RAPID ASSESSMENT Flashcards
ABCDE: Airway - what would you assess?
AIRWAY: Observe for signs of airway obstruction: Complete - no breath sounds, central cyanosis, no chest movement: Partial – paradoxical chest/abdominal movements, noisy breathing.
ABCDE: Breathing - what would you assess?
BREATHING: Observe: ↑RR, symmetry of chest movement, absence of air entry, additional breath sounds, respiratory distress, sweating, central cyanosis, accessory muscle use, abdominal breathing, ability to speak in full sentences, positioning, posterior chest assessment
ABCDE: Circulation - what would you assess?
CIRCULATION: Peripheral vascular checks, capillary refill, manual pulse, BP, temperature. Assess for signs of reduced cardiac output, ↓LOC, ↓Urine output. Consider drain output/bleeding. Fluid balance e
ABCDE: Disability - what would you assess?
DISABILITY/Deficit: CNS function Assess GCS/AVPU, pain, BGL. Check for reversible drug induced causes of depressed consciousness. Assess facial muscles and limb movements.
Respiratory - Q.1, Using the Rapid Assessment Framework, list the assessments you would undertake and the associated expected findings.
Assess airway patency – airway patent
Assessing positioning – positioned at 90 degrees
Assessing skin – no sign of clamming
Assessing work of breathing – accessory muscles used, chest expansion symmetrical
Assessing vitals – BP, HR, RR, PR, AVPU/regular irregular, bounding
Assessing fluids – normal water intake
Assessing neuro changes – GCS score 15 – responsive. Orientated to time and place. Anxious – has family supports.
Assessing circulation – Cap refill, oedema, urine output, temp.
Pain relief, 02?
Respiratory Q.2, List three other nursing assessments you would undertake and give your rationale.
CXR – to assess for bronchopneumonia and if any obstructions
ABG – assess gas exchange and PaC02 and Pa02, assess pH level
Sputum – to examine for culture and identify organism, can be used to confirm a diagnoses
PFM Peak flow measurement – measures maximum forced exhaled air flow, effective to evaluate interventions e.g. inhalers for asthma.
Respiratory Q.4, List five priority nursing interventions that should be implemented during the next four hours for Joe Bloggs and give the rationale for your choice.
For example, sit the patient up to expand the lungs and improve gas exchange.
Breathing – positioning / sit upright,, support with pillows, mobilise. Cough techniques – huffing, deep breathing. Administer prescribed medications 02. Anxiety reduction. Hydration to thin secretions.
Circulation – skin appearance. Temperature. Cap refill time. Oedema. HR, BP, Renal function urin output. Hr and bp irregular or regular weak or bounding?
Disability – AVPU, GCS [Normal is 15, anything less is less responsive]. Orientated to time and place? Restlessness? Anxiety – mood, dyspnoea, breathlessness, Pain – COLDSPA
KIDNEYS Q.1, Using the Rapid Assessment Framework, list the assessments you would undertake and the associated expected findings.
Airway -
Breathing – increased HR?
Circulation – provide skin care,
DISABILITY/Deficit: CNS function Assess GCS/AVPU, pain, BGL. Check for reversible drug induced causes of depressed consciousness. Assess facial muscles and limb movements.
Enviro – Smoking cessation, education on smoking. Alcohol free days in the week, adequate BGL control [diabetes a risk factor and smoking and alcohol], exercise [ hypertension a RF] reduce salt intake-evaluate nutrition, provide education on condition
KIDNEYS Q.2, List three other nursing assessments you would undertake and give your rationale.
Fluid balance chart – measure urine output, assess’s interventions, assess levels of hydration
Vital signs/ESW – evaluate presentation, see any changes, assess if signs of poor perfusion e.g. slow cap refill, decreased BP, increase HR.
Bloods – GFR – assess’s kidney function and blood flow through the kidneys, can assess severity of kidney injury
KIDNEYS Q.4, List five priority nursing interventions that should be implemented during the next four hours for Joe Bloggs and give the rationale for your choice.
Maintain nutrition
Promote activity and rest as tolerated
Provide education on condition and complications
Monitor EWS/BP – hypertension a RF for KI – kidney injury
Fluid chart, check for signs of dehydration – sign of poor perfusion
NEURO Q.1, Using the Rapid Assessment Framework, list the assessments you would undertake and the associated expected findings.
GCS – Normal is E4, V5, M6. Eyes, verbal, motor.
Swallowing – trouble swallowing is common due to damage to the brain. AIRWAY: Observe for signs of airway obstruction: Complete - no breath sounds, central cyanosis, no chest movement: Partial – paradoxical chest/abdominal movements, noisy breathing.
BREATHING: Observe: ↑RR, symmetry of chest movement, absence of air entry, additional breath sounds, respiratory distress, sweating, central cyanosis, accessory muscle use, abdominal breathing, ability to speak in full sentences, positioning, posterior chest assessment
CIRCULATION: Peripheral vascular checks, capillary refill, manual pulse, BP, temperature. Assess for signs of reduced cardiac output, ↓LOC, ↓Urine output. Consider drain output/bleeding. Fluid balance e
DISABILITY/Deficit: CNS function Assess GCS/AVPU, pain, BGL. Check for reversible drug induced causes of depressed consciousness. Assess facial muscles and limb movements.
NEURO Q.2, List three other nursing assessments you would undertake and give your rationale.
Mental status – LOC [LEVEL OF CONCIOUSNESS using GCS], orientation and memory, speech, alertness? Mood / to assess responsiveness
CN111 reflex test – assess brain stem function, assess nerve injury/damage.
Muscle/Resistance test – differentiate any atrophy or weakness in upper/lower extremities, if pt has control or not – this can be indicative or neurologic injury. Assess’s cerebellum function
NEURO Q.3 Identify two actual problems and two potential problems for Joe Bloggs
Causes of neuro deteoriation – alcohol, epilepsy, insulin, opiates, tumour, injury, psychiatric, stroke. Any of these can be a problem
Decrease in ADL’s. Irritability. Impaired mental ability. Impaired vision and coordination
NEURO Q.4, List five priority nursing interventions that should be implemented during the next four hours for Joe Bloggs and give the rationale for your choice.
Positioning at 30 degrees Supplemental 02 Oral care Pressure Injury care Re-orientate pt to time and place to < anxiety Mobility?
GASTRO Q.1, Using the Rapid Assessment Framework, list the assessments you would undertake and the associated expected findings.
VITALS NORMAL
BOWEL MOTION REGULAR
SKIN CARE INTACT
FLUID AND ELECTROLYTE BALANCE RESTORED
PT EATING AND DRINKING HEALTHY DIET
Anticoagulants – prevention of DVT
IVF fluids or blood – replaces electrolytes and recovery
DRUG/ALCOHOL USE
PAST AND CURRENT MEDICATION USE
Bowel chart – consistency, frequency, urgency.
Checking sign of shock, rapid pulse, cold extremities, lethargy – signs of dehydration
Medication – laxative abuse, opiosds, antidepressants – affects bowels, can be constripation
Abdo assessment – check pain around abdomen
Pain control
Skin integrity, wound care
NUTRITIONAL FLUID STATUS
