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Nursing Skills > Clinical Measurement > Flashcards

Clinical Measurement Flashcards

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1
Q

What is clinical measurement?

A

Clinical measurement is the development, use, on-going support, and maintenance of technology for diagnosing, aiding or treating patients.

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2
Q

What is vomiting?

A

Vomiting involves the forceful movement and elimination of the contents of the stomach by the constant action of the abdominal muscles with the opening of the gastric cardia.

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3
Q

What causes vomiting?

A
  • Dehydration
  • Nutritional deficiencies
  • Electrolyte and acid-base imbalance
  • Toxins
  • Metabolic conditions
  • Organ failure/ disorders of viscera
  • Neurological conditions
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4
Q

What two areas are associated with the pathophysiology of vomiting?

A
  • The pathophysiology of nausea and vomiting is complex. The act of emesis is associated with 2 main centres located in the medulla oblongata (the brain stem)
  • The vomiting centre
  • The chemoreceptor trigger zone (CTZ)
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5
Q

What is CTZ (vomiting)?

A
  • Chemoreceptor trigger zone
  • The CTZ is an area of the brain not fully separated from the blood by the blood brain barrier so it can detect chemicals in the blood and cerebrospinal fluid and initiate vomiting.
  • The CTZ is also stimulated by signals from the gut to the inner ear
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6
Q

What are the two general mechanisms for vomiting?

A

Neurological and peripheral

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7
Q

What is the physiology of vomiting in the brain?

A

Brain area- Medulla Oblongata- Centre of MO is called vomiting centre-> muscarinic receptor gets stimulated= vomiting reflex

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8
Q

What is the physiology of vomiting in the CTZ?

A

Near the MO is chemoreceptor trigger zone (CTZ) is chemically stimulated- has 5 HT and dopamine 2 receptors- chemotherapy can trigger CTZ= CTZ triggers MO vomiting centre= vomiting

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9
Q

What is the physiology of vomiting in the ear?

A

Motion sickness- labyrinth in inner ear

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10
Q

What is the neurological mechanism of vomiting?

A
  • Stimulation of the Medulla Oblongata (within the brain stem) which ‘senses’ noxious chemical agents e.g poisons, chemotherapy agents, digoxin, causing nausea and the emesis reflex (vomiting)
  • Diseases of the central nervous system (brain and spinal cord) such as infections or tumours which stimulate structures within CNS to elicit nausea and vomiting
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11
Q

What is the peripheral mechanism of vomiting?

A
  • Diseases such as those of the gastrointestinal (GI) tract. Brain centres where nausea is perceived stimulate vomiting
  • Tumours, infections or drugs in the periphery may cause local dysfunction, in a variety of organ systems that is sensed as nausea that, when severe causes vomiting
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12
Q

What toxins cause vomiting?

A
  • Medications/drugs e.g cytoxics, opioids, NSAIDs, antibiotics, anticonvulsants, iron and many others
  • Poisoning
  • Substance abuse
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13
Q

What metabolic conditions cause vomiting?

A
  • Hypercalcaemia
  • Hyponatremia
  • Ketoacidosis
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14
Q

What is hypercalcaemia?

A

A condition in which the calcium level in your blood is above normal. Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with how your heart and brain work. Hypercalcemia is usually a result of overactive parathyroid glands.

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15
Q

What is hyponatremia?

A

Hyponatremia means that the sodium level in the blood is below normal. When the sodium level in your blood is too low, extra water goes into your cells and makes them swell. This swelling can be dangerous especially in the brain, since the brain cannot expand past the skull.

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16
Q

What is ketoacidosis?

A

Diabetic ketoacidosis (DKA) is a serious problem that can happen in people with diabetes if their body starts to run out of insulin. When this happens, harmful substances called ketones build up in the body, which can be life-threatening if it’s not found and treated quickly.

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17
Q

What organ failure/ viscera disorders cause vomiting?

A
  • Liver
  • IBS (VD)
  • Renel obstruction e.g gastric outlet, bowel, biliary, pancreatic
  • Severe constipation
  • Gastroparesis inflammation or irritation e.g gastroenteritis
  • Hepatitis
  • Cholecystitis- inflammation of the gallbladder
  • NSAID- Non-steroidal anti-inflammatory drugs
  • Chemotherapy (radiation)
  • Malignancy- the state or presence of a malignant tumour; cancer
  • Ascites- Ascites is the abnormal buildup of fluid in the abdomen
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18
Q

What is a viscera disorder?

A

Visceral pain, defined as pain originating from the internal organs, is a hallmark feature of multiple diseases, including inflammatory bowel disease, pancreatitis, irritable bowel syndrome (IBS), and functional dyspepsia.

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19
Q

What neurological conditions cause vomiting?

A
  • Increased intracranial pressure e.g malignancy, haemorrhage, cranial irradiation or abscess
  • Meningeal infiltration
  • Vestibular e.g labyrinthitis or effects of medications/drugs
  • Anxiety
  • Pain
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20
Q

What is haematemesis?

A

Presence of blood in vomit, bright pink or ‘coffee ground’

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21
Q

What is copraemesis?

A

Odour or presence of faeces in vomit

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22
Q

What is retching?

A

Movements associated with vomiting without the expulsion of gastrointestinal contents

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23
Q

What is nausea?

A

Subjective experience of feeling sick, unpleasant feeling, often leads to vomiting

24
Q

What is the pre-procedure for nursing a vomiting patient?

A

1) Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed
2) Ensure the patient is in a safe place and position to avoid and unnecessary injury or fall
3) Decontaminate hands and apply personal protective equipment

25
Q

What is the procedure for nursing a vomiting patient?

A
  • Close the door or draw the curtains around the patient’s bed area
  • Provide the patient with a vomit bowl and tissues
  • Remain with the patient
  • Once the patient has stopped vomiting, remove the vomit bowl and offer warm water and towels for them to wash their face and hands
  • Assist the patient to find a comfortable position and leave the second, clean vomit bowl with them
  • Take the first vomit bowl to the dirty utility (sluice) room and, where necessary, measure the volume and note the characteristics (colour, consistency and smell) of the vomit
26
Q

What is the post-procedure for nursing a vomiting patient?

A
  • Dispose of the contents safely and place the vomit bowl in the washer or disposal unit
  • Remove personal protective equipment
  • Wash hands using soap and water or use alcohol-based hand rub
  • Record the volume and any notable characteristics of the vomit in the patient’s notes
  • Administer any prescribed antiemetics
  • Return to the patient and assess them at regular intervals, evaluating the effectiveness of any interventions
27
Q

What is sputum?

A
  • Sputum is a term used to describe mucus that has been expectorated (coughed up) consisting of secretions and other matter from the lungs and large airways
  • Sputum is always abnormal because healthy people swallow bronchial secretions
  • Sputum analysis is important as it enables diagnosis of conditions such as, pneumonia, tuberculosis, lung abscess and lung cancer
  • The nurse should record the colour, amount and consistency of sputum
28
Q

What are the characteristics of bronchiectasis sputum?

A

Purulent, yellow or green, malodorous, may be intermittently bloodstained

29
Q

What are the characteristics of lung cancer sputum?

A

Repeatedly blood stained

30
Q

What are the characteristics of pulmonary tuberculosis sputum?

A

Purulent, intermittently bloodstained

31
Q

What are the characteristics of lung abscess sputum?

A

Copious, purulent and malodorous, may be bloodstained

32
Q

What are the characteristics of pneumococcal pneumonia sputum?

A

Purulent, stained with rusty red blood

33
Q

What are the characteristics of pulmonary oedema sputum?

A

Pink or white and frothy

34
Q

What are the characteristics of pulmonary embolus sputum?

A

Bright red

35
Q

What are the characteristics of blood clotting abnormality sputum?

A

Bright red

36
Q

What are the characteristics of trauma sputum?

A

Blood stained

37
Q

What are the characteristics of COPD sputum?

A

Mucoid (clear, grey or white, like raw egg white)

38
Q

What are the characteristics of infection/dehydration sputum?

A

Thick and tenacious

39
Q

What are the characteristics of infection, allergy, secretions that have not been expectorated sputum?

A

Purulent, yellow or green- immune cells arrive, fight, die and are carried off in the mucus turning it yellow

40
Q

What are the characteristics of asthma sputum?

A

Sputum plugs or stringy sputum

41
Q

What are the characteristics of the presence of eosinophils (indicative of infection) sputum?

A

Green or yellow

42
Q

What are the characteristics of the presence of pseudomonas infection sputum?

A

Thick, green, musty smell, sticky

43
Q

What are the characteristics of haemoptysis sputum?

A

Contains blood varying from slight streaks to frank bleeding

44
Q

What is the equipment used while obtaining a sputum sample?

A
  • Alcohol gel, depending on local policy
  • Sterile gloves
  • A disposable apron
  • Protective eyewear
  • Sterile 0.9% sodium chloride solution for inhalation via a nebuliser if required
  • Sputum specimen collection container
  • Clinical waste bin
45
Q

What is the pre-procedure to obtaining a sputum sample?

A
  • Explain the procedure to the patient and gain informed consent
  • Decontaminate hands
  • Position the patient in an upright position in a chair, on the edge of the bed or well-supported by pillows in bed (high fowler position) as this will ensure maximum lung expansion
  • The patient’s mouth should be rinsed with water before the sample is collected, to avoid contaminating the sample with food residue. It can also be helpful to remove dentures
  • Administer a prescribed sodium chloride 0.9% nebuliser to help to loosen secretions if they are thick and difficult to expectorate
  • Decontaminate hands and put on an apron, non-sterile gloves and a facemark if you are likely to come into contact with bodily fluids. This reduces the risk of contamination of the specimen and the risk of cross infection
46
Q

What is the procedure whilst obtaining a sputum sample?

A
  • Ask the patient to take several deep breaths- breathing in through the nose and exhaling through the mouth- to help loosen secretions
  • Ask the patient to force a deep cough to ensure a sample is obtained from the lower respiratory tract
  • The patient should expectorate into the specimen pot and secure the lid to prevent contamination. Ensure the specimen is sputum rather than saliva, as samples contaminated with oropharyngeal secretions and saliva are difficult to interpret and can be misleading
47
Q

What is the post-procedure whilst obtaining a sputum sample?

A
  • Remove gloves, apron and face mask then decontaminate hands to reduce the risk of cross infection
  • Label the sample and complete microbiology forms
  • Send the sample to the laboratory as soon as possible (within four hours)
  • Document the procedure in the patient’s notes
48
Q

What is BMI?

A
  • Body Mass Index
  • Body weight is the most widely used measure of nutritional status in clinical practice. Body weight remains a one-dimensional metrics, however, it is simple, readily obtainable and usually precise measure which can be reviewed over time to note general changes in nutritional status
  • The measurement of height enables an additional metric to be utilised to gain further insight into nutritional status
49
Q

What is the BMI equation?

A

BMI= weight (kg)/ height (m2)

50
Q

What is a healthy BMI score?

A

18.5-24.9

51
Q

What is an overweight BMI score?

A

25

52
Q

What is an obesity | score?

A

30

53
Q

What is an obesity || score?

A

35

54
Q

What is an obesity ||| score?

A

40

55
Q

What should you take into consideration when using BMI ?

A

BMI should be used as a practical estimate of adiposity in adults. BMI should be interpreted with caution as it is not a direct measure of adiposity. Consideration should be given to utilising waist circumference, in addition to BMI, in people with a BMI of less then 35kg/M2

56
Q

What waist circumference measurements should men have when considering weight?

A

For men, waist circumference of less than 94cm is low, 94-102cm is high and more than 102cm is very high

57
Q

What waist circumference measurements should female have when considering weight?

A

For women, waist circumference of less than 80cm is low, 80-88 is high and more than 88cm is very high

Nursing Skills (9 decks)

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