ASPECT OF CARE – REVIEW CRITERIA
ASPECT OF CARE – REVIEW CRITERIA
BREATHING DIFFICULTY
100% of all trip sheets of patients with Breathing Difficulty shall be reviewed to include the following Aspects of Care.
BLS CRITERIA:
PATIENT HISTORY:
• Past medical history (any past history of breathing and/or cardiac problems)
• Medications
• Allergies
• Focused Medical History (OPQRST)
O = Onset (when did trouble breathing start?)
P = Provocation (can any specific activity or condition be attributed to cause)
Q = Quality (does anything make breathing better/worse, ie: position, use of medications or excursion?)
R = Radiation (any pain associated with difficulty breathing? Does pain radiate?)
S = Severity (level of distress; mild, moderate, severe?)
T = Time (when did trouble breathing begin? How long has this been going on?)
OXYGEN ADMINISTRATION:
Oxygen administration with patient documentation to reflect flow selected (non-rebreathing mask vs. nasal cannula). Upon reassessment, where patient no longer requires high flow oxygen, document lower flows administered.
PHYSICAL EXAM:
• Lung sounds
• JVD (neck veins flat? distended)
• Edema
ALS CRITERIA:
• All BLS criteria with addition of:
• Full physical exam findings
• Pulse oximeter
• Cardiac monitor
• Detailed description of adventitious breath sounds
• Medications administered and patient response to pharmacological treatment
• IV lock or KVO when indicated by patient condition
• Intubation (where indicated) with #8.0 ET for oral/ or appropriate ET tube size for nasal intubation. Documentation of patient’s response to intubation.
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