ACCS - Patient Assessment answered

ACCS - Patient Assessment
The four critical life functions include:
1. Ventilation
2. Oxygenation
3. Circulation
4. Perfusion
Life functions
Definition: Necessary to deliver oxygen from the inspired air to all of the cells in the body.
Ventilation is defined as
moving air in and out of the lungs
Oxygenation is defined as
getting oxygen into the blood
Circulation is defined as
moving the blood through the body
Perfusion is defined as
getting blood and oxygen into the tissue
Ways to evaluate ventilation include (6):
- respiratory rate (RR; f)
- tidal volume (VT)
- chest movement
- breath sounds
- ETCO2
- PaCO2
Ways to evaluate oxygenation (5):
- heart rate
- color
- sensorium
- SpO2
- PaO2
Ways to evaluate circulation (2):
- pulse/heart rate and strength
- cardiac output (QT)
Ways to evaluate perfusion (5):
- blood pressure
- sensorium
- temperature
- urine output
- hemodynamics
When you have an emergency, the FIRST priority is __1__, the SECOND is __2__, the THIRD is
__3__, and finally the FOURTH is __4__.
1. Ventilation (establish an open airway and breathe)
2. Oxygenation (increase FiO2)
3. Circulation (chest compressions, defibrillate, heart drugs, etc)
4. Perfusion (maintain blood pressure)
Signs are...

,objective information; those things that you can see or measure (color, pulse, edema, blood pressure,
etc.)
Symptoms are...
subjective information; those things that the patient must tell you (dyspnea, pain, nausea, muscle
weakness, etc.)
Pack years =
( # of packs per day ) x ( # of years smoked )
DNR
- Do Not Resuscitate
- Request not to have cardiopulmonary resuscitation (CPR) performed
- DNR orders are accepted in all state
DNI
- Do Not Intubate
- Request not to be intubated
- NIV may be used if necessary
Living Will
- Describes treatment patient would want if they become terminally ill ( < 6 months to live)
- Does not allow patient to appoint someone else to make medical decisions
Normal urine output
40 - 80 mL/hr
- Approx. 1 - 2 L/day
Sensible water loss includes:
- urine
- vomiting
Insensible water loss includes:
- lungs
- skin
If intake EXCEEDS output, this could result in:
- weight gain
- electrolyte imbalance
- increased hemodynamic pressures
- decreased lung compliance
Changes in what pressure can indicate changes in fluid balance?
CVP
Decreased CVP ( < ____ mmHg ) can indicate hypovolemia. How would you treat this?
< 2 mmHg
- Treat with fluid challenge
Increased CVP ( > ____ mmHg ) can indicate hypervolemia. How would you treat this?
> 6 mmHg
- Treat with diuretics
LOC: Alert and responsive
- Normal
LOC: Lethargic, somnolent, sleepy
- Consider a drug overdose
- Consider sleep apnea
LOC: Stuporous, confused
- Responds inappropriately
- Drug overdose
- Intoxication

, LOC: Semicomatose
- Responds only to painful stimuli
LOC: Obtunded
- Drowsy state
- May have decreased cough of gag reflex
LOC: Coma
- Does not respond to painful stimuli
GCS: Eye-opening response
4 - Spontaneous opening
3 - To verbal stimuli
2 - To pain
1 - None
GCS: Most appropriate verbal response
5 - Oriented
4 - Confused
3 - Inappropriate words
2 - Incoherent
1 - None
GCS: Most integrated motor response (arm)
6 - Obeys commands
5 - Localizes pain
4 - Withdraws from pain
3 - Flexion to pain
2 - Extension to pain
1 - None
When assessing the patient's emotional state, anxiety and nervousness may indicate:
- asthma
- respiratory distress
- hypoxemia
When assessing the patient's emotional state, panic may indicate:
- hypoxia
- tension pneumothorax
- status asthmaticus
Orthopnea is...
difficulty breathing EXCEPT in the upright position.
- May be indicative of CHF
General malaise is...
run down feeling, nausea, weakness, fatigue, headache.
- May indicate ELECTROLYTE IMBALANCE
Dyspnea is...
a feeling of shortness of breath or difficulty breathing.
Pain is...
a reaction of a specific nervous tissue.
- May increase BP and HR
Syncope is...
temporary loss of consciousness.
Types of syncope: Vasovagal syncope
- Common dizziness and fainting
- Caused by loss of peripheral venous tone