NSE203 Midterm Flashcards
What is assessed in the ‘A’ of the primary survey?
Airway Assessment:
- Check your patient’s level of consciousness - if they don’t respond to pain, they likely won’t notice that they aren’t able to breathe very well!
- Is their mouth empty?
- Do they have any facial or airway trauma?
- Assess accessory muscle use
- Is inspiratory stridor present?
- Is breath coming out of the mouth?
What is assessed in the ‘B’ of the primary survey?
Breathing Assessment:
- Measure the respiratory rate
- Evaluate work of breathing
- Measure oxygen saturation
- Is the patient cyanotic?
- Assess accessory muscle use
- Are thoracic excusions symmetrical
- Does the respiratory rate rapidly decrease after increasing
What is assessed in the ‘C’ of the primary survey?
Circulatory Assessment:
- Palpate pulse rate and rhythm
- Measure BP by auscultation
- Assess urine output
- Listen to the heart
- Feel the skin
- Patient in shock usually has low blood pressure and increased heart rate
What is assessed in the ‘D’ of the primary survey?
Disability Assessment:
- Assess level of consciousness
- Evaluate speech
- Assess for pain
- Assess for changes in facial and body symmetry and sudden changes in vision
- Check pupils
- Glasgow Coma Scale
- Check for Meningeal irritation
- Check glucose
What is assessed in the ‘E’ of the primary survey?
Exposure Assessment:
- Measure body temperature
- Inspect skin integrity
- Inspect and palpate skin for signs of pressure injury
- Observe any wounds, dressings or drains, invasive lines
- Observe ability to transfer and mobilize
- Assess for bowel movements
Which cues observed in the primary survey are significantly associated with death?
- Partial airway obstruction
- Low or high respiratory rate
- Poor peripheral circulation
- Low SpO2 and low systolic BP
- Decreased urine output
- Alteration in mentation and decreasing Glasgow Coma Scale
- New pain
- Greater than expected fluid loss
Describe the steps involved in a Respiratory Brief Scan
- Check for airway patency
- Check for the presence of breathing & respiratory rate
- Check for work of breathing & signs of distress
- Check Oxygen Saturation
- Check level of consciousness, facial expression, and body positioning
- Check color changes
What is the normal body temperature ranges in adults?
36.5-37.5, a wider temperature range is acceptable in infants and young children (35.5-37.7) older adults tend to have lower body temperatures.
Oral: 35.8-37.3
Axillary: 34.8-36.3
Tympanic: 36.1-37.9
Rectal: 36.8-38.2
What is the normal heart rate range in adults, and what other signs are you measuring?
60-100 is the normal range in adults, you should also measure for pulse force (0-3+), pulse equality, pulse rate & rhythm
What is the normal respiration rate for adults?
Adults: 10-20 bpm
12-18 years: 12-22 bpm
7-11 years: 18-30 bpm
2-6 years: 22-36 bpm
Six months to one year: 26-40 bpm
Newborn to six months: 30-60 bpm
Normal respiratory rates for children decrease from birth to adolescence and then slightly increase over the age of 65
What is the normal oxygen saturation range for adults?
97-100% in a healthy individual. However, there are reasons why a lower range occurs in some case:
- Older adults typically have lower O2 sat
- People who are obese or have chronic conditions such as COPD and sleep apnea tend to have lower O2 sat
In practice, the SpO2 range of 92-100% is generally acceptable for most clients
What is the normal blood pressure range for adults?
- Newborn to 6 months: 45-90 Systolic/ 30-65 Diastolic
- 6 months to 2 years: 80-100 Systolic/ 40-70 Diastolic
- Children (2-13 years): 80-120 Systolic / 40-90 Diastolic
- Adolescent (14-18 years): 90-120 Systolic/ 50-80 Diastolic
- Adult (19-40 years): 95-135 Systolic/ 60-80 Diastolic
- Adult (41-60 years): 110-145 Systolic/ 70-90 Diastolic
- Older Adult (61 years and older): 95-145 Systolic / 70-90 Diastolic
Define Hypotension
considered less than 95/60 mm Hg in a normotensive adult
Define Hypertension
considered 140/90 mm Hg or above and is chronic and persistent in the adult
When should a head-to-toe Assessment be performed?
on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context
What is a General Appearance Survey?
Also known as the ‘doorway assessment’ is when an hcp begins to collect data on the patient at first interaction that provides cues for the provider to further investigate. It includes:
1. Physical appearance
- appears stated age
- level of consciousness and signs of distress
- skin color & facial features
2. Body structure
- nutritional status
- posture and position
- symmetry/deformities
3. Mobility
- ROM and gait
4. Behavior
- facial expression
- mood and affect
- speech and hearing
- personal hygiene
What is the Bedside Assessment?
Hospitalized clients require a specialized examination focusing on certain parameters at least every 8 hours and is customized to each client. It involves an initial assessment with continuous monitoring of certain parameters where abnormal findings may prompt a more comprehensive and focused assessment. It includes:
- the primary survey
- general appearance survey
- health history (i.e., isolation precautions, allergies, fall precautions, pain assessment, check iv/fluid rates)
- vitals
- neurological system (i.e., loc, orientation, speech, pupils, motor response, ability to swallow)
- body systems (i.e., respiratory, cardiovascular)
What are some critical findings needing immediate attention that may be found during a Bedside Assessment?
- Altered level of consciousness/confusion
- Systolic BP less than 90 or greater than 160
- Temperature greater than or equal to 38
- Heart rate less than 60 or greater than 100
- Respiratory rate less than 10 or greater then 28
- Oxygen Saturation less than 92
- Urine output less than 30 ml/hour for 2 hours
- Dark amber or bloody urine
- Postop pain or nausea and vomiting not relieved with medication, unusual chest pain
- Bleeding
- Sudden, restless anxiety
What is the Complete Health Assessment?
Includes both a subjective and objective assessment, usually the client’s first entry into a hospital/clinic. A subjective assessment can be complete or limited and includes the biographical data, reason for seeking care, present health, past health and family history, review of systems, and a functional assessment. An objective assessment uses a cephalocaudal approach and is systematic it includes a general appearance survey, measurements (weight/height/BMI), vital signs, and body systems assessment.
What is the behavioral approach to health promotion?
The behavioral change model on Health Promotion is a preventive approach and focuses on lifestyle behaviors that impact on health. * It seeks to persuade individuals to adopt healthy lifestyle behaviors, to use preventive health services, and to take responsibility for their own health (i.e., smoking cessation, healthy eating)
