Nursing Assessments

Question 1

Neurovascular

Answer 1

Assessment
* Warmth
* Movement
* Sensation
* Capillary refill
* Imaging

(5 P’s)
○ Pain
○ Pallor
○ Pulselessness
○ Paraesthesia
○ Paralysis

Question 2

Primary Survey

Answer 2

A = airway
B = breathing
C = circulation
D = disability/discomfort (includes GCS)
E = exposure/examination

Question 3

Secondary Survey

Answer 3

F = full set of vitals
G = give pain relief and comfort
H = health history/head-to-toe assessment
- Medications
- Allergies
- Past medical history
- When they last ate or drank
- Symptoms
- Pain
I = inspect posterior surfaces
J = jot it down i.e. document

Question 4

Neurological

Answer 4

GCS
* Eye opening
* Verbal response
* Motor response

BE FAST
* Balance
* Eye (Pupil; Movement)
* Facial (Symmetry)
* Arm (Motor; Sensation; Strength)
* Speech
* Time (When was the onset of symptoms)

CRANIAL NERVES
* Eye movement
* Pupillary reaction
* Facial mobility and symmetry
* Jaw opening
* Swallowing
* Gag reflex
* Speech (light, tight, dynamite)

Question 5

Cardiovascular

Answer 5

• Blood pressure
• Peripheral pulse
• Carotid artery
• Apical impulse
• Auscultate each valve

VALVES
* Aortic = R) 2nd ICS
* Pulmonary = L) 2nd ICS
* Mitral = L.MC) 5th ICS
* Tricuspid = L) 4th ICS

Question 6

Respiratory

Answer 6

Inspection
- Ease of breathing
- Quality of breathing
- Symmetry
- Ability to speak
- Respiratory rate
- Skin perfusion
- Recession of intercostal muscles

Auscultation
- Normal breath sounds: soft, low pitch, sounds become softer during expiration
○ Vesicular (more peripheral)
○ Bronchovesicular (close to sternum)
○ Bronchiolar (trachea)
- Wheeze = narrow airway
- Stridor = narrow upper airway
- Crackles = fluid

Question 7

GIT

Answer 7

*Symmetry
* Contour of abdomen
* Bowel sounds
* Masses or tenderness

Hyperactive, high pitched bowel sounds = may be present in early presentations of obstruction.

Absent bowel sounds = constipation/prolonged obstruction/rupture.

Question 8

Musculoskeletal

Answer 8

Bedside Mobility Assessment Tool (BMAT)
Assess patient mobility in acute care.

1. Perform Safety Screen Assessment (e.g. M.O.V.E.S)
2. Sit and Shake (Assessing trunk strength and balance)
3. Stretch and Point (Assessing lower extremity strength and stability)
4. Stand Assessment (Assessing lower extremity strength)
5. Walk Assessment (Assessing balance and gait)

GALS Assessment
Tool used to quickly detect locomotor abnormalities and functional disability in a patient.

Gait: steadiness, ability to turn quickly

Arms: symmetrical muscles, hands out to side, hands behind head, hands at right angle to body

Legs: symmetrical muscles, rotation, knees to chest, patella tap

Spine: straight, posture, movement (touch toes, head to shoulder)

Question 9

Sepsis Management

Answer 9

Rapid Priority Action
1. Obtaining blood cultures and secure IV access
2. Checking for allergies
3. Administering broad spectrum parenteral antibiotics immediately after blood cultures are obtained
4. Administering parenteral fluids
5. Administering supplemental oxygen as required
6. Rapid escalation and review by a Senior Clinician experienced in managing sepsis
7. Obtain blood biochemistry, lactate and Full Blood Count (FBC)
8. Respond to blood culture results by either modifying parenteral antimicrobials or ceasing completely as indicated
9. Monitor the patient closely as deterioration can be rapid, even after the initial clinical interventions are undertaken
Consider the need to transfer for ongoing care early