Exam Prep Flashcards
What are the 8 points of the CRC
- Consider patient situation
- Collect cues/information
- Process information
- Identify problems and issues
- Establish goals
- Take action
- Evaluate outcomes
- Reflect on process and new learning
What is the difference between a comprehensive and focused assessment
Comprehensive: involves all areas and attributes of the patient - A-E assessment - includes PQRST and FLACC
Focused assessments: target specific areas of complaint/presenting issue - HIPPA
What is the difference between growth and development
Growth: physical changes - measured quantitatively
Development: function and skill progression - physical, cognitive and social/emotional
What are the areas of cognitive development
Sensory motor: 0-2
Pre-operational: 2-7
Concrete operational: 7-11
Formal operational: 11+
What is psychosocial development
Erikson: the acquisition of social attributes and skills - development of personality
What are paediatric specific nursing assessments
- Age and Development Stage
- Modification of language and communication style
- Family centred care
- Play techniques
- Observation first
- Cluster assessment
What is the paediatric assessment structure
History
General Appearance
Vital signs
Additional measurements - weight, height, head circumference, BSL
Physical assessment
What is the paediatric assessment triangle
- Appearance: tone, interactiveness, consolability, look/gaze, speech/cry
- Work of breathing: sounds, position, retractions, flaring, apnea/gasping
- Circulation to skin: pallor, mottling, cyanosis
What is the data collected from an eye exam (objective and subjective)
Objective: pain, blindness
Subjective: inspection, distance vision, near vision, colour vision, examination of visual fields (external eye and lacrimal apparatus, extraocular muscle function and anterior segment structures)
What equipment is required in an eye exam
- penlight
- non-sterile gloves
- snellen chart
- rosenbaum near vision pocket screening card
- vision occulode
- cotton-tipped application
Ear exam: subjective and objective data
S: changes in loss or hearing, otaliga (discomfort), tinnitus (ringing), otorrhoea (liquid drainage)
O: external ear abnormalities (asymmetry, deformity, haematoma, cyst), swelling, redness, clear liquid
What does clear liquid coming out of an ear mean and why is it urgent
CSF drainage (if testing positive for glucose) - urgent because it indicates severe brain damage
How to complete an ear exam
- auditory screening: voice whisper test, tuning fork test (webber and Rinne test)
- Inspection: external ear, palpation
- Otoscopic examination
How to assess the nose
- inspect the external surface
- asses patency
- test olfactory sense
- conduct internal assessment with nasal speculum
- inspect, percuss, palpate
- subjective data (pain, discharge/secretions, blockage, congestion, swelling)
- objective data: deformities, haematomas, redness, swelling, masses
Pre-op preparations and considerations
Preparations: patient education - explain ongoing care (analgesia and PCA)
Considerations: assessment, consent, planning, education, communication
Post-operative considerations
- vital signs and oxygenation
- skin perfusion and temp
- analgesia and other meds
- FBC
- dressings/drains/wounds
- catheters, cannulas. lines
- post op void and wash
- frequent positioning
- deep breathing and coughing exercises
- teds and flowtrons
- diet and hydration
- clinical management pathways
- nursing care plan
Op nursing management
- Drains/dressings/equipement
- anaesthetic history - meds
- IVT and infusions
- Vitals and monitoring thoughout procedure
- estimated blood loss
- post-op diagnosis and plan/orders
- medications charted for the recovery room
- medication charted for ongoing care
post op nursing considerations
- neurological - LOC/PEARRL/GCS
- respiratory: pneumonia, atelectasis, pe
- circulatory: hypovolaemia, haemorrhage, shock
- Thrombophlebitis, thrombus, embolus
- Urinary: retention, UTI
- GI: nausea, vomiting, constipation, ileus
- wound: infection, dehiscence, SSI
- Psychologic: depression, body image
Post op nursing management
- Assessments
- Full vital signs - deterioration chart
- Review and update dressing care/management
- Assist with ADL’s
- Interdisciplinary level collaboration
- Documentation nursing care plan
- Handover
Post op complications
- Respiratory: atelectasis, pneumonia, RR changes/alterations, PE
- Cardiovascular: BP/HR changes, arrhythmias, shock, DVT, bleeding
- GI: infection, wounds, pain, fever, phlebitis, vomiting/nausea, constipation/diarrhoea, analphylaxis, dehydration
- Neurological: altered consciousness, stroke/CVA
- Muscoskeletal: compartment syndrome, reduced function, NVO compromise
What is antimicrobial stewardship
improving safe and appropriate use of antimicrobials to reduce patient harm and prevent/contain antimicrobial resistance in Australia
What is included in a Focused Respiratory Assessment
- patient concerns
- symptoms that are common
- health history
- subjective and objective data
- Other: rapid primary, reassess and intervene, secondary/focused, HIPPA
Objective respiratory assessment data
IPPA:
- I: rate, thorax, supreficial veins, distress, muscles used, skin colour (bruising, scars), respiration (rate, pattern, depth, symmetry, audibility, patient position, mode, sputum)
P: tenderness, general palpation, pulsations, massess
P: resonance (normal over lungs), hyper-resonance (hyperinflation: COPD, asthma), tympany (gas-filled: pneumothorax), dull (consolidated tissue: pneumonia, fluid-filled pleural space), flat (dense tissue with no air - posterior chest)
A: vesicular (all lung areas other than major bronchi - 3:1 inspiration ratio), bronchovesicular (medium pitch and intensity - mainstem bronchi and posterior scapulae - 1:1), bronchial (trachea in neck - loud, high pitch - 2:3 ratio)
Additional Respiratory Assessment (other than HIPPA)
- Imaging: chest x-ray, CT, MRI, VQ scan
- Pathology: FBC, UEC, blood culture, ABG
- Sputum culture
- Spirometry
- Other: bronchoscope, lung biopsy, pleural aspirate
Managing hypoxia
assessment, establish airway/breathing, positioning, oxygen therapy, find/reverse cause, MDI/Nebs, chest physio, deep breathing/coughing and spirometry, hydration , reassurance
Managing croup
steroids
Managing pneumonia
antibiotic initiations
oxygen therapy
hydration
nutritional support
breathing exercises
early ambulation
pain management
Managing pulmonary oedema
assessment, positioning, diuretics, oxygen, monitor
Managing Pulmonary Embolism
semi-fowlers position, IV access, O2, assessments, lab results, emotional support and reassurance, patient education
Types of Oxygen Therapy
Nasal canula: 4-6L
Hudson: 5-10L
Non-rebreather: 10-15
What is an angina
sharp or stabbing pain that doesn’t change with changing position or breathing
Due to not enough blood and oxygen supply to heart
Types of angina
Stable (chronic): when heart is working more than normal
Unstable: at rest and following an irregular pattern
Variant (Prinzmetal): at rest with no underlying CAD
What is Acute Coronary Syndrome (ACS)
the once-stable plaque ruptures, exposing and entering the blood and stimulate platelet aggregation and local vasoconstriction with thrombus formation
Types of ACS
Unstable angina pectoris (UAP): history of cardiac disease - no ECG evidence of MI and negative troponin
Non St-elevation MI (NSTEMI): elevated troponin levels in absence of ST elevation
ST-segment elevation MI (STEMI): S-T elevation on ECG or new LBBB with full thickness wall damage
Considerations of a cardiovascular assessment
- explain procedure
- consent
- supine position for assessing anterior chest
- warm/neutral room
- Privacy
Subjective and Objective data of a cardiovascular assessment
S: profile, chief complain, health history, social history
O: vital signs, IPPA, ECG/cardiac monitor, visible JVP, pulses, documentation
ECG Electro and Lead Placement
- V1: 4th intercostal, 2 finger space right of sternum
- V2: 4th intercostal, 2 finger space left of sternum
- V3: between V2 and V4
- V4: 5th intercostal at midclavicular line
- V5: 5th intercostal space - left anterior axillary line
- V6: 5th intercostal space - left mid axillary line
- Limb leads: RL, RA, LL, LA
shockable rhythms
ventricular tachycardia
ventricular fibrillation
What is prediabetes
where blood glucose levels are higher than normal, though not high enough to classify as diabetes
What are the types of pre-diabetes conditions
- Impaired glucose tolerance (IGT)
- Impaired fasting glucose (IFG)
What is type 1 diabetes
autoimmune condition where the body’s own immune system is activated to destroy the beta cells in the pancreas which produce insulin
Symptoms: excessive urination and thirst, weight loss, weakness, fatigue and blurred vision
What is Type 2 Diabetes
where the body becomes resistant to the normal effects of insulin and gradually loses the capacity to produce enough insulin in the pancreas
managed with a combination of regular physical activity, healthy eating and weight reduction
Nursing management of diabetes
- subjective and objective data information
- weight and history of nutritional intake, food intolerance and weight fluctations
- emotional and physical stress - may result in hyperglycaemia
- acute illness, injry and surgery may evoke a counterrgulartory hormone response - hyperglycaemia
Management of hypoglycaemia
positioning
hypo kit on ward - biscuits, jellybeans, lemonade
>3.8mmol: complex carbs and protein snack
immediate-acting carbs followed by long-acting carb
5-15 mins reassess
Hyperglycaemia Management
rapid-acting insulin administration
check ketones if T1 diabetes and BGL=>15mmol/L
Cause of diabetic ketoacidosis
profound deficiency of insulin and is characterised by hyperglycaemia, ketosis, acidosis and dehydration
What is VTE
DVT: when blood clots form in veins where they cause symptoms of pain, tenderness, redness or swelling
PE: when a blood clot breaks off and moves through the veins to block blood vessels in the lungs - causes shortness of breath, coughing up blood, chest pain, faintness and loss of consciousness
Reason for Neurovascular Assessments
for early identification of decreased peripheral tissue perfusion so that measures preventing compartment syndrome or providing prompt treatment of it can occur
What are the 6 P’s of Neurovascular Assessments
Pain
Poikilothermia
Paresthesia
Paralysis
Pulselessness
Pallor
Patients at risk of neurovascular compromise or compartment syndrome
limb fractures, vascular injuries and proceduers, trauma/surgery to limbs/joints, external fixators, casts, splints and constrictive dressings to limbs
Assessment and components of a neurovascular assessment
- check the contralateral limb first
- pain, circulation, sensation, motor function
What are the components of a neurovascular assessments
- Skin Colour: normal, red, pale, dusky, cyanosed, mottled
- Pressure: oedema causes tenseness - check for blood or ooze
- Pain
- Circulation: colour, temp, cap refill, pulse
-Movement: normal movement, sensation - Swelling: nil, mild, movement, large
- Blood loss: nil, small, moderate, large
What types of nerves are assessed in a neurovascular assessment
Upper Limb, sensation:
- Radial nerve: movement-wrist dorsiflexion
- Median nerve: movement thumb opposition
- Ulnar nerve: abduction and adduction
Lower limb movement
- Peroneal nerve: dorsiflexion of ankle and toes
- Tibial nerve: plantar flexion of ankle and toes
What is the pathophysiology of compartment syndrome
- Increased pressure within compartment
- Vascular compromise
- Muscle ischaemia
- Histamine and serotonin release - dilated capillaries
- Increased swelling
- Nerve damage
- Permanent nerve scarring and paralysis (anaerobic metabolism, tissue pH falls, muscular necrosis develops)
- Cell death, contractures, limb death
Signs and Symptoms of compartment syndrome
6 P’s
What is peripheral vascular disease
reduced circulation of blood to a body part other than brain or heart due to a narrowed or blocked blood vessel
Treatments of peripheral vascular disease
- procedures to weiden the artery
- medications to reduce the build-up of fatty deposits within blood vessels
- lifestyle changes such as weight loss and regular exercise
What are venous vs arterial leg ulcers
V: medial malleolus area, are large and shallow, have sloped edges
A: heel and toe area, are small and deep, have punched out margin
What is compression therapy used for
Venous ulcers - provide a constant pressure gradient (graduated compression) which improves venous return and reduces oedema
Contraindications for a compression therapy
- Should not be applied before an appropriate assessment and exclusion of peripheral artery disease
- Appropriate assessment of: cardiac, renal or liver failure, cellulitis and acute deep vein thrombosis
Precautions and adverse effects
- should be used in patients who can detect increased pain or complications and for who the compression system can promptly be removed
- adverse effects associated with bandages are avoidable and falls risk due to reduced agility
Consideration of selection of compression systems
- size and shape of the leg
- patient tolerance and preference
- clinician experience
- environment (temperature)
- ease of application and removal
- access to services
- presence of other diseases
level of activity/weight-bearing and cost
Assessments required before, during and after application of graduated compression therapy (GCT)
- neurovascular status of limbs and comfort
- pain scores
- observed for pain, colour/perfusion, warmth, sensation, movement, cap return
complications of compression therapy
pain, pressure damage, loss of calf muscle, skin problems, allergy alert, bandage slippage, swelling of toes or knee, footwear, ineffective compression, tourniquet effect
What are some nutritional nursing assessments
- Anthropometric measurements: height, weight, BMI, rate of weight change, amount of weight loss
- Physical exam: appearance, mass and strength, dental and oral health
- Health history
- Diet history: chewing and swallowing ability, changes in appetite, taste or intake, food and nutrient intake, glucose, electrolytes, lipid profile, serum urea
- Functional status: ability to perform basic and instrumental activities of daily living, handgrip strength, mini nutritional assessment, malnutrition universal screening tool
Steps for an Abdominal Physical Assessment
H: presenting problem (symptoms, elimination pattern, onset, precipitating factors, quality, region, severity and duration)
I: contour, symmetry, pigmentation and colour, scars, striae, respiratory movement, umbilicus
A: bowel sounds, vascular sounds (presence of bruits) - abnormal: hypo/absent, hyperactive/high pitched, tinkling metallic sounds
P: detects position, size and density of organs - hyper-resonance (gas), dullness (distended bladder, adipose tissue, fluid or mass)
P: light and deep - tenderness, muscular resistance, masses, swelling, distended bladder, hepatomegaly
What is the risk for aortic rupture
- Do not palpate an aorta that you suspect has an aneurysm or a pulsating sensation under the skin
- Notify the patient’s doctor or call for emergency transport
- at risk of dissection and may cause renal failure, loss of lim and death
Contraindications for abdominal palpation assessment
- suspected appendicitis or dissecting abdominal aortic aneurysm
- polycystic kidneys
- transplanted organs
Indications for an NGT
- decompression of stomach and upper bowel
- empty stomach of gas and fluid
- gastric lavage the stomach of toxic fluid
- provide enteral feedings
Types of NGT
Large bore: salem sump, levin - removal of secretions and gaseous substances from GIT
Fine bore - radio-opaque enteral feeding
Levin, salem sump: irrigation of stomach for active bleeding, poisoning or gastric dilation
What equipment is required for inserting an NGT
- NG tube
- Lubricant or normal saline
- Fresh water and straw
- Gloves and apron
- pH indicator strips
- 50mL oral syringe
- tongue blade and penlight
- Low-suction apparatus
- Drainage bag (if required)
- Feeding apparatus and ordered fluid
- Adaptor
- Elastic band and safety pin
- Hypo-allergenic adhesive tape
- Absorbent pad
- Clamp or plug
- Tissue
- Oral hygiene equipment
Cautions for NGT insertion
- if pH is greater than 5 a chest x-ry must be ordered
- radiological confirmation must be ordered if gastric aspirate unable to be obtained
- never use auscultation as form of tube position confirmation
- never use litmus paper to confirm pH
Documentation required for a NGT tube
- reason for insertion
- consent
- type and size of NGT used
- ease of insertion
- confirmation of placement and length of tube from nares to hub
- amount of aspirate and nature - pH reading
- type of apparatus connected
- persons’ response to the procedure
- increase communication between healthcare professionals and comply with legal requirements for reporting changes
Complications of an NG tube
- refeeding syndrome (fluid retention and electrolyte imbalances)
- hypophosphataemia - low phosphate
- chronic alcoholism, vomiting/diarrhoea, chemotherapy and major surgery
What are the types of Nervous Systems
- Central Nervous System: brain and spinal cord
- Peripheral Nervous System: cranial and spinal nerves - Somatic (voluntary movement - skeletal muscle) and Autonomic (Sympathetic vs parasympathetic)
What is Monro-Kellie hypothesis
The skull is a rigid compartment - volume remains constantly in dynamic equilibrium (if one increases volume, the other must decrease) - affects intracranial pressure
What is the 4 stages of volume-pressure relationship
Skull: fixed volume - over compensation leads to an increased ICP
Stage 1: high compliance
Stage 2: compliance beginning to decrease
Stage 3: significant reduction in compliance
Stage 4: ICP rises to terminal levels with little increase in volume
What are neurological vital signs
Temperature: hyperthermia (hypothalamus damage), increase O2 requirements (increase cerebral hypoxia), hypothermia (spinal shock, exposure, brain stem lesions)
Pulse and BP: cushing’s triad/response (death), elevated systolic, bradycardia respiratory abnormality
What are some causes of failing consciousness
AEIOU, TIPPS
- Alcohol, epilepsy, insulin, opiates, urates
- Trauma, infection, psychological, poison, shock
What are the important descriptions of consciousness
- drowsiness, obtundation, stupor, coma
- Assessed through AVPU
What are some aspects of neurological assessments
Pupil size and response: PEARRL (pupils equal and reactive to light)
Glasco Coma Scale
Motor assessment - voluntary and involuntary movement, limb strength
What is a comprehensive neurological assessment
Mental status, sensation, cranial nerve assessment, motor function, cerebellar function, reflexes
How is mental status assessed
LOC, physical appearance, behaviour, speech/communication, cognitive abilityes, mood and suicidal ideation
What is a Head to toe neurological assessment
inspect head and face for:
- lacerations, contusions, abrasions
- haematoma
- Battle’s sign/mastoid ecchymosis
- periorbital edema and ecchymosis
- otorrhea
- rhinorrhoea
- pupil dysfunction
- exposed brain
What are the types of cranial nerves and their functions
- Olfactory: smell
- Optic: vision
- Oculomotor: regulation of light to retina, eye movement
- Trochlear: eye movement
5: Trigeminal: face sensation, pain, touch, heat and cold and mastication - Abducens: rotates eyeball outward
7: Facial: expressions, smiling, closing eyes and grimacing
8: Acoustics: hearing, influences balances, maintenance of body position - Glossopharyngeal: taste, gag and swallowing reflexes
- Vagus: cough and gag reflex
- Spinal accessory: shoulder shrugging
12: hypoglossal: innervates the tongue to permit speech and swallowing
What are the nursing interventions and management for head injury
A: airway and alertness
B: RATES, oxygen, intubate if GCS
C: IV access, manage MAP
D: manage and monitor BGL and GCS
E: remove clothing, control external bleeding, temperature management
Nursing Implementation for head injuries
Acute intervention:
- reduce IC volume - manage CO2, jugular venous drainage
- manage O2
- manage oxygen demand and temperature
- manage seizures
- measure for leaking CSF (head of bed elevated, loose colelction pad, no sneezing/nose blowing, no NG tubes, no nasotracheal suctioning)
What is a CVA
the blood supply to a part of the brain is altered via the lack of arterial blood flow or a cerebral arterial rupture
What are the classifications of CVA
Ischaemic: thrombolytic or embolic
Haemorrhagic
What is a TIA
Transient Ischaemic Attack: episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia but without acute infarction of the brain
What is delirium
an acute change in mental status often triggered by illness/injury/surgery/infection or adverse effects
Symptoms of delirium
inattention, confusion, lethargy, problems with awareness, change in behaviour, hallucinations, mood changes, irritability
