Patient Assessment

Question 1

GCS

Answer 1

Glasgow coma scale

Eye opening
spontaneously - 4
to speech - 3
to pain - 2
none - 1

Verbal response
orientated - 5
confused - 4
inappropriate - 3
incomprehensible - 2
none - 1

motor response
obeys commands - 6
localises to pain - 5
withdraws from pain - 4
flexion to pain - 3
extension to pain - 2
none - 1

Question 2

NEWS

Answer 2

National early warning score

Scoring system for physiological measurements to aid to identify acutely ill adults

Question 3

Spotting an unwell patient - respiratory

Answer 3

Increased respiratory rate - often first observation to change
Cyanosis - starts in extremities
Accessory muscle use
Tripod position
Pursed lip breathing
Unable to speak in full sentences

Abnormal sounds: wheeze (air passing through obstructed airway during expiration), crackles (air passing through fluid or mucus), stridor (partial obstruction of larynx or trachea causing high pitched sounds during inhalation)

Question 4

Spotting an unwell patient - cardiovascular

Answer 4

Diaphoresis - sweating
Breathlessness
Vomiting
Pallor - pale
Absolute bradycardia - 40bpm or less
Chest pain (cardiac sounding) - crushing, ripping or tearing
Palpitations
Sense of impending doom

Question 5

Spotting an unwell patient - GI/renal

Answer 5

Haematuria - blood in urine
Malena - black tarry stools
Haemotochezia - blood in faeces
Faecal vomiting
Guarding - involuntary tensing
Pulsating mass

Question 6

Spotting an unwell patient - neurological

Answer 6

Reduced GCS
Vomiting
Nystagmus - uncontrollable symmetrical movement of both eyes
Incontinence
Photophobia
Unequal pupils

Question 7

Spotting an unwell patient - paediatric

Answer 7

Depressed fontanelle
Intercostal and sternal recession - increased work to breathe
Tracheal tug - trachea being sucked in due to increased work to breathe
Laying down on behaving unusually.