Clinical Placement Flashcards
What are the 5 things we do to start the clinical process?
Consent, privacy, environment, background knowledge, and interpreting the data.
What are the 4 things you need to cover in introductions?
Comfort - are they relaxed. Hearing - can they hear you. Sight - Can they read paperwork. And Mobility - any aids?
Define rapid assessment.
Quick assessment enabling the gathering of important data quickly providing a foundation to deliver safe and effective care. Gathering both subjective and objective data.
An accurate nursing assessment allows for what?
The development of an appropriate plan of care
What does ABCDE stand for?
Airway, breathing, circulation, disability, everything else/environment.
What do we observe under ‘Airway’ as apart of ABCDE?
Look for patency of the airway to see if there is partial obstruction or complete obstruction. Do this via talking to patient. If asleep check for rise and fall of chest and looking for obstruction and at colour.
What do we observe under ‘breathing’ as apart of ABCDE?
Look at the patient and observe/look for: Nasal flaring, pursed lips, accessory muscle use, colour change, oxygen use. Positioning and rise and fall of the chest. Look for cough and sputum.
What do we observe under ‘circulation’ as apart of ABCDE?
Inspect for general appearance, skin colour, cap refil, pulse, HR, Diaphoresis, fluid intake, urine output, and oedema.
Define Diaphoresis.
Sweating, especially to an unusual degree as a symptom of disease or a side effect of a drug.
What do we observe under ‘Disability’ as apart of ABCDE?
Look listen and feel. For example in nutrition noting how much they are eating/drinking. Or assessing falls risk or mental state risk. And looking at AVPU, PERRLA, COLDSPA, EWS, and GCS
What does AVPU stand for?
Awake, Voice, Pain, Unconscious
What does COLDSPA stand for?
Character, onset, location, duration, severity, pattern, associated factors.
What do we observe under ‘Environment’ as apart of ABCDE?
Looking at blood test results, safety, exposure (full body check) and then everything else.
What demographics do you need to get from the patient.
Age, name, sex, resus status, date of assessment, reason for admission, presenting concern, past medical history, allergies.
Can you use a patients name in the clinical notes?
NO
