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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
What does peak flow measurement readings compare?
Compares the patients age with their height, giving a peak flow
26
What does NEWS stand for?
National early warning score
27
What is the NEWS system?
- Devise which identifies early deterioration of patient
28
What 4 reasons should BGM occur?
- Someone on parenteral nutrition - Someone who is prescribed steroids - Someone with a pancreas disease - Part of routine health checks
29
What does BGM do?
It helps to detect low blood glucose levels and high blood glucose levels
30
What 3 ways can you test blood glucose levels?
- Urinalysis - Venous blood sample for blood glucose - Capillary blood spot testing
31
How is BGM measured?
Millimoles per lite (mmol/l)
32
What is diabetes mellitus?
Where the blood glucose levels variate until treated and controlled by insulin
33
How do you do BGM? | What must you ensure the patient does?
- 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
What does Hyperventilation mean?
Prolonged Deep Rapid Ventilation
35
What does hypoventilation mean?
Shallow and slow ventilation
36
What does mmHg stand for? | What does it measure?
Millimetres of Mercury | - Measures pressure
37
How slowly should you realise the pressure when doing blood pressure?
Done at 2mm/s
38
How do you take someone’s temperature with a disposable chemical thermometer?
- 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
How much % should the BP cuff cover on the patients arm?
80%
40
What are the 3 types of thermometers?
Chemical Electronic Tympanic
41
What does Pyrexia mean?
The body temperature is over 37.5
42
What does hypothermia mean?
The core body temp is below 35
43
What 4 times should a patients temperature be taken?
- On admission - Before and after surgery - During blood transfusion - To monitor patients condition?
44
What is BP?
Blood pressure - the pressure within the major arteries when the left ventricle pumps blood into the aorta
45
What is systolic BP?
Pressure in artsier s during contraction of heart muscle
46
What is diastolic BP?
Blood pressure when the heart is between beats
47
``` Where is the... Brachial Pulse? Radical Pulse? Popliteal Pulse? Temporal Pulse? Carotid Pulse? Femoral Pulse? ```
- 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
What are the 3 aspects of the pulse which are assessed?
Heart beat (BPM) Rhythm (regular or irregular) Volume (strong or weak)
49
What does hyproxemia mean?
Inadequate levels of oxygen in blood
50
What does bradypnoea mean?
Respiratory rate under 12 bpm
51
What does tachypnoea mean?
Respiratory rate under 20 bpm
52
What are 4 factors which affect breathing?
- Smoking - Activities - Genetics - Pain
53
What does haemoptysis mean?
Blood in sputum
54
What is pulmonary oedema?
Build up of fluid in the lungs
55
What are the four types of sputum? | What might they indicate?
- Green/yellow/creaming = infection - White frothy/pink = pulmonary oedema - Black specks = cigarette smoke/smoke inhalation - Haemoptysis (blood)= carcinoma or trauma
56
What should you do before any observations?
- Hand hygiene and protective clothing, if required | - Tell the patient what you are going to do and get their consent
57
When should you not do observations?
After the patient has smoked, carried out physical activity or earthen - wait 15 minutes
58
Why are observations taken? (4)
- Baseline on admission - Detects deterioration - Detects improvement - To monitor the patients condition
59
What is normal range for... 1) temperature? 2) Pulse? 3) Respiration? 4) Blood pressure?
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
How many times should you get the patient to do their peak flow measurement? And why?
3 times, just in case they have done the first one wrong. You should take the highest reading out of the 3
61
In regards to NEW, what dos a scarce of 0 to 4 indicate? Who do you contact?
Low The ward
62
In regards to NEW, what dos a scarce of 5 to 6 Indicate? What is the response?
Medium Urgent Response
63
In regards to NEW, what dos a scarce of 7 or more indicate? What do you contact?
High | Urgent or emergency response

Yr1 HS1011 (7 decks)

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