australia-queensland-6th edition primary clinical care manual 2009 - section 1 - patient assessment...

8/8/2019 Australia-Queensland-6th Edition Primary Clinical Care Manual 2009 - Section 1 - Patient Assessment and Transport

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Page 9Primary Clinical Care Manual 2009

Patient assessment and transport

Patient presentation (adult or child)

When a patient presents for health care the clinician is required to gather an orderlycollection of information to identify the patients health status. This information forms thebasis of patient assessment and is gained through: Taking a patient history Performing clinical observations Performing a physical examination Use of diagnostic and pathology services Collaboration with other members of the team

It is a requirement that all clinicians document their findings in a clear and concise way.Quality professional documentation is the cornerstone of effective communication [1].This section is set out to assist with documentation. It is recommended that cliniciansdocument the page number of HMP/CCG referred to.

Presenting concern/sThe first priority is to assess whether the person is: seriously ill and needs immediate management or, is a non urgent presentation, and there is time for a complete patient history and

health education to occurWhere possible use a private setting for the patient interview.Use open ended questions to begin with to provide general rather than more focusedinformation. For example, how do you usually deal with an asthma attack? [2].Closed questions can be used to focus the interview, pinpoint specific areas of concernand gain information quickly and efficiently. For example, has this type of allergicreaction happened before? [2].

Commence by introducing yourself and;1. Asking the person what brought them to the facility / clinic today? The person may

be presenting at the invitation of a health professional.2. Ask about the length of time the patient has had the illness / symptoms / problem and

the exact details of the signs and / or symptoms. For each of these ask: [2] Have they had this before? If so when and what happened? Location of problem / symptom original site of presenting concern, where does

it hurt? point to the area Radiation does it spread from the original site? If so where Quality ask the patient to describe the way it feels to them? sharp, stabbing,

burning (use patients own words) Quantity is it mild, moderate or severe? can use a pain score 0-10 Associated manifestations are there any signs or symptoms associated with

the presenting concern? e.g. nausea and vomiting, photophobia and headache.Document relevant negative symptoms that are not present

Aggravating factors what things make the problem worse? Alleviating factors what makes it better? sleeping, lying down, taking

medication? Setting what were you doing when it started? where you at home? At work? Timing when did it start? onset? duration and frequency


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Page 10 Primary Clinical Care Manual 2009


Meaning and impact what does this problem mean to the patient and whatimpact does it have on their life? e.g. relative may have died at a young agehaving experienced a similar problem or the person may have withdrawn fromsocial contact

Always ask the patient specifically if they have Fever?

Pain? Shortness of breath? Diarrhoea? Weight loss?

Patient history (adult or child) There are four types of history taking [2]1. Complete patient history comprehensive history of the patients past and present

health status. Usually done at initial visit in a non-emergency situation2. Episodic history is shorter and specific to the patients current presenting concern3. Interval or follow-up history builds on a preceding visit. It documents the follow-

up required from the prior visit4. Emergency patient history only information required immediately to treat the life

threatening condition is gathered from patient or witnesses. Once this has past amore comprehensive history may be taken once the patient has stabilised

This section outlines what is required for a complete patient history. The history may begiven by the patient, parent or carer in the case of a child, or legal guardian whereappointed. Consider that the patient may be visually or hearing impaired or may notspeak English. In Aboriginal and/or Torres Strait Islander communities Health Workerswill be the cultural and linguistic interpreters.Consent is always required. The circumstances of the presentation will determine the

extent of patient history taken.

Demographicinformation

Name, address, date of birth, gender, alias, occupation, next of kin, emergencycontact details, Medicare number, ethnic status

Medical history Have you had any illnesses / sickness in the past?Do you have diabetes? high blood pressure? high cholesterol?Any big worry problems? depression?Have you ever had chest pain? heart attack? epilepsy? asthma?For detail of special medical history such as obstetric, sexual health see relatedsection

Surgical history Have you had any operations? Do you know what it was for? Were there anycomplications? When and where did you have the operation?


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Is the patient on any medication? (regular; occasional; prescription, non-prescription, complementary, or bush medicine)

For each medicine the patient is taking, the following details are important: the generic name, strength and form (often patients are unable to recall or

are unaware of the full details, in which case ask the patient what they aretaking the medicine for, ask if they have their medicines with them as these

details can be obtained from the containers) dose and frequency duration of therapy, i.e. when therapy started are they taken as prescribed? (does the patient have difficulty

remembering or do they miss taking their pills for any reason? Rememberthat non-adherence may be the reason why the patient appears to be notresponding to prescribed medication.)

ask the patient to demonstrate use of puffers, or describe how they use eyedrops, or ear drops for example

Patients often dont mention medicines they think are not relevant. Therefore

using a checklist to prompt specific questions e.g. asking females whetherthey are on the oral contraceptive pill, will assist in obtaining a comprehensivemedication history. See Appendix 1 Medication History Checklist

Document medications on Medication Action Plan form Ask the patient if they have recently ceased or changed any of their

medications? Ask the patient if there is any medication they have tried for their illness which

has not worked It may be necessary to contact the referring facility, other primary health care

facilities, guardian or other health care providers to confirm or obtain the

medication information requiredMedication allergies / adverse drug reactions (ADR) Try to be specific. Find out the name of drug/substance, type of reaction

suffered and its severity e.g. rash, nausea, swelling of the lips, tongue orbreathing difficulties and date that reaction occurred or approximatetimeframe e.g. 20 years ago. Document this information on the adverse drugreaction (ADR) section of the medication chart according to the StatewideMedication Chart Guidelines and Non-inpatient rural and remote medicationchart guidelines. Also attach an adverse drug reaction sticker to medicationchart

All Queensland Health non-inpatient facilities (and facilities dischargingpatients to non-inpatient facilities, who document medication for supply ondischarge) are required to use the Non-inpatient rural and remote medicationchart and the Non-inpatient rural and remote Warfarin medication chart

Medicationhistory

See Appendix 1 Mediation History Checklist Medication Services Queensland for Medication Action Plan training and

competency on Medication Historyhttp://qheps.health.qld.gov.au/qhmms/home.htm or phone 07 36369095 Fax07 36369098

Allergies Besides medicines, is there anything else you are allergic to?For example - bee stings? sticking plaster for dressing? nuts?What happens? Do you carry an Epi-pen / medication?


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Standard clinical observations To be performed on each patient who presents for acute care (minimum)

Normal rangeadult

Normal rangechild

Pulse rate (heartrate) beats perminute

60 100 bpm Age Beats per minute (mean)


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If indicated also perform with standard clinical observationsBlood glucose level(BGL)

4-8 mmol / L (random capillary)

Urinalysis (U/A) Record results of dipstickSpecific gravity, pH, protein, leucocytes, blood ketones

Oxygen saturation

(PaSO2)

PaSO2 > 94%

PaSO2 90 92% for patients with COPD and chronic hypoxiaBody measurements

Normal range - adult Normal range - childHeight Plot on growth chart for age and gender Plot on growth chart for age and

genderWeight Plot on growth chart for age and gender

Record on medication chartPlot on growth chart for age andgender AND on medication chart

Adults Not applicable for childrenMen Women Risk

< 94 cm < 80 cm Low

94-101 cm 80-87 cm High

Waist circumference

102 cm 88 cm Very highGeneral appearance Inspection Identify if patient meets stated versus apparent age

Body fat / distribution? Stature their posture, body proportions (are their limbs in proportion to

body) Facial features is there anything significant? (consider foetal alcohol

spectrum disorder). Facial expressions? Motor activity the way the person walks (gait and speed), weight bearing

are they favouring or guarding parts of their body? Is there decreasedmovement in any part of the body?

Body and breath odours How is the person groomed? dressed? personal hygiene? What is the persons mood? manner? Verbal and non-verbal body language? Is the person distressed? physically? psychological or emotionally?


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Neurologicalsystem(mental andconscious state)

For detailed mental status examination (MSE) see Mental Health section.Conscious state:1. AVPU -A alert / V responds to verbal statement / P responds to

painful stimuli / U no response (unresponsive) 2. Glasgow coma scale (adult, child, infant)

Glasgow coma scale (GCS) adult, child and infant

AdultChild > 5 years

Child2-5 years

Infant0-23 months

Eyes Open 4. Opens eyes spontaneously3. Opens eyes on command or to speech2. Opens eyes with pain (pinching)1. No eye opening/no response

Best VerbalResponse

5. Fully orientated4. Confused,

disorientated:not sure of their name

or wherethey are or whathappened

3. Inappropriate:meaningless words

2. Incomprehensiblenoises: grunts, moans

1. No sounds

5. Appropriatewords andphrases

4. Inappropriate

words3. Cries and/orscreams

2. Grunts1. No response

5. Smiles, coos, criesappropriately

4. Cries but consolable3. Persistent cries and/or

screams2. Grunts1. No response

Best MotorResponse

6. Obeys commands5. Localises to pain4. Withdraws to pain3. Flexor response to pain (bends arm or leg)2. Extensor response to pain (straightens arm or

leg) 1. No response

6. Obeys commands5. Localises pain4. Withdraws to stimuli3. Abnormal flexion2. Extensor responses1. No response

Score Maximum score= Eyes 4 + Verbal 5 + Motor 6 = 15 (fully alert, conscious) Minimumscore = Eyes 1+Verbal 1+Motor 1 = 3 (unconscious)Always act - on score less than 14 / act immediately on a score of 13 orless in a child / drop of 2 or more from last assessment / if less than 8consider intubation

GCS not valid if patient has - direct eye injury or periorbital swelling after head trauma; intubated

patients; immobilised limbs. In these situations it is appropriate to record the individual scores for eachmeasurable response (motor, verbal or eyes) [3]

SkinInspect Through out physical examination note:

Colour, bleeding, bruising, rashes Vascularity (presence of lesions skin tags, sores, scabies, fungal

infection, skin cancers Palpate Moisture - sweating, dry

Temperature - cool, warm, hot? Texture - is the skin thin / thick? Turgor - (elasticity / amount of fluid in skin), normal turgor is when fully


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hydrated and skin snaps back to normal position; decreased skin turgor isa late sign of dehydration. It is normal for skin turgor to decrease as skinages.

Oedema - excessive fluid in subcutaneous tissues Head and face Inspect The shape of the head

Head and scalp Colour and distribution of hair note any head lice, nits Face eyes (position), eyebrows, ears, nose and mouth

Palpate Head and scalp Lymph nodes

EyesInspect Eye lids, conjunctiva, sclera, cornea, iris, pupil, lensTest Visual acuity near and distant

Corneal reflexes Cover test Red eye reflex

If skilled Look at the back of the eye with ophthalmoscopeEars Inspect External ear alignment, shape, colour, size and any lesions of pinna

Ear canal, tympanic membrane (ear drum), middle ear with otoscope.Note discharge, swelling, signs of infection, fungal infections, lumps orbony growths, foreign body, wax

Palpate External ear Mastoid bone

Lymph nodes of neckTest if skilled Hearing with audiometer Middle ear function with tympanometer

Nose and sinusesInspect The external surface of the nose

Is the nose patent? (can the patient breath through their nose?) Frontal and maxillary sinuses Is there any discharge / foreign body?

Palpate Frontal and maxillary sinuses (above eyebrow and each side of nose tocheeks)

Percuss Frontal and maxillary sinuses (above eyebrow and each side of nose tocheeks). Tap middle finger of one hand to the middle finger of other handplaced over the sinus. Does it make a dull or hallow sound?

Mouth and throatInspect Note breath odour

Lips, mucosa of mouth Gums, hard and soft palate (if applicable) Tongue ask the patient to stick their tongue out Tonsils swollen, red? Ask the patient if they have any trouble with taste? swallow? gagging?

reflux?Palpate Lips and mouth if indicated


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Neck Inspect Skin of neck colour, lesions

Muscles of neck are they extended? The trachea is it central? to one side? The thyroid is it enlarged? The lymph nodes / glands in front of the ears, behind the ears, under

jaw, chin, lower jaw, tonsillar area, above and below claviclePalpate Muscles of the neck, is there any swelling? can the patient lift their

shoulders? The trachea The carotid arteries one at a time The thyroid stand in front or behind patient and feel The lymph nodes / glands in front of the ears, behind the ears, under

jaw, chin, lower jaw, tonsillar area, above and below clavicleIf skilled Inspect the jugular vein for distension, and estimate the venous pressure (JVP)

if indicatedArms & hands Inspect Nail bed colour pink, blue? Shape clubbing can occur as a result of

long term hypoxia Muscle size, upper and lower arm Presence of lesions

Palpate Texture of nail bed or nail Joints of fingers, writs, elbows and shoulders Temperature Radial and brachial pulses

Assess Range of motion and strength of fingers, wrists, elbows and shouldersIf skilled

Capillary refill

Assess capillary refill on nail bed as an indication of peripheral circulation Check capillary refill by pressing on the nail until blanching occurs.

Release the nail and count the time for the nail to return to its previouscolour. Check capillary refill on all extremities

Normal capillary refill is 2- 3 sec. A delayed capillary refill may occur withheart failure, shock or peripheral vascular disease

Upper back of chest (posterior thorax) Inspect Cervical, thoracic, lumbar spine

Size and shape of chest wall

Size, shape and position of shoulders, scapulaAuscultate The posterior thorax and lateral thorax (chest)Palpate Cervical, thoracic, lumbar spinePercuss The posterior thorax and lateral thorax (chest)If skilled Palpate the thyroid (posterior approach)

Perform diaphragmatic expansion -is there equal expansion of both sidesUpper front of chest (anterior thorax) Inspect Size, shape of chest wall

Angle of ribs, intercostal spaces Muscles used for respiration, is the sternum being retracted? muscles

between ribs? muscles of neck? Respirations Count the respirations (One breath in and out = 1 bpm)


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Auscultate The anterior thorax (chest wall)Palpate The anterior thorax (chest wall)Percuss The anterior thorax (chest wall)If skilled Perform anterior thoracic expansion-is there equal expansion of both

sides?Heart Inspect Chest wall, pulses in neckAuscultate (with bellof stethoscope)

The apical (apex) of the heart Describe, sounds rhythm, rate Count the pulse

If skilled Palpate the cardiac landmarks for pulsations, thrills, and heavesFemale breasts as appropriate to presentation by skilled practitioner Inspect Breasts for colour, size, shape, equal on both sides? Any obvious

discharge? Lesions / thickening / oedema

Palpate Both breasts and Lymph nodes under arm, pectoral, clavicle

If skilled Teach breast self examinationMale breasts as appropriate to presentation by skilled practitioner Inspect Breasts for colour, size, shape, equal on both sides? Any obvious

discharge? Lesions / thickening / oedema

Palpate Both breasts Lymph nodes under arm, pectoral, clavicle

If skilled Teach breast self examination

Abdomen Inspect The size, shape, colour and pigmentation Note scars, stretch marks, visible peristalsis, masses, pulsation Umbilicus

Auscultate Bowel sounds - describePercuss Quadrants of the abdomen

Note liver span and descent Spleen, stomach and bladder

Palpate Palpate lightly all quadrants of the abdomen Note any guarding Palpate (deeply) if skilled Liver, spleen, kidney, aorta and bladder

Inguinal area Inspect Inguinal lymph nodes

For inguinal herniasPalpate Inguinal lymph nodes

Femoral pulsesLegs and feetInspect Colour, oedema, lesions, scars, hair distribution, varicose veins

Muscle size upper and lower leg and feet are they equal?Palpate Temperature, oedema,

Texture skin and nails Pulses popliteal, dorsalis pedis, posterior tibial pulses


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Muscles legs and feet Joints of the hips, knees, ankles and feet

Assess Range of movement hips, knees, ankles and feetIf skilled Check capillary refill (as per arms & hands)Female genitalia, anus and rectum as appropriate to presentation by skilled practitioner See Health Check Women Male genitalia as appropriate to presentation by skilled practitioner Inspect Hair distribution, penis, scrotum

Urethral meatus for discharge, location on head of penisPalpate Penis, urethral meatus and scrotum

Inguinal area for herniasIf skilled Teach testicular self examinationMale anus, rectum and prostate as appropriate to presentation by skilled practitioner Inspect The perineum, sacrococcygeal area, anal mucosaPalpate (if skilled) The anus, rectum and prostate

Diagnostic and pathology servicesDiagnostic and pathology services are limited in rural and remote facilities.

Patients may be required to travel in order to access some diagnostic services.Visiting outreach services including those provided by the RFDS may also bring portablediagnostic devices to the patient.

Refer to the current edition of the Pathology Handbook for Rural and Remote Queenslandfor information on ordering of pathology tests, labelling, collection of specimens,pre-laboratory processing, transport of specimens and accessing of results.

It is very important when diagnostic tests have been performed that the results arefollowed up, the patient informed of the results and abnormal results acted on. Consult aMedical Officer for advice if unsure about results. MO must review all abnormal results.

Collaboration with other members of the team

To ensure the patient receives the appropriate care for their condition, collaborating withother members of the team, often by remote consultation, is required.

Collaborative practice is the term used to describe the practice relationship between Registered

Nurses, Medical Practitioners, Aboriginal and Torres Strait Islander Health Workers and otherhealth professionals who use the PCCM as a guide to practice. The collaborative practicerelationship incorporates the dual notions of collaboration and delegation.

The defining characteristics of the collaborative practice relationship are: Mutual respect and acknowledgment of each professions role, scope of practice and

unique contribution to health outcomes Clearly stated protocols and guidelines for clinical decision-making which comply with

relevant legislation and are supported by the health facility and the health organisation Clearly defined levels of accountability with an acceptance that joint clinical decision-

making is an integral component of collaborative practice A belief that the best health outcomes are achieved when well prepared healthprofessionals work in collaboration and partnership in both the practice and

educational setting


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Royal Flying Doctor Service (RFDS)and

Queensland Emergency Medical System (QEMS) Coordination Centres

Queensland RFDS is part of the Queensland Emergency Medical System (QEMS) withQueensland Health (QH), Queensland Ambulance Service (QAS) and Queensland

Department of Emergency Services (DES). This integrated system includes roadtransport, rotary and fixed wing aircraft and reduces the impact of time and distance on thetreatment of sick and injured patients living, working or travelling in Queensland.

Queensland RFDS provides services from its network of strategically located Bases inBrisbane, Bundaberg, Cairns, Charleville, Longreach, Mt Isa, Rockhampton andTownsville. All RFDS Bases in Queensland, except Longreach provide aero-medicalretrieval / transport service. The RFDS Longreach base provides mental health service topeople living in central western Queensland.

Fixed-wing RFDS aircraft based in Cairns, Charleville and Mt Isa are coordinated byRFDS Medical Officers. Fixed-wing RFDS aircraft based in Brisbane, Bundaberg,Rockhampton and Townsville are coordinated by the QEMS Coordination Centres (QCC).

The QCC is a collaboration between Queensland Healths Retrieval Services Queensland(RSQ) and the Department of Emergency Services QAS. With centres in Brisbane andTownsville, the QCC has oversight for all Primary (000) and Interfacility aeromedicalretrievals and transfers of adult, paediatric, neonatal and high risk obstetric patientsthroughout Queensland. RSQ Medical Coordinators provide clinical guidance in retrievaldecisions and clinical support to referring clinicians regarding patients requiring aero-medical and some road transfers.

RFDS Mission StatementProviding excellence in aeromedical and primary health care across Australia

Services provided by RFDS (Queensland Section)

1. Provision of routine and emergency medical advice and clinical support to RegisteredNurses and Aboriginal and Torres Strait Islander Health Workers

Routine and emergency medical advice can be obtained 24 hours a day fromyour nearest RFDS Base with RFDS Medical Officers (Cairns, Charleville andMt Isa ) by telephoning one of the contact numbers

Rural and Isolated Practice Endorsed Registered Nurses and AuthorisedAboriginal and Torres Strait Islander Health Workers should consult with theappropriate local Medical Officer or nearest RFDS Medical Officer as stipulatedby Health Management Protocol (HMP) and Clinical Care Guideline (CCG)detailed in the PCCM. Other Registered Nurses are encouraged to use thePCCM as a guide to their practice and consult as required and in accordancewith Health (Drugs and Poisons) Regulation 1996

All requests for medical advice should be accompanied by clear presentation ofan appropriate history and examination, including basic observations as detailedin clinical assessment and history taking section of the PCCM. It is preferable tohave the patient present in case further information is required by the Medical

Officer


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Patient assessment and transport In rural and remote areas of north and western Queensland the RFDS also

provides primary care services through a network of clinic locations. Cliniclocations range from Queensland Health facilities with no resident doctor, tosmall isolated properties and mines

2. Provision of advice regarding patient retrieval and transport Health professionals unsure of the patient transport requirements may seek the

advice of an RFDS Medical Officer (Cairns, Charleville, Mt Isa) or RSQ MedicalCoordinator (Brisbane, Townsville). In most cases there are several options formanagement and several potential methods of transport which can be explored.All RFDS Medical Officers and RSQ Medical Coordinators are experienced inproviding this kind of practical support

It is preferable to make contact early, even if transport requirement is notconfirmed, as this allows more efficient use of resources

3. Coordination of patient retrieval and transport using RFDS aircraft (and otheravailable resources)

RFDS Medical Officers and RSQ Medical Coordinators are able to task RFDSfixed wing aircraft or make use of other available resources as appropriate. Allpatient transports are prioritised according to clinical need and availability of localresources. Less urgent cases may be delayed to facilitate the transfer of urgentcases from other locations

Consulting the Medical Officer

If it is necessary to consult with a Medical Officer (MO), try to present your findings in aclear and methodical way.

It is often easier if you write your findings down first (time permitting) It is helpful to advise the MO early that you have a patient about whom you want someadvice or alternately who you think may need evacuation

Begin with the name and age of the patient, then the presenting concern and proceedthrough the patient history, clinical observations and physical examination findings

Say what you think is wrong your assessment is important; after all, you are actuallywith the patient

Always consult with the MO if you are not sure. Take the opportunity to discussgeneral or specific cases or issues with the MO at the next clinic visit

What to tell the RFDS Medical Officer or RSQ Medical Coordinator

1. Appropriate clinical information: Patient name, DOB, gender, weight, specific location Details of patient history obtained including current medications & allergies Clinical observations, physical examination and investigation findings Management commenced, including drugs administered and infusions in

progress Intravenous lines, drains, catheters, splints, dressings


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2. Change in clinical condition: Please inform the RFDS Medical Officer or RSQ Medical Coordinator of any

change to the clinical condition of the patient (worsening or improving) in orderthat flight priority can be appropriately reassessed.

Note : a MO does not accompany all RFDS flights. If a patients condition worsensit may be necessary for an MO to accompany the flight when it was not originallyplanned to do so.

3. Admission details If the referring health professional is a Registered Nurse (RN) / Aboriginal and

Torres Strait Islander Health Worker (IHW), the RFDS Medical Officer or RSQMedical Coordinator will organise admission to an appropriate facility. Otherwise,the following information is also required: reason for inter-hospital transfer receiving hospital and unit (bed availability must be confirmed prior to transfer) name of accepting doctor

What the RFDS Medical Officer or RSQ Medical Coordinator will tell you1. Requirements

The RFDS Medical Officer or RSQ Medical Coordinator will discuss the patient andconfirm any requirements. Please ask if there is anything you are unsure about

2. TimeframeA planned time frame will be given but accurate estimated time of arrival (ETA) will not be confirmed until the aircraft is in flight . Retrievals and patient transports areprioritised and timing is subject to amendment

3. PriorityYou will be informed of significant change to planned activity such as anothermore urgent case taking priority

How to prepare a patient for transport

1. General Considerations All patients must be adequately prepared and stabilised prior to transport. In many

cases this can be done prior to arrival of the RFDS team Please discuss with the RFDS Medical Officer or RSQ Medical Coordinator as

required

Complete the RFDS Aeromedical Retrieval Checklist. This is to be completedfor all patients requiring transport with the RFDS

2. Specific Clinical Conditions Many patients require preparation specific to transport and the aero-medical

environment. The following table illustrates some clinical conditions of particularimportance.

Please discuss with the RFDS Medical Officer or RSQ Medical Coordinator asrequired.See following table for further detail.


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Patient assessment and transport GeneralConsiderations Rationale Requirement

Documentation

Documentation isrequired by the flightcrew and by thereceiving facility in orderto provide appropriateongoing care

All patients must be accompanied byappropriate documentation including: referral letter copy of medical / nursing records pathology results ECG print out X-rays(where digital radiology is available, ifpossible, ensure the electronic transferof x-rays to the receiving facility hasoccurred)

Analgesia

Any transfer involvesmovement of the patient,which may exacerbatepain

The patient should receive analgesiaprior to transfer

See Pain management inter-facilitytransfer HMP or consult MO

Antiemetic

Vomiting willpotentially exacerbatecertain clinicalconditions by raisingintracranial andintraocular pressureand placing the airwayat risk

Motion sickness iscommon in the aero-medical environment

Routine use of antiemetics is notindicated

Antiemetics considered if there historyof motion sickness

Promethazine or prochlorperazine ispreferred for motion sickness given 30minutes prior to transfer

Parenteral administration of anantiemetic is essential for patients withhead, spinal injury or penetrating eye

injury For general nausea consider

metoclopramide or ondansetron Consult MO

Parenteraldrug

infusion

The RFDS carries acomprehensive butlimited range of drugs

Infusions areadministered usinginfusion pumps orsyringe pumps. Timeis saved if infusion isprepared prior toRFDS arrival

Please prepare infusions prior totransfer using RFDS compatibleequipment if possible

Nasogastriccatheter

Nasogastric / orogastriccatheters allow drainageof stomach contents andreduce the risk ofvomiting and aspiration

All ventilated patients andpatients with bowel obstruction shouldhave an NGT/OGT inserted andsecured prior to transfer

Conscious, alert and cooperativespinal injured patients do not require anasogastric tube

Consult MO


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GeneralConsiderations Rationale Requirement

Urinary

catheter

There are no toilet facilities onRFDS aircraft. The use ofbedpans is avoided due tolimitations of space and wastedisposal

A urinary catheter is required forall incontinent or potentiallyincontinent patients. Those whowear a continence pad may notrequire catheterisation

All patients should have theirbladders empty prior to transfer

Venouscannula

Venous access may bedifficult to achieve duringtransfer due to spacelimitations and turbulence

Critically ill and disturbed patientsshould have 2 patent IV cannulaeinserted and secured prior totransfer

The majority of patients shouldhave one IV cannula

Infectiousconditions

Confined space in the aircraft

limits the ability to isolatepatients with infectiousconditions

Advise RFDS Medical Officer/ RSQ

Nursing or RSQ MedicalCoordinators of infectious conditionswhen requesting aerial transfer

Patientescort

Seating availability is oftenlimited, particularly if morethan one patient is carried

There are strict weightrestrictions for take off andlanding which influenceamount of fuel andpassengers numbers

An escort will be carried if possible,at the discretion of the pilot

Baggage

Space and weightrestrictions limit thecapacity to carry baggage

Baggage is carried in thesame area as medicalequipment, which must beeasily accessible at alltimes

Maximum baggage allowance is 1small bag with a weight of 8 kg(B200 aircraft) and 5kg (PC12aircraft)

Medical aids and additionalbaggage will be carried at thepilots discretion

Handoverlocation

Where clinically appropriate,airport handover of the patientreduces time and increasesaircraft availability

Patients who have beenappropriately stabilised andprepared may be handed over tothe RFDS crew at the airport

Critical and unstable patients willbe retrieved from the healthfacility. Handover location will bediscussed during the coordinationprocess


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Special Considerations Rationale Requirement

Spinal injury

All patients with proven orsuspected spinal injuries aretransported on a vacuummattress

Insertion of a urinary catheter isnecessary to monitor urineoutput and maintainimmobilisation

All ventilated spinal injuredpatients require a nasogastrictube

A nasogastric tube should beconsidered for all spinal injuredpatients who are uncooperative orhave an altered level ofconsciousness. Consult MO

Bowelobstruction

Trapped gas will expand involume at altitude and causepain

A nasogastric catheter mayallow escape of trapped gas

and reduce vomiting

All patients with bowel obstructionshould have a nasogastriccatheter inserted. Leavenasogastric tube on free drainageor attach anti-reflux valve. Do notspigot nasogastric tube

Administer parenteral antiemeticas indicated and adequateanalgesia prior to transfer

Pneumothorax

Trapped gas in the pleuralcavity will expand at altitudeand may result in respiratorycompromise (Underwater sealdrains are avoided due to therisk of retrograde flow duringtransfer)

All patients with provenpneumothorax should have anintercostal catheter inserted andconnected to a Heimlich valve orPortex ambulatory chest drainagesystem. Suspected pneumothorax must be excluded by X-ray

Penetrating eyeinjury

Trapped gas in the globe willexpand at altitude andpotentially worsen the injury

Vomiting may also worseninjury by raising intraocularpressure

All patients with proven or

suspected penetrating eye injurymust receive a parenteralantiemetic

They will be transported atreduced cabin altitude

Mental illness

Mental health emergencypatients are a potential threat to

aviation safety Appropriate physical +/-

chemical restraint is used toreduce this threat

Mental health emergency patientsare transported in daylight hourswith no other patients on board theaircraft. They require physicalrestraint and reliable intravenous

access +/- appropriate sedation A Medical Officer or additional

escort trained in restraint is alsorequired

All cases must be discussed in fullwith the RFDS Medical Officer orRSQ Medical Coordinator


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Special Considerations Rationale Requirement

Women inlabour

An aircraft is not anappropriate place fordelivery

Transport may occur iflabour is suppressed,otherwise it may be moreappropriate to deliverlocally and transport motherand baby as required

All cases must be discussed in fullwith the RFDS Medical Officer orRSQ Medical Coordinator

Anaemia

Anaemia reduces theoxygen carrying capacity ofthe blood. This isexacerbated at altitude dueto the reduced partialpressure of oxygen

Patients with haemoglobinconcentration of less than 70 g/Lshould ideally be transfused prior totransfer. All cases must bediscussed in full with the RFDSMedical Officer or RSQ MedicalCoordinator

References

1. Queensland Nursing Council. Professional documentation standards information sheet no. 3 . 2005 [cited 10/6/09]; Available from: www.qnc.qld.gov.au.

2. Estes M and Schaefer KP, Health assessment & physical examination . 2nd ed. 2002,Albany, NY: Delmar.3. Therapeutic Guidelines, Trauma primary survey: initial neurological assessment .

2008, Therapeutic Guidelines Ltd: Melbourne.


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Patient assessment and transport If required, originals of this document can be obtained from your nearest RFDS service


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Pain management for inter-facility transfer(Adult)

This HMP is for inter-facility transfers initiated by a Medical Officer within anIsolated Practice Area as defined by the Health (Drugs and poisons) Regulation1996Recommend

Where a clinical condition has been identified follow the appropriate HMPPatients in pain receive analgesia in a timely and safe manner to achieve comfortThe aim of pain control is to achieve patient comfort, it is not always possible toachieve a pain score of 0 and patients are often comfortable with a pain score of 0 3, thus it is appropriate to ask the patient are you comfortable rather than are you inpain ie do not give the expectation of achieving zero pain.Pain intensity the best scientific tool for measuring pain intensity is the patients selfreport using a pain rating scale. The most commonly used measurement tool is thenumeric pain score 0-10. The self reported pain score is used in conjunction withclinical assessmentResearch indicates that the elderly may find it easier to describe their pain as mild,moderate or severe, rather than using a numerical pain score.

BackgroundPain is defined as an unpleasant sensory and emotional experience associated withactual or potential tissue damage, or described in terms of such damage. [1] Pain ishighly subjective to the individual experiencing it and is the most frequent reason forpeople seeking health care professional consultation.

Related topics:Glasgow coma scale, page 15

Poisoning and drug emergencies (Opiates), page 194

1. May present with: Self report of pain Pre-existing medical condition causing pain Increased heart rate, respiratory rate and blood pressure History of pain related to medical condition Pallor, muscle tension/guarding, sweating Dilated pupils Nausea/vomiting Emotional responses (crying, screaming, anger, grimacing)

2. Immediate management: Identify the patients self reported level of pain 1-10 and pre-existing medical

condition / complaint

No pain M i l d M o d e r a t e S e v e r e Worst possible pain

0 1 2 3 4 5 6 7 8 9 10


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3. Clinical assessment: Obtain patient history including presenting complaint e.g. cancer patient Perform standard clinical observations + Glasgow coma scale (GCS) Inspect the size of the patients pupils Is the patient able to swallow? Do they have a patent IV cannula insitu?

Obtain history of current episode of pain onset and duration (when did it start? gradual or sudden onset?) duration (how long has the patient had the pain? have they experienced

pain like this before?) intensity (using a scale of 1-10 with 0 being no pain and 10 being the

worst pain you can imagine, rate the pain you are experiencing now? [2] site and radiation (eg. where is the pain? Does the pain go elsewhere?) character (eg. sharp pain, dull pain, burning pain) associated features (eg. nausea, vomiting) what makes it better or worse (eg. Lying down, sitting up)

Previous methods / analgesics used to control pain? what has worked / whathasnt? has there been any side effects?

Take medication history current medications / allergies / is the patient takingany over the counter medications?

4. Management: Perform GCS, BP, pulse, respirations and pain score and sedation score prior to

and post administration of analgesia If further doses are required, GCS must be 14 or above, systolic blood pressure

>90mmHg, respiratory rate >10 and sedation score 1 or less prior to each dose Consult MO if observations outside these parameters If patient develops a depressed level of consciousness, respiratory depression

or severe hypotension following the administration of Morphine or Fentanyl seePoisoning and drug emergencies (opiates)

Monitor vital signs, pain score and sedation scores at intervals appropriate to

analgesia givenPain score 1-3, and clinical assessment indicates mild pain . If not allergicconsider paracetamol (paracetamol is rapidly absorbed after oral administration, witha peak concentration in 10 to 60 minutes)

Sedation Score0 = awake1 = mildly drowsy, responsive to voice stimuli2 = moderately drowsy, responds to touch only3 = severely drowsy, not responding


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Schedule 2 Paracetamol DTPNP / IHWAuthorised Indigenous Health Workers may proceedNurse Practitioner may proceed

Form Strength Route of Administration Recommended Dosage Duration

Tablet 500mg Oral Adults:1-2 tabs every 4hrs to maximum 8tabs/day

Stat and as orderedby MO or NP up to48 hours only

Provide Consumer Medicine Information if available:Management of Associated Emergency: Consult MO

ORPain score 4-6, and clinical assessment indicates moderate pain . If not allergicconsider give paracetamol 500mg / codeine phosphate 30mgs . (Codeine is wellabsorbed from the gastrointestinal track peak onset of action is 1-2 hours). [3]

And / or If not allergic and does not have asthma, renal disease, heart disease, GI bleedingconditions, dehydration, in the 3 rd trimester of pregnancy, lactation, significant liverdisease or coagulation disorder or on ACE-inhibitors, diuretics, warfarin, lithiumconsider Ibuprofen

Schedule 4 Ibuprofen DTPNP / IHWAuthorised Indigenous Health Workers may proceedNurse Practitioner may proceed

Form Strength Route of AdministrationRecommended

Dosage Duration

Tablet 400mg Oral Adult: 400 mg Stat and repeat in 6hours if required

Precautions do not use in patients with - asthma, renal disease, heart disease, GI bleedingconditions, dehydration, in the 3 rd trimester of pregnancy, lactation, or on ACE-inhibitors, diuretics,warfarin, lithiumProvide Consumer Medicine Information if availableManagement of Associated Emergency: Consult MO see Poisoning: Opiates HMP

Schedule 4 Paracetamol 500mg /

codeine phosphate 30mg

DTP

NP / RIN / IHWAuthorised Indigenous Health Workers & Isolated Area Paramedics must consult MORural and isolated practice nurses may proceedNurse Practitioner may proceed

Form Strength Route of AdministrationRecommended

Dosage Duration

Tablet Paracetamol500mg / CodeinePhosphate 30mg

Oral Adult: 1-2 tabs Stat and repeat in 4hours if required

Precautions CNS depressantProvide Consumer Medicine Information if available : may cause drowsiness, GI upset, nausea /vomiting, constipation, dizziness, bronchospasmManagement of Associated Emergency: Consult MO see Poisoning: Opiates HMP


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If allergic to Morphine or significant renal disease give Fentanyl: N.B. Fentanyl has a rapidonset of action

Schedule 8 Fentanyl DTPIHW / RIN / NPAuthorised Indigenous Health Workers must consult MORural and Isolated Practice Endorsed Registered Nurses may proceedNurse Practitioners may proceed

Form Strength Route of Administration Recommended Dosage Duration

Ampoule 100microgram/2 mL

IM Adults only:1.5micrograms / kg / dose upto a maximum of 100microgram

Stat. Consult the MO if the patient requiresmore than therecommended dose


IV(IHW may notadminister IV)

Adults only:25 microgramincrements slowly,repeated every 10 min if required to a max. of 100microgram



Intranasal Adult only1.5 microgram/kgundiluted up to a maximumof 100 microgram


Administration instructions for intranasal fentanyl. Draw up dose into 1ml or 2 ml syringe. If using amucosal atomisation device (MAD) attach to the syringe. Position patient sitting up at a 45 degreeangle or with head resting to one side. Position the atomiser or syringe into the nostril loosely, aimingfor the centre of the nasal cavity. Depress the syringe plunger quickly. If 100microgram / 2 ml is beingused split the dose between both nostrils to minimise loss due to sneezing or swallowing.Intranasal fentanyl may be unreliable if patient has blocked nose .Provide Consumer Medicine Information if available: Advise can cause nausea and vomiting, drowsinessManagement of Associated Emergency:Respiratory depression is rare. If it should occur give Naloxone as per Poisoning: Opiates HMP NB: asNaloxone counteracts the narcotic, it may cause the return of severe pain

5. Follow up:Monitor patients response to analgesia and document vital signs including GCS, BP,pulse and respirations, pain and sedation scoreIf sedation score is 3 or respiratory rate < 8 administer Naloxone give O via Hudsonmask and consider need to assisted ventilation ie bag/valve/mask.

6. Referral / Consultation:Consult MO if further analgesia is required and maximum dose has been administered

References1. International Association for the Study of Pain Subcommittee on Taxonomy, Classification of

chronic pain syndromes and definitions of pain terms. Pain, 1986. 3(Suppl. 3): p. S1-S226.2. Estes M and Schaefer KP, Health assessment & physical examination . 2nd ed. 2002,

Albany, NY: Delmar.3. MIMS Online. Prescribing information . 2009 [cited 14/5/09]; Available from: https://www-

mims-hcn-net-au.

australia-queensland-6th edition primary clinical care manual 2009 - section 1 - patient assessment...

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