A-E Assessment & Head-to-Toe Assessment PDF
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Uploaded by EasiestFresno
Curtin University
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Summary
This document provides an overview of an A-E assessment and a head-to-toe assessment, outlining observations and interventions for each. It includes sections for airway, breathing, circulation, disability, and exposure, providing details on evaluating a patient's condition and responding with appropriate actions. The head-to-toe assessment section provides important information to use when conducting an assessment of patient's health.
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## RECOGNISE AND RESPOND TO CLINICAL DETERIORATION ### A-E Assessment | Observations | Interventions | | ----------------------------- | ---------------------------------------------------------------...
## RECOGNISE AND RESPOND TO CLINICAL DETERIORATION ### A-E Assessment | Observations | Interventions | | ----------------------------- | ---------------------------------------------------------------------------------------------- | | **Airway** | - Reposition Patient | | - Ensure patent airway | - Head tilt, chin lift | | - Ask the patient how they are feeling | - Suction | | | - Consider Oropharyngeal adjunct | | | - Consider Nasopharyngeal adjunct | | | - Consider Advanced airway techniques (LMA) | | **Breathing** | - Repositioning patient | | - Respiratory rate | - Suction | | - Auscultate | - Medications | | - Tracheal positioning | - Low flow oxygen | | - Effort | - Nasal prongs | | - Saturations of oxygen | - Hudson mask | | | - Non-Rebreather mask | | | - Arterial blood gases | | **Circulation** | - Cannulation | | - Organ perfusion | - Venepuncture (blood collection) | | - Colour, fluid intake and output | - ECG 3 or 12 lead | | - Peripheral perfusion | - Catheterisation | | - Cap refill, skin turgor | - Control bleeding | | - Cardiac output | - Fluid replacement | | - HR, BP, auscultate chest | - Medications | | - Temperature | | | - Abdominal assessment | | | **Disability** | - Glasgow Coma Scale/AVPU | | - Drugs | - Blood sugar level | | - Review medication administered | - Review medication intake | | - Diabetes | | | - Record a blood sugar level | | | - Documentation | - Review response to interventions | | - Review all patient documentation | - Establish ISOBAR handover | | **Exposure** | - Continue observations | | - Examine entire patient skin surface | - Consider transferring to higher level care | | - Establish a thorough clinical history | | | - Review medical notes | | | - Review laboratory investigations | | ## Head-to-Toe Assessment ### Introduction - Knock - Introduce yourself - Wash hands - Provide privacy - Verify patient ID and DOB - Explain what you are doing (using non-medical language) ### Orientation - What is your name? - Do you know where you are? - Do you know what month it is? - Who is the current U.S. president? - What are you doing here? - A&O X4 = Oriented to Person, Place, Time, and Situation ### "Normal" Vital Signs - PULSE: 60-100 bpm - BLOOD PRESSURE: 120/80 mmHg - 02 SATURATION: 95-100% - TEMPERATURE: 97.8-99.1° F - RESPIRATIONS: 12-20 breaths per min ### Head & Face #### Head - Inspect head/scalp/hair - Palpate head/scalp/hair #### Face - Inspect - Check for symmetry - To assess Cranial Nerve 7, check the following: - Raise eyebrows - Smile - Frown - Show teeth - Puff out cheeks - Tightly close eyes #### Eyes - Inspects external eye structures - Inspect color of conjunctiva and sclera - PERRLA - Pupils Equal, Round, Reactive to Light, & Accommodation ### Neck, Chest (Lungs) & Heart #### Neck - Inspect and palpate - Palpate carotid pulse - Check skin turgor (under clavicle) #### Posterior Chest - Inspect - Auscultate lung sounds in posterior and lateral chest. Note any crackles or diminished breath sounds #### Anterior Chest - Inspect: - Use of accessory muscles - AP to transverse diameter - Sternum configuration - Palpate: symmetric expansion - Auscultate lung sounds - anterior and lateral. Note any crackles or diminished breath sounds #### Heart - Auscultate heart sounds (A, P, E, T, M) with diaphragm and bell. Note any murmurs, whooshing, bruits, or muffled heart sounds ### Peripherals #### Upper extremities - Inspect and palpate. Note any texture, lesions, temperature, moisture, tenderness, & swelling - Palpate radial pulses bilaterally (+1,+2,+3,+4) #### Shoulder - Inspect, palpate, and assess #### Elbows - Inspect, palpate, and assess #### Hands and Fingers - Inspect hands/fingers/nails - Palpate hands and finger joints - Check muscle strength of hands bilaterally. Does each hand grip evenly? - +1 = Diminished - +2 = "Normal" - +3 = Full - +4 = Bounding, strong ### Lower Extremities (Hips, knees, ankles) #### Lower Extremities - Inspect: - Overall skin coloration - Lesions - Hair distribution - Varicosities - Edema - Palpate: Check for edema (pitting or non-pitting) - Check capillary refill bilaterally #### Hips - Inspect and palpate #### Knees - Inspect and palpate #### Ankles - Inspect and palpate - Post tibial pulse (+1, +2, +3, +4) - Dorsal pedis pulse bilaterally (+1, +2, +3, +4) - Check strength bilaterally - Dorsiflexion flexion against resistance ### Spine - Have the patient stand up (if able) - Inspect the skin on the back. - Inspect: spinal curvature (cervical/thoracic/lumbar) - Palpate spine - Note any lesions, lumps, or abnormalities ### Abdomen - Inspect: - Skin color - Contour - Scars - Aortic pulsations - Auscultate bowel sounds: all 4 quadrants (start in RLQ and go clockwise) - Light palpation: all 4 quadrants - ABSENT: Must listen for at least 5 minutes to chart absent bowel sounds - HYPOACTIVE: One bowel sound every 3-5 minutes - NORMOACTIVE: Gurgles 5-30 time per minute. - HYPERACTIVE: Can sometimes be heard without a stethoscope constant bowel sounds, > 30 sounds per minute ### Overall - Positions and drapes patient appropriately during exam (gave patient privacy) - Gave patient feedback/instructions - Exhibits professional manner during exam, treated patient with respect and dignity - Organized: exam followed a logical sequence (order of exam "made sense")
