RAPID ASSESSMENT CARDIOVASCULAR&NEURO

Question 1

NEUROLOGY - Airway assessment and expected findings?

Answer 1

Assessment: Patency, saliva/obstruction

Expected findings: Patent airway. > saliva (under threat due to secretions or dropping of tongue

Question 2

NEUROLOGY - Breathing assessment and expected findings? And rationale

Answer 2

Assesment: RR, WOB/accessory muscle use, speaking in full sentences, Sp02, Posterior chest assesment, 02 use

Expected findings: ^RR, ^ WOB, >muscle use/speaking full sentences,

Question 3

NEUROLOGY - Circulation assessment and expected findings?

Answer 3

Assesment: BP, HR, Cap refill, T, Sepsis, EWS, GFR, Fluid balance
Expected findings: ^BP, ^HR, CRT>3 secs, pale, cool extremeties, +/- Urine output - normal

Question 4

NEUROLOGY - Disability assessment and expected findings?

Answer 4

Assesment: AVPU = Alert. Change to GCS. Speech? Dysarthia - slurring. Braden scale [PI] mild risk 15-18. no risk 18-23. Motor strength - out of 5, 1//5 worse, 5/5 perfect = any weakness?

Question 5

NEUROLOGY - Enviro assessment and expected findings?

Answer 5

Assesment: Falls risk, Braden, family, ADL, Culture, polypharmacy, HX
Expected findings: +/- risk falls, pressure injuries and meds. Falls risk - moderate, severe.

Question 6

NEUROLOGY - Acute Nursing interventions

Answer 6

Position head @ 30 degrees for prevention of secondary injury from ICP. Supplementary 02 to assist with V/Q. Ted stocking to prevent DVT r/t immobility. Remove excess bedding to decrease metabolic demand. Analgesia to reduce SNS. Reorientate pt.

Question 7

Cardio - Airway assessment and expected findings?

Answer 7

Patency - patent

Question 8

Cardio - Breathing assessment and expected findings?

Answer 8

RR - Rhythm depth=increase.

Question 9

Cardio - Circulation assessment and expected findings?

Answer 9

CR=>3secs. Assess cyanosis-nocyanosis/pale greyish tinge. Oedema starting. +/- diaphoresis. R. +/-temp.

Question 10

Cardio - Disability assessment and expected findings?

Answer 10

Anxious. AVPU=alert. +/-BGL. Braden scale [PI] mild risk 15-18. no risk 18-23. Wound pain?

Question 11

Cardio - Enviro assessment and expected findings?

Answer 11

Falls risk. smokng alcohol? Falls risk - moderate, severe.

Question 12

CARDIO - Acute Nursing interventions

Answer 12

Reg vitals-monitor CO + gas perfusion [Sp02].
IPPA - A=dyspnoea, SOB, crackles indicate worsening
Administer 02 - decrease effects of hypoxia and ischemia
Administer cardiac medication - decrease cardiac workload, ^ contractions.
Elevate head of bed to decrease WOB
Encourage rest

Question 13

Neuro potential problems

Answer 13

^in ICP > CPP = cerebral ischemia
Sodium levels causing LOC and worsening brain function
Brain strophies with age so symptoms can take longer to present
CPP worsens, brain stems is compressed causing irreg resps

Question 14

KIDNEY/RENAL/CARDIAC.
AKI - GFR falls - low BP&CO/severe vomitting

Interventions?

Answer 14

Interventions
FBC - monitor Urine O. Low urine O sign of AKI.
Daily Weigh - signs of low GFR is weight loss
CRT - to assess oedema, signs of low GFR r/t AKI.
Bloods - GFR/Electrolytes/CBC - assess renal/cardiac function

Give IV fluids to replenish what has been lost through urine/vomitting etc.

Question 15

How do you know if someone has HF?

What assessments would you use?

Answer 15

c/p, heavy weight, indigestion, SOB, SOBOE, 
Increased HR (to pump more oxygen around body) 
BP low
Ability to speak
ECG
Oxygen saturations and/or ABG
Cyanosis/colour/diaphoresis 
Sounds (gurgling/snoring/apnoea) 
Agitation/confusion
Anxiety
Dyspnoea

ASK: WHAT ASSESSMENTS WOULD YOU USE? Rapid Ax, Posterior Chest Ax, Peripheral vascular Ax

Question 16

Cardio potential problems

Answer 16

Low Urine O r/t poor perfusion

SOB r/t HF = fluids in lungs = impaired gas exchange

Question 17

Stroke interventions

Answer 17

30degrees to reduce ICP
Continuous neuro obs - help identify deterioration and initiate intervention and treatment
NBM until assessed by speech therapist to prevent aspiration of oral food and fluid
Reg turns, maintain skin integriy
Positioning of paralysed limbs to maximise function of rehabili