Client Assesment Flashcards
Causes of hypothermia
Post operative
Prolonged exposure to a cold environment
What is hypothermia?
A lowered body temperature, below 34.4 degrees
Nursing care of hypothermia
Take vital signs Warm blankets Space blanket Warm fluids Radiant heat lamps
What is hyperthermia?
An elevated body temperature, above 39 degrees
Causes of hyperthermia?
Metabolic disorder
Infection
Neurological disease
Trauma
Nursing care of hyperthermia
Take vital signs
Sponge bath or cold compress
Encourage rest to decrease production of heat
What is hypertension?
Systolic bp: above 140
Diastolic bp: above 90
What is hypotension?
Systolic bp: below 90
Diastolic bp: below 60
What is Orthostatic hypotension?
Also known as postural hypotension.
Is a significant hypotension occurring when a patient goes from sitting or lying down to standing
Sites for taking pulses:
Radial artery Common carotid artery Superficial temporal artery Facial artery Apical artery Brachial artery Femoral artery Popliteal artery Posterior tibial artery Dorsalis pedis artery
Vital signs
Body temperature: 36-37.5 degrees Oxygen saturation: 97-100% Blood pressure: systolic: 100-140 mmHg diastolic: 60-90 mmHg Pulse: 60-100bpm Respirations: 12-20 breaths per minute
What is systolic pressure?
Is the pressure exerted during contraction of the ventricles
Systolic blood pressure provides info about the force of the left ventricular contraction
What is diastolic pressure?
Is the pressure during the relaxation of the ventricles
Diastolic blood pressure provides info about the resistance of the blood vessels
What is bradycardia?
Slow or decreased heart rate
Pulse rate below 60bpm
What is tachycardia?
Fast or increased heart rate
Pulse rate above 100bpm
What is afebrile?
“Without fever”
A normal ranging temperature
What is febrile?
“With fever”
High body temp above 38.5 degrees
What is dyspnoea?
Difficult or uncomfortable breathing
What is apnoea?
Cessation of breathing for several seconds
What is orthopnoea?
The ability to breathe only in an upright position
What are rigors?
Periods of rise and fall in body temperature
Severe shivering
Indicates infection
What is tachypnoea?
Rapid breathing
Respiratory distress, signs and symptoms
Cyanosis Coughing Wheezing Alteration in depth or rate Elevated bp and pulse Abnormal respiratory rate Flaring of nostrils
What is subjective information?
Clients perception of his/her health condition
What is objective information?
Observations which are measured by the nurse
What is hypoglycaemia?
Blood sugar level below 3.5 mmol/L
Signs and symptoms of hypoglycaemia:
Headache Irritability Blurred vision Dizziness Cool pale skin Tachycardia Shakiness Peculiar behaviour
What is hyperglycaemia?
Blood sugar level above 8.0mmol/L
Signs and symptoms of hyperglycaemia:
Polydipsia Polyphagia Lethargic Polyuria Glycosuria Ketonuria Warm/flushed skin Dry skin Weight loss
What is ketoacidosis?
A complication of diabetes mellitus, where the chemical balance of the body becomes far too acidic
Signs and symptoms of ketoacidosis:
High blood sugar levels Polyuria Thirsty Lethargic Nausea Vomiting Abdominal pain Rapid breathing
What is diabetes mellitus type 1?
When the body does not produce insulin due to the destruction of insulin-producing beta cells of the pancreas
- insulin dependent
- sudden onset
What is diabetes mellitus type 2?
When the pancreatic beta cells don’t produce enough insulin or the body’s cells don’t respond properly to the insulin
- non insulin dependent
- slow onset
Risk factors for developing diabetes mellitus type 2:
Obesity
Aboriginal people over the age of 35
People over the age of 65
Hx diabetes
Normal range of blood glucose level:
3.5-8.0 mmol/L
Discharge information for individuals with diabetes mellitus type 1:
Info on low fat diet Low gi foods Regular exercise Medication Information on type 1 diabetes
Discharge informations or individuals with diabetes mellitus type 2:
Weight loss Healthy eating Regular exercise Stop smoking Medication Info on diabetes type 2
Reason for doing urine testing?
To detect any abnormalities Routine evaluation Evaluate the effectiveness of medication Help confirm or rule out diseases On admission to hospital
What is polyuria?
Excessive excretion of urine
What is proteinuria?
Protein in the urine
What is dysuria?
Painful or difficult urination
What is oliguria?
Abnormally small amounts of urine output
What is Anuria?
No urine output
What is the normal specific gravity?
1010-1030
General signs and symptoms of a UTI:
Nausea Vomiting Febrile Pelvic discomfort Malaise
Urinary signs and symptoms of a UTI:
Smelly (offensive) urine Frequency Urgency Burning on micturition Cloudy Haematuria
What role doss a div 2 nurse have if the patient has abnormalities on dipstick urinalysis?
Document results
Report to supervisor
Save specimen
What is GCS? And the significance of it?
GCS stands for Glasgow coma scale,
It is an accurate assessment tool to assess the level of a conscious patient with a head injury, neurological status and monitor any changes that may arise
What 3 responses does the GCS evaluate?
Eye opening
Verbal response
Motor response
Early signs and symptoms of ICP:
Altered LOC Behaviour changes Headache Lethargy Changes in motor function Pupil response
Late signs and symptoms of ICP
Irregular respirations
Temperature
Hypertension
Bradycardia
Neurovascular observations:
CWMS
Colour
Warmth
Movement
Sensation
What do antiembolic stockings (TEDS) do? And why are they used?
They facilitate venous flow return from the lower extremities, prevent venous thrombosis and venous statis
Compartment syndrome, signs and symptoms
Oedema Coolness Pallor Sluggish capillary refill time, indicates compromised circulation Cyanosis Pain intensity due to tissue and nerve ischemia Numbness from nerve compression Absence of pulses
