo or rk k t te es st ts s. .

A Ab bn no or rm ma al l f fi in nd di in ng gs s
T Th he e p pa at ti ie en nt t i is s u un na ab bl le e t to o h he ea ar r w wh hi is sp pe er re ed d w wo or rd ds s. . A A w wh hi is sp pe er r i is s a a h hi ig gh h- -f fr re eq qu ue en nc cy y s so ou un nd d a an nd d i is s u us se ed d t to o d de et te ec ct t h hi ig gh h- - p pi it tc ch he ed d l lo os ss s

C Cr ra an ni ia al l n ne er rv ve e 9 9
G Gl lo os ss so op ph ha ar ry yn ng ge ea al l- - m mo ot to or r a an nd d s se en ns so or ry y n ne er rv ve e, ,s sw wa al ll lo ow wi in ng g a ac ct ti iv vi it ty y t to on ng gu ue e m mo ov vt t. . T Ta as st te e( (p po os st te er ri io or r t to on ng gu ue e) )
A As sk k c cl li ie en nt t t to o m mo ov ve e t to on ng gu ue e f fr ro om m s si id de e t to o s si id de e u up p a an nd d d do ow wn n. .
A Ap pp pl ly y t ta as st te e o on n t th he e p po os st te er ri io or r t to on ng gu ue e

C Cr ra an ni ia al l n ne er rv ve e 1 10 0
V Va ag gu us s m mo ot to or r a an nd d s se en ns so or ry y n ne er rv ve e, ,t th hr ro oa at t s se en ns sa at ti io on n, ,v vo oc ca al l c co or rd d m mo ov vt t. .
A As ss se es ss se ed d w wi it th h C CN N 9 9, ,g ga ag g, ,s sw wa al ll lo ow w , ,l li is st te en n t to o v vo oi ic ce e q qu ua al li it ty y. .
C Cr ra an ni ia al l n ne er rv ve e 1 11 1
A Ac cc ce es ss so or ry y- - m mo ot to or r n ne er rv ve e, ,h he ea ad d m mo ov vt t. .s sh hr ru ug gg gi in ng g o of f s sh ho ou ul ld de er rs s. .
A As sk k c cl li ie en nt t t to o s sh hr ru ug g s sh ho ou ul ld de er rs s a ag ga ai in ns st t r re es si is st ta an nc ce e f fr ro om m y yo ou ur r h ha an nd ds s, ,a an nd d t tu ur rn n h he ea ad d t to o s si id de e a ag ga ai in ns st t r re es si is st ta an nc ce e o on n y yo ou ur r h ha an nd d. .
C Cr ra an ni ia al l n ne er rv ve e 1 11 1
H Hy yp po og gl lo os ss sa al l- - M Mo ot to or r n ne er rv ve e, ,t to on ng gu ue e p pr ro ot tr ru us si io on n

A As sk k t th he e c cl li ie en nt t t to o p pr ro ot tr ru ud de e t to on ng gu ue e a at t m mi id dl li in ne e, ,t th he en n m mo ov ve e i it t s si id de e t to o s si id de e. .





ASSESSMENT
Assessment is the first step in caring for a patient.

Careful assessment is fundamental in order to recognise when a patient is becoming compromised,

Structured Assessment
A AIRWAY (with C spine protection in trauma)
B breathing
C circulation
D disability (central nervous system function)
E exposure (with temp. control)
Assessment


What nurses know
What nurses see
What nurses find a quick physical assessment.
PRIMARY SURVEY
eyeball the patient do they look sick?
Airway assessment + C-spine
If possible trauma protect the C-spine
*Can the patient talk normally? (If so, the airway is patent)
Stridor/gurgling/snoring (partial airway obstruction)
Chest wall movement
Feel for breath
Look in mouth
*Oxygen if patient sick

Airway problems:
If evidence of actual or potential airway obstruction get anaesthetics help early
Dont wait for O2 saturations to drop by that stage your patient may be in big trouble
Remember airway adjuncts if inability to maintain an airway due to decreased conscious level
Consider suctioning (call chest physio) if evidence of retained secretions i.e. gurgling noises
Mini assessment
Airway Assessment
Determine patency of the airway.

Look. Listen. Feel.Count the Resp. Rate.

AIRWAY OBSTRUCTION
Inspiratory Stridor : a rasping sound heard during inspiration as a result of obstruction above or involving the larnyx

Wheeze : is usually heard on expiration as a result of the lower airways collapsing
AIRWAY OBSTRUCTION
Gurgling occurs when secretions or liquid is present in the upper airways.
Snoring occurs during partial occlusion of the oropharynx due to relaxation of the oropharyngeal muscles and tongue
High pitched crowing sounds occur during laryngeal spasm
BREATHING
LOOK

LISTEN

FEEL
Breathing assessment
look/feel/listen
*Obvious distress?
Use of accessory muscles?
Cyanosis?
*Respiratory rate (This is the single most useful marker of critical illness)
Tracheal tug/deviation
Chest wall movement + expansion
Percussion
*Air entry/breath sounds
*Added sounds
Vocal resonance
*Oxygen Saturations (aim for >93%, but if <97% in a normally healthy young person, think about why)
Breathing problems:

There are only a few things that commonly cause life-threatening breathing problems:
Pneumonia
COPD + Asthma (i.e. bronchospasm)
Pulmonary oedema
Pulmonary embolus
Pneumothorax
These can co-exist.
O2 Saturations of 92% in a young, previously healthy patient are not ok.
Not everyone with tachypnoea has a primary respiratory problem, it can be secondary to a metabolic acidosis or a CNS problem
O2 Sats of 97% might be ok on room air, but if it takes high-flow oxygen to achieve this, something is badly wrong with gas exchange in the lungs

Circulation
Look : skin colour. Dehydration
drug chart.electrolytes.signs of
haemorrhage/fluid loss

Listen : accurate assessment of the heart
rate,pulse blood pressure

Circulation
Feel : pulse why? What can it tell us?
Circulation assessment (Hands-face-chest-abdomen-legs)

*Cool, clammy/warm and flushed?
Colour pale? Grey? Mottling?
*Peripheries warm or cool
Capillary refill time
*Central pulse rate, volume, regular (Need SBP>80mmHg for radial pulse)
JVP
*BP
Heart sounds
?DVT
Peripheral oedema ankles/legs/arms/flanks
Peripheral pulses
*IV access
Circulatory problems:

Shock is a failure to adequately perfuse organs, not just hypotension. Hypotension means advanced shock.
Think of the cardiovascular system as plumbing. Things that can go wrong:
Not enough fluid (Hypovolaemia e.g. bleeding, vomiting)
Pump failure (Cardiogenic shock MI, fluid overload, arrhythmia, valve disease, cardiomyopathy, myocardial depression due to drugs or
acidosis)
Blocked pipes (Obstruction to flow PE, cardiac tamponade, high intrathoracic pressures)
Leaky or poorly functioning pipes (Vasodilatation septic shock, anaphylaxis)

Finally, neurogenic shock - rare, due to loss of sympathetic input in C/T- spine injuries, causing vasodilatation and bradycardia.
In most cases, fluid resuscitation is the first-line treatment for shock, but not always.

In cardiogenic shock, fluids will tend to make a bad situation worse, and the management is to treat any immediate cause eg arrhythmia or MI,
and/or use inotropes.



Unless there is obvious pulmonary oedema, a fluid challenge is worthwhile (250-500mls of colloid e.g. Voluven or Gelofusin over15-30mins, and
assess response HR, BP, urine output and CVP if available). Never use hypotonic fluids e.g. 5% dextrose for resuscitation purposes. If bleeding
+ hypotensive, use blood, ideally cross-matched.


Disability
Neurological assessment
Disability
URINE OUTPUT.
HALF A ML.X KG. X 24HRS.

OLIGURIA. Production of between 100
400mls x 24hrs.
ANURIA. Below 100mls in 24hrs
ABSOLUTE ANURIA NO URINE
Disability assessment

Quick neurological screen time to do a full assessment later:
AVPU score Alert/Responsive to Voice/Responsive to Pain/Unresponsive
Pupils equal & reactive?
*GCS (E,M,V) esp. posturing
*Check capillary blood glucose
Disability problems

New focal neurology? Is it haemorrhage? this is the most treatable cause.
Generalised deterioration in conscious level- 1 CNS cause, or a response to other pathology?
Confusion/agitation can be a manifestation of hypoxia/shock/hypoglycaemia/lots of other things for which sedation is not the treatment.

Check capillary blood glucose

EXPOSURE
TEMP.

Also a top to toe assessment allow us to see any areas that may have been missed in the initial ABCD eg wounds, areas of inflammation
E-exposure (SECONDARY ASSESSMENT + INVESTIGATIONS)

History (Chest pain/SOB/palpitations/thirst/pain/fatigue/dizziness)
Examine abdomen including for Neuro or other exam as indicated
Input/output chart consider urinary catheter and hourly urometry
Medications

CXR / ECG / ABG / Blood tests / Other investigations as indicated
ABG analysis is not just for diagnosing respiratory failure it gives information on perfusion and lots of other useful things.
Find out normal state ask nurses/check notes/call relative
Are they an ICU/HDU candidate? If so, inform them early.
Are you competent to deal with this patient by yourself?

Conclusion
A B C D E

Coupled with the MINI ASSESSMENT TOOL.

Provides a structured approach to patient
Assessment and a basis for further intervention / treatment
Specific Management of Some Common Emergencies

Cardiac Arrest
Basic Life Support (BLS):
Call for Help
A: Head tilt + chin lift/jaw thrust. Clear mouth.
B: If not breathing - give 2 breaths
C: If no pulse - give 15 chest compressions at 100/minute, per 2 breaths.

Advanced Life Support (ALS):

If witnessed arrest - give Precordial thump.
BLS.
Attach defib/monitor.
If VF or pulseless-VT => DC Shock 200, 200, 360 joules; CPR 1 minute; reaccess rhythm & pulse; reshock 3 x 360 joules.
If non-VF or VT-with-pulse => 3 minutes CPR; reassess rhythm & pulse.
During CPR: correct reversible causes, IV access, give 1mg IV Adrenaline each 3 minutes, consider intubation.
Consider amiodarone, atropine, pacing, buffers.
Reversible causes:

Hypoxia
Hypovolaemia
Hypokalaemia, hyperkalaemia
Hypothermia
Tension pneumothorax
Tamponade
Toxic/therapeutic disturbance
Thromboembolic/mechanical obstruction.

2. Myocardial Infarction

Management: (BOOMASS)
Bed rest
Oxygen
Opiates
Monitor rhythm (ECG)
Aspirin (300mg) (GTN and Beta-blockers can help)
Steptokinase or tPA (if within 12hr and elevated ST, but no contraindications)
Stop smoking (exercise, diet, physio)
In more detail:

ECG Monitor
O2 (High flow)
IV Access.
FBP, U+E, Glucose, Lipids, Cardiac enzymes.
Aspirin 300mg
Morphine (5-10mg IV) or Diamorphine (2-5mg IV) + Antiemetic, eg: Metoclopramide (10mg IV)
GTN spray or Buccal Suscard (unless hypotensive)
Beta-blocker (eg. atenolol 5mg IV, unless asthma or LVF)
Thrombolysis (Streptokinase or Alteplase, rt-PA) - if within 12 hrs (still may help up to 24 hrs) and ST elevation, BUT no internal bleeding, no
surgery in past 2 weeks, BP not over 200/120mmHg, previous allergic reaction, pregnancy, don't give streptokinase if it is 5 days to 1 year since
last administration. If there are thrombolysis contra-indications, consider urgent angioplasty instead.
CXR
Prophylaxis - Management of any existing Diabetes, DVT Prophylaxis
Stop Calcium channel antagonists

Contraindications to Thrombolytics (Variation between clinicians these are typical):

Recent trauma/surgery
Bleeding disorder
Head injury
Previous haemorrhagic CVA
CVA within 6 months
Brain tumour
Active peptic ulcer
Active bleeding (not menstruation)
Prolonged CPR
Warfarin therapy (relative C/I)
3. Acute severe Asthma

Signs of Severe attack:
Cannot complete sentences
Resp rate > 25/minute
Pulse > 110/minute
Peak flow < 50% of predicted or best
Signs of Life-threatening attack:
Peak flow < 33% of predicted or best
Silent chest, cyanosis, feeble respiratory effort
Bradycardia or Hypotension
Exhaustion, confusion, or coma
Normal or high PaCO2, Low PaO2, Low pH.
3. Acute severe Asthma
Treatment:
Sit patient up,
100% O2
Salbutamol (5mg) with O2. Repeat continuously if needed.
Hydrocortisone (200mg IV)
Ipratropium Bromide (500mcg) neb.
Consider Magnesium infusion, Aminophylline or salbutamol infusion.
If severe, warn ITU.
CXR - exclude pneumothorax.

Treatment:

Sit patient up,
100% O2
Salbutamol (5mg) with O2. Repeat continuously if needed.
Hydrocortisone (200mg IV)
Ipratropium Bromide (500mcg) neb.
Consider Magnesium infusion, Aminophylline or salbutamol infusion.
If severe, warn ITU.
CXR - exclude pneumothorax.

4. Anaphylactic Shock

Symptoms & signs:
Skin: Itching, Erythema, Urticaria, Oedema.
Breathing: Wheeze, Laryngeal obstruction.
Heart: Tachycardia, Hypotension.
Management:

Secure Airway
High-flow Oxygen
If respiratory obstruction imminent intubation & ventilation
Adrenaline IM, 0.5ml of 1:1000 (=0.5mg), repeat each 5 minutes if needed
IV Access
Chlorpheniramine 10mg IV
Hydrocortisone 200mg IV
IV fluid resuscitation with saline or colloid (eg 500ml per 15 minutes). Be guided by response to successive fluid challenges
If wheeze, treat for asthma.
May need ventilatory support, and Intensive care.

5. Diabetic Ketoacidosis

Dehydration is more life threatening than any hyperglycaemia.
Signs & symptoms:
Polyuria, lethargy, hyperventilation, ketotic breath, dehydration, vomiting, abdominal cramp, coma.
Management:

ABCDE. Expect tachypnoea and signs of dehydration +/- shock
IV Fluids (Saline 1 litre stat, 1L over 1hr, 1L over 2hr, 1L over 4hr. Careful if >65years or CCF. Dextrose saline when glucose<15mmol/L). Be
guided by the response.
Plasma glucose. If > 20mmol/L give 10 units soluble insulin (actrapid) IV.
Tests: Lab glucose, U+E, HCO3, osmolality, blood gases, FBP, blood culture, urine ketones & MSU.
NG Tube if nausea/vomiting/unconscious.
Insulin sliding scale with hourly blood glucose tests.
Potassium replacement be guided by regular U+E measurement
6. Acute upper GI bleed

Assess for shock:
Cold nose and fingers
Slow capillary refill
Pulse>100/min
Systolic BP < 100mmHg
Urine output < 30ml/hr

If shocked:
Protect airway. Nil by mouth.
2 large cannulae.
Draw bloods (FBP, U+E, LFT, glucose, clotting screen).
Cross-match 6 units.
High-flow O2.