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38 Cards in this Set
- Front
- Back
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Primary Survey |
DRABCDE. Dangers, Response, Airway, breathing, circulation, disability, environment. Haemorrhage in c |
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Pt is unwell and primary survey required |
-unconscious -altered conscious -Obviously SOB -Obviously Pale and sweaty |
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PSA |
BP HR Skin Consciousness |
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GCS adult |
Eyes Verbal Response Motor Response |
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Paediatric Assessment Triangle |
Appearance Work of breathing Circulation to skin |
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Paediatric Triangle-Appearance |
Tone Interactivity Consolability Gaze/look Crying/speech |
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Paediatric Triangle- Work of Breathing |
Abnormal sounds Abnormal positioning Nasal flare Retractions |
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Paediatric Triangle- Work of Breathing |
Abnormal sounds Abnormal positioning Nasal flare Retractions |
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Paediatric triangle- circulation to skin |
Pallor Mottled skin Cyanosis |
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RSA components |
Appearance Speech Sounds Rate Rhythm Effort Skin HR Conscious state |
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Small Child VSS |
RR-20-40 HR- 85-150 BP-70 |
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Small Child VSS |
RR-20-40 HR- 85-150 BP-70 |
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Medium Child VSS |
RR-16-34 HR-70-135 BP-80 |
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Large infant vss |
HR-105-165 RR-25-55 BP-65 |
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Newborn and small infant VSS |
HR-110-170 BP-60 RR-25-60 |
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APGAR |
Appearance Pulse Grimace Activity Respiratory effort |
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APGAR SCORES 1 |
Appearance- body pink extremities blue Pulse- less than 100 Grimace- Grimaces Activity- extremity flexion Respiratory effort-weak/gasping/ineffective |
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Newborn and small infant VSS |
HR-110-170 BP-60 RR-25-60 |
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APGAR |
Appearance Pulse Grimace Activity Respiratory effort |
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APGAR SCORES 1 |
Appearance- body pink extremities blue Pulse- less than 100 Grimace- Grimaces Activity- extremity flexion Respiratory effort-weak/gasping/ineffective |
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APGAR 0 |
Appearance- blue/pale Pulse-absent Grimace-none Activity-limp Respiratory effort-absent |
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APGAR 2 |
Appearance-totally pink Pulse-greater than 100 Grimace-cries Activity-active motion Respiratory effort-strong cry |
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APGAR SCORE BRACKETS |
Satisfactory 7-10 Respiratory Depression may require ventilation 4-6 Ongoing resuscitation 0-3 |
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Term |
37 weeks or more gestation |
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Term |
37 weeks or more gestation |
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Pre-term |
Less than 37 weeks gestation |
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Non viable infant |
Less than 23 weeks gestation |
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HEART |
History of cardiac Elephant pressure Altered pain (women) Radiation to back,arms/ Risk factors Tripod/toilet |
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5HEDS |
5 or more minutes LOC Skull fracture Vomit more than once Neurological deficits Seizure activity |
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5HEDS |
5 or more minutes LOC Skull fracture Vomit more than once Neurological deficits Seizure activity |
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5HEDS |
5 or more minutes LOC Skull fracture Vomit more than once Neurological deficits Seizure activity |
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MASS |
Facial droop, speech, grips, BSL |
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5HEDS |
5 or more minutes LOC Skull fracture Vomit more than once Neurological deficits Seizure activity |
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MASS |
Facial droop, speech, grips, BSL |
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SPINAL65 |
Sensation Past history of bone disease/pain Intoxication Neck rotation with nil pain Arm push,pull,squeeze Legs push,pull, flex Not over age 65 |
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DOLORS |
Describe pain Onset Location Other symptoms Relieving factors/radiation Severity |
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DOLORS |
Describe pain Onset Location Other symptoms Relieving factors/radiation Severity |
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SIRS CRITERIA |
two or more of: Temp outside 36-38 RR greater than 20 HR greater than 90 BP less than 90 |
