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Nursing Acutely Ill > General Assessment and management > Flashcards

General Assessment and management Flashcards

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1
Q

Apyrexial/afebrile definition

A

35-37C

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2
Q

Hyperthermia/pyrexia/febrile definition

A

> 37.5C

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3
Q

Hypothermia definition

A

<35C

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4
Q

Hyper pyrexia definition

A

> 41C

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5
Q

Temperature is regulated by the …

A

Autonomic nervous system from the hypothalamus

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6
Q

What are the max and min temps and what can each result in

A

Max >41C result in convulsions

Min <32C result in cardiac arrhythmias

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7
Q

What direction does pyrexia shift the oxygen dissociation curve? And why does this occur?

A

To the right. As increased temperature results in a higher oxygen demand due to the increase in metabolic activity. This causes haemoglobin to have a lower affinity for oxygen meaning more oxygen is unloaded at the tissue cells.

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8
Q

What direction does hypothermia cause the oxygen dissociation curve to shift to? And why does this occur?

A

Shift to the left. Cells are less metabolically active. Haemoglobin has a higher affinity for oxygen.

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9
Q

Symptoms of pyrexia. Why they occur.

A 
>37.5C
sweating 
shivering 
feeling cold
high HR 
high RR 
Due to increase cellular metabolism
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10
Q

Normal urine output

A

0.5-1ml/kg/hr.

UO usually = to input with a degree of insensible loss.

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11
Q

Oliguria definition

A

UO <0.5ml/kg/hr = <30ml/hr

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12
Q

Positive fluid balance means

A

Fluid intake > fluid output

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13
Q

Negative fluid balance means

A

Fluid output > fluid input

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14
Q

Anuria definition

A

No urine output or a UO <100ml/24hrs

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15
Q

What does NEWS stand for

A

National Early Warning Score

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16
Q

How fast should NaCl 0.9% be administered?

A

1L/hr

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17
Q

What are factors that may lead to the insertion of an NG tube?

A

Reduced oral intake
Diarrhoea
Vomiting

18
Q

What are risk factors associated with having an NG tube present?

A

Feed going into lung
Chocking
Perforation of the oesophagus

19
Q

What are the clinical signs and symptoms of a critically ill adult despite the cause

A 
Tachypnoea 
Reduced arterial BP 
Tachycardia 
Hypotension 
Reduced/ fluctuating GCS 
Reduced urine output
20
Q

What are the 5 stages of the ABCDE approach?

A
  1. Initial assessment
  2. Treat life threatening problems
  3. Regular reassessment
  4. Assess the effects of treatments/interventions
  5. Escalate/refer if necessary
21
Q

What does diuresis mean?

A

Increased or excessive urine production

22
Q

What three factors should be taken into account when prescribing opioids such as morphine?

A

Patients: age, body mass and pain response.

23
Q

Which low values on two blood related tests would indicate blood loss?

A

Low haemoglobin and haematocrit

24
Q

How many mls per degree of elevated temperature should fluid resuscitation be increased by?

A

500mls.

25
Q

What percentage of total adult body weight is fluid?

A

60%

26
Q

What is the ratio of fluid distribution between the ECF and ICF?

A

ICF 2: ECF 1

27
Q

How frequent should one be with a NEWS of 0-1?

A

12hrly

28
Q

What are the 11 different types of venous blood test and what can they indicate?

A 
Full blood count- anaemia, infection 
Urea and electrolytes- renal function 
Thyroid function test 
Liver function test 
Cholesterol 
Glucose 
Microbial- CRP, cultures, viral titres 
Clotting factors- on anticoagulants 
Creatinine 
CBG 
ABG
29
Q

What are the 3 types of microbial blood test done to detect infection?

A

CRP
Cultures
Viral titres

30
Q

Before ABCDE what should always be observed?

A

Danger and Risks of approaching to you or pt

31
Q

What are the different factors to be assessed to see if Airway is at risk?

A 
Consciousness- low GCS unable to maintain airway require mechanical ventilation
Vomiting/nausea 
Talking
Choking 
Seesaw breathing 
Flail chest 
Surgical emphysema 
SOB 
Noise: wheeze, stridor, croaking
Volume of breathing 
Sputum production
Cough 
Equal lung expansion 
Chest percussion: ?fluid 
Central trachea
32
Q

What are the different areas of assessment in Breathing?

A 
Effort: ?dyspnoea
Pyrexial- increased O2 demand 
Rate, rhythm, depth: bradypnoea, tachypnoea, chyne-stokes respiration
Kussmal breathing- metabolic acidosis 
Low GCS
Damage to cervicale spine- C1-2 innerviates lungs, damage=inability to breathe 
SaO2 
Sputum
Pain- ineffective breathing= broken rib, pneumothorax, infection, deflated lobe/lung
Chest percussion 
Noisy breathing 
COPD
33
Q

What are the potential causes of breathing compromise?

A 
Airway obstruction 
COPD 
Asthma 
Infection 
Cardiac failure 
Chest trauma 
Shock
34
Q

What are the different areas of assessment in Circulation?

A

Skin assessment: warm? colour? dry or moist?
CRT
BP: normotensive, hypotensive, hypertensive
Pulse pressure
UO: decreased kindey perfusion- oliguria, anuria
Chest pain: decreased cardiac perfusion
Consciousness: cerebral perfusion
Nausea: GI perfusion
Stool output: large bowel perfusion
ECG
ABG: indicated at <95% sats
MAP?
Blood tests: FBC, U+E, Cultures, CRP, viral titre, liver/thyroid function test, cholesterol, glucose, clotting factors, creatinine test, cross match.
Raised jugular venous pressure
Manually palpate pulses for rate, rhythm, strength: bradycardia, tachycardia

35
Q

Potential causes of cardiac compromise?

A

ACS
Heart failure
Shock- tachycardia with reduced BP
PE

36
Q

What are the different areas of assessment in Disability?

A 
CBG: hypo/hyperglycaemia 
Scans: CT scan, X-Ray 
Distress 
AVPU -> GCS 
Drugs 
Pain
37
Q

What are the potential causes of altered GCS?

A 
Hypoxia 
Reduced CPP 
Cerebral pathology 
Hypercapnia 
Uraemia 
Hypovolaemia 
Cardiac arthythmia 
Pre/post cardiac arrest
38
Q

What are the different areas of assessment in Exposure?

A

Full body exposure: feel for swelling, wetness, injury, pain, heat, coolness
Look for rashes, injury, swelling,
PMHX: allergies, surgery, drugs, medical conditions, illness
PSHX: living circumstance, family, NOK, partner, dependants
Case notes
Documentation
MDT involvement
Care level
Temperature: pyrexia, hypothermia
SBAR: situation, background, assessment, recommendations

39
Q

What does SBAR stand for?

A

Situation
Background
Assessments
Recommendations

40
Q

What is Base Excess?

A

The amount of an acid or base required to change 1L of blood to a pH of 7.4

Nursing Acutely Ill (11 decks)

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