Bringing it to the Bedside Flashcards
What is the 60 second assessment ABCDE
Airway- airway is patent, patient talking, not obstructed
Breathing- assess RR/quality, no respiratory distress or use of accessory muscles
Circulation- assess circulation/evidence of skin colours (pink), LOC is alert
Devices- O2 (correct delivery and dose) IVs (correct solution/rate) catheter (amount/colour urine)
Environment- safety/concerns with patient, call bell within reach, bed rails up…
What does SO-B-IT stand for?
S- suction (working, supplies)
O- oxygen (working, supplies, flow rate, verify order)
B- bed (call bell, side raises, brakes, pressure points)
I- IV (sites, solution, tubing, rate)
T- tubes (catheters, drains, epidural, NG)
What 5 things does safe patient care include?
- Knowledge- nursing process, medications, pathophysiology
- Critical thinking- apply knowledge, consider patient situation
- Workload- staff available, staff to patient ratio
- Teamwork/communication- document, role clarification, patient/family centred care
- Caring- therapeutic communication, empathy, supportive helping skills
What is hypertension?
Causes headache/fatigue/dizzy/vision problems/SOB. BP is elevated. Risk factors are smoking/poor diet/high BMI/diabetes/low exercise/older age 60+/family hx of CV disease. Test with urinalysis, blood chemistry. Adverse outcomes are TIA/stroke/CAD.
What is COPD?
Experience dyspnea/decreased activity tolerance/productive cough/weight loss. Increased RR/decreased SPO2/elevated BP. For respiratory system it cause tripod breathing, prolonged expiration, shallow breaths, wheezes/crackles, and barrel chest.
If it goes on long then cause edema and cyanosis.
What is chronic diabetes?
Causes blurred vision/fatigue/infections. Skin changes are delayed wound healing/foot injuries/reduced hair growth/thin skin/paleness. CV changes are HTN/weak pulse/claudication/slow capillary refill. Neuro are numb/tingle/loose sensation. GI is polyuria (excessive urine), polyphagia (excessive hunger) polydispsia (excessive thirst).
What is myocardial infarction?
Risk factors are smoking, HTN, family hx, inactivity, alcohol, stress. Causes chest pain/dyspnea/nausea/restlessness. Skin changes are diaphoresis, flushed skin (acute) pale (prolonged). CV changes are irregular rhythm, decreased cap refill, and weak peripheral pulses. Vitals are elevated pulse/BP/RR.
What is pneumonia?
Infection in lungs in lower respiratory tract and alveoli fill with pus so it reduces SA for gas exchange. Risk factors (elderly, hospitalized, kids, post op). Causes dyspnea with exertion/rest, decreased activity, extreme fatigue, harsh cough, decreased appetite. Objectively it causes decreased chest expansion, guarding, decreased breath sounds, adventitious sounds (crackles because of fluid in alveoli), percussion dull. All voice sounds test positive. Have increased RR/temperature and decreased SpO2. Labs have elevated WBC, positive sputum culture, and do chest x-ray.
What is a stroke (CVA)?
Risk factors- diabetes, obesity, HTN, atrial fibrillation (clots form/travel to brain), hx of ischemic attack. Causes SOB/tingling/numbness. Know symptoms onset time/last seen normal. CV changes are carotid bruits, irregular pulse, HTN. Neuro changes altered LOC, mental status, dysphagia, gait, balance, asymmetry of features. Need CT for confirmation of a stroke.
What is a UTI?
Causes frequent urine, urgency, dysuria, back pain, hematuria, chills. Urine is cloudy/dark/concentrated. Bladder distension (don’t wanna go pee because it hurts). Elevated temp/pulse/decreased BP if infection progresses. Urinalysis may show increased WBC.
