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Acute Care > Assessment > Flashcards

Assessment Flashcards

1
Q

What should you check prior to seeing a patient?

A
  • Medical records (case notes)
  • Observation (charts)
  • Investigations eg. Imaging & Targeted evaluation of tests (blood sample or gas, sputum, other microbiology)
  • Talk to Patient care nurse &/or treating doctor if needing to clarify any contra- indications/precautions
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2
Q

What information should we gather from social history?

A 
Accomodation 
Home support 
Work
Pre-admission activity & mobility 
ADLs
Home set up 
Falls Hx
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3
Q

What information can we get from nursing observation charts?

A 
Temperature
O2 sats
Blood pressure
Pulse rate 
RR
Blood glucose
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4
Q

What investigations may we see?

A 
Medical imaging (X-ray/CT)
ECG 
Spirometry 
ABG
Blood exam (FBE)
Coagulation studies 
Microculture and sensitivity tests
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5
Q

What are the important initial parts to cover in a subjective exam?

A

Hand hygiene
Observations (positioning, comfort, RR, colour, wakefullness, O2 worn correctly)
Introduce self
Draw curtains/maintain privacy
Explain my role/purpose
Gain consent
Assess assessments and general environment

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6
Q

What are the cardinal signs?

A 
Pain (including chest)
Cough 
Sputum 
Haemoptysis
Breathlessness 
Wheeze
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7
Q

What are some important special questions to ask in an acute subjective?

A 
Smoking Hx
Mobility 
Social Hx 
Physical activity & exercise tolerarnce 
Self-managment 
Goals 
Medications
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8
Q

What do we want to know about pain?

A 
Type of pain relief and when they last had it 
Current pain? 
Where?
Score out of 10?
At rest ?
With movement?
When coughing?
Pain elsewhere?
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9
Q

What are some possible causes of chest pain?

A

Pleural
Musculoskeletal
Cardiac
Mediastinum

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10
Q

Pleural causes of pain?

A

Pleurisy
Pulmonary embolus
Pneumothorax
Tumours

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11
Q

Musculoskeletal causes of pain?

A

Rib #
Muscular
Costochondritis
Neuralgia

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12
Q

Cardiac causes of pain?

A

IHD: angina
IHD: myocardial infarction
Pericarditis

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13
Q

What is angina?

A

Chest pain caused by reduced blood flow to the heart.

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14
Q

What is pericarditis?

A

Swelling & irritation of the pericardium (membrane surrounding the heart)

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15
Q

Mediastinum causes of pain?

A

Dissecting aortic aneurysm

Oesophageal mediastinal shift

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16
Q

What is a dissecting aortic aneurysm?

A

A tear in the inner layer of the aorta

17
Q

What is a oesophageal mediastinal shift?

A

Deviation of the pleural structures towards one side of the chest cavity. Usually due to asymmetry in intrathoracic pressures eg. pleural effusion

18
Q

What are some symptoms commonly associated with chest pain or SOB?

A
  • fainting/syncope
  • weakness
  • light-headedness (hypotension)
  • loss of consciousness
  • Palpitations (arrhythmia)
19
Q

What may pink sputum indicate?

A

Pulmonary oedema

20
Q

What may dark green/brown sputum indicate?

A

Pseudomonas

21
Q

What may yellow sputum indicate?

A

Haemophilus (bacterial infection caused by Haemophilus influenzae type b.

22
Q

Chronic causes of breathlessness?

A
  • COPD
  • lung cancer
  • ILD
  • anaemia
23
Q

Sudden causes of breathlessness?

A
  • acute asthma
  • PE
  • pneumothorax
  • cardiac: MI/pulm oedema/arrhythmia
  • anaphylaxis
  • anxiety
24
Q

Recent causes of breathlessness?

A
  • exacerbation COPD
  • Pneumonia
  • LHF
  • Pleural effusion
  • other: metabolic acidosis, anaemia
25
Q

What questions should we ask regarding smoking?

A
  • Have you ever smoked?
  • How long for?
  • How many cigarettes a day?
  • When did you stop?
26
Q

What is the calculation for someones pack year smoking Hx?

A

pkts/day x years smoked

27
Q

What general observations can be made in the objective exam?

A
  • Level of consciousness
  • Colour, face, skin
  • Posture
  • Attachments
  • Surgical incision
  • Hands & feet (clubbing? discolouration?)
28
Q

Common acute care attachments?

A 
– Oxygen delivery and oximeter
– Arterial line
– Intra-venous (CVC, PICC, Jelco, PCA) 
– Chest drains (ICC, UWSD)
– Nasogastric tube (NGT) – Wound drains
– Epidural
– Stoma
– Urinary catheter
– ECG /pacing wires
29
Q

What visual assessments can we make from looking at a patient breathing?

A
  • Inspiratory:Expiratory = 1:2 = normal
  • Rate
  • Accessory muscle use
  • Active expiration
  • Nasal flaring
  • Pursed lip breathing
30
Q

What should we listen for during the objective exam?

A
  • Auscultation

- Cough

31
Q

4 ways to describe a cough:

A

strong/weak
dry/moist
effective/ineffective
productive/non-productive

32
Q

What should we feel for in the objective exam?

A
  • Basal expansion (bucket handle action & symmetry)

- Diaphragm movement (upper chest vs abdominal breathing)

Acute Care (6 decks)

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