Introduction to nursing practice: Patient assessment

Question 1

Cardiac output

Answer 1

The volume of blood that is ejected out of the heart every minute determined by the heart rate and stroke volume that can be written as an equation.

Cardiac output = heart rate x stroke volume.

Question 2

Stroke volume

Answer 2

The volume of blood that is ejected out of the heart’s left ventricle per beat with the normal healthy adult stroke volume being 50-70mL).

Question 3

Heart rate

Answer 3

The number of times the heart contracts and ejects blood out of the ventricle per minute, measures as beats per minute. Heart rate is assessed by counting the number of pulsations per minute. The rate can be modified by the autonomic nervous system as the presymplectic stimulation slows the heart rate through the vagus nerve and the sympathetic stimulation accelerates the heart rate through the sympathetic cardiac fibres.

Question 4

Blood pressure

Answer 4

The pressure exerted by the blood against the walls of the arteries affected by both the cardiac output and peripheral resistance.The most common sites for blood pressure measurement is in the person’s arm over the brachial artery.

Question 5

Vital signs

Answer 5

Measured routinely in an acute care setting to monitor wellbeing, so that any changes can be detected and acted upon in a timely and appropriate manner. They Reflect the efficiency of oxygen delivery and the integration of the circulation and respiratory systems. Vital signs include pulse, blood pressures, respiratory rate and temperature.

Question 6

Pulse rhythm

Answer 6

The patterns of pulsations and the time interval between them is even. It describes the regularity of the heartbeat and how evenly the heart is beating: regular (the beats are evenly spaced), or irregular (the beats are not evenly spaced)

Question 7

Blood volume

Answer 7

With each beat of the heart new volume of blood distends the arteries with each wave spreading further and further along the aorta to the smaller arteries. The ease with which the pulse can be felt depends upon how much the arterial wall distends.

Question 8

Escalation of care

Answer 8

The immediate actions to be initiated when someone’s physical condition deteriorates.

Question 9

Pulse

Answer 9

The tactile palpation of the wave of blood from the heart distending the arterial wall .The pulse should be examined for volume, rate and rhythm.

Question 10

Pulse volume

Answer 10

A measurement of the strength of the force exerted by the injected blood against the arterial wall with each contraction. It is described as normal (full, easily palpable), weak (difficult to feel, thready and usually rapid) or strong (bounding or difficult to compress.

Question 11

Pulse rhythm

Answer 11

The patterns of pulsations and the time interval between them is even. It describes the regularity of the heartbeat and how evenly the heart is beating regular (the beats are evenly spaced), or irregular (the beats are not evenly spaced).

Question 12

Respiration

Answer 12

The transport of oxygen from the outside air to the cells within tissues, and the transport of carbon dioxide in the opposite direction.

Question 13

Respiration rate

Answer 13

The number of breaths (one inhalation and on exhalation) taken in one minute. Tachypnoea is the term for respiratory rates above the normal range. Bradypnoea is the term for respiratory rates below the normal range.

Question 14

Oxygen saturation

Answer 14

Arterial oxygen saturation (SaO2) is the percentage of haem finding sites (where oxygen attaches) on the haemoglobin molecule then saturated with oxygen. There are four haem sites and for oxygen binding sites per haemoglobin molecule. Arterial oxygen saturation (SaO2) can be measured non-invasively using machine called a pulse oximeter which measures the percentage of oxygen bound to haemoglobin in the blood.

Question 15

Temperature

Answer 15

Normal human body temperature is known as normothermia or euthermia. Thermoregulation is the body’s physiological function of heat regulation to maintain a constant internal body temperature measured using units called degrees.

Question 16

Electronic medical records (EMR)

Answer 16

Digital system used to store, damage, and update patient health information which provide a more effective method of documenting patient data compared to traditional paper-based methods.

Question 17

Korotkoff’s sounds

Answer 17

Korotkoff’s sounds are heard with stethoscope during the auscultation of the blood pressure.

Question 18

Describe the five stages of Korotkoff’s sounds

Answer 18

Phase 1: Clear tapping sounds heard for at least two consecutive beats – this is the systolic blood pressure.

Phase 2: The softening of the tapping sounds and the addition of a swishing sound.

Phase 3: The return of tapping sounds, as heard in phase 1, but with an increase in sharpness and intensity.

Phase 4: The abrupt muffling of sounds, exhibiting a soft and blowing quality, the first diastolic blood pressure reading.

Phase 5: The complete disappearance of all sounds – this is the second diastolic blood pressure reading.

Question 19

Debridement

Answer 19

The removal of dead, damaged or infected skin tissue to help a wound heal.

Question 20

Necrotic

Answer 20

The death of tissues of the body that form when tissue isn’t getting enough blood as a result of injury, infection or chemical exposure.

Question 21

Eschar

Answer 21

Dead tissue that falls of healthy skin caused by bedsores, burn injuries or infectious skin disease that may appear black, brown, red or tan in appearance.

Question 22

Pressure injuries

Answer 22

Pressure injury, pressure ulcers, pressure sore, decubitus ulcer, are used to describe a localised injury to the skin and or underlying tissue, usually over a bony prominence as a result of unrelieved pressure, shear and or friction or a combination of these factors.

Question 23

Iatrogenic problems

Answer 23

Errors in medical or nursing care that are clearly identifiable come off preventable, in serious and their consequences for a persons affected, and they indicate a real problem with the safety and credibility of a healthcare facility.

Question 24

Describe the term schema in relation to pressure injuries

Answer 24

The pressure causes ischemia, that is, a temporary deficiency of blood supply to tissue or an organ that results in localised damage that causes tissue necrosis when the soft tissue and blood supply are compressed between bony prominence and an external surface for prolonged periods of time.

Question 25

Blanching

Answer 25

If the area blanches with fingertip pressure or if the redness disappears within an hour, no tissue damage is anticipated. If the redness persists and no blanching occurs, then tissue damage is present as a pressure injury.

Question 26

Shearing

Answer 26

The force exerted against the skin when a person is moved or repositioned in the bed by being pulled or allowed to slide down the bed. The skin and subcutaneous tissue tend to adhere to the bed surface and remain stationary while deeper underlying tissues pull away and slide in the direction of movement which results in the stretching and tearing of blood vessels, reduced blood flow, and necrosis.

Question 27

Friction

Answer 27

The force of two surfaces moving across one another which can remove the superficial layers of the skin, making it more prone to breakdown.

Question 28

List some risk factors that exacerbate pressure injury formation

Answer 28

Intensity and duration of pressure increases with immobility and inactivity;

Decreased mental status and diminished or altered sensory perception (e.g., unconscious, sedates or paralysed persons);

Obesity adds to the intensity of the pressure;

Medical devices can provide pressure (e.g., urinary catheter under a leg, or endotracheal tubes at the corner of the mouth);

Question 29

Sloughing

Answer 29

Shedding of dead tissue as a result of tissue ulceration.

Question 30

Wound

Answer 30

A disruption in the integrity of body tissue.

Question 31

Serous exudate

Answer 31

Composed of the clear portion of blood, is watery in appearance and is important to the healing process because it provides moisture, nutrients and oxygen to the new granulating tissue and removes toxins and debris when it is resorbed into the bloodstream.

Question 32

Purulent exudate (pus)

Answer 32

Usually accompanied by infection that usually occurs with severe inflammation and is usually thicker than serous exudate, that can be yellow, green, or brown.

Question 33

Unintentional wounds

Answer 33

Unanticipated and are often the results of trauma or an accident that are created in unsterile environment that pose a greater risk of infection.

Question 34

Intentional wounds

Answer 34

Occur during treatment of therapy usually under aseptic conditions. For example, surgical incisions.

Question 35

Superficial wounds

Answer 35

Epidermal (first-degree) wounds are confined to the epidermis layer, which comprises the four outermost layers of skin.

Question 36

Partial-thickness wounds (first to second degree wounds)

Answer 36

Involves the epidermis and upper dermis, the layer of skin beneath the epidermis. Deep (second-degree) wounds involve the epidermis and deep dermis.

Question 37

Full-thickness wounds (third-degree wounds)

Answer 37

Refer to skin loss that extends through the epidermis and the dermis and into subcutaneous fat and deeper structures.

Question 38

Forth-degree wounds

Answer 38

Fourth-degree wounds are deeper than full-thickness loss, extending into muscle and bone.

Question 39

Wound assessment (location)

Answer 39

Assessment of location begins with a description of the anatomical location of the wound (e.g., 12com structure line on the right lower quadrant of the abdomen).

Question 40

Wound assessment (size)

Answer 40

Assessment of size begins with the length, width, and depth of a wound measured in centimetres (cm).

Question 41

Wound assessment (general appearance)

Answer 41

Assessment of the general appearance begins with the description of the wounds colour, and surrounding areas help determine the wound’s present phase of healing by gently palpating the edges of the wound for swelling.

Question 42

Wound assessment (pain)

Answer 42

Assessment of pain beings with notifying the prescribing practitioner of any pain or tenderness at the wound site as pain may indicate infection or bleeding.