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Assessment Tools Summary

1 Overview
- PQRSTU - SAMPLE - AVPU - ABCDE - EWS - ISBAR ( Pain Assessment ) ( Pain Assessment ) ( Level of Consciousness ) ( Initial Assessment ) ( Identify Critical Patients ) ( Communicate with Multidisciplinary Team )

2 Pain Assessment Tools

PQRSTU
Framework used for gathering data about a presenting concern Good for nding out characteristics of pain. ( Jarvis pp 77 ) P Q R S T U ( Palliative/Provocative ) ( Quality/Character/Quantity ) ( Region/Radiation ) ( Severity ) ( Timing/Duration/Frequency ) ( Patients Understanding )

SAMPLE
S A M P L E ( Signs & Symptoms ) ( Allergies ) ( Medication currently used ) ( Past illnesses/Pregnancy ) ( Last meal ) ( Events/Environment related to injury )

3 Additional Assessment Tools

AVPU
Used in Hospitals and Long-term care facilities to quickly determine level of consciousness. Can be used as part of other assessment frameworks such as ABCDE or a general Neurological assessment - The AVPU scale has only 4 possible outcomes for recording - The assessor should always work from best ( A ) to worst ( U ) to avoid unnecessary tests on patients who are clearly conscious. + Alert - A fully awake ( although not necessarily orientated ) patient - This patient will have spontaneously open eyes - Will respond to voice ( although may be confused ) and will have bodily motor function.

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+ Voice - The patient makes some kind of response when you talk to them - Response could be in any of the three component measures of Eyes, Voice or Motor - The response could be as little as a grunt, moan, or slight move of a limb when prompted by voice + Pain - The patient makes a response on any of the three component measures when pain stimulus is used on them. - A fully conscious patient would normally locate the pain and push it away, however a patient who is not alert and who has not responded to voice ( hence having the test performed on them ) is likely to exhibit only withdrawal from pain, or even involuntary exion or extension of the limbs from the pain stimulus. + Unresponsive - Sometimes seen noted as Unconsciousness', this outcome is recorded if the patient does not give any Eye, Voice or Motor response to voice or pain.

ABCDE - Initial Assessment

Useful when assessing a patient in a First Aid situation or Emergency scenario such as a suspected MI due to atline + This Comprises - Primary survey ( ABCD ) - Resuscitation - Secondary survey ( E + comprehensive ) - Denitive treatment or transfer for denitive care

Primary survey
For speed and efcacy a logical sequence of assessment to establish treatment priorities must be gone through sequentially, although with good team work some things will be done simultaneously + A = Airway maintenance cervical spine protection - Are there signs of airway obstruction - Establish a clear airway ( chin lift or jaw thrust ) - Protect the cervical spine at all times. - If the patient can talk the airway is likely to be safe but remain vigilant and recheck. - Cervical spine protection is paramount throughout airway management process. - Possible treatments ( May be just secretion control ) + B = Breathing and ventilation - Evaluate breathing: lungs, chest wall, diaphragm. - Chest examination with adequate exposure: watch chest movement, auscultate, percuss to detect lesions acutely impairing ventilation: - It can be difcult to tell whether the problem is an airway or ventilation problem. + C = Circulation with haemorrhage control - Blood loss is the main preventable cause of death after trauma. Observe: - Level of consciousness - Skin colour - Pulse. - Bleeding should be assessed and controlled ( direct pressure or surgery to control bleeding ) + D = Dysfunction of Neurological status - After A,B and C above rapid neurological assessment is made - Establish level of consciousness, using AVPU or Glasgow Coma Scale - Pupils: size, symmetry and reaction - Any lateralising signs

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- Level of any spinal cord injury ( limb movements, spontaneous respiratory effort ) - Note: remember oxygenation, ventilation, perfusion, drugs, alcohol and hypoglycaemia may all also affect level of consciousness.

Secondary Survey
+ E = Exposure/ environmental control - Undress patient, but prevent hypothermia. - Clothes may need to be cut off, but after examination attention to prevention of heat loss with warming devices, warmed blankets etc is important - Intravenous uids should be warmed before infusion.

EWS
- Introduced through Christchurch Hospital - Identies patients who are critically ill- not just in intensive care settings - Vital sign/ observations are used to provide information regarding physiological status - Patient scored using EWS table - Single score of 3 = prompt attention - Does not replace clinical assessment & decision making skills - Scores weighted - Vital signs used as provide essential information- thats why important you know how to take vital signs accurately - Awarded score of 1,2 or 3 - O2 sats not included only resps ( more sensitive indicator ) - EWS > 6 activate Intensive Care outreach

ISBAR
Used to communicate clinical information clearly and concisely. It may be used in many clinical contexts. + Identify - Yourself: name, position location. - Patient: name, age and gender. + Situation - Admission date - Diagnosis - History - Investigations ( e.g. what has been done so far ) + Background - Explain what has happened ( and if calling why ). + Assessment - Give a summary of the patients relevant condition or situation. - If there is a problem explain what you think it is. + Request/ Recommendations - State what you want or what needs to be done ( eg; your request, the plan of care, and or recommendations )

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