Saturday, February 26, 2011

Patient Assessment

The weatherman said it was supposed to snow last night and rain today.  Wrong.  We hardly got any rain last night and this morning woke up to a bright sunny day.  It started off cold but not freezing.  It ended up in the 50s or so. 

Grandson had a friend come over to play today.  Boy's friend is an only child and gets rather bored at home.  His parents have given him every video game player and game imaginable, including many that aren't appropriate for a 9 year old.  Most of the conversation coming out of friends mouth has to do with video game characters, whom he speaks of like they are human friends and enemies.  When he comes over here he usually brings some of his games to play on our Wii or on the computer.  I gave them an hour total of electronics, then it was time to go outside. 

They had a set of walki-talkis and they played hide and seek using the walki-talkis.  They had a great time.  Then Grandson came in dripping blood from his foot.  Friend was screaming about how hurt Boy was.  Boy dripped all the way into the living room and started to plop himself down on the sofa.  Like a good grandparent I said get off the sofa and go sit on the kitchen chair. 

Army daughter (Boy's aunt) came in and said that she'd take care of him.  After all, she didn't want me to pass out from the sight of all the blood.  Cut it out and get an orange rag from the hall closet.  Get it wet and bring it to me.  As she was doing that I played 20 questions with boy. 

If this was a real patient assessment I'd be asking the following:
Patient Information:
Name, Weight, Date of Birth/Age, Sex, Chief Complaint
Oriented to:
Person, Purpose, Time, Place
Response to pain:
Purposeful, No response, Non-purposeful, Unconscious
Normal, Unequal, Rales, Stridor, Wheezes, Apnea, Other
Skin Vitals:
Color: Normal, Pale/Ashen, Cyanotic, Flushed
Moisture: Normal, Dry, Moist, Profuse
Temperature: Normal, Hot, Cool, Cold
Equal and reactive to light (acronym: pearl), Fixed, Unequal, Dilated
Patient History:
Cardiac, Seizure, Diabetes, Hypertension, Other, Unknown History

As you go through this assessment the patient usually calms down.  After all, they are being treated so all will be better soon.  The calmer you can make your assessment the better things will be.

But this was Boy.  I could skip the Patient Information.  I know his name, weight, age, sex, and chief complaint.  Toe is cut and bleeding.  He was oriented to his surroundings.  He went straight for the comfortable furniture.  Response to pain: Purposeful. Friend was screaming, Boy was crying that it hurt but friend was more panicked.  Breathing: Normal.  Skin Vitals: All normal.  Pupils: Normal. Patient History: It's Boy.  Bleeds at least once a week. 

Additional assessment questions:  What were you doing? What cut you? Does it feel like anything is still in your toe?  Were you wearing shoes?

Let's get it washed off.  I'll put some antibiotic ointment on it and tape it up.  You are as good as new.  Put a sock on and go play.

1 comment:

  1. Great idea for calming the patient, but as you said the assessment is really for the aid provider.