Assessment

Question 1

Adult Adequate Perfusion

Answer 1

Skin: warm, pink, dry
Pulse: 60-100
BP: >100 SYS
Conscious State: Alert
CRT: <2sec

Question 2

Adult Borderline Perfusion

Answer 2

Skin: cool, pale, clammy
Pulse: 50-100
BP: 80-100 SYS
Conscious State: Alert
CRT: >2sec

Question 3

Adult Inadequate Perfusion

Answer 3

Skin: cool, pale, clammy
Pulse: <50 or >100
BP: 60-80 SYS
Conscious State: Either alert or confused
CRT: >2sec

Question 4

Adult Extremely Poor Perfusion

Answer 4

Skin: cool, pale, clammy
Pulse: <50 or >110
BP: <60 or unrecordable
Conscious State: altered or unconscious
CRT: >2sec

Question 5

Adult No Perfusion

Answer 5

Skin: cool, pale, clammy
Pulse: absent
BP: unrecordable
Conscious State: unconscious
CRT: nil

Question 6

Adult Normal Respiratory

Answer 6

Conscious: Alert
Appearance: calm and quiet
Pulse: 60-100
Effort: normal chest movement
RR: 12-16
Rhythm: regular
Sats: >94%
Chest Sounds: normal air sounds
Speech: calm and steady
Skin: normal

Question 7

Adult Mild Respiratory Distress

Answer 7

Conscious: Alert
Appearance: calm or anxious 
Pulse: 60-100
Effort: slight increase in effort
RR: 16-20
Rhythm: (asthma prolonged exp. phase)
Sats: >94%
Chest Sounds: Asthma: mild exp. wheeze LVF: minor crackles at bases
Speech: full sentences
Skin: normal

Question 8

Adult Moderate Respiratory Distress

Answer 8

Conscious: may be altered
Appearance: distressed or anxious
Pulse: 100-120
Effort: marked chest movement, use of accessory muscles
RR: >20
Rhythm: (asthma prolonged exp. phase)
Sats: <94%
Chest Sounds: Asthma: exp. wheeze +/- insp. LVF: minor crackles at mid and bases
Speech: short phrases
Skin: pale and sweaty

Question 9

Adult Severe Respiratory Distress

Answer 9

Conscious: altered conscious state or unconscious
Appearance: distressed, anxious, exhaustion
Pulse: 100-120
Effort: marked chest movement, use of accessory muscles, intercostal recession, tracheal tug
RR: >20 or <8
Rhythm: (asthma prolonged exp. phase)
Sats: <90%
Chest Sounds: Asthma: exp. wheeze +/- insp. LVF: full field crackles Obstruction: Stridor
Speech: single words
Skin: pale and sweaty +/- cyanosis

Question 10

Mental Health Assessment (9)

Answer 10

Appearance
Behaviour

Mood
Response

Speech
Perceptions

Thought Content
Thought Flow
Concentration

Question 11

Paediatric Age Groups

Answer 11

Newborn - First few hours
Infant - 0-1 years
Small Child - 1-9 years
Large Child - 10-12 years

Question 12

Newborn Pulse

Answer 12

120-160

Question 13

Infant Pulse

Answer 13

100-160

Question 14

Small Child Pulse

Answer 14

80-120

Question 15

Large Child Pulse

Answer 15

80-100

Question 16

Newborn BP

Answer 16

N/A

Question 17

Infant BP

Answer 17

> 70mmHg

Question 18

Small Child BP

Answer 18

> 80mmHg

Question 19

Large Child BP

Answer 19

> 90 mmHg

Question 20

Newborn RR

Answer 20

40-60

Question 21

Infant RR

Answer 21

20-50

Question 22

Small Child RR

Answer 22

20-35

Question 23

Large Child RR

Answer 23

15-25

Question 24

Paediatric Respiratory Distress Signs (8)

Answer 24

Tachypnoea
Grunting
Wheezing
Pallor
Chest Wall Retraction
Use of Accessory Muscles
Cyanosis (Late sign)
Abdominal Protrusion

Question 25

Respiratory Distress Assessment

Answer 25

Exertional SoB
Cough
Pain on coughing
Able to swallow
Drooling
Sleeping Position
Nocturnal Dyspnoea
Previous hospital or intubation
Recent med changes
Meds compliance
Frequency of use
Clot risks (calf pain, surgery, prolonged stasis)

Question 26

Chest Pain Assessment

Answer 26

Sweating
Palpitations
Nausea/Vomiting
Dizziness/Lightheaded
SoB
Calf Pain
Peripheral Oedema
BP L vs  R
Diarrhea
Constipation