airway management - shenandoah county · 2011-10-13 · chapter 6 airway management limmer et al.,...
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CHAPTER 6
Airway Management
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Management
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Review of theReview of theRespiratory SystemRespiratory System
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Respiratory SystemRespiratory System
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RespiratoryRespiratorySystemSystem
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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The respiratory system’s main function:The respiratory system’s main function:
ExhalationExhalationInhalationInhalation
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Adequate breathing?
or
Respiratory AssessmentDetermination
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
or
Inadequate breathing?
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Signs of Adequate Breathing
Look
Does chest rise and fall equally?
What is the skin color?
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Listen
Does air pass easily through nose & mouth?
Any abnormal noises in lungs?
Continued…
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Signs of Adequate Breathing
Feel
Can you feel air moving in and out of nose and mouth?
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Adequate Breathing:Normal Rates
Adults
12–20/min.
Children
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Children
15–30/min.
Infant
25–50/min.
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Adequate Breathing
Rhythm
Usually regular
Quality
Breath sounds present and equal
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Breath sounds present and equal
Minimal effort
Depth
Chest expands adequately and equally
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Critical Findings
Respiratory Failure
Oxygen intake not enough to
support life
Inadequate Breathing
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
support life
Respiratory Arrest
Breathing stops completely
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Inadequate Breathing
Rate
Outside normal range (fast or slow)
Rhythm
Regular or irregular
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Regular or irregular
Depth
Chest expansion shallow
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Inadequate Breathing
Quality
Abnormal breath sounds (Noisy,
diminished, or absent)
Chest expansion unequal
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Increased breathing effort
Skin
Pale, cyanotic, cool, or clammy
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Nasal flaring
See-saw breathing
Inadequate Breathing:
Infants and Children
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
See-saw breathing
Retractions
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Child vs. Adult AirwayChild vs. Adult Airway
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Opening the AirwayOpening the Airway
Goal is to establish and maintain a patent (clear and open) airway!
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
patent (clear and open) airway!
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HeadHead--Tilt, ChinTilt, Chin--Lift ManeuverLift Maneuver
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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JawJaw--Thrust ManeuverThrust Maneuver
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Techniques ofTechniques ofArtificialArtificial
VentilationVentilation
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
VentilationVentilation
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Methods of Artificial Ventilation
1. Mouth-to-mask
2. Two-person bag-valve mask
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
3. Flow-restricted, oxygen-powered
ventilation device
4. One-person bag-valve mask
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Pocket Masks
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Adult, Child, & Pediatric Bag- Valve Masks
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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BagBag--Valve Mask ComponentsValve Mask Components(Also known as a bag mask or bag(Also known as a bag mask or bag--mask device)mask device)
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Open the airwayOpen the airwaywith the headwith the head--tilt,tilt,chinchin--lift techniquelift technique(if no suspected(if no suspected
trauma).trauma).
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Select mask of correct size.Select mask of correct size.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Position yourself behind the patient’s head.Position yourself behind the patient’s head.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Hold the mask with your thumbs over Hold the mask with your thumbs over the top half and your index and middle the top half and your index and middle fingers over the bottom half.fingers over the bottom half.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Place the top of the mask over the Place the top of the mask over the patient’s nose and lower the bottom half patient’s nose and lower the bottom half of the mask over the mouth and chin.of the mask over the mouth and chin.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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If the mask has a large round cuff aroundIf the mask has a large round cuff aroundthe ventilation port, center the port overthe ventilation port, center the port overthe patient’s mouth.the patient’s mouth.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Use your ring and little fingers to lift the Use your ring and little fingers to lift the chin and maintain the head tilt.chin and maintain the head tilt.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Attach to oxygen at 15 lpm and have an Attach to oxygen at 15 lpm and have an assistant squeeze the bag once every 5 assistant squeeze the bag once every 5 seconds seconds (3 seconds for a child or infant).
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Mouth to Mask Method
Attach oxygen to mask at 15 lpm
(if available).
Follow same steps as BVM to
obtain a seal with mask.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
obtain a seal with mask.
Slowly exhale for 1½ to 2
seconds (1 to 1½ seconds in infants and
children).
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MouthMouth--toto--Mask VentilationMask Ventilation
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Bag-Valve Mask (Trauma)
Same as for medical applications,
EXCEPT:
Use jaw-thrust technique.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Do not tilt head or neck.
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Using a BagUsing a Bag--Valve Mask when Trauma Is Valve Mask when Trauma Is SuspectedSuspected
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Chest does not rise and fall.
Ventilating too slowly or too fast.
Signs of Inadequate Artificial Ventilation
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Heart rate does not return to
normal.
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If no chest rise…
Reposition head.
Check for seal at mask and no air
leaks.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Check for blockages in BVM or
tubing.
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If chest still does not rise, try a
pocket mask or manually triggered
device.
If no chest rise…
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Ventilating through a Stoma orVentilating through a Stoma orTracheotomy TubeTracheotomy Tube
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OpeningOpening
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Ventilating a Stoma
Clear any secretions in stoma
(most common problem).
Place head in a neutral position.
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Choose a pedi size mask.
Ventilate at age-appropriate rate.
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If unable to ventilate, suction.If unable to ventilate, suction.
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Aspiration of Stoma Aspiration of Tube
(Insert 3–5 inches.)
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If no chest rise…
If air escapes from the mouth and/or nose when ventilating via stoma, seal the mouth and nose.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
stoma, seal the mouth and nose.
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Flow-Restricted, Oxygen-Powered Ventilation Device
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Flow-Restricted, Oxygen-Powered Ventilation Device (FROPVD)
Peak flow rate of 40 lpm.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Pressure relief valve that opens at
60 cm water (audible alarm also
sounds).
Use on adult patients only.
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Open airway and apply mask just as withOpen airway and apply mask just as withbagbag--valve mask. Trigger device until chestvalve mask. Trigger device until chestrises. Repeat every 5 seconds.rises. Repeat every 5 seconds.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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If no chest rise…
Reposition head.
Check for seal at mask and no air
leaks.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Check for blockages.
Consider alternate devices.
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FROPVD (Trauma)
Same as for medical applications,
EXCEPT:
Use jaw-thrust technique.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Do not tilt head or neck.
Use extreme caution to not worsen
chest injuries with overinflation.
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Airway AdjunctsAirway Adjuncts
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Open airway manually first.
Ensure there is no gag reflex for
oral airway, no possible skull
fracture for nasal airway.
Rules for Airway Adjuncts
Limmer et al., Emergency Care Update, 10th Edition
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fracture for nasal airway.
Maintain manual airway method
even with airway in place.
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Do not force tongue into pharynx.
Have suction available.
Remove adjunct if patient gags or
Rules for Airway Adjuncts
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Remove adjunct if patient gags or
regains consciousness.
Maintain infection control.
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Oropharyngeal Oropharyngeal (Oral) Airways(Oral) Airways
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
(Oral) Airways(Oral) Airways
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An oral airway can help prevent the An oral airway can help prevent the tongue from obstructing the airway of an tongue from obstructing the airway of an unresponsive patient without a gag reflex.unresponsive patient without a gag reflex.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Measure for the correct size.Measure for the correct size.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Open the mouth and insert the airway Open the mouth and insert the airway with tip towards roof of the mouth.with tip towards roof of the mouth.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Insert airway along hard palate untilInsert airway along hard palate untilyou reach the soft palate, then rotate 180you reach the soft palate, then rotate 180°°..
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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You can also insert an oral airway right-
side-up, IF you use a tongue depressor
to press the tongue down and forward.
If adjunct seems too long or short,
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
If adjunct seems too long or short,
remove it and select a better size.
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Nasopharyngeal Nasopharyngeal (Nasal) Airways(Nasal) Airways
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
(Nasal) Airways(Nasal) Airways
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Choose the correct size.Choose the correct size.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Lubricate the airway.Lubricate the airway.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Insert the airway posteriorly. If it doesInsert the airway posteriorly. If it doesnot advance, try the other nostril.not advance, try the other nostril.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Techniques ofTechniques ofSuctioningSuctioning
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
SuctioningSuctioning
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To remove blood, other liquids, and
food from the airway
Purpose of Suctioning:
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
WHEN YOU HEAR GURGLING,
SUCTION!
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Types of Suction UnitsTypes of Suction Units
Oxygen-PoweredBattery-Powered
Limmer et al., Emergency Care Update, 10th Edition
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Mounted
Oxygen-PoweredBattery-Powered
Manual Suction
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Suction Catheters
Hard
Useful for most secretions
Soft
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
SoftUseful for nasopharynx and when
hard catheter won’t work
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Always use infection control
measures
Suction for no more than 15
seconds at a time (fewer in
Rules of Suctioning
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
seconds at a time (fewer in
children and infants)
Place tip of catheter where you
want to begin suctioning, and
suction on way out
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Body Substance Isolation EquipmentBody Substance Isolation Equipment
Limmer et al., Emergency Care Update, 10th Edition
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Inspect and test suction unit Inspect and test suction unit beforebefore you you need it.need it.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Position the patient and yourself properly.Position the patient and yourself properly.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Open the patient’s mouth while protecting Open the patient’s mouth while protecting your fingers. your fingers.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Without Without suctioning, suctioning, insert hard insert hard catheter to catheter to base of base of tongue.tongue.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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If using a soft catheter, insert it only as If using a soft catheter, insert it only as far as the distance from the lips to the far as the distance from the lips to the earlobe or angle of the jaw.earlobe or angle of the jaw.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Once tip of catheter is in the right place, Once tip of catheter is in the right place, apply suction, move tip, and remove fluid apply suction, move tip, and remove fluid in airwayin airway
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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If Patient Is Producing Frothy Sputum
Remove catheter as fast as you can
Ventilate for 2 minutes and repeat
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Ventilate for 2 minutes and repeat
Transport promptly and consult
medical direction
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SupplementalSupplementalOxygenOxygen
Limmer et al., Emergency Care Update, 10th Edition
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Respiratory/cardiac arrest
Stroke
Shock
Conditions Requiring Oxygen
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Blood loss/Fractures
Many other conditions
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Portable Oxygen Cylinders
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Fixed Oxygen Cylinders
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An OxygenAn OxygenDelivery SystemDelivery System
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Position desired cylinder upright, stand toPosition desired cylinder upright, stand toone side, and remove the wrapper.one side, and remove the wrapper.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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If your system uses a replaceable washer,If your system uses a replaceable washer,keep it, and crack the cylinder’s valve for keep it, and crack the cylinder’s valve for 1 second.1 second.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Select the appropriate regulator.Select the appropriate regulator.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Place washer on regulator if appropriate,Place washer on regulator if appropriate,and turn flowmeter to zero or off.and turn flowmeter to zero or off.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Align pins or thread by hand.Align pins or thread by hand.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Tighten screw by hand or with a wrench.Tighten screw by hand or with a wrench.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Safety with Oxygen
Inspect before using
Use non-sparking wrenches.
Store and maintain cylinders properly.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Do not drop cylinders or leave
standing unsecured.
Do not smoke or use near open flame.
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Administering Oxygen
If the patient is not breathing, use
artificial ventilations.
If the patient is breathing and needs
supplemental oxygen, use:
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
supplemental oxygen, use:
Nonrebreather mask, OR
Nasal cannula
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Non-Rebreather Mask
Can deliver up to 90% oxygen
Must fill bag before placing mask on
patient
Use setting of 8-15 lpm
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Use setting of 8-15 lpm
Adult, child, & pediatric sizes
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Non-Rebreather Mask
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© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Explain procedures to patient and attach Explain procedures to patient and attach tubing to regulator.tubing to regulator.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Open valve, adjust flowmeter, fOpen valve, adjust flowmeter, fill bag of nonrebreather mask . . .
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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. . . and place mask on patient.. . . and place mask on patient.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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Adjust flowmeter . . .Adjust flowmeter . . .
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
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. . . and secure tank. . . and secure tank
Limmer et al., Emergency Care Update, 10th Edition
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Nasal Cannula
Delivers low-concentration oxygen
(24-44%)
Useful for patients who do not
tolerate mask
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
tolerate mask
Use a setting of 2-6 lpm
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Nasal Cannula
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SpecialSpecialConsiderationsConsiderations
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ConsiderationsConsiderations
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There are many blood vessels in the
face. This can lead to two problems:
Severe swelling from blunt injury
Facial Injuries
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Bleeding into the airway
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Foreign Body AirwayObstruction (FBAO)
When FBAO persists:
Perform 3 cycles of FBAO procedure.
Transport while performing additional
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
Transport while performing additional
attempts of FBAO procedure.
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Dentures
Leave in place under ordinary
circumstances; remove if it blocks
airway.
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
If a partial plate becomes loose,
leave it in place unless it causes a
problem.
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Avoid excessive hyperextension
when opening the airway.
Avoid excessive pressure when
ventilating.
Infants and Children
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
ventilating.
Gastric distention may be common.
Use properly sized BVM,
nonrebreather, and suction
equipment.
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1. Describe the steps involved in
normal inhalation and exhalation.
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
2. List the signs of adequate and
inadequate breathing.
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3. Describe how the airway of a child
or infant differs from an adult’s.
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
4. How can you tell if you are
adequately ventilating a patient?
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5. List the steps in using a suction
unit.
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
6. What are the best methods for
ventilating a patient?
7. Describe the steps in using a bag-
valve mask.
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8. What is different about
ventilating a patient who may
have sustained trauma?
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
9. How should you size and insert
an oral airway? A nasal airway?
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10. How much pressure is in a full
oxygen tank?
11. Describe how to change
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
11. Describe how to change
portable oxygen tanks.
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12. How should you administer
oxygen through a nonrebreather
mask?
Review Questions
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
mask?
13. What should you do if the FBAO
procedure is not working?
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What is your first priority when
STREET SCENESSTREET SCENES
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
What is your first priority when
starting to assess this patient?
What type of emergency care should
you be prepared to give?
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What equipment should you
STREET SCENESSTREET SCENES
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
What equipment should you
have taken into the house to
make sure you are properly
prepared for this call?
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What is the best way to determine if
STREET SCENESSTREET SCENES
Limmer et al., Emergency Care Update, 10th Edition
© 2007 by Pearson Education, Inc. Upper Saddle River, NJ
What is the best way to determine if
the ventilations are adequate?
What additional assessment should
be done on this patient?