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Client Assesment Flashcards

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0
Q

Causes of hypothermia

A

Post operative

Prolonged exposure to a cold environment

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1
Q

What is hypothermia?

A

A lowered body temperature, below 34.4 degrees

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2
Q

Nursing care of hypothermia

A 
Take vital signs
Warm blankets
Space blanket
Warm fluids
Radiant heat lamps
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3
Q

What is hyperthermia?

A

An elevated body temperature, above 39 degrees

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4
Q

Causes of hyperthermia?

A

Metabolic disorder
Infection
Neurological disease
Trauma

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5
Q

Nursing care of hyperthermia

A

Take vital signs
Sponge bath or cold compress
Encourage rest to decrease production of heat

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6
Q

What is hypertension?

A

Systolic bp: above 140

Diastolic bp: above 90

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7
Q

What is hypotension?

A

Systolic bp: below 90

Diastolic bp: below 60

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8
Q

What is Orthostatic hypotension?

A

Also known as postural hypotension.

Is a significant hypotension occurring when a patient goes from sitting or lying down to standing

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9
Q

Sites for taking pulses:

A 
Radial artery
Common carotid artery
Superficial temporal artery
Facial artery
Apical artery
Brachial artery
Femoral artery
Popliteal artery
Posterior tibial artery
Dorsalis pedis artery
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10
Q

Vital signs

A 
Body temperature: 36-37.5 degrees
Oxygen saturation: 97-100%
Blood pressure: 
systolic: 100-140 mmHg
diastolic: 60-90 mmHg
Pulse: 60-100bpm
Respirations: 12-20 breaths per minute
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11
Q

What is systolic pressure?

A

Is the pressure exerted during contraction of the ventricles

Systolic blood pressure provides info about the force of the left ventricular contraction

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12
Q

What is diastolic pressure?

A

Is the pressure during the relaxation of the ventricles

Diastolic blood pressure provides info about the resistance of the blood vessels

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13
Q

What is bradycardia?

A

Slow or decreased heart rate

Pulse rate below 60bpm

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14
Q

What is tachycardia?

A

Fast or increased heart rate

Pulse rate above 100bpm

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15
Q

What is afebrile?

A

“Without fever”

A normal ranging temperature

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16
Q

What is febrile?

A

“With fever”

High body temp above 38.5 degrees

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17
Q

What is dyspnoea?

A

Difficult or uncomfortable breathing

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18
Q

What is apnoea?

A

Cessation of breathing for several seconds

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19
Q

What is orthopnoea?

A

The ability to breathe only in an upright position

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20
Q

What are rigors?

A

Periods of rise and fall in body temperature
Severe shivering
Indicates infection

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21
Q

What is tachypnoea?

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A

Rapid breathing

22
Q

Respiratory distress, signs and symptoms

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A 
Cyanosis
Coughing
Wheezing
Alteration in depth or rate
Elevated bp and pulse
Abnormal respiratory rate
Flaring of nostrils
23
Q

What is subjective information?

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A

Clients perception of his/her health condition

24
What is objective information?
Observations which are measured by the nurse
25
What is hypoglycaemia?
Blood sugar level below 3.5 mmol/L
26
Signs and symptoms of hypoglycaemia:
``` Headache Irritability Blurred vision Dizziness Cool pale skin Tachycardia Shakiness Peculiar behaviour ```
27
What is hyperglycaemia?
Blood sugar level above 8.0mmol/L
28
Signs and symptoms of hyperglycaemia:
``` Polydipsia Polyphagia Lethargic Polyuria Glycosuria Ketonuria Warm/flushed skin Dry skin Weight loss ```
29
What is ketoacidosis?
A complication of diabetes mellitus, where the chemical balance of the body becomes far too acidic
30
Signs and symptoms of ketoacidosis:
``` High blood sugar levels Polyuria Thirsty Lethargic Nausea Vomiting Abdominal pain Rapid breathing ```
31
What is diabetes mellitus type 1?
When the body does not produce insulin due to the destruction of insulin-producing beta cells of the pancreas - insulin dependent - sudden onset
32
What is diabetes mellitus type 2?
When the pancreatic beta cells don't produce enough insulin or the body's cells don't respond properly to the insulin - non insulin dependent - slow onset
33
Risk factors for developing diabetes mellitus type 2:
Obesity Aboriginal people over the age of 35 People over the age of 65 Hx diabetes
34
Normal range of blood glucose level:
3.5-8.0 mmol/L
35
Discharge information for individuals with diabetes mellitus type 1:
``` Info on low fat diet Low gi foods Regular exercise Medication Information on type 1 diabetes ```
36
Discharge informations or individuals with diabetes mellitus type 2:
``` Weight loss Healthy eating Regular exercise Stop smoking Medication Info on diabetes type 2 ```
37
Reason for doing urine testing?
``` To detect any abnormalities Routine evaluation Evaluate the effectiveness of medication Help confirm or rule out diseases On admission to hospital ```
38
What is polyuria?
Excessive excretion of urine
39
What is proteinuria?
Protein in the urine
40
What is dysuria?
Painful or difficult urination
41
What is oliguria?
Abnormally small amounts of urine output
42
What is Anuria?
No urine output
43
What is the normal specific gravity?
1010-1030
44
General signs and symptoms of a UTI:
``` Nausea Vomiting Febrile Pelvic discomfort Malaise ```
45
Urinary signs and symptoms of a UTI:
``` Smelly (offensive) urine Frequency Urgency Burning on micturition Cloudy Haematuria ```
46
What role doss a div 2 nurse have if the patient has abnormalities on dipstick urinalysis?
Document results Report to supervisor Save specimen
47
What is GCS? And the significance of it?
GCS stands for Glasgow coma scale, It is an accurate assessment tool to assess the level of a conscious patient with a head injury, neurological status and monitor any changes that may arise
48
What 3 responses does the GCS evaluate?
Eye opening Verbal response Motor response
49
Early signs and symptoms of ICP:
``` Altered LOC Behaviour changes Headache Lethargy Changes in motor function Pupil response ```
50
Late signs and symptoms of ICP
Irregular respirations Temperature Hypertension Bradycardia
51
Neurovascular observations: | CWMS
Colour Warmth Movement Sensation
52
What do antiembolic stockings (TEDS) do? And why are they used?
They facilitate venous flow return from the lower extremities, prevent venous thrombosis and venous statis
53
Compartment syndrome, signs and symptoms
``` Oedema Coolness Pallor Sluggish capillary refill time, indicates compromised circulation Cyanosis Pain intensity due to tissue and nerve ischemia Numbness from nerve compression Absence of pulses ```

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