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Client Assesment Flashcards

0
Q

Causes of hypothermia

A

Post operative

Prolonged exposure to a cold environment

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1
Q

What is hypothermia?

A

A lowered body temperature, below 34.4 degrees

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2
Q

Nursing care of hypothermia

A 
Take vital signs
Warm blankets
Space blanket
Warm fluids
Radiant heat lamps
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3
Q

What is hyperthermia?

A

An elevated body temperature, above 39 degrees

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4
Q

Causes of hyperthermia?

A

Metabolic disorder
Infection
Neurological disease
Trauma

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5
Q

Nursing care of hyperthermia

A

Take vital signs
Sponge bath or cold compress
Encourage rest to decrease production of heat

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6
Q

What is hypertension?

A

Systolic bp: above 140

Diastolic bp: above 90

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7
Q

What is hypotension?

A

Systolic bp: below 90

Diastolic bp: below 60

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8
Q

What is Orthostatic hypotension?

A

Also known as postural hypotension.

Is a significant hypotension occurring when a patient goes from sitting or lying down to standing

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9
Q

Sites for taking pulses:

A 
Radial artery
Common carotid artery
Superficial temporal artery
Facial artery
Apical artery
Brachial artery
Femoral artery
Popliteal artery
Posterior tibial artery
Dorsalis pedis artery
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10
Q

Vital signs

A 
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
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11
Q

What is systolic pressure?

A

Is the pressure exerted during contraction of the ventricles

Systolic blood pressure provides info about the force of the left ventricular contraction

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12
Q

What is diastolic pressure?

A

Is the pressure during the relaxation of the ventricles

Diastolic blood pressure provides info about the resistance of the blood vessels

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13
Q

What is bradycardia?

A

Slow or decreased heart rate

Pulse rate below 60bpm

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14
Q

What is tachycardia?

A

Fast or increased heart rate

Pulse rate above 100bpm

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15
Q

What is afebrile?

A

“Without fever”

A normal ranging temperature

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16
Q

What is febrile?

A

“With fever”

High body temp above 38.5 degrees

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17
Q

What is dyspnoea?

A

Difficult or uncomfortable breathing

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18
Q

What is apnoea?

A

Cessation of breathing for several seconds

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19
Q

What is orthopnoea?

A

The ability to breathe only in an upright position

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20
Q

What are rigors?

A

Periods of rise and fall in body temperature
Severe shivering
Indicates infection

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21
Q

What is tachypnoea?

A

Rapid breathing

22
Q

Respiratory distress, signs and symptoms

A 
Cyanosis
Coughing
Wheezing
Alteration in depth or rate
Elevated bp and pulse
Abnormal respiratory rate
Flaring of nostrils
23
Q

What is subjective information?

A

Clients perception of his/her health condition

24
Q

What is objective information?

A

Observations which are measured by the nurse

25
Q

What is hypoglycaemia?

A

Blood sugar level below 3.5 mmol/L

26
Q

Signs and symptoms of hypoglycaemia:

A 
Headache
Irritability
Blurred vision
Dizziness
Cool pale skin
Tachycardia
Shakiness
Peculiar behaviour
27
Q

What is hyperglycaemia?

A

Blood sugar level above 8.0mmol/L

28
Q

Signs and symptoms of hyperglycaemia:

A 
Polydipsia
Polyphagia
Lethargic
Polyuria
Glycosuria
Ketonuria
Warm/flushed skin
Dry skin
Weight loss
29
Q

What is ketoacidosis?

A

A complication of diabetes mellitus, where the chemical balance of the body becomes far too acidic

30
Q

Signs and symptoms of ketoacidosis:

A 
High blood sugar levels
Polyuria
Thirsty
Lethargic
Nausea
Vomiting
Abdominal pain
Rapid breathing
31
Q

What is diabetes mellitus type 1?

A

When the body does not produce insulin due to the destruction of insulin-producing beta cells of the pancreas

  • insulin dependent
  • sudden onset
32
Q

What is diabetes mellitus type 2?

A

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
33
Q

Risk factors for developing diabetes mellitus type 2:

A

Obesity
Aboriginal people over the age of 35
People over the age of 65
Hx diabetes

34
Q

Normal range of blood glucose level:

A

3.5-8.0 mmol/L

35
Q

Discharge information for individuals with diabetes mellitus type 1:

A 
Info on low fat diet
Low gi foods
Regular exercise
Medication
Information on type 1 diabetes
36
Q

Discharge informations or individuals with diabetes mellitus type 2:

A 
Weight loss
Healthy eating
Regular exercise
Stop smoking
Medication
Info on diabetes type 2
37
Q

Reason for doing urine testing?

A 
To detect any abnormalities
Routine evaluation
Evaluate the effectiveness of medication
Help confirm or rule out diseases
On admission to hospital
38
Q

What is polyuria?

A

Excessive excretion of urine

39
Q

What is proteinuria?

A

Protein in the urine

40
Q

What is dysuria?

A

Painful or difficult urination

41
Q

What is oliguria?

A

Abnormally small amounts of urine output

42
Q

What is Anuria?

A

No urine output

43
Q

What is the normal specific gravity?

A

1010-1030

44
Q

General signs and symptoms of a UTI:

A 
Nausea
Vomiting
Febrile
Pelvic discomfort
Malaise
45
Q

Urinary signs and symptoms of a UTI:

A 
Smelly (offensive) urine
Frequency
Urgency
Burning on micturition
Cloudy
Haematuria
46
Q

What role doss a div 2 nurse have if the patient has abnormalities on dipstick urinalysis?

A

Document results
Report to supervisor
Save specimen

47
Q

What is GCS? And the significance of it?

A

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

48
Q

What 3 responses does the GCS evaluate?

A

Eye opening
Verbal response
Motor response

49
Q

Early signs and symptoms of ICP:

A 
Altered LOC
Behaviour changes
Headache
Lethargy
Changes in motor function
Pupil response
50
Q

Late signs and symptoms of ICP

A

Irregular respirations
Temperature
Hypertension
Bradycardia

51
Q

Neurovascular observations:

CWMS

A

Colour
Warmth
Movement
Sensation

52
Q

What do antiembolic stockings (TEDS) do? And why are they used?

A

They facilitate venous flow return from the lower extremities, prevent venous thrombosis and venous statis

53
Q

Compartment syndrome, signs and symptoms

A 
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

Client Assessment (1 decks)

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