University:
Towson University
Course:
NURS 332 | Professional Nursing I: Introduction To Nursing
Academic year:

2022
Views:

129

Pages:

2
Author:

Alma Hester

ISBAR and Head to toe assessment resources ISBAR Example: ISBAR I Identify S Situation Content  Introduce yourself and check you are speaking to the correct person  Identify the patient you are calling about (who and where)  Say what you think the current problem is, or appears to be  State what you need advice about  Useful phrases: - The problem appears to be cardiac / respiratory / neurological / sepsis - I’m not sure what the problem it but the patient is deteriorating The patient is unstable, getting worse and I need help B Background  Background information about the patient  Reason for admission Relevant past medical history A Assessment  Include specific observations and vital sign values based on ABCDE approach - Airway - Breathing - Circulation - Disability - Exposure The early warning score is... R Recommendation Reason  State explicitly what you want the person you are calling to do  What by when?  Useful phrases - I am going to start the following treatment, is there anything else you can suggest? - I am going to do the following investigations, is there anything else you can suggest? - If they do not improve, when would you like to be called? I don’t think I can do any more, I would like you to see the patient urgently Head to toe example Primary and Secondary Survey Guidelines Airway Breathing Circulation •Rapid assessment or signs of airway obstruction - talking to pt. •Check in mouth. •Establish patent airway while ensuring c-spine protection in all trauma patients (Jaw Thrust). •ETT if GCS <9 •If unable to intubate consider Laryngeal Mask Airway (LMA) or Cricothyrotomy •Deliver high flow oxygen, attach SpO2 •Look listen feel - includes assessment of tracheal alignment and presence of crepitus •Auscultate •Inspect and palpate - breathing symetrical? •Respiratory rate? •LIFE THREATENING PROBLEMS •Airway obstruction, tension pneumothorax, Open pneumothorax, Massive haemothorax, Flail chest •General appearance? Indications of perfusion? Colour? Warmth? •Control haemorrhage with direct pressure to the wound •Obtain large bore IV access x 2 (send bloods for pathology) •Assess haemodynamic status - level of consciousness, pulse •Assess for signs of internal haemorrhage •LIFE THREATENING PROBLEMS Hypovolaemia from blood loss, Cardiac Tamponade Disability •NEUROLOGIC EVALUATION: A - Alert V - Responds to vocal stimuli P - Responds to painful stimuli U Unresponsive •Responds to instruction? (Wiggle toes) •Evaluation pupil size and response •Check BSL Exposure •Completely undress/expose the patient to check for hidden signs of injury/illness •Check Temperature •Regain/Maintain normal body temperature: warm blankets, bair hugger, warm fluids Environment

ISBAR and Head to toe Assessment Resources

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