1002 Part 1 of exam Flashcards
1
Q
What is subjective data?
A
= family or patients account of what is going on (patients story)
- data collection - interview and health history
- What is going on here?
2
Q
What is Objective data?
A
= physical examination, results of diagnostic test.
- very clear and obvious data
what does this mean?
- collecting estimating and judging the value and significance of the data.
3
Q
What is a primary assessment?
A
- crucial first element in every patient encounter
- sets a baseline
- structured and systematic
- A-G approach
- vital signs
- allows for identification of threats to immediate health
- subjective and objective data
- A-G
- identify threats to patients safety first
4
Q
What is a secondary assessment?
A
= more focused in depth assessment
- systematic, logical and organised
- body system
- if something in the primary assessment was not right there will be a focused assessment on it
5
Q
A-G assessment list
A
Airway Breathing Circulation Disability Exposure Fluid Glucose
6
Q
Airway
A
Look
- For signs of airway obstruction
- For evidence of mouth/ neck/ swelling/ haematoma
- For security of artificial airway
Listen
- For noisy breathing e.g. gurgling, snoring or stridor
Feel
- For the presence of air movement
- For security of artificial airway
7
Q
Breathing
A
Look
- At chest wall movement, to see it its normal and symmetrical
- To see if the patient is using their neck and shoulder muscles to breath (accessor muscles)
- At the patient to measure their respiratory rate
Listen
- To the patient talking to see if they can complete full sentences
- For noisy breathing e.g. stridor, wheezing
Feel
- For the position of the trachea to see if it is central
- For surgical emphysema or crepitus
- If the patient is diaphoretic (sweaty)
8
Q
Circulation
A
Look
- At the skin colour for pallor and peripheral cyanosis
- At the capillary refill time
- At the patient’s central venous pressure and jugular venous pressure
Listen
- To the patient for complaints of dizziness and headaches
- For patients’ blood pressure and heart sounds
Feel
- Your patients hands and feet to see if they are warm or old
- Your patients’ peripheral pulses for presence, rate, quality
9
Q
Disability
A
Look
- Level of consciousness
- Facial symmetry, abnormal movements, seizure activity or absent limb movements
- Pupil size, equality and reaction to light
Listen
- To patient’s response to external stimuli and pain
- For slurred speech
- For patient’s orientation to person, place and time
Feel
- For patients response to external stimuli
- For muscle power and strength
10
Q
Exposure
A
Look
- For any bleeding e.g. investigate wounds and drains that may be hidden under bed clothes
Listen
- For air leaks in drains
- For bowel sounds
Feel
-The patients abdomen
11
Q
Fluid
A
Look
- At the observation and fluid charts, noting the fluid input and output
- At losses from all drains and tubes
- At the amount and colour of the patient’s urine and urinalysis results
Listen
-For patients’ complaints of thirst
Feel
- The skin turgor
12
Q
Glucose
A
Look
- At blood glucose level
- For signs of low glucose, including confusion and decreased conscious state
- At medication chart for insulin and oral hypoglycaemics
Listen
- For patients’ complaints of thirst
- For patient’s orientation to person, place and time
Feel
- If the patient is diaphoretic (sweaty, cold or clammy)
13
Q
What is involved in pain assessment
A
PQRST
Provocation/ palliation
- what were you doing when it started?
- what caused it?
- what relieves it?
- what aggravates?
Quality/quantity
- what does it feel like - describe words
Region/ radiation
- where is the pain located?
- does it move? where to?
Severity scacle
- scale of 0-10
Timing
- when did the pain start?
- How long did it last?
- how often does it occur
14
Q
What are the 6 vital signs and their normals?
A
Blood pressure = 120/80
Heart rate = 60 - 100
Oxygen saturation = 95 - 100%
Respiratory rate = 16-100 bpm
Temperature = 36.2 - 37.5
Pain = 0-10
15
Q
How do you interoperate heart rate?
A
• Sites used
• Character of pulse
- Rate, rhythm, strength, equality
• Be aware of factors influencing heart rate
E.g. drugs, emotions, exercise,
haemorrhage, postural changes,
pulmonary conditions
• If HR abnormal or irregular use apical
pulse rate to confirm
16
Q
Reliability
A
= Does it measure something correctly?
- can it be relied on every time
- does it represent the consistency of measure obtained
17
Q
Validity
A
= does it measure what is is supposed to
- how do i know that the test, scale, instrument i use measure what it is supposed to
- extend to which an instrument reflects the true measurement being observed
18
Q
How do you avoid Error in measurement?
A
- repeat
- Check equipment
- Use different piece of equipment
- Calibration - process of comparing the pressure gauge against a known accurate reference manomometer
19
Q
Ways to reduce error in readings?
A
- is it on properly
ECG
- no belt buckles
- sit still
- explain that it wont hurt
- put the dots on properly
Blood pressure
- is it on correctly
- remove thick clothing
- is their arm straight?
20
Q
What is the cardiac cycle?
A
= one cycle consists of contraction and relaxation of both atrias followed by systole and diastole of both ventricles.
- Initiated by impulse (action potential) from sinus atrial (SA) node
- Period of
- Depolarisation = Contraction - systole
- Repolarisation = Relaxation - diastole
21
Q
Why does heart rate vary?
A
- autonomic nervous system regulates the sinus node
- analysis of the sinus rhythm provides information about the state of the autonomic nervous system (sympathetic/ parasympathetic)
22
Q
How does the blood flow through the heart?
A
- Superior vena cava + Inferior Vena Cava
- Right Atrium
- Right ventricle
- Pulmonary artery to lung
- lung to Pulmonary vein
- Left atrium
- Left ventricle
Valves open and close together
23
Q
What is the cardiac conduction?
A
- pace maker SA node
- generates 60-100 beats/min
- Controlled by sympathetic and parasympathetic
- AV node
- delays impulse 0.07 secs
- Bundle of HIS (AV bundle)
- can initiate and sustain impulse 40-60 min
- Left and right branch bundles
- bundle branches terminate in purkinje fibres
24
Q
What is in a cardiovascular assessment?
A
- a-g assessment
Inspection
- skin colour
Palpation
- pulses for circulation - extremities
- capillary refill
- skin temperature
- calves for tenderness
Auscultation
- listen to the heart -> apex beat
ECG
25
When do you do an ECG?
- complaints of chest pain
- pneumothorax
- high heart rate
- irregular heart beat on palpation
- preoperatively
- syncope or fainting
- LOC
- SOC
Tests: cardiac stress tests
26
What is "the standard 12 lead"?
- Consists of 6 limb leads (1, 11, 111, aVR, aVL, aVF)
- they record electrical activity in the frontal plane
(travelling up/down and left and right)
- 6 chest or precordial leads (V1-V6)
- they record electrical activity in the horizontal plant
(travelling right/left and anterior and posterior)
27
What is ventilation?
- Pulmonary and minuet?
Pulmonary ventilation = breathing
- active process: inspiration occurs due to contraction of
muscles that cause negative intrathoracic pressure.
Minuet ventilation = the amount of gas that is inhaled and exhaled in one minuet.
= (tidal volume - dead space) X RR
- dead space is the part of the air inhaled that does not
take part in thee gas exchange
- Tidal volume is the amount of gas that is inhaled and
then exhaled in one breath
28
What is cellular respiration?
= the process by which glucose or other small molecules are oxidised to produce energy
- this requires oxygen and generates carbon dioxide
29
What is DO2?
= Delivery of fully oxygenated blood from pulmonary
| alveoli to peripheral tissue capillaries.
30
What is the use of oxygen in cells?
- Production of ATP for energy requires adequate level of
oxygen to cells.
- Electron transport system in mitochondria supplies 95% of cellular energy but uses 90% of DO2
- This delivery of oxygen (DO2) is dependent on cardio-vascular sufficiency, the focus of future lectures
WITHOUT OXYGEN, CELLS DIE
31
What does a respiratory assessment involve?
- Primary a-g assessment
- clinical history
- focused
- inspection
- palpation
- percussion
- auscultation
32
Focused respiratory assessment:
Inspection
- airway
- breathing
- shape and configuration of chest
- posterior chest
- Barrel chest
- Anterior chest - ribs sloping backwards
- fingernail chubbing - occurs in conditions of
sustained hypoxia
33
Focused respiratory assessment
Palpation
Using fingers to palpate the entire chest wall:
- palpate position of trachea (deviation - pulled one side)
- Symmetrical expansion
- Tenderness
- skin temp
Using fingers and palms:
- crepitus
- course crackling sensation
- caused by air in subcutaneous tissue (air trapped)
- Fremitus
- vibration of chest wall due to vocalisation of "99"
- increased fermitus - lungs become filled with fluid or
more dense
- decreased - lung hyper-inflated - barrel chest
- absent - pneumothorax and lung alveolar collapse
34
Focused respiratory assessment
Percussion
= involves tapping the body with finger tips to evaluate size, borders and consistency of body organs
Sounds:
- Resonance = lung tissue
- hyper resonance = air trapped
- Dull = consolidation (may be heart or liver)
- Tympanic = stomach
- Flat = bones
35
Focused respiratory assessment
Auscultation
= listening to the sounds produced by the body
Stertor - snoring sound when secretions block the trachea
Stridor - inspiratory wheeze indicating upper airway obstruction
Wheezing - high pitch musical sound occurring on inspiration, indicated partial obstruction of lower airways and narrow airways
Inspiratory grunt - babies occluded airway
Wet crackles - pulmonary oedema = fluid on the lungs
36
What is Basic life support?
= the preservation or restoration of life by the establishment and or maintenance of airway, breathing and circulation and related emergency care.
- temporary measure to maintain ventilation and circulation
- the aim is to provide adequate myocardial and cerebral oxygenation until defibrillation, persons trained in advanced life support and equipment are available.
37
What are the steps of basic life support?
DRS ABCD
DANGERS - ensure safety for patient and self
RESPONSIVE
- assess the collapsed victims response to verbal and
tactile stimuli ensuring that this does not cause injury
- no response - must call for emergency help
SEND FOR HELP
- push emergency buzzer above pt
OPEN AIRWAY
- Assessment
- LOC, vocalisation, gurgling, tongue, loos teeth/
foreign objects, bleeding, vomit
- Open airway
- unconscious victim care of airway takes
precedence over injury
- move the head gently to obtain clear airway
- clear airway - roll, finger sweep
- Head tilt/ chin lift
NORMAL BREATHING
- victims who are gasping, breathing abnormally or unconscious need resuscitation
- LOOK for movement of in chest
- LISTEN for air from nose or mouth
- LOOK for movement of the chest and air at mouth
START CPR - 30 compressions: 2 breaths
- chest compressions combined with rescue breathing to temporarily preserve brain function
- give the chest time to recoil - ventricles to refill again
ATTACH DEFIBRILLATOR
- passage of electrical currents induces depolarisation of
myocardial cells simultaneously
- allows pacemaker to resume control
- interoperates rhythm as shockable or non shockable
38
What does DETECT stand for in a deteriorating patient?
```
Detect deterioration
- recognise that you have a problem by gathering
information relating to your pt
- use a-g
- identify early and late warning signs
```
Evaluate
- likely causes of deterioration
- whether your skills will meet patients needs
- the urgency of the call
- continue to re-evaluate
Treatment
- prioritise interventions using A-G in order to guide decision
- commence simple treatments - oxygen, positioning, establishing IV access
- begin BLS
Escalate
- be aware of signs of further deterioration
- know who to call for more assistance
Communicate with your team
- provide leadership where appropriate
- coordinate activities within the team
- use ISBAR
- document the patients outcome
- revise, prepare and communicate the patients care plan
39
What are the key signs of deterioration?
1. Respiratory rate
2. Altered conscious state
3. Tachycardia
4. Hypotension/ pallor
5. Decreases urine output
6. Desaturation
40
When things are not going to plan what do you do?
- call for help
- never leave deteriorating patient
- document and communicate all treatment provided
- this plan should include expected outcomes
What is going on here? what can be done?
41
Describe BTW?
= is a 'safety net' designed to protect patients from deteriorating unnoticed and to ensure they receive appropriate care if they do.
White band is good
Yellow - clinical review - supervisor
Red - Rapid response - emergency
42
Describe BTW?
= is a 'safety net' designed to protect patients from deteriorating unnoticed and to ensure they receive appropriate care if they do.
White band is good
Yellow - clinical review - supervisor
Red - Rapid response - emergency
43
What is the process if your patient is in the yellow zone?
= If a patient has any YELLOW observations or additional criteria on the standard observation chart your must:
- initiate appropriate clinical care
- repeat and increase frequency of observations as indicated by patients condition
- consult promptly with the nurse in charge and decide whether a clinical review call should be made
44
What is the process if clinical review is called?
- Reassess your patient and escalate according to local CERS if the call is not attended within 30 mins
- document an A-G assessment, reason for escalation, treatment and outcome in your patients health care record.
- inform the attending that the call was made
What to do while you wait?
- continue observing and monitoring patient
- stay with the patient
- rerassure
45
What is the aim of a mental health assessment?
= a collaborative attempt to evaluate a persons social and emotional wellbeing in order to assist them towards a more satisfying life
- nurses should be as interested in abilities, activities and positive relationships as we are in symptoms of distress and illness
46
What is a mental health assessment?
= a collaborative attempt to evaluate a persons social and emotional wellbeing in order to assist them towards a more satisfying life
47
What are the two types of mental health assessments?
1. Exploration
- use conversation with a person and people who know
them, along with observations of their behaviour to
assess mental health
2. Measurement
- we screen a persons response to questionnaires to
get a sense of how big or small their perceptions of
their problems are compared to a set of preconceived
parameters
e.g. how many difficulties are they experiencing?
48
What is the purpose of a mental health assessment?
- engagement and consent
- identifying data
- chief complaint/ presenting problem (how and why)
- history of the present illness (nature of symptoms,
onset, intensity, pattern)
- precipitation factors - changes in level of function
- Treatment history
- response, medication, satisfaction, hospitalisation,
relapse, carers, support network
- Personal history - development of aims at
understanding the relationship of past life to current
mental health
49
What is involved in a mental state exam?
- appearance
- behaviour
- speech
- mood/ affect
- thought form / thought content
- perception
- cognition
- insight/judgement
50
Mental health exam:
| Appearance
- identifying details, setting, time of day
- description of appearance and overall physical impression
- distinguishing characteristics
- posture, body type
- signs of anxiety, tense
51
Mental health exam:
| Appearance
- identifying details, setting, time of day
- description of appearance and overall physical impression
- distinguishing characteristics
52
Mental health exam:
| Behaviour
- activity - retardation, agitation, hyper-activity
| - mannerisms, gestures, stereotyped
53
Mental health exam:
| Speech
- quantity - responsive, loquacious (talkative), garrulous (excessively talking), hesitant, poverty of speech, mute
- Rate - responsive, rapid, pressured, slow, stuttering, blocking
- Quality - loud, whispered, dramatic, monotone, slurred, mumbled
54
Mental health exam:
Mood/ affect
Mood - subjective - feelings
Affect - outsiders impression as represented by client
- stability
- appropriateness
- restricted.
55
Mental health exam:
Thought form and thought content
form = How a person puts their ideas together
- coherent or incoherent
- logical, not logical
- loosening of associations of thought disorder
Content = what is the person actually thinking about
- ideas, beliefs, values
- obsessions
- ideas of reference
- delusions
56
Mental health exam:
Cognition
- consciousness orientation, concentration, memory and
flexibility
- distractibility
- attention
57
What are effective communication strategies?
SURETY
- Sit at an angle to the patient
- Uncross legs and arms
- Relax
- Eye contact
- Touch (appropriate)
- Your intuition (guy feeling)
58
What are effective communication strategies?
SURETY
- Sit at an angle to the patient
- Uncross legs and arms
- Relax
- Eye contact
- Touch (appropriate)
- Your intuition (guy feeling)
59
What is effective nursing communication?
- focus on the needs of the patient
- time orientated
- goal orientated
- initiate the relationship - therapeutic
- non judgemental
60
What are the stages of cardiac cycle?
1. Atrial systole
2. Isovolumetric ventricular contraction
3. Ejection
4. Isovolumetric ventricular relaxation
5. Passive Ventricular filling
61
Oxygen delivery
Oxygen delivery = CO X Arterial O2 content
CO = stroke volume x HR
- Preload
- after load
- contractility
Arterial = hB X SaO2
- hb = haemoglobin
- SaO2 - how much o2 is attached
