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Vital signs
Psychological status
Position and thorough description of burn(s)
Signs of an infection (purulent drainage, strong aroma,
inflammation or swelling, etc. ) at or around burn site
Pain evaluation (position, nature, severity, etc. )
Any other wounds suffered at time of burn


Patient’s age and sex
Detailed explanation of how burn occurred,
especially if new
Outcomes of burn therapies to date
All current diagnoses
All current prescription drugs, including any recent
Any recent lab or diagnostic test results

First Degree
Pink to red, slight edema, which
decreases rapidly
Pain may last up to 48 hrs,
allayed by cooling
Sunburn is a common illustration

Second Degree
Pink or red; blisters (vesicles)
form; weeping, edematous,
and elastic
. Superficial layers of skin are
destroyed; would be moist and
Hair does not pull out easilv
Deep dermal:
Mottled white and red; edematous
reddened spots blanch on stress
May be yellowish, but delicate and
elastic – may or may not be sensitive
to contact; sensitive to cold air. Hair pulls out easily

3rd Degree
Damage of epithelial tissues; epidermis and dermis
destroyed. Reddened spots do not blanch
with pressure
Not painful; inelastic; pigmentation
ranges from waxy white to brownish;
leathery devitalized tissue is
referred to as eschar
Destruction of epithelium, fat
muscles and bone.


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Vital signs, including changes such as increased/decreased
pulse rate and tempo, blood pressure, and respiratory rate
Heart and lung evaluation, including any rales, wheezes,
rhonchi, labored inhaling and exhaling, jugular vein distension, and
peripheral edema
Stomach evaluation for epigastric discomfort to palpation
Pain assessment including quality (tightness or heaviness,
pressure, radiating localized, or vague discomfort), starting point and
length of the pain, and precipitating, irritating (such as
enhanced pain with motion or contact), and relieving components
Evidence of musculoskeletal discomfort
Signs of dizziness, palpitations, queasieness, or heartburn,
Skin (cool and clammy, diaphoretic)


Patient’s age and sex
Onset, timeframe, rate of recurrence, intensity of signs or symptoms
If continual, comparison of current to typical symptoms
Relieving factors (such as antacids or nitroglycerin, position
changes, etc. )
All current medications, including any recent adjustments
Relevant history of heart or GI troubles
All current diagnoses
Recent lab or diagnostic test results, including EKG results, if

Following the preliminary interventions, additional
information regarding chest pain can be obtained
by carrying out a heart and lung assessment.

Listen to the heart for a rate, rhythm and to see if there is a murmur. A murmur is a soothing-blowing;
swooshing sound that can be observed on the chest wall with a stethoscope.
When listening to sounds of the lungs you want to listen for:
Crackles: These are high pitched,
discontinuous noises similar to the sound
generated by rubbing your hair in between your fingers (also known as Rales).
Wheezes: These are normally high pitched and
“musical in quality. Stridor is am inspiratory
wheeze associated with upper airway
obstruction (croup).
Rhonchi: These often have a “snoring”, or
“gurgling” quality. Any extra sound that is not
a crackle or a wheeze is probably a rhonchi.
Look to see if the resident is short of breath or has an uncommon breathing pattern or is cyanotic.


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Vital signs
Any findings on assessment of known or suspected
site of infection
Evidence of sources of likely spread (f or
example, fecal incontinence, open wounds that
are not able to be contained, etc. )

Patient’s age and sex
Background on communicable illness (when
acquired, present and previous treatment, whether
severe or long-term, recurrent, colonization only, etc. )
Latest laboratory results (cultures, serology tests, chest
x-ray, etc. )
All present diagnoses
Level of the infection in the affected person, including
response to any treatments
Infection control precautions in use such as
isolation, if any

Since person-to-person spread can play a
significant role in the spread of some enteric
pathogens, hand hygiene is a vital element of
any outbreak prevention and control strategy.
Wash Your Hands The Right Way:
When cleansing hands with soap and water:
Wet your hands with clean running water and
apply soap. Use warm water if it is available.
Rub hands together to make a lather and clean
all surfaces.
Continue rubbing hands for 15-20 seconds.
Need a timer? Envision singing “Happy
Birthday” two times through to a close friend.
Rinse hands well under running water.
Dry your hands using a paper towel or air
dryer. Use a dry paper towel to turn off the
sink or use the backside of your hands.
Always use soap and water if your hands are
visibly soiled.
CDCG recommendations for Standard Safeguards:
http: //www. cdc. gov/hicpac/2 007IP /
2007isolationPrecautions. html
CDCH hand washing and Hand Sanitizer Recommendations:

http: //www. cdc. gov/cleanhands/.


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Vital signs
Neurological assessment, including any indicators of motor weakness,
facial weakness, lethargy, or significant change in functionality
Any indications of respiratory distress, O2 sat.
Indicators of nausea and vomiting
Blood sugar level (finger stick)
Signs of fluid discrepancy
Any signals or indications of acute infection (fever, chills, alterations
in urinary routine, etc. )
Indicators of bruising or other wounds
Pain assessment (location, nature, severity, etc. )
Examine and gather particulars of disposition, behavior orientation, and


Patient’s age and sex
Beginning, length of time, frequency of problem
Food and fluid ingestion habits over preceding 7 days
Full description of behavior in comparison to typical tendencies
All current prescription drugs, including any recent adjustments
Any history of acute or persistent psychiatric ailments
Current level of bowel and bladder function
Any recent background of fall, head trauma injury
Results from previous neurologic or psychiatric treatments
All present diagnoses
Any recent lab or diagnostic test results, including blood sugar,
if affected person is a diabetic

A commonly utilized instrument, the Confusion
Assessment Method (CAM) is based on
consideration of 11 different issues that lead to
answers to the following questions:
Is the change in mental status acute and does
it fluctuate all through the course of the day?
Does the patient have difficulty focusing
Is the patient’s speech disorganized or
Is the patient’s level of awareness altered?
The CAM Tool:
http: //conslutgerrin. org/uploads/File/trythis /
try_this_13. pdf.

Confusion among the elderly is a common problem. Delirium can be distinguished as having varying degrees of restlessness, agitation, confusion and possibly even abnormal behavior, hallucinations, delusions and illusions. Dementia has common features with delirium (disorientation, confusion, inability to stay focused, and coherent thinking). However, dementia is seen in those with a normal level of consciousness whereas those experiencing delirium have a clouding on consciousness. Other conditions such as depression and psychosis can also cause confusion, but disorientation and clouding of consciousness is not present. Clinicians must stay alert that agitated or aggressive behaviors may be associated with these conditions.

Be sure to see all confused patients immediately is they also have abnormal vital signs, their level of consciousness is decreased, there are agitated or are aggressive.


Is the patient acutely confused, and in what way? Does the confusion fluctuate during the day?
Or is there a depressed level of consciousness?
What is the recent change in the level of consciousness?
What are the other vital signs?
Have there been previous similar episodes?
Is the patient aggressive?
Is there an obvious reason for the patient’s behavior?
Is the patient diabetic?
What measures have been tried to reason or calm the patient?
Are staff or patients at risk of injury, or actually injured?
What additional personnel are there to help now?

Possible causes of confusion or a decreased level of consciousness

Head Trauma
Cerebral vasculitis
Wernicke encephalopathy
Vitamin B12 deficiency
Hypertensive encephalopathy
Primary dementias
Parkinson disease
Alcohol withdrawal
Narcotic and sedative drug excess or withdrawal. The elderly can experience confusion even with standard doses of these drugs.
Psychotropic medications
Miscellaneous (steroids, antihistamines, anticholinergics, NSAIDs)
Other poisoning (carbon monoxide, heavy metals, toxic alcohols, chronic silicylism)
Respiratory failure
Congestive heart failure
Renal failure
Liver failure
Hyperglycemia, hypoglycemia
Hypernatraemia, hyponatraemia
Hyperthyroidism or hypothyroidism
Mania, depression, schizophrenia – altered behavior
Personality disorders or traits – aggressive behavior
Pain, cold, urinary retention, bowel impaction, sudden decrease in vision or hearing, unfamiliar surroundings, bereavement/separation


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Vital signs
Neurological evaluation including any evidence
of motor weakness, facial weakness, listlessness,
substantial change in function
Signs or signs of acute infection (fever, chills,
etc. )
Explanation of present intestinal and bladder function
Any indicators of bruising or other injuries
Pain assessment (location, characteristics, severity, etc. )
Evaluate and obtain particulars of mood, behavior,
orientation, and alertness
Blood sugar level
O2 sats


Patient’s age and sex
All present medications, including any recent adjustments
Any history of severe or chronic psychiatric disorders
Any recent history of fall, head injury or injury
Conclusions from prior neurologic or psychiatric
All current diagnoses
Any recent laboratory or diagnostic test results, including
blood sugar if patient is a diabetic

Assess whether resident can comply with basic
Ask resident name, particular date/time, place
Evaluate the appropriateness of the verbal
Measure clearness of speech
Observe change in degree of consciousness such
Alert: conscious and responds appropriately
Lethargic: very tired, but arouses to
Stuperous: not completely alert, but responds
to discomfort
Comatose: is entirely unresponsive to
Glasgow Coma Scale (GCS) is a neurological
scale that aims to present a reliable, objective way
of recording the conscious state of a person for
initial, as well as future analysis.

http: //www. strokecenter. org/trials/scales/

glasgow_coma. pdf.


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When reporting the consultation report to the
practitioner, the information should contain (at a
Name of consultant and specialty
Reason for consultation
Report of f indings
lf the patient is going out for an appointment or
consultation, it is recommended that you send
the most recent lab results and diagnostic tests
with the patient. This is important for consistency
in information transfer with transitions of care.


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Vital signs
Neurological assessment, which includes any evidence of
considerable change in degree of consciousness
Particulars (location, length of time, severity, and
recurrence, etc. ) of any seizure activity, including
local or generalized motor activity, intestinal or
bladder incontinence, or behavior changes
Specifics of any injury or problems affiliated
with the convulsion or seizure


Patient’s age and sex
Any history of seizure disorder or actual seizure
All present prescription drugs, including any recent
adjustments, particularly medications affiliated with
enhanced seizure probability
All present diagnoses
Date and time of any recent or current seizure
Contrast of any current seizure activity related
to regular patterns
Relevant and recent laboratory or diagnostic examination results,
particularly BMP, calcium, and anticonvulsant blood

Nonspecific Hints That Suggest the Existence of
One or more of the subsequent clues may signify
the presence of seizures (although no single
clue indicates with confidence that seizures
are existing. ) In patients with moderate to
severe communication difficulties (aphasia,
cognitive impairment, language limitations, etc.),
it is important to observe and document these
nonspecific signs and to look for additional analysis
for possible seizures if any clues are observed.
These symptoms usually last a very brief time
(such as 2 minutes) in the course of a seizure; some
indicators may last for up to a weeks time after a
Become a Seizure Detective:
Altered mental state
Language changes (such as slurred speech)
Lapse of awareness
Memory disturbance
Inexplicable confusion
Unresponsive; staring off into the distance

Witnessing a patient experiencing a seizure may be very dramatic, but remember to stay calm as most seizures resolve on their own within 1 – 2 minutes. Be sure to see the patient who seized immediately, even if the patient has recovered.

QUESTIONS (may need to ask witnesses some questions)

Is the patient still having a seizure and how long has it lasted?
Patients who are actively having seizures are at risk of hypoxia, aspiration, metabolic acidosis, hyperpyrexia and cerebral oedema, ultimately leading to irreversible cellular damage.
What type of seizure was witnessed? Was the seizure generalized, tonic-clonic, or focal?
Was there a preceding aura of postictal drowsiness?
Was the patient incontinent of urine?
What is the blood pressure? (Palpate for the femoral pulse, which if present indicates a SBP of at least 70 mmHg. Sinus tachycardia and hypertension are common and usually settle over 10-30 minutes.)
What is the patient’s current level of consciousness?
Has there been any secondary damage (head, tongue, other injury)?
Does the patient look well (comfortable), sick (uncomfortable or distressed) or critical (about to die)?
What is the respiratory rate? (increased rate is normal as patient recovers)
What is the temperature? (A mildly raised temperature is usual, but should settle rapidly. A persistent temperature 38C requires a search for an infection. Perform blood cultures, CXR, MSU, CT, then LP. A temperature 39.5C indicates hyperthermia. Urgent cooling is necessary.)
What is the fingerprick glucose result? (Hypoglycemia must be treated.)


Syncopal episode
Narcolepsy, cataplexy (including following laughter)
Transient global amnesia
Movement disorder (e.g., hemiballismus, choreo-athetosis, tics, Tourette syndrome, myoclonic jerks)
Complicated migraine
Dystonic reaction
Carpopedal spasm from hyperventilation
Decerebrate posturing


Place the bed in the lowest position
Keep the side rails up and pad with a rolled-up towel or blanket
Provide a firm pillow, commence oxygen and keep suction handy
Keep the patient in bed until reviewed medically, in the lateral position to avoid aspiration
Provide direct supervision when the patient uses sharp objects


Cerebral oedema (if seizures continue more than 1 hour)

Moderate to severe communication problems (aphasia, cognitive impairment, language barriers, etc.) are considered nonspecific clues and should be observed and documented. If any clues are also observed, evaluate for possible seizures. The nonspecific and specific clues may only last 2 minutes during a seizure or may last up to a week after the seizure.


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Vital signs
Head, mouth/throat, teeth/gums evaluations, including indicators of
inflamed tongue, inflamed throat, dental or periodontal ailment,
nasal blockage or drainage, or sinus tenderness
Thorough outline of cough (dry hacking, productive)
Description of sputum, if productive
Respiratory examination, including dyspnea, wheezing, rales-rhonchi,
use of accessory muscles, any cyanosis
Soreness with coughing
O2 sats.
Any signs connected to the gastrointestinal (GI) tract, such as
epigastric discomfort or abdominal discomfort


Patient’s age and sex
Onset, length of time, regularity, exacerbating and alleviating factors
Any symptoms linked to nasal congestion, post nasal drip, sore
throat, etc.
Whether coughing has any relation to meals (if coughing happens a few
hours after eating, etc. )
Whether or not coughing is associated with patient’s position (worse when
lying down, etc. )
Whether cough is persistent or intermittent, or is disturbing sleeping
Any recent history of pneumonia, bronchitis, tracheitis, or sinusitis
Previous meal intake (aspiration)
Hx of aspirations?
Any background of smoking
Does cough improve upon subjection to cool air?
All current medicines, including any recent alterations, particularly
prescription drugs associated with cough such as ACE inhibitors
All present diagnoses
Any recent labs (CBC, electrolytes) and diagnostic assessments

Description of sputum:
White or mucoid sputum is frequently observed with
common colds, viral infections, or bronchitis
Yellow or green sputum is generally associated
with bacterial infections
Blood in the sputum is connected with more
serious conditions
Rust tinted sputum is associated with
tuberculosis or pneumococcal pneumonia
Pink frothy sputum may be indicative of
pulmonary edema
Listen to lung noises:
Crackles: These are high pitched,
discontinuous sounds similar to the sound
generated by rubbing your hair in between your
fingers (also known as Rales).
Wheezes: These are generally high pitched and
“musical” in quality. Stridor is an inspiratory
wheeze associated with upper airway
blockage (croup).
Rhonchi: These often have a “snoring” or
“gurgling” quality. Any additional sound that is not
a crackle or a wheeze is in all probability a rhonchi.


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Vital signs
Neurological, behavioral, and cognitive assessments which include
affect, degree of consciousness, responsiveness, or cognitive
Any indications of listlessness, confusion, apathy, weakness
Pain assessment (position, characteristics, intensity, etc. )
Any actions by the patient that could indicate an attempt to injure
or kill himself/herself
Outcomes of depression testing


Patient’s age and sex
Starting point, duration, regularity, and severity of signs and
symptoms, including sobbing, sleeplessness, or anorexia
Level of activities of day-to-day living (ADLs) performance
Extent of socialization and involvement in activities
All current medications, including any recent adjustments,
especially those known to cause depression, or suicidal
All current diagnoses
Recent or current medical, psychological or interpersonal episodes
connected to grief or loss, such as demise of a family member
Any statements by the individual that could indicate patient wish
or plan to harm or kill himself/herself
Any recent psychiatric consults or treatments

Symptoms of Major Depression
Depressed mood most of the day; pretty much every day
Reduced interest or pleasure in most activities most of
the time
Feelings of dying or committing suicide
Difficulty making decisions
Feelings of helplessness, worthlessness, or hopelessness
Inappropriate feelings of remorse
Psychomotor agitation or retardation not attributable to
other causes
Societal withdrawal, avoidance of social interactions, or
going out
Appetite change
Morning sluggishness and lack of energy that improves
markedly later in the day
Change in capacity to think or focus
Change in activities of daily living (ADLs)
Family history of mood issues
Exhaustion or loss of energy, worse than baseline
Insomnia or hypersomnia nearly every day
Increased complaints of pain
Preoccupation with poor health or physical limits
Weight loss or gain
Geriatric Depression Scale (GDS):
http: //www. stanford. edu/~yesavage/GDS. english. long. html
Cornell Scale for Depression in Dementia (CSDD)
http: //geridoc. net/cornellscale-form2. pdf.


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Vital signs
Any symptoms of a current severe illness including
infection (urinary, skin/wound, respiratory, etc. ) or an
unstable chronic affliction
Significant alterations in function, degree of awareness,
orientation, disposition and cognition


Patient’s age and sex
Patient’s blood sugars over past 7 days when compared to
typical trend over recent months
Onset and duration of any blood sugar variations
Changes in food and fluid intake and urine productivity over
the past 7 days
All current prescription drugs, including any recent changes
All current diagnoses
Doses and times of most current anti-hyperglycemic
medicine given (oral or insulin)
Recent lab or diagnostic examination results
Results of finger stick blood sugar, if accessible, including
average day-to-day glucose levels
Recent or present adjustments in dietary intake, for
example, friends and family started bringing in food
Any current skin dysfunction
Presence of neuropathy
Baseline A1c
Any new infection

Possible Indicators and Signals of Hypoglycemia
in the Frail Elderly
Altered conduct and psychological function
Altered level of consciousness (sleepiness,
listlessness, etc. )
Confusion or disorientation
Generalized weakness
Craving for food
Inadequate attentiveness and coordination
Possible Symptoms and Signs of Hyperglycemia
in the Frail Elderly
Blurred vision
New or escalating confusion
Polydipsia, polyphagia
Weight loss
Worsening incontinence
Fruity breath scent.