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Yr1 HS1011 > Clinical Assessment > Flashcards

Clinical Assessment Flashcards

1
Q

What is the adult nutrition assessment of BMI?

A

The height to weight ratio which determines if someone if underweight, normal weight of obese

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2
Q

What is the adult nutrition assessment of MUST?

A
  • Malnutrition universal screening tool
  • Identifies risk of malnutrition and obesity
  • Takes into account BMI, percentage of unplanned weight loss, impact of acute illnesses
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3
Q

What is the nutrition intake for adults?

A
  • Women 1500 to 2400 Kcal

- Men 2000 to 3000 Kcal

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4
Q

What is the nutrition intake for children?

A
  • 1000 Kcal + age00

- E.g a 5 year old needs 1500 Kcal

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5
Q

How can nutrition affect someone’s health?

A
  • Having poor nutrition will slow the recovery time for illnesses
  • Having poor nutrition can result in health problems such an increase risk of heart disease, diabetes and stokes
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6
Q

What 4 nutrition interventions can be carried out to ensure the patient has a good nutrition intake?

A
  • Offering the patient choice of food
  • Help the patient to eat if required
  • Food charts
  • Food supplements
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7
Q

What is enteral nutrition?

A

A tube in the stomach and liquid feed

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8
Q

What is parental nutrition?

A

Nutrition which is given directly into the vein

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9
Q

How much water is there in saliva?

What does it mean if they mouth is dry?

A

97%-99%

Indicates dehydration

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10
Q

What are 2 disadvantage of maintaining personal hygiene?

A
  • Patient may feel a lack of privacy and embarrassment

- Increase level of stress

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11
Q

Which 2 ways can a nurse assist a patient with personal hygiene?

A
  • Use equipment to prevent cross contamination

- Observe the patient carrying out hygiene

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12
Q

What is Oral Candida?

A

A fungal infection, white patches on the tounge

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13
Q

What is Jaundice?

A

The yellowing of the skin and eye caused by bilirubin levels in blood

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14
Q 
What can...
Blood 
Protein
Glucose
Ketones 
Bilirubin 
Indicate on a urinalysis?
A
  • Blood = UTI, renal stones or enlarged prostrate
  • Protein = infection or congestive heart failure
  • Glucose = diabetes, pancreatitis or patient has high stress levels
  • Ketones = breakdown of body fat
  • Bilirubin = liver disease or biliary tract obstruction
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15
Q

What does micturition mean?

A

The act of passing urine

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16
Q

What does anuria mean?

A

No urine output

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17
Q

What does glycosuria mean?

A

Glucose in the urine

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18
Q

What does diuresis mean?

A

Increased production of urine

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19
Q

What does haematuria mean?

A

Blood in the urine

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20
Q

What does Malaena mean?

A

tar like stool

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21
Q

What does Constipation mean?

A

Hard faeces that is difficult to pass

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22
Q

What does Steatorrhoea mean?

A

Pale coloured, fatty, smelly stool

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23
Q

What does Diarrhoea mean?

A

Frequent, loose stool

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24
Q

What does a peak flow meter measure?

A

The max speed of air leaving the lungs during a forced expiration

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25
Q

What does peak flow measurement readings compare?

A

Compares the patients age with their height, giving a peak flow

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26
Q

What does NEWS stand for?

A

National early warning score

27
Q

What is the NEWS system?

A
  • Devise which identifies early deterioration of patient
28
Q

What 4 reasons should BGM occur?

A
  • Someone on parenteral nutrition
  • Someone who is prescribed steroids
  • Someone with a pancreas disease
  • Part of routine health checks
29
Q

What does BGM do?

A

It helps to detect low blood glucose levels and high blood glucose levels

30
Q

What 3 ways can you test blood glucose levels?

A
  • Urinalysis
  • Venous blood sample for blood glucose
  • Capillary blood spot testing
31
Q

How is BGM measured?

A

Millimoles per lite (mmol/l)

32
Q

What is diabetes mellitus?

A

Where the blood glucose levels variate until treated and controlled by insulin

33
Q

How do you do BGM?

What must you ensure the patient does?

A
  • BGM is done by using a glucometer.
  • Patients hands must be washed and dried prior to the BGM (traces of sugar could be on hands)
  • Indicate the patients hands downwards, and warm up the finger
34
Q

What does Hyperventilation mean?

A

Prolonged
Deep
Rapid

Ventilation

35
Q

What does hypoventilation mean?

A

Shallow and slow ventilation

36
Q

What does mmHg stand for?

What does it measure?

A

Millimetres of Mercury

- Measures pressure

37
Q

How slowly should you realise the pressure when doing blood pressure?

A

Done at 2mm/s

38
Q

How do you take someone’s temperature with a disposable chemical thermometer?

A
  • Check expiry date
  • Insert Thermometer under tongue in the centre
  • Ask patient to close mouth but not teeth
  • Leave for 1 minute
  • Remove, read and document
39
Q

How much % should the BP cuff cover on the patients arm?

A

80%

40
Q

What are the 3 types of thermometers?

A

Chemical
Electronic
Tympanic

41
Q

What does Pyrexia mean?

A

The body temperature is over 37.5

42
Q

What does hypothermia mean?

A

The core body temp is below 35

43
Q

What 4 times should a patients temperature be taken?

A
  • On admission
  • Before and after surgery
  • During blood transfusion
  • To monitor patients condition?
44
Q

What is BP?

A

Blood pressure - the pressure within the major arteries when the left ventricle pumps blood into the aorta

45
Q

What is systolic BP?

A

Pressure in artsier s during contraction of heart muscle

46
Q

What is diastolic BP?

A

Blood pressure when the heart is between beats

47
Q 
Where is the...
Brachial Pulse?
Radical Pulse?
Popliteal Pulse?
Temporal Pulse?
Carotid Pulse?
Femoral Pulse?
A
  • Inner side of the bicep
  • Inner wrist under the thumb
  • In the knee and the back of the legs
  • Above and towards the outside eye
  • Side of neck
  • Near pelvic bone
48
Q

What are the 3 aspects of the pulse which are assessed?

A

Heart beat (BPM)
Rhythm (regular or irregular)
Volume (strong or weak)

49
Q

What does hyproxemia mean?

A

Inadequate levels of oxygen in blood

50
Q

What does bradypnoea mean?

A

Respiratory rate under 12 bpm

51
Q

What does tachypnoea mean?

A

Respiratory rate under 20 bpm

52
Q

What are 4 factors which affect breathing?

A
  • Smoking
  • Activities
  • Genetics
  • Pain
53
Q

What does haemoptysis mean?

A

Blood in sputum

54
Q

What is pulmonary oedema?

A

Build up of fluid in the lungs

55
Q

What are the four types of sputum?

What might they indicate?

A
  • Green/yellow/creaming = infection
  • White frothy/pink = pulmonary oedema
  • Black specks = cigarette smoke/smoke inhalation
  • Haemoptysis (blood)= carcinoma or trauma
56
Q

What should you do before any observations?

A
  • Hand hygiene and protective clothing, if required

- Tell the patient what you are going to do and get their consent

57
Q

When should you not do observations?

A

After the patient has smoked, carried out physical activity or earthen - wait 15 minutes

58
Q

Why are observations taken? (4)

A
  • Baseline on admission
  • Detects deterioration
  • Detects improvement
  • To monitor the patients condition
59
Q

What is normal range for…

1) temperature?
2) Pulse?
3) Respiration?
4) Blood pressure?

A

1) 36 to 37.2
2) 60 to 80 bpm (beats)
3) 12 to 20 bpm (breaths)
4) 90/60 to 140/90 mmHg

60
Q

How many times should you get the patient to do their peak flow measurement? And why?

A

3 times, just in case they have done the first one wrong. You should take the highest reading out of the 3

61
Q

In regards to NEW, what dos a scarce of 0 to 4 indicate? Who do you contact?

A

Low

The ward

62
Q

In regards to NEW, what dos a scarce of 5 to 6 Indicate? What is the response?

A

Medium

Urgent Response

63
Q

In regards to NEW, what dos a scarce of 7 or more indicate? What do you contact?

A

High

Urgent or emergency response

Yr1 HS1011 (7 decks)

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