Deck 1 Flashcards
What is the two types of Delirium
Hypoactive
Hyperactive
What is the assessments tools for delirium
4at
confusion assesment model
single question
pinch me
what does pinch me stand for
P= Pain IN= Infection C= Constipation H= Hydration M= Medication E= Environment
What are the two assesments in neurological assessment
Glasgow coma scale
AVPU
What are the four steps for a glasgow coma scale
Assess, verbal, motor and eyes opening responses.
what is avpu?
Alert, voice, pain and unresponsive
what is emesis
vomit
wha is haematemis
blood in vomit
what is copramesis
prescene of faeces in vomit
what is blood glucose
needed for people with diabetes
anyone actually unwell
what is hyperglycaemia
a random plasma glucose of more than one 11mmol
cause of hyperglycaemia
Infections, stress, inadequate of insulin, surgery.
what is sepsis
when the Immune system overreacts as response to an infection
assessment tools for sepsis
NEWS2
ABCDE
What is ABCDE
airways, breathing, circulation, disability, expourse
what is sbar
situation, background, assesment, recommendation
what is soler?
effective communcation
what are the 5 points in soler
sit squarely open posture lean forward eye contact relax
How may times do you do BD
twice a day 12 hours
how many times is tds
3 times - 8 hours
how many times is qds
4 times a day - 6 hours
what are the two terms of respiratory rate
external
internal
what is tachypnoea
hyperventilation
what is bradypneoea
hypoventiliation
what is dyspnoea
shortness of breath
what is apnoea
absesne of breathing
what is hyperpnoea
deep and laboured breathhing
what are the 4 terms of art of noticing
hearing
sight
touch
smell
what is noticing
Noticing - interpretation - repsond to interpretation - review outcome
how do we notice? what are the four terms
sight, smell, touch and listen.
what does airway consist of
- look for signs of obsruction
- treat obstruction as a medical emergency
- give oxygen at a high level
what are the three steps to circulation
- pulse/ heart rate per min
- assess rhythm and quality
- blood pressure
what is normal temp
36-37.5
what is normal resperation
12-20pm