Patient’s medications (amiodarone, beta-blockers and ACE-inhibitors for example can have respiratory side effects). Quantify smoking by the number of “pack-years” (1 pack-year = 20 cigarettes/day for 1 year). Smoking: Risk factor for lung cancer and COPD.
Sick contacts: Are any of your friends/family members sick? Have you travelled anywhere (especially overseas) recently? Occupation: Occupational exposure to asbestos and certain mining/farming areas may predispose patients to certain diseases. If your patient can talk, begin by taking a background: Whilst doing the above, ideally another nurse on the ward should ensure that both the patient’s inpatient folder and medication/observations folder are by the bedside, ready for easy access by the doctors. Remove unnecessary clothes/layers, but keep a blanket on to maintain body warmth and respect the dignity of the patient. Perform a 12-lead ECG if the patient has chest pain.ĭisability – do a finger-prick test to assess blood glucose level.Įxposure – help expose the patient’s body for examination. Give a fluid bolus if the patient’s blood pressure is low. "Another consideration is to compare the data you have collected to the previous set of observations, has it changed dramatically? If yes, it might be time for a MET.”Ĭirculation – insert 2 large IV cannula and take blood. "If the patient fits all the normal criteria but you are still worried, you should call a MET anyway. "You should call a MET team if your patient has a respiratory rate outside of normal range, appears blue in the face or has a stridor - loud, noisy breathing caused by an obstruction to the throat. When is a MET (Medical Emergency Team) call required?Įach hospital has their own policy and criteria for calling a Medical Emergency Team - in some states this is called a Rapid Response Team. "Look at the way the chest rises and falls - how fast, is it equal, how deep, listen to the sound of the lungs - can you hear an audible sound, is air entry equal, are there any unusual sounds, and feel - place your hand on the chest, feel the depth of breathing, the symmetry." In addition to this, the assessor will check oxygen saturations (SpO2) and observe the colour of the skin.
"A thorough respiratory assessment involves checking the respiratory rate, the symmetry, depth and sound (auscultation) of breathing, observes for accessory muscle use and tracheal deviation," says Ms Stokes-Parish.
#HEAD TO TOE ASSESSMENT CHECKLIST COPD FULL#
The patient’s ability to talk in full sentences is a good indicator of their breathing status. The acceptable oxygen saturation is >96% for patients without hypercapnic respiratory failure or chronic obstructive pulmonary disease (COPD) and 88-92% for patients with those conditions or at risk of worsening hypercapnia. Looking for any respiratory distress signs, assessing the depth and pattern of the respiratory cycle for 15 seconds and counting the respiratory rate for a full minute is recommended. Noise-free that is, no wheezing, stridor (a harsh vibrating noise) or rattling ĭuring the breathing component of assessment, nurses must use the ‘Look, Listen and Feel’ technique. In a healthy patient, breathing should be:Īt a rate of 12-20 breaths per minute (respiratory rate) No air entry at auscultation (no chest movement) Signs of complete airway obstruction include: Signs of partial airway obstruction include:īreathing sounds (gurgling, stridor, bubbling, expirtory wheeze) The main causes of airway obstruction are: The aim of airway assessment is to ensure that any obstruction of the anatomy of the airway is identified. It comprises the 'A' and 'B' of a physical assessment - airway and breathing. A respiratory assessment forms a key part of the A-G method.Ī respiratory assessment forms part of the A-G model and is a way to assess the respiratory system function.
Its systematic approach has been proven effective in identifying deteriorating patients or those at risk of deterioration. However, it is also useful for systematic baseline patient assessment and can improve patient mortality in hospital.Ī-G covers: airway, breathing, circulation, disability, exposure, further information (including family and friends) and goals. It integrates the procedure mandated for resuscitation and emergency situations. The A-G method is becoming a commonly used tool in primary and secondary care settings.
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