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Questions and Answers
What is the purpose of the 'jaw thrust' maneuver during airway evaluation?
Which of the following factors is NOT assessed during the Breathing phase?
In the Pain assessment OPQRST, what does the 'S' stand for?
During the Exposure phase, what is the primary focus?
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What is the objective of the FLACC pain assessment tool?
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What is the characteristic of bronchial sounds?
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Which assessment technique involves both touch and sound?
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Which of the following breath sounds indicates the presence of fluid?
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Which device is NOT typically used during the secondary phase assessment?
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Which condition is characterized by a barking cough and upper airway obstruction?
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What is assessed during the Inspection step of the IPPA approach?
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What is a common sign of hypoxia?
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Which imaging technique is NOT typically used in additional assessments for respiratory conditions?
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In which condition does inflammation of the bronchial tubes lead to airway swelling?
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What is the mechanism behind pleural rub sounds?
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Which assessment finding would be indicative of acute limb ischemia?
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What is the purpose of administering isotonic IV fluids?
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Which of the following is NOT a factor in recognizing abdominal distension?
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What should be performed post-insertion of a nasogastric tube to confirm placement?
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What is a significant complication that can arise in patients with severe malnutrition when re-feeding?
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Which assessment technique is used to detect the position, size, and density of abdominal organs?
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What condition may necessitate special considerations for nasogastric tube insertion?
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Which vital sign assessment is particularly relevant for determining fluid status?
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What is the primary objective of collecting cues and information in nursing practice?
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Study Notes
Primary Assessment
- Airway: Assess for patency, maintain cervical spine, use jaw thrust or head tilt if needed, look for obstructions, such as vomit, blood, tongue, or teeth.
- Breathing: Check if the patient is breathing, assess respiratory rate, depth, chest rise and fall, symmetry, and work of breathing.
- Circulation: Look for external hemorrhaging, assess heart rate, skin warmth, capillary refill, consider ECG, IV fluids, blood tests, and IVC insertion.
- Disability: Assess level of consciousness, blood sugar levels.
- Exposure: Remove clothing, check for rashes or external bleeding, maintain patient warmth and monitor core temperature.
Secondary Assessment
- Full Set of Vital Signs: Obtain a complete set of observations.
- History: Gather information from the patient or family.
- Monitoring Devices: Implement monitoring devices, such as blood tests, telemetry, nasogastric or orogastric tubes, pulse oximetry. Assess pain.
- Head-to-Toe Assessment: Perform a thorough inspection and palpation of the entire body, including head, chest, abdomen, pelvis and perineum, and extremities.
- Continuous Monitoring: Monitor vital signs, injuries, and primary assessment findings. Manage pain.
Pain Assessment
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OPQRST:
- Onset: When did the pain start? What was the patient doing when it started?
- Provocation: What makes the pain better or worse? Rest, repositioning, medication?
- Quality: Describe the pain: sharp, dull, constant?
- Radiation: Does the pain spread?
- Severity: How severe is the pain? 0-10?
- Timing: How long has the pain lasted? Is it getting better or worse over time?
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FLACC:
- Face: 0= no expression, 1= frown or withdrawn, 2= clenched jaw and frown
- Legs: 0= relaxed, 1= restless, 2= kicking
- Activity: 0= normal, 1= squirming, 2= jerking
- Cry: 0= no cry, 1= moans, 2= crying
- Consolability: 0= relaxed, 1= touching and needs a hug, 2= difficult to console
HIPPA
- History: Patient history
- Inspection: Sight, sound, and smell
- Palpation: Touch and sound
- Percussion: Touch and sound
- Auscultation: Sound via stethoscope
Respiratory Assessment
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IPPA Assessment (Inspection, Palpation, Percussion, Auscultation): Used for a systematic approach to respiratory assessment.
- Inspection: Respiratory rate, oxygen saturation, chest shape, symmetry, signs of distress, normal respiratory pattern, superficial veins, nasal flaring, pursed lips, tracheal tug.
- Palpation: Chest wall tenderness, pain, feel bilaterally for any differences.
- Percussion: Normal (hollow), dull (pleural effusion or consolidation) - note pitch and duration.
- Auscultation: Listen to the entire breath in and out, assessing shortness of breath, speech ability, loudness, presence of crackles, rhonchi, wheeze, cough type (dry or moist).
Abnormal Breath Sounds
- Crackles: Fine sounds indicating fluid.
- Wheeze: High-pitched sounds.
- Pleural rub: Creaking sounds.
- Rhonchi: Low-pitched sounds.
Additional Respiratory Assessments
- Imaging: Chest x-ray, CT scan, MRI, VQ scan.
- Pathology: Full blood count, urinalysis, blood cultures, arterial blood gases.
- Spirometry: Measures lung function.
Hypoxia
- Definition: Low levels of oxygen in the body.
- Signs and Symptoms: Decreased level of consciousness, tachypnea, pallor, unstable vital signs, work of breathing, cyanosis.
- Management: Assessment, ensure airway and breathing are patent, positioning, oxygen administration, address the underlying cause, chest physiotherapy.
Croup
- Definition: Upper airway obstruction.
- Signs and Symptoms: Narrowing of the airway, barking cough or voice, shortness of breath, wheeze.
Asthma
- Definition: Inflammatory disease of the lower airways (chronic).
- Signs and Symptoms: Chest pain, shortness of breath, changes in level of consciousness, fever, clammy skin, cough, wheezing.
- Management: Bronchodilators.
COPD
- Definition: Inflammation of the bronchi, causing swelling that limits airflow in and out of the lungs.
- Signs and Symptoms: Cough, fatigue, shortness of breath, dyspnea, wheeze.
Pneumonia
- Definition: Infection that causes inflammation and fluid within the alveoli.
- Hospital-Acquired Pneumonia (HAP): Occurs >48 hours post-admission, often due to immobility, post-operative aspiration, or aspiration.
Pulmonary Embolism (PE)
- Definition: Blockage of the pulmonary arteries by a thrombus, fat or air embolus, or tumor tissue.
Pneumothorax
- Definition: Air leaking into the pleural space, resulting in a partial or complete lung collapse.
Cardiac Assessment
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IPPA Assessment (Inspection, Palpation, Percussion, Auscultation): Used for a systematic approach to cardiac assessment.
- Inspection: Chest wall inspection, presence of cyanosis, pallor, jugular vein distention (JVD), peripheral edema, DVT, base of heart pulsations, epigastric aortic aneurysm (AAA).
- Palpation: Peripheral pulses (rhythm, rate, strength), edema, base of heart pulsations, epigastric aortic aneurysm (AAA), capillary refill (30mmHg = fasciotomy).
Comartment Syndrome
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Signs and Symptoms:
- Pain: Severe pain in the affected limb.
- Pressure: Increased pressure within muscles, tight feeling on palpation.
- Pulses: Absent or decreased pulse.
- Paresthesia: Numbness, tingling, or loss of sensation.
- Paralysis: Decreased movement.
- Pallor: Skin becomes pale and cool.
- Poikilothermia: Decreased core temperature.
Pre and Post-Op Assessment
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Pre-Op Preparation:
- ID Band and Allergies: Verify patient identification and document allergies.
- Dentures/Contact Lenses/Dental Prosthesis: Address the need for dentures, contact lenses, or other dental prosthesis.
- ECG: Perform an electrocardiogram.
- Implantable Devices: Record information about any implantable devices.
- Special Preparation: Address any required special preparation, such as shaving or bowel preparation.
- NPO: Nothing by mouth (NPO) for solids 6 hours and water 2 hours prior to surgery.
- Post-Op Care: Assess all vital parameters - airway, breathing, circulation, disability, and pain management.
Preventing Post-Op Complications
- Monitor intake and output, blood results, VTE (venous thromboembolism), pain management, and prevent nausea.
Fluids and Electrolytes
- Electrolytes: Sodium, potassium, magnesium, phosphate, sulfate.
- Intravenous Therapy (IVT): Used to sustain fluid, electrolytes, and medications.
Types of IV Fluids
- Isotonic: Having the same concentration of solutes as blood plasma. Used to restore vascular volume.
- Hypertonic: Greater concentration of solutes than plasma.
- Hypotonic: Lesser concentration of solutes than plasma.
Abdominal Assessment
- History: Presenting problem and past medical history. Use PQRST.
- Inspection: Contour, symmetry, scars, respiratory movements.
- 7 F's of Distension: Fat, fluid, fetus, flatus, feces, "filthy" big tumor, "phantom" pregnancy.
- Auscultation: Listen to the bowel sounds in the RLQ, RUQ, LUQ, and LLQ. Normal bowel sounds are 5-35 times per minute. Abnormal sounds include silence for 5 minutes, high-pitched sounds, and tinkling.
- Percussion: Detects position, size, and density of abdominal organs. Dullness over fluid or mass.
- Palpation: Assess for tenderness, guarding, swelling, and masses.
Nasogastric Tube (NGT)
- Purpose: Decompresses the stomach by emptying accumulated gas and fluid.
- Indications: Used for people unable to take adequate nutrition, such as those with dysphagia, unresponsive patients, anorexia, or serious illness.
- Special Considerations: Decreased level of consciousness, cervical spinal cord injury, nasal injuries, skull fractures, active upper GI bleed, abnormalities of the esophagus.
- Measurement: Measure distance from the nose to the tragus to the middle of the abdomen for NGT size.
- Post-Insertion: X-ray to confirm placement in the stomach and not the lungs.
- Documentation: Type and size of the NGT, ease of insertion, confirmation of placement, and what it is connected to.
Complications
- Re-feeding syndrome: Fluid retention and electrolyte imbalances in severely malnourished patients when refeeding begins.
Nursing Process
- Collect Cues and Information: Review existing information gather new information, recall knowledge.
- Process Information: Analyze cues, narrow down information.
- Identify the Problem and Issue: Use facts to make a nursing diagnosis.
- Establish Goals: Determine desired outcomes.
- Take Action: Implement a course of action.
- Evaluate Outcomes: Assess the effectiveness of the interventions.
- Reflect on Process and New Learning: Identify lessons learned from the experience.
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Description
Test your knowledge on primary and secondary assessments in emergency medical situations. This quiz covers essential steps to evaluate airway, breathing, circulation, disability, and exposure. Assess your understanding of critical patient evaluation techniques.
