Week 1 - Assessments

Question 1

What do nurses use to help guide their practice?

Answer 1

• Tools
• Frameworks
• Processes
• Policies
• Procedures
• Best Practice Guidelines

Question 2

What does ADPIE stand for?

Answer 2

A - Assess
D - Nursing Diagnoses (Identify actual problems and potential problems)
P - Plan care and undertake
I - Intervention (intervene in their care for a better outcome for the patient - sitting them up 90 degrees to increase lung expansion and better breathing)
E - Evaluate care

Question 3

What are the components of the rapid assessment framework?

Answer 3

• Airway
• Breathing
• Circulation
• Disability
• Environment/exposure

Question 4

What things are we looking for with the airway component?

Answer 4

Observe for signs of airway obstruction - no breath sounds, central cyanosis (blue skin), no chest movement: Partial - paradoxical chest/abdominal movements, noisy breathing

Question 5

What things are we looking for with the breathing component?

Answer 5

Observe: Increase RR, symmetry of chest movement, absence of air entry, additional breath sounds, respiratory distress, sweating, accessory muscle use, abdominal breathing, ability to speak in full sentences, positioning, posterior chest assessment

Question 6

What things are we looking for with the circulation component?

Answer 6

Peripheral vascular checks, capillary refill, Manuel pulse, BP, Temp. Assess for signs of reduced cardiac output. Decreased level of consciousness, decreased urine output. Consider drain output/bleeding

Question 7

What things are we looking for with the Disability component?

Answer 7

Assess GCS/AVPU, Blood Glucose Levels (BGL). Check for reversible drug induced causes of depressed consciousness. Assess facial muscles and limb movements, anxiety, pain, mobility

Question 8

What things are we looking for with the Environment component?

Answer 8

Risk assessments (falls, braden, alcohol, drugs), past medical history (Previous respiratory issues, drug reactions, medications, allergies) Early Warning score, any oxygen required?

Question 9

What does the Health Assessment Framework include?

Answer 9

• Psychosocial
  
  • Patients account of their history/presentation
  • Vital signs
  • Systems review
    
    • Subjective (questioning) and objective (physical examination) data
  • Medications
  • Discharge planning and ongoing care
    
    • Education and health promotion needs
    • Discharge considerations
  • Assessment summary

Question 10

What does COLDSPA stand for?

Answer 10

C - Character (describe…)
O - Onset (When did it begin?)
L - Location (where is it? Does it radiate?)
D - Duration (How long does it last? Does it recur?)
S - Severity (How bad is it?)
P - Pattern (What makes it better or worse?)
A - Associated Factors (What other symptoms occur with it? How does it affect you and every day life?)

Question 11

What is the Glasgow Coma Scale sections?

Answer 11

Eye Opening Response:
4 - Spontaneous 
3 - To Sound
2 - To Pain
1 - Non
Coma: no eye opening

Best Verbal:
5 - Response/Orientation
4 - Confused
3 - Inappropriate words
2 - Incomprehensible sounds
1 - None

Best Motor Response:
6 - Obeys Commands
5 - Localises to stimulus/pain
4 - Withdraws from painful stimulus (flexion)
3 - Abnormal flexion in response to pain (decorticate rigidity)
2 - Abnormal extension in response to pain (decerebrate rigidity)
1 - Flaccid/no response

Question 12

What is the Glasgow Coma Scale?

Answer 12

The Glasgow Coma Scale is a clinical scale used to reliably measure a person’s level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body.

Question 13

What is the normal GCS of a person?

Answer 13

GCS of 15

Question 14

What does AVPU stand for?

Answer 14

A - Alert
- The patient is lucid and fully responsive, can answer your questions, can see what you’re
doing
V - Voice
- The patient responds to your voice, but may be drowsy, keeps their eyes closed and may
not speak coherently
P - Pain
- The patient is not alert and does not respond to your voice, but a painful stimulus. EG,
shaking the shoulders or possibly pinching an war lobe, elicits a response
U - Unresponsive
- The patient is unresponsive to any of the above. They are unconscious

(anything other than A, then perform a GCS)

Question 15

What does ISBAR stand for?

Answer 15

Tool used for handover of information clearly and concisely:

    I - Identify
    S - Situation
    B - Background
    A - Assessment
    R - Request/Recommendations

Question 16

What are the three principles of acute management?

Answer 16

• Correct the Immediate and Life-threatening problems
• Treat the cause
• Prevent further attacks/episodes/complications

Question 17

What do you need to be aware of when administering a drug?

Answer 17

Approved Generic name and drug group or category

• Monitoring requirements
• Patient education
• Common adverse effects and how to detect them
• Significant drug interactions, contra-indications and precautions
• Pharmacodynamics mechanism and site of action
• Pharmacokinetics particular parameters and concerns to be aware of