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CVR > Objective assessment > Flashcards

Objective assessment Flashcards

1
Q

ABCDE

A

Airway
Breathing
Circulation
Disability
Exposure

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2
Q

What are the 3 important things to consider when assessing patients?

A

Look
Listen
Feel

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3
Q

End-o-bed-o-gram

A

Look at patient and gather information - what are they attached to, environment, how alert are they

Temp of the room

Patient warm?

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4
Q

Observation chart-

A

Respiration rate
Air or oxygen
SpO2
Blood pressure
Consciousness
Temperature

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5
Q

News2

A

System for scoring the physiological measurements that are routinely recorded at the patients bedside.

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6
Q

SpO2 normal values

A

94-98%

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7
Q

Respiratory rate

A

12-16

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8
Q

pH normal values

A

7.35-7.45

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9
Q

pCO2

A

4.7-6.0

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10
Q

pO2

A

10.7 - 13.3

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11
Q

HCO3 (mmols)

A

22-26

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12
Q

BE (mmols)

A

-2 to +2

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13
Q

HR normal values

A

60-100

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14
Q

BP

A

120/80

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15
Q

Systolic

A

95-140

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16
Q

Diastolic

A

60-90

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17
Q

Urine output (ml per kg/hour)

A

0.5-1

18
Q

Ear temp (centigrade)

A

35.7 - 38

19
Q

Capillary refill test CRT

A

Less than 2 secs

20
Q

What should you be looking for with airway

A

Type? Own +/- adjunct
Artificial

Patent?

21
Q

What should you be looking out for when hearing the airway

A

Abnormal sounds
* Stridor
* Gurgling
* Wheeze
* Snoring

No sound

22
Q

What you should be looking out for when feeling airway

A

Air movement

23
Q

What you should visually be looking out for when assessing breathing

A

Colour
Mode of ventilation
RR
SpO2 and FiO2
Pattern of breathing
Expansion of the chest
Accessory muscle use
Sputum
ABGs
CXRs

24
Q

ABG

A

Arterial blood gas test

Measures the balance of oxygen and carbon dioxide in your blood

25
Q

What you should be assessing when audibly assessing breathing

A

Able to speak?
Auscultation
Cough
Percussion Note

26
Q

Feeling assessments of breathing - what are you looking out for

A

Chest wall movement
* Apical vs. Diaphragmatic
* Expansion

Tactile fremitus

27
Q

Assessing ciruclation - visual assessment

A

Colour​
HR and rhythm (on ECG trace)
BP (on a machine)
Capillary refill time (CRT)
Temperature (core)
Urine output and colour
Fluid balance
Limb oedema

28
Q

Auditory assessment of ciruclation

A

BP manual

29
Q

Circulation assessments - touch

A

Pulse
* HR
* Strength and regularity
Skin temperature
Assess for pitting oedema

30
Q

Disability assesments (conscious state) - visual

A

Level of consciousness
* ACVPU
* GCS
* RASS
Pupils
Blood sugars
4-7mmol/L before eating
8.5-9mmol/L 2hrs post meal

31
Q

Alert, confused, voice, pain, unresponsive assessment

A

Alert- fully awake

Confused- new onset or worsening confusion

Voice- responds to voice stimulus

Pain- responds to pain stimulus

Unresponsive- no response

32
Q

GCS

A

Eye reponse
Motor response
Verbal response
Pupil response

33
Q

RASS

A

Used to assess level of sedation

Scale from combative to unarousable

34
Q

Disability conscious state- auditory assessment

A

Verbal responses
Agitation
Pain?
VAS

35
Q

Exposure visual assessment

A

Patient position
Body habitus of patient
?muscle wasting
Attachments
Wounds/dressings
Signs of infection
Signs of bleeding
Finger clubbing
Nicotine stains
Mobility aids
General condition of the patient

36
Q

Exposure auditory assessment

A

Chest drains – bubbling
Alarms – what are they?

37
Q

Exposure feel assessment

A

Skin temperature
ROM/muscle strength if applicable

38
Q

What are the problems we are hoping to identify

A

Loss of lung volume
Sputum retention
Increased WOB
Respiratory Failure - Type 1 or Type 2
Reduced exercise tolerance
Pain
Fatigue
Or a combination of the above

39
Q

What documentation format should you follow

A

SOAP

40
Q
A

CVR (11 decks)

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