Assessment Of pt

Question 1

What are you assessing when you assess AIRWAY?

Answer 1

Stridor, Wheeze, Snoring & whether it’s patent and maintained by pt

Question 2

Nursing Consideration for Airway Management:

Answer 2

Optimise airway and position pt.

Question 3

What are you assessing when you assess Breathing?

Answer 3

Resp. Rate. Work of breathing. Use of accessory muscles. SpO2

Question 4

Nursing considerations for breathing?

Answer 4

O2 administration - position pt

Question 5

Circulation Ax looks for?

Answer 5

PR. CO. Perfusion. Cyanosis. BP

Question 6

Circulation Nursing Considerations:

Answer 6

Position pt to optimise perfusion to major organs.

Question 7

Disability Ax?

Answer 7

Functional limitations, GCS

Question 8

Exposure Ax:

Answer 8

Temperature look at skin sweating? Wounds?
Skin pallor.

Question 9

Nursing Considerations: Exposure

Answer 9

ECG. ROM. Ascultation. Ability to Wt Bear?

Question 10

Fluid Ax:

Answer 10

Input. Output. Hydration. Skin turgor.

Question 11

Nursing Considerations: fluids.

Answer 11

Oral/IV fluids, ask MO to increase rate, ax for dehydration. FBC

Question 12

Glucose Ax:

Answer 12

BSL, electrolytes, blood gases

Question 13

Nursing considerations: glucose

Answer 13

Manage hypo/hyperglycaemia

Question 14

Late signs deterioration: systemic circulation.

Answer 14

Cardiac arrest. SBP <80 or >240. PR <40 or >140. Urine O/P <200mls/24hrs. Anuria.

Question 15

Early signs of deterioration: blood loss

Answer 15

More than expected blood loss. New bleeding. Increased drain fluid loss.

Question 16

Late signs of deterioration: blood loss

Answer 16

High vol. blood loss, unable to be controlled by local staff.

Question 17

Early signs of deterioration: cerebral circ.

Answer 17

Alterations to mental state, GCS 9 - 11 or fall or 2 or more. Any seizure.

Question 18

Late signs of cerebral circ. Deterioration.

Answer 18

Unresponsive to verbal command. GCS <8. 2 or more seizures w/o return to baseline.

Question 19

Early deterioration: Cell Energy.

Answer 19

BSL 1-2.9 or 16-25.

Question 20

Late deterioration for cell energy

Answer 20

BSL <1 or >25

Question 21

Early signs of deterioration for pain:

Answer 21

Chest pain. Uncontrolled pain. New or changed pain.

Question 22

Late s. Of respiratory system Deterioration:

Answer 22

Total airway obstruction. Complete stridor. RR < 5 or >40. spO2: <90%. Base deficit: -8. pH: <7.2. Abnormal blood gases paO2<50. paCO2: >60

Question 23

GCS: 4 aspects of eye opening.

Answer 23

Spontaneous, to sound, to pressure, none.

Question 24

GCS: aspects to verbal.

Answer 24

Orientated. Confused. Words. Sounds. None.

Question 25

GCS: aspects of motor response.

Answer 25

Obeys commands.
Localising.
Normal flexion.
Abnormal flexion.
Extension.
None.

Question 26

What is a mild GCS impairment?

Answer 26

13-15

Question 27

What is a moderate GCS impairment?

Answer 27

9-12.

Question 28

What is a severe GCS impairment?

Answer 28

3-8.