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NURS123 > Final > Flashcards

Final Flashcards

1
Q

Circulation interventions

A
  • Chest compressions
  • Control of bleeding
  • IV access
  • Fluids, medications, blood transfusion
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2
Q

Disability interventions

A
  • Attempt to elicit a response – verbal, painful
  • If unresponsive, obtain help and check breathing and pulses, repeat vital signs
  • Administer glucose as needed
  • Treat pain
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3
Q

Exposure interventions

A
  • Control bleeding – apply pressure, tourniquet
  • Maintain a normal temperature
  • Investigate unusual markings or signs of abuse
  • Remove wet/soiled pad or linens
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4
Q

Appropriate VS ranges

A
  • HR < 50 or > 90
  • RR < 8
  • BP systolic < 90 or >180
  • Temp < 36.0 or > 38.0
  • O2 saturation < 95%
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5
Q

4 checks of Exposure

A
  • Uncover and assess face & head, torso (front and back), extremities for unusual markings
  • Skin color and temperature
  • Uncontrolled bleeding
  • Incontinence
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6
Q

4 checks of Disability

A
  • AVPU/GCS
  • Blood glucose/dextrose
  • Pupil response
  • Pain

ABPP

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7
Q

7 checks of Circulation

A
  • Heart rate and rhythm
  • Quality of pulses
  • Skin color, temperature, cap refill
  • Blood pressure
  • Signs of bleeding
  • Intravenous access – lines, site to source
  • Output - urine

HQOSBIS

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8
Q

4 checks of breathing

A
  • Respiratory rate and effort
  • Depth and symmetry of chest rise
  • Breath sounds - auscultate
  • Oxygen saturation
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9
Q

3 checks of the Airway

A
  • Listen for air movement
  • Feel for air movement at nose and mouth
  • Look at position of head and trachea
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10
Q

Neuro Qs

A

Tremors
Difficulty speaking
One-sided weakness
Head/brain history

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11
Q

cardio Qs

A

SOB
Chest pain
Cardiac risk factors (high BP, high cholesterol, obesity)

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12
Q

Respiratory Qs

A

SOB (OE)
Hx of infection
Resp. related habits (smoking)
Environmental exposure

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13
Q

Integumentary Qs

A

Hx of skin disease
Change in moles/skin pigment
Rashes
Healing delay or bruising

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14
Q

Neuro focused assessment MAIN Tasks

A

Inspect pupils

Inspect GCS

Motor Assessment

Sensation

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15
Q

Neuro motor assessment

A

Symmetry
Grip
Pronator drift
Flexion of legs
Sensation

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16
Q

Cardio focused assessment

A

Qs:
1. Any chest pain or tightness?
2. Any shortness of breath? (SOB)
5. Do you seem to tire easily?
9. Any past history of heart disease?
10. Any family history of heart disease?
11. Assess cardiac risk factors

Inspect
* CWMS and capillary refill
* PMI and JVD and carotid pulse

Auscultate
- PMI for 1 min
- HR, rythym + extra heart sounds
* right 2nd intercostal space (ICS), (aortic)
* left 2nd ICS, (pulmonic)
* left 3rd ICS space, (Erb’s)
* left 5th ICS, (tricuspid)
* PMI (mitral)
- radial pulse match apical pulse??

Inspect ARMS and legs
Check radial pulse
* CWMS
* Edema
* Hair distribution
* Varicose veins
* Wound healing
* Check feet pulses (DP, PT)
- Cap refill

17
Q

Respiratory focused assessment

A

Qs:
2. SOB? SOBOE?
3. Chest pain with breathing?
4. Hx of respiratory infections
5. Smoking hx?
6. Environmental exposure?

Inspect
- symmetry
-RR + Pattern
- Effort of breaths (uses of accessory muscles)
- Face &mouth and Extremity skin colour

Palpate
- symmetrical expansion
- Skin massess
- Temperature
- Pain
- Tactile fremitus (vibration of chest walls during speaking certain words)

Auscultate anterior and posterior back
- Verbalize adventitious lung sounds

18
Q

Integ focused assessment

A

Inspect
- Colour
- Irregularities
- Wounds/dressings

19
Q

Airway interventions

A
  • Reposition – head tilt/chin lift/jaw thrust
  • Suction – secretion, emesis
  • Airway – adjunct, endotracheal intubation
20
Q

Breathing interventions

A
  • Elevate head of bed or position of comfort
  • Apply oxygen – nasal prongs, face mask
  • Assist ventilation – bag-valve mask
21
Q

Examples of adventitious lung sounds

A

crackles,
wheezes,(musical on expiration)
stridor (whistle on inspiration),
pleural rub (bumping, with inflammation)

22
Q

GU/GI Focused assessment

A
  1. Food intolerance
  2. Abdominal pain?
  3. Nausea or vomiting
  4. Bowel habits
  5. Abdominal history – diseases, surgeries

Urinary symptoms for males
Menstrual history for females
- Contact with STIs for both

GI inspection
- Contour (Distension
- Symmetry
- * Skin
* Pulsation or Movement
* (comfort)

Auscultate
- Quadrants (Verbalize findings hypo/hyper/normal)

Palpate the abdomen last
- For lumps or tenderness
- * palpate symphysis pubis for bladder distention
* verbalize examine tender areas last

GU
* Check urine for color, sediment, hematuria, odor
* Record amount - verbalize normal is > 30 ml/hr
* Assess fluid status – weight, edema, neck vein distension, skin moisture and elasticity, eyes sunken, BP
* Genitalia – visualize only if indicated

23
Q

Integ. Focused Assessment

A

Qs

  1. Previous hx of skin disease? Diabetes? CV disease?
  2. Excessive dryness or moisture?
  3. Rashes or lesions? (Be able to ask LOTTAARRPP)
  4. Medications?
  5. Hair loss?
  6. Changes in nails?

Inspect skin
* Color
* Irregularities
- Wounds/dressings

Verbalize for the areas to check for pressure ulcers for immobile patients
Head, Scapulae, Ribs, Elbows, Coccyx, Hips, Ankles and Heels.

Palpate
Texture
Turgor
Temp
Mositure
Edema

Inspect hair and nails
Colour
Texture
Distribution
Lesions

Nails
- Shape, contour, consitency
- Clubbing?
- Cap refill in fingers and toes

24
Q

Neuro Focusedd assessment

A

Qs:
Headinaches, dizziness, nausea?
Hx of head injury
One sided weakness or general weakness
Numbness or tingling
Hx of stroke or any brain event?

Inspect
PERRLA
GCS Scoring

  • EYES - assess for spontaneous eye opening
  • VERBAL Response – assess orientation (A+Ox3)
  • MOTOR Response – assess if able to follow commands

Motor assessment
- * Facial symmetry
* Hand grip
* Pronator drift
* Leg raise
* Dorsiflexion & plantarflexion

Sensation (Numbness or tingling)
* touch feet, legs, hands, and arms

25
Q

AVPU

A

Alert (independently)
Verbally response
Pain Responsive
Unresponsive

26
Q

Verbalize normal amount of urine output

A

30ml/hr

27
Q
A

NURS123 (13 decks)

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