Head to Toe: Rapid Response Assessment

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Head to ToeRapid Response Assessment

• Kelly Thelen APRN, FNP, CRRN
• Madonna Rehabilitation Hospital
• Lincoln, NE

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Objectives

• Summarize the appropriate circumstances for a
  focused exam vs complete head to toe assessment
• Describe the steps in assessment of the
  cardio-pulmonary system and other body systems
• Identify appropriate patient interventions/examina
  tions by RTs and RNs in the acute and post
  acute settings

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Why assess beyond the obvious?

• Changes in the patients physical and/or mental
  status
• Presenting concerns to the team
• Presenting concerns to the physician, PA, or
  nurse practitioner
• Making decisions regarding emergent vs.
  non-emergent

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Patient History

• Past Medical History
• Medications
• Allergies
• Subjective data from patient
• Dont forget the family!!
• Direct care staff report

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General Appearance

• Vital Signs
• Affect
• Dress, Grooming, and personal hygiene
• Posture, facial expression, manner, and attention
  span
• Speech
• Judgement

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HEENT

• Head
• Incisional changes
• S/S of infection
• Increased swelling
• New onset of HAs or change in HAs
• Ears
• Eyes
• PERRLA, tracking, neglect, visual-perceptual
  changes, conjunctiva, Sclerae, Nystagmus
• Nose
• Throat
• C/O pain, changes in voice quality

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Neck

• Trach site
• Supple
• Cervical Adenopathy
• Carotid Bruits
• Jugular distention

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Pulmonary

• Chest diameter
• Respiratory Rate, Rhythm, and Effort
• Accessory Muscles
• Auscultation
• Crackles (rales)
• Wheezes
• Rubs
• Percussion

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Cardiac

• Carotids and Jugular veins
• Rate and Rhythm
• Murmurs
• Pulses in the extremities
• Color of the extremities
• Swelling

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Abdomen

• Contour
• Bowel Sounds
• Aortic region
• Percussion
• Palpation
• Rebound tenderness

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Genital/Rectal

• Edema
• Urine output
• Concentration
• Odor
• Pain
• Bowel Movements
• Constipation
• Diarrhea

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Musculoskeletal

• New pain vs. old pain
• Location, quality, relieving factors,
  exacerbating factors
• Gait
• Numbness tingling
• Posture

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Skin

• Turgor
• Color
• Temperature
• Moisture
• Rashes or lesions
• Wounds
• Ecchymosis

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Psychological

• Sleep pattern
• Personality
• Affect
• Delerium
• Anxiety
• Depression

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Neurological

• Many components addressed in other areas of
  evaluation
• LOC
• Cognition
• Orientation
• Sensation
• Reflexes
• Strength
• Speech
• Swallow

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Diagnostics When and Why?

• Labs
• UA
• Blood Cultures
• CBCs, BMPs, CMPs
• Liver Function
• Pre-Albumin
• ABGs
• EKGs
• X-rays

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When do I call the physician, PA, or NP

• ERROR ON THE SIDE OF CAUTION
• New orders needed
• More extensive assessment needed
• Transfer requested
• Per provider request

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How do I determine if it is a Medical Emergency

• When in doubt, ask the treating provider
• Significant change in status
• Requiring services not offered at the current
  facility

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Available Resources

• Staff members who consistently care for the
  patient
• RTs, Nurses, Therapists, Nursing Assistants
• Physicians, NPs, and PAs
• Response Team
• Reference items

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Rapid Response in Acute Care

• Rapid Response Team (RRT)
• Outline management of patients who have been
  identified to be in a threatening situation.
• A threatening situation is defined as a system or
  multi-system failure that is evidenced by a
  change in LOC, respiratory distress or cardiac
  changes.

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Rapid Response Criteria

• RRT
• Primary Reasons for calling
• Staff worried
• Respiratory
• Change in VS
• Change in LOC
• New onset of pain
• IO discrepancy
• Failure to respond to treatment

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Rapid Response Criteria cont

• Staff member is worried about the patient
• Acute ? in HR lt 40 or gt130
• Acute ? in systolic B/P lt 90 mmHg
• Acute ? in RR lt8 or gt30 bpm
• Acute ? in SpO2 lt 90 despite oxygen
• Acute ? in concious state
• Acute ? in UO to lt 50 ml in 4 hours

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Rapid Response Interventions

• RRT
• Suspected problems leading to the call and action
  plans for the team
• Stroke-initiate stroke team/orders
• Sepsis-initiate protocol
• MI- 12 lead, MONA
• Hypovolemia-fluid resuscitation
• Respiratory Distress identify cause, manage
  airway, suction and supplement with O2
• Oversedation-Narcan and airway management

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Rapid Response in Post Acute Care

• P.A.C.E. Team
• Presentation, Assessment, Collaboration,
  Evaluation
• Madonna Rehabilitation Hospital
• Benefits
• Decreases the number of patients returned to
  acute care and interrupted stays
• Second assessment for the patient to establish
  the best plan of care or next steps
• As a provider, the PACE team provides me with a
  thorough assessment and evaluation of the patient
  and situation when I am not at the hospital

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P.A.C.E. Response Criteria

• Something is just not right
• Mental status changes
• Significant ? in vitals
• (HR, RR, B/P, T, Pain)
• ? O2 needs
• ? Activity tolerance
• ( 2 missed therapies in 12-24 hrs)
• Unrelieved pain
• Significant weight gain 1 lb/day
• Changes in LAB values

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Thank you for your participation!

• Please feel free to contact me with questions!
• 402-483-9883
• Cellular phone [phone]
• E-mail kthelen_at_madonna.org