Week 3 Nursing

Question 1

Primary Assessment

Answer 1

• Rapid assessment used to identify life threatening conditions, to allow for prompt management.
• Performed shortly after the person is admitted to a healthcare service or when you first enter their room.
• Enables care to be prioritised based on immediate patient requirements based on their current state of health.
• Help recognise when more senior nursing and medical help is required.

Question 2

Danger

Answer 2

• Identify any dangers to patient and self or other healthcare professionals involved in the situation.
• Dangers can include aggressive bystanders, blood and bodily fluids, sharps, spills on the floor.
• Stop and remove the dangers if safe to do so before attempting to help the patient. Do not place yourself at danger.

Question 3

Response

Answer 3

• Can you elicit any verbal or motor response?
• Do this by asking the patient to open their eyes or touch and squeeze their shoulder.
• Failure to respond is a clear indicator of serious illness.
• Very little time should be spent on this. If there is no response from your patient you need to quickly move on to the next step.

Question 4

Send for help

Answer 4

• If you cannot elicit a response OR there is danger call for help!
• Press the emergency call button, shout for help or dial the hospital emergency number
• Never leave an unconscious patient alone, always stay with them until help arrives.

Question 5

Airway and c-spine

Answer 5

• Ensure airway is patent
• Perform a head tilt and chin lift manoeuvre to open the airways.
• Assess for airway compromise – consider using suction to remove any fluid or Magill’s forceps to remove solid material.
• Think about potential spinal cord injury and manage as required
• Use a jaw-thrust manoeuvre if you suspect a spinal injury.

Question 6

Breathing

Answer 6

• Assess for effective respirations
• Assess air entry to the lungs
• Assess skin and mucous membrane colour
• Check chest wall movement, expansion and symmetry

Question 7

Circulation

Answer 7

• Check for signs of impending cardiovascular collapse
• Assess central pulses
• Assess pulse rate and quality
• Assess skin colour and warmth
• Assess capillary refill
• Assess/manage internal and external haemorrhage
• Auscultate to hear the S1 and S2 heart sounds

Question 8

Disability

Answer 8

• Assessment of central nervous system function
• AVPU (Alert, responsive to Verbal stimulus, responsive to Painful stimulus, Unconscious and unresponsive)
• Check pupil response (PEARL) and consensual reaction. Pupils Equal And Reactive to Light
• Limb assessment for strength and sensation
• Ask about pain
• Check for reversible causes of reduced consciousness:
  – Medications (i.e. opioids, benzodiazepines, hypnotics)
  – Blood glucose level
  – Haemorrhagic shock and hypotension
  – Overdose
  – Anaphylaxis

Question 9

Exposure and environment

Answer 9

• Remove clothing to expose patient as required
• Maintain body temperature during exposure
• Assess for signs of injury, trauma or illness (i.e. anaphylaxis
• Assessment for clues to the cause of patient condition
• Ensure emergency equipment is available at bedspace:

Question 10

Health History Interview

Answer 10

1. Biographical data
2. Reason for seeking care
3. Perception of present state of health
4. Past health and medical history
5. Family history
6. General overall health and wellbeing
7. Health and lifestyle management

Question 11

Physical Examination

Answer 11

• Head-to-toe or systems assessment of body systems:
  – General survey
  – Head and neck
  – Neurological
  – Cardiovascular
  – Respiratory
  – Gastrointestinal
  – Genitourinary
  – Skin and extremities
  – Endocrine
  – Posterior

Question 12

Focused Assessment

Answer 12

• Thorough assessment of a particular clinical manifestation related to a particular body system.
• Completed throughout each shift and at handover to review patient progress and detect deterioration.
• Using the skills of inspection, auscultation, palpation and percussion.