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| Frage | Antworten |
| Clinical signs of internal haemorrhage: | - no visible signs - may appear as a firm lump - may look blue |
| Clinical signs of external bleeding: | - more obvious, obviously - assess dressing - check under patient's bedding/sheets - bleeding can occur silently |
| How can you tell the difference between an arterial bleed & a venous bleed? | Arterial blood bleeds rapidly due to increased pressure, is pulsating, and can be brighter in colour. Veins are slower to bleed, can be a constant dribble and can be darker in colour. |
| What additional assessments do you make on a patient who is bleeding? | take vital signs, watch the trends, look at urine output, ask them how they are |
| What nursing action should you take for external bleeding? | - APPLY GLOVES - notify staff/call for help - apply pressure directly to bleeding (and do not remove pressure, it may dislodge the clot) - elevate limb - ABC - vitals & neurovascular obs - monitor wound and DOCUMENT how much blood loss and action taken |
| What nursing action should you take for internal bleeding? | - lie patient flat with feet elevated |
| Haematemisis | vomiting blood |
| Haemoptysis | coughing up blood |
| haematuria | blood in urine |
| haemothorax | blood in pleural cavity |
| melena | bowel, fecal matter |
| epistaxis | blood nose |
| haematoma | bleeding tissue |
| What are we recording when we take a person's blood pressure? | Systolic is the maximum pressure against the arterial walls. Diastolic is the minimum arterial pressure when ventricles are at rest. |
| What are we recording when we take a person's blood pressure? | --- |
| What are we recording when we take a person's rest rate? | --- |
| What do vital signs tell us about our patients? Temp, BP, HR, Resps, SaO2 | --- |
| Define syncope. | The transient loss of consciousness (fainting) and tone in the body that results from inadequate blood supply to the brain. |
| What are the common causes of syncope? | - orthostatic hypotension (decrease in BP due to body's inability to adapt) - micturition syncope - vasovagal syncope(most common) |
| How should syncope be managed? | - DRABC - check the response - call for help and note time - lay pt down -check pulse - elevate legs - monitor BP - document |
| How should you position a patient who has fainted? | Lie them down! initially elevate legs, get onto their side just in case they vomit. |
| What are the clinical signs and symptoms of hypotension? | Dizziness or lightheadedness. Fainting (syncope) Lack of concentration. Blurred vision. Nausea. Cold, clammy, pale skin. Rapid, shallow breathing. Fatigue. |
| What should you do if the patient is hypotensive? | Get patient to sit or lie down. Elevate feet. |
| How do you recognise a seizure? | Sometimes they can feel it coming on. muscle spasms, drooling, frothing at the mouth, falling. |
| What emergency management is required for a seizure? | ABC. Cot sides up, pillow for safety, maintain airway, put oxygen, call for help immediately. note how long it lasts for. DOCUMENT. |
| What are the 6 rights? | 1. Right patient. 2. Right drug. 3. Right dose. 4. Right time. 5. Right route. 6. Right documentation. |
| Formula for IV infusions? | Volume / hours x 20 dpm / 60 minutes |
| Where is the most suitable IV placement positions? | - non dominant hand - avoid near joints - veins large enough for IV catheter |
| What are some complications of IV therapy? | - site can become inflamed, be irritating or get sore - phlebitis (inflammation of the wall of a vein) - necrosis (death of tissue) - occasionally leaks - line can get bubbles/kinks in it - fluid overloading - dislodging of the canal into the tissue -local irritation to medication |
| Define Type 1 diabetes. | Usually juvenile onset or insulin dependent. results from the progressive destruction of pancreatic B cells due an autoimmune process |
| Define Type 2 diabetes | Non-insulin dependant. Occurs after age 40. Usually begins with insulin resistance. Fat, muscle, & liver cells do not use insulin properly. Pancreas produces more insulin in response to the additional glucose, then over time the pancreas loses ability to secret enough insulin. 80% of pts are overweight. |
| How do you take a BGL? | ___ |
| What is the normal range for a BGL on a non-diabetic patient? | Between 4-8 |
| What is the normal range for a BGL for a diabetic patient? | 4-10 (a bit higher than usual??? lecture) |
| How do you prepare the pt for taking their BGL? | wash their hands with a warm flannel (and not alcohol gel) |
| Why do we monitor patients BGL's? | it varies due to what the patient eats, is fasting, not their usual lifestyle, under stress. |
| What is Hypoglycemia? | Not enough glucose in the blood. Below 4. |
| What are the symptoms of hypoglycaemia? | Clammy, pale, thirsty, unconscious, feeling faint coma |
| What is the treatment? Conscious? Unconscious? | Conscious: fast acting sugar (lollies), then slow acting sugar (bread) Unconscious: glycogen injection |
| What does the hypo kit contain? | - electrodes - lancing devices & lancets - cotton balls -glycogen injection -fast/slow action sugars -biscuits, drink |
| When should you calibrate the BGL machine & why? | The machine should be calibrated once a shift. Make sure the new box of electrodes are calibrated to the machine. To ensure the reading is correct (therefore not too high or low). |
| How do we assess pain in a patient? | Scale 1-10 when doing obs. consider; - pain history - location of pain - intensity of pain - cognitive development and understanding of pain |
| What is the PQRST of pain assessment? | Provocation, quality, region, severity, timing. |
| What effect does pain have on the vital signs of a patient? | Pain causes the heart rate, respiratory rate and blood pressure to rise. |
| What kinds of non-pharmacological interventions can you implement for a patient who has pain? | Ice for swelling & inflammation. Heat, hot blanket. Massage to relax muscles. |
| What is an acceptable oximetry reading for a healthy patient? | 97%-100% |
| What is the difference between hypoxia and hypoxemia? | Hypoxemia can be defined as a condition where arterial oxygen tension or partial pressure of oxygen (PaO2) is below normal (normal value is between 80 and 100 mmHg). On the other hand, hypoxia is defined as the reduction of oxygen supply at the tissue level, which is not measured directly by a laboratory value. |
| What does an oximetry reading tell us? | It tells us what percentage of oxygen is in the blood. |
| What can affect a correct oximetry reading? | Cold hands, nail polish, dirty fingers. |
| What measures do you implement if your patient's oximetry reading is low? | If it was just a little bit low, I'd ask them to take a couple of big deep breaths. Or i might test it on my own finger just to test it and check it is working. Consider putting 2 litres of oxygen on the patient. Consider sitting them up as usually the lungs work better when upright. |
| What are the signs and symptoms of hypoxia | Changes in the color of your skin, ranging from blue to cherry red. Confusion. Cough. Fast heart rate. Rapid breathing. Shortness of breath. Sweating. Wheezing. |
| What is meant by a normal breathing pattern? | slow, regular, nasal only, diaphragmatic, invisible and inaudible (no panting, no wheezing, sighing, yawning, no deep inhalations or exhalations). They take small inhalations and then relax for the exhalation. The exhalation is followed by an automatic pause (or period of no breathing) of about 2 seconds. |
| What is the importance of coughing and breathing exercises? | If a patient is trying to not cough, they may end up with lots of mucus/fluid in their lungs and this could lead to further illness such as pneumonia. |
| How do you teach coughing and breathing exercises? | You might use a laminated hand out and stick it near where the patient can see it and is constantly reminded to breath properly/practice the breathing exercise. There are also aids for patients to blow into. ---- |
| What does febrile / pyrexia mean? | Febrile is showing symptoms of a fever. Pyrexia is a raised body temperature. |
| What are the clinical signs and symptoms of pyrexia? | Sweating. Shivering. Headache. Muscle aches. Loss of appetite. Dehydration. General weakness. |
| How do we treat pyrexia? | Make room temperature comfortable. Cool sponge bath. Monitor vital signs. Promote rest & fluids to avoid dehydration. |
| What are the clinical signs and symptoms of hypothermia? | Shivering (although as hypothermia worsens, shivering stops). Clumsiness or lack of coordination. Slurred speech or mumbling. Confusion. Drowsiness or very low energy. |
| Why is it difficult to obtain an oximetry reading on a hypothermic patient? | Its always difficult to get an accurate reading when patents are cold anyway! Due to the reduction in blood flow/poor blood circulation, the sensor may not be able to pick up adequately the pulsatile waveform resulting in no signal or loss of accuracy. |
| SIX RIGHTS | PATIENT DRUG DOSE ROUTE TIME DOCUMENTATION |
| What sorts of things would (SHOULD) you find on the drug ORDER? | Patient's name, DOB, UR number, date of order, name of the drug, dose/amount, route, rate (if applicable), time of administration, time of last administration, prescriber's signature and pager number, ALLERGIES. |
| AURICULAR | ears |
| BUCCAL | Administration directed toward the cheek, generally from within the mouth. |
| CONJUNCTIVAL | Administration to the conjunctiva, the delicate membrane that lines the eyelids and covers the exposed surface of the eyeball. |
| SUBLINGUAL | under tongue |
| IM | intramuscular |
| What is the difference between side effect and allergy? | Side effects can be expected when taking certain drugs. Allergies are unexpected/unpredictable events. |
| PO/O | orally |
| ID | intradermal (vaccines) |
| IM | intramuscular |
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