Health Assessment - Assessing the Older Adult

16%

Between 21-23%

1.1%

<p>Between 3.6% and 4.4%</p> Signup and view all the answers

<p>Approx. 4.2 million</p> Signup and view all the answers

<p>0.5%</p> Signup and view all the answers

<p>The physiological changes that occur in the human body as a result of ageing.</p> Signup and view all the answers

<p>Structural and physiological changes.</p> Signup and view all the answers

<p>Neurological system.</p> Signup and view all the answers

<p>Decreased cardiac output, calcifications and fibrosis of cardiac valves, and increased arterial rigidity.</p> Signup and view all the answers

<p>Limiting chest wall expansion, decreased respiratory endurance, increased anteroposterior diameter, and increased airway resistance.</p> Signup and view all the answers

<p>Kidney shrinkage, decreased glomerular filtration rate, and decreased renal filtration and efficiency.</p> Signup and view all the answers

<p>Decreased salivary secretions, decreased peristalsis, decline in large bowel transit time, and decreased production of digestive enzymes.</p> Signup and view all the answers

<p>Decreased oestrogen production, decreased secretions, atrophy of epithelial lining of vagina, and atrophy of internal and external reproductive organs.</p> Signup and view all the answers

<p>Decreased bone density, muscle atrophy, decreased muscle mass and strength, and decreased joint mobility.</p> Signup and view all the answers

<p>Dry, scaly skin, decreased elasticity, wrinkles, and fat distribution changes.</p> Signup and view all the answers

<p>To assess pain in patients with dementia who are unable to verbalize their pain.</p> Signup and view all the answers

<p>0 to 14+</p> Signup and view all the answers

<p>Moderate</p> Signup and view all the answers

<p>A sudden increase in chronic pain.</p> Signup and view all the answers

<p>To assess pain in patients who are unable to verbalize their pain.</p> Signup and view all the answers

<p>JH &amp; JD Gunn Medical Research Foundation</p> Signup and view all the answers

<p>Confusion Assessment Method</p> Signup and view all the answers

<p>Impairments, activity limitations, and participation restrictions</p> Signup and view all the answers

<p>To assess pain in people with dementia who cannot verbalise</p> Signup and view all the answers

<p>To identify possible signs of pain, such as whimpering, groaning, or crying</p> Signup and view all the answers

<p>By looking for signs such as fidgeting, rocking, guarding a part of the body, or withdrawn behaviour</p> Signup and view all the answers

<p>To monitor the effectiveness of pain management and adjust treatment accordingly</p> Signup and view all the answers

<p>By looking for signs such as temperature, pulse, or blood pressure outside normal limits, perspiring, flushing, or pallor</p> Signup and view all the answers

<p>To identify potential signs of pain, such as skin tears, pressure areas, arthritis, contractures, or previous injuries</p> Signup and view all the answers

<p>Because people with dementia may not be able to verbalise their pain</p> Signup and view all the answers

<p>To improve pain management and reduce suffering in people with dementia</p> Signup and view all the answers

<p>15</p> Signup and view all the answers

<p>4</p> Signup and view all the answers

<p>Very High Risk</p> Signup and view all the answers

<p>The patient is at risk</p> Signup and view all the answers

<p>Scores can be discounted after 48 hours if the patient is recovering normally</p> Signup and view all the answers

<p>To assess the risk of pressure ulcers</p> Signup and view all the answers

<p>High Risk</p> Signup and view all the answers

<p>J. Waterlow</p> Signup and view all the answers

<p>History of present illness (HPI)</p> Signup and view all the answers

<p>Vital signs</p> Signup and view all the answers

<p>Integumentary system</p> Signup and view all the answers

<p>Abnormal vital signs</p> Signup and view all the answers

<p>Airway assessment</p> Signup and view all the answers

<p>Social and cultural history</p> Signup and view all the answers

<p>Laboratory and diagnostic test results</p> Signup and view all the answers

<p>Neurological system</p> Signup and view all the answers

<p>Decreased processing speed and reaction time, impaired memory, especially short-term and working memory, decreased executive function, including planning, decision-making, and problem-solving</p> Signup and view all the answers

<p>Increased risk of falls and injuries, decreased independence and social participation, impaired communication and relationships</p> Signup and view all the answers

<p>Identifying risk of falls and injuries, evaluating functional ability and independence, developing exercise and rehabilitation programs</p> Signup and view all the answers

<p>Adverse drug reactions and interactions, decreased medication adherence, increased risk of falls and hospitalization, impaired cognitive function and quality of life</p> Signup and view all the answers

<p>Urinary incontinence (UI), fecal incontinence (FI), dual incontinence (UI and FI)</p> Signup and view all the answers

<p>Gait speed and balance, muscle strength and endurance, range of motion and flexibility, functional tasks (e.g., walking, transfers, stairs)</p> Signup and view all the answers

<p>Medication reconciliation and review, deprescription and optimization of medications, patient education and support</p> Signup and view all the answers

<p>Age-related changes in bladder and bowel function, medical conditions (e.g., diabetes, stroke, dementia), medications (e.g., diuretics, anticholinergics)</p> Signup and view all the answers

<p>Children's response to illness differs from adults due to their absolute size and relative body proportions that change with age.</p> Signup and view all the answers

<p>Engaging parents in the assessment process helps to build rapport and relax the child, making the process more effective.</p> Signup and view all the answers

<p>The Paediatric Triangle determines the need for further immediate assessment and emergency action in paediatric patients.</p> Signup and view all the answers

<p>Pulse rate varies with age in paediatric patients, requiring age-specific normal ranges for accurate assessment.</p> Signup and view all the answers

<p>Blood pressure measurement is essential in paediatric patients to identify hypertension and hypotension, which can be indicative of underlying conditions.</p> Signup and view all the answers

<p>Temperature assessment in paediatric patients requires age-specific normal ranges and consideration of factors like fever and infection.</p> Signup and view all the answers

<p>The capillary refill technique is used to assess peripheral circulation and identify potential circulatory problems in paediatric patients.</p> Signup and view all the answers

<p>Understanding vital sign variations in paediatric patients is crucial to identify potential health issues and provide accurate diagnoses.</p> Signup and view all the answers

<p>Apex beat using a stethoscope</p> Signup and view all the answers

<p>To ensure accurate measurement, as measurement varies with cuff size</p> Signup and view all the answers

<p>Reflects cardiac perfusion, delivery of oxygen and nutrients like glucose</p> Signup and view all the answers

<p>Rate varies with age, and a rate &gt;40 is always a cause for immediate assessment by a skilled practitioner</p> Signup and view all the answers

<p>Look for presence of sub-sternal recession, intercostal retractions, or tracheal tug</p> Signup and view all the answers

<p>100-160 beats per minute</p> Signup and view all the answers

<p>Initially assesses the level of consciousness, alertness, and response to voice, pain, and unresponsiveness</p> Signup and view all the answers

<p>By increasing heart rate and cardiac output, and shunting blood from peripheries to vital organs</p> Signup and view all the answers

<p>Assesses the child's response to stimuli, and can be used to identify potential neurological deficits</p> Signup and view all the answers

<p>To ensure accurate assessment and identify potential neurological deficits in non-verbal children</p> Signup and view all the answers

<p>The correct technique is to apply pressure for 5 seconds and then release, moving from distal to central. The normal range for capillary refill time in children is less than 2 seconds.</p> Signup and view all the answers

<p>Using a correctly sized cuff is necessary to ensure accurate blood pressure measurement. A cuff that is too small will overestimate the BP, while a cuff that is too large will underestimate it.</p> Signup and view all the answers

<p>The normal range for body temperature is 36.6-37.5°C. In infants, digital or glass thermometers should be used under direct supervision, and oral/rectal thermometers should not be used.</p> Signup and view all the answers

<p>Capillary refill time indicates peripheral perfusion. An abnormal result (e.g., &gt;2 seconds) may indicate hypovolemic shock or cardiac disease.</p> Signup and view all the answers

<p>In pediatric patients, blood pressure measurement requires attention to cuff size and technique. Hypotension is a late finding in children with cardiopulmonary compromise and indicates decompensated shock and possible imminent cardiopulmonary arrest.</p> Signup and view all the answers

<p>Pediatric patients, especially infants, have poor temperature regulation and are prone to hypothermia. Therefore, temperature assessment and management are critical in this population.</p> Signup and view all the answers

<p>Gross motor skills and fine motor skills</p> Signup and view all the answers

<p>Respect for diversity and individuality, empowerment, and participation in decision-making</p> Signup and view all the answers

<p>Developmental disabilities, physical disabilities, and sensory disabilities</p> Signup and view all the answers

<p>Pharmacological interventions and non-pharmacological interventions</p> Signup and view all the answers

<p>To assess developmental milestones in children</p> Signup and view all the answers

<p>Problem-solving, memory, language, and thinking skills</p> Signup and view all the answers

<p>To provide individualized support and accommodations</p> Signup and view all the answers

<p>To gather objective data through observation, inspection, palpation, percussion, and auscultation</p> Signup and view all the answers

<p>The normal color of stool in adults is brown to green. Diet can influence the color of stool.</p> Signup and view all the answers

<p>Constipation is characterized by a decrease in frequency, hard, dry, pebbly stool. It differs from diarrhea, which is characterized by frequent bowel movements and loose, fluid motions.</p> Signup and view all the answers

<p>The Bristol Stool Chart is a method of categorizing stool into seven types based on shape and consistency. It is significant in health assessment as it can indicate certain health conditions, such as gastrointestinal disorders or malabsorption.</p> Signup and view all the answers

<p>The common health problems related to the upper GI system include mucositis, oesophageal varices, indigestion, gastroesophageal reflux disease, gastritis, gastroenteritis, dysphagia, peptic ulcers, pyloric stenosis, hiatus hernia, and nausea and vomiting.</p> Signup and view all the answers

<p>It allows the examiner to palpate the patient's abdomen effectively and comfortably.</p> Signup and view all the answers

<p>The common health problems related to the lower GI system include constipation, diarrhea, faecal incontinence, prolapse of the bowel, bowel cancer, celiac disease, Crohn's disease, ulcerative colitis, diverticular disease, irritable bowel syndrome, and hemorrhoids.</p> Signup and view all the answers

<p>It is important to assess changes in bowel habits because they can indicate underlying health conditions, such as gastrointestinal disorders or malabsorption.</p> Signup and view all the answers

<p>To identify any abnormalities or changes in the organs.</p> Signup and view all the answers

<p>Inspecting the abdomen during a physical examination can provide information about the presence of any abnormalities, such as distension or masses.</p> Signup and view all the answers

<p>Rebound tenderness is a sign of peritoneal irritation, and it is assessed by quickly releasing pressure on the abdomen and observing the patient's response.</p> Signup and view all the answers

<p>It helps to identify any underlying muscle tension or guarding that may indicate an underlying condition.</p> Signup and view all the answers

<p>The purpose of percussion and palpation in abdominal assessment is to assess the size and position of abdominal organs and detect any abnormalities, such as tenderness or masses.</p> Signup and view all the answers

<p>It helps to identify any abnormalities or changes in these organs that may indicate an underlying condition.</p> Signup and view all the answers

<p>It helps to identify any abnormalities in bowel function or motility that may indicate an underlying condition.</p> Signup and view all the answers

<p>Contour, symmetry, skin: colour, moisture, scaring, pulsation or movement, umbilicus: midline, inverted, everted, swelling.</p> Signup and view all the answers

<p>To listen for bowel sounds, which can indicate normal or abnormal bowel function.</p> Signup and view all the answers

<p>It helps to identify any underlying gastrointestinal conditions or disorders.</p> Signup and view all the answers

<p>Percussing the abdomen to assess the resonance and dullness of the sounds produced.</p> Signup and view all the answers

<p>It helps to identify any nutritional deficiencies or imbalances that may contribute to gastrointestinal symptoms.</p> Signup and view all the answers

<p>Right and left hypochondriac, right and left lumbar, epigastric, umbilical, hypogastric, right and left iliac fossa, and the right and left inguinal regions.</p> Signup and view all the answers

<p>To identify normal or abnormal bowel function, which can indicate bowel obstruction, ileus, or other gastrointestinal disorders.</p> Signup and view all the answers

<p>Percussion involves tapping the abdomen to assess the resonance and dullness of the sounds produced, whereas palpation involves feeling the abdomen to detect masses, tenderness, or guarding.</p> Signup and view all the answers

<p>To prevent the transmission of infections and maintain asepsis during the assessment process.</p> Signup and view all the answers

<p>To establish a baseline for future comparisons and identify any changes in the patient's condition.</p> Signup and view all the answers

<p>To obtain informed consent, reduce anxiety, and promote patient cooperation.</p> Signup and view all the answers

<p>To identify any abnormalities in bowel function, such as constipation or diarrhea.</p> Signup and view all the answers

<p>Obtaining history (social, medical, surgical, general, obstetric, family), physical assessment (abdominal exam, height, weight, BMI, baseline observations), and learning needs assessment.</p> Signup and view all the answers

<p>To assess fetal size, position, and movement, as well as to detect any abnormalities.</p> Signup and view all the answers

<p>Ensure bed height is comfortable, position the woman correctly, ensure an empty bladder, provide privacy, and ensure cultural safety.</p> Signup and view all the answers

<p>120-160 bpm</p> Signup and view all the answers

<p>To differentiate between maternal and fetal heart rates.</p> Signup and view all the answers

<p>Assessment, documentation, and learning needs assessment.</p> Signup and view all the answers

<p>To assess skin changes, abdominal shape, and fetal movement.</p> Signup and view all the answers

<p>To assess fetal heart rate and detect any abnormalities.</p> Signup and view all the answers

<p>It helps identify any abnormalities or irregularities in the menstrual cycle, which is essential for evaluating reproductive health and detecting potential issues, such as polycystic ovary syndrome (PCOS) or endometriosis.</p> Signup and view all the answers

<p>A pelvic examination is essential to evaluate the reproductive system and detect any potential issues, such as genital or vaginal irritation, infection, or sexually transmitted diseases, before initiating contraception.</p> Signup and view all the answers

<p>Assessing reproductive cancers helps identify potential risks or existing conditions, such as cervical, ovarian, or endometrial cancer, allowing for early intervention and treatment.</p> Signup and view all the answers

<p>Evaluating Mittelschmerz, or mid-cycle ovary pain, helps identify potential underlying issues, such as ovulation disorders or pelvic inflammatory disease, and inform reproductive health decisions.</p> Signup and view all the answers

<p>Assessing sexual history helps identify potential risks or existing conditions, such as sexually transmitted diseases, and informs reproductive health decisions, including contraception and disease prevention.</p> Signup and view all the answers

<p>Assessing menopause symptoms helps identify and manage symptoms, such as hot flashes, excessive sweating, and vaginal dryness, to improve quality of life and reproductive health outcomes.</p> Signup and view all the answers

<p>Reassuring the patient about privacy and confidentiality helps to establish trust and reduce anxiety, allowing the patient to feel more comfortable and relaxed during the examination, and ensuring that they are more likely to provide accurate information and cooperate fully.</p> Signup and view all the answers

<p>The key features to examine during the inspection stage include symmetry, testicular positioning, swelling, inflammation, rashes, and surgical procedures.</p> Signup and view all the answers

<p>The purpose of palpation is to assess the texture of the skin and tissues, and to detect any abnormalities such as tumours, cysts, or scar tissue.</p> Signup and view all the answers

<p>In males, ambiguous genitalia may include micropenis, bifid scrotum, and bilateral undescended testes. In females, ambiguous genitalia may include an enlarged clitoris, enlarged labia majora, and fused labia majora.</p> Signup and view all the answers

<p>The correct positioning is the reclining position with knees flexed and close to the buttocks. The healthcare provider should assess the glans, foreskin, and scrotum for shape, size, and color.</p> Signup and view all the answers

<p>Circumcision involves the removal of the foreskin, exposing the glans. This can affect the examination of the male genitalia, as the healthcare provider may not need to retract the foreskin during the examination.</p> Signup and view all the answers

<p>Volume, colour, odour, consistency, and pain</p> Signup and view all the answers

<p>Strictures, tumours, and renal calculi</p> Signup and view all the answers

<p>It helps identify potential issues related to reproductive health and hormonal changes</p> Signup and view all the answers

<p>Urinary frequency, urgency, nocturia, and pain</p> Signup and view all the answers

<p>1.015-1.025</p> Signup and view all the answers

<p>It helps identify potential kidney damage or complications</p> Signup and view all the answers

<p>Regulation of electrolyte levels in the body</p> Signup and view all the answers

<p>500-800 ml</p> Signup and view all the answers

<p>Red blood cell maturation</p> Signup and view all the answers

<p>Ureters</p> Signup and view all the answers

<p>Production of seminal fluid</p> Signup and view all the answers

<p>Excretion</p> Signup and view all the answers

<p>Cystitis</p> Signup and view all the answers

<p>Urethra</p> Signup and view all the answers

<p>Dysuria</p> Signup and view all the answers

<p>Prostate</p> Signup and view all the answers

<p>Vaginal dryness</p> Signup and view all the answers

<p>Urgency incontinence</p> Signup and view all the answers

<p>Thermoregulation</p> Signup and view all the answers

<p>Internal urethral sphincter</p> Signup and view all the answers

<p>Uterus, cervix, and adnexa</p> Signup and view all the answers

<p>Urinary system and sexual health</p> Signup and view all the answers

<p>Urine specific gravity, blood pressure, and edema</p> Signup and view all the answers

<p>To evaluate hydration status and detect signs of dehydration or overhydration</p> Signup and view all the answers

<p>To evaluate digestive function and identify potential gastrointestinal disorders</p> Signup and view all the answers

<p>To identify potential abnormalities or lesions</p> Signup and view all the answers

<p>To identify potential urinary tract infections (UTIs) or kidney stones</p> Signup and view all the answers

<p>To assess for kidney tenderness or pain</p> Signup and view all the answers

<p>To identify potential gastrointestinal disorders or obstruction</p> Signup and view all the answers

<p>To maintain adequate hydration and prevent dehydration or overhydration</p> Signup and view all the answers

<p>Testicular degeneration resulting in decreased testicular size, decreased testosterone levels, decreased sperm count, and prostate enlargement.</p> Signup and view all the answers

<p>Decreased oestrogen production, decreased secretions, atrophy of epithelial lining of vagina, atrophy of internal and external reproductive organs, decreased uterine size, and atrophy of pelvic muscles.</p> Signup and view all the answers

<p>Decreased salivary secretions, decreased number of taste buds, decreased peristalsis, decline in large bowel transit time, decreased production of digestive enzymes, and reduced oesophageal and gastric motility.</p> Signup and view all the answers

<p>Kidney shrinkage, decreased glomerular filtration rate, decreased renal filtration, and decreased renal efficiency.</p> Signup and view all the answers

<p>Kidney shrinkage, decreased glomerular filtration rate, decreased renal filtration, decreased renal efficiency, and decreased urinary output.</p> Signup and view all the answers

<p>Musculoskeletal changes of the chest, leading to limiting chest wall expansion, and diaphragm flattening.</p> Signup and view all the answers

<p>Decreased bone density, muscle fibers deteriorate and are replaced by fibrous connective tissue, muscle atrophy, decreased muscle mass and strength, bone demineralisation, and decreased joint mobility.</p> Signup and view all the answers

<p>Skin colour changes, moisture changes, decreased perspiration, decreased elasticity, wrinkles, and fat distribution changes.</p> Signup and view all the answers

<p>Size of cardiac muscle decreases, decreased cardiac output, calcifications and fibrosis of cardiac valves, and arterial system becomes increasingly rigid.</p> Signup and view all the answers

<p>Decrease in mental flexibility, abstract thinking, and recall.</p> Signup and view all the answers

<p>A decrease in testosterone levels, leading to decreased libido and erectile dysfunction.</p> Signup and view all the answers

<p>A decrease in estrogen levels, leading to vaginal dryness, hot flashes, and a decrease in fertility.</p> Signup and view all the answers

<p>A decrease in digestive enzyme production, leading to decreased nutrient absorption and constipation.</p> Signup and view all the answers

<p>A decrease in nephron function, leading to decreased kidney function and filtration rate.</p> Signup and view all the answers

<p>A decrease in bladder muscle tone, leading to urinary incontinence and retention, and an increase in prostate size in men, leading to urinary tract symptoms.</p> Signup and view all the answers

<p>An increase in prostate size, leading to urinary tract symptoms, such as hesitancy and frequency.</p> Signup and view all the answers

<p>Decreased nutrient absorption, leading to malnutrition and related health issues.</p> Signup and view all the answers

<p>A decrease in bladder muscle tone, leading to urinary incontinence and retention, and an increase in urinary tract infections.</p> Signup and view all the answers

<p>A decrease in the liver's ability to metabolize drugs, leading to increased risk of adverse drug reactions.</p> Signup and view all the answers

<p>A decrease in pancreatic enzyme production, leading to impaired glucose regulation and digestion.</p> Signup and view all the answers

<p>Renal function decline in older adults is characterized by a decrease in kidney function, leading to a decrease in glomerular filtration rate (GFR). This decline can lead to increased risk of kidney disease, hypertension, and electrolyte imbalance, ultimately impacting their overall health.</p> Signup and view all the answers

<p>With age, the gastrointestinal system undergoes changes such as decreased gut motility, reduced secretion of digestive enzymes, and impaired gut barrier function. These changes can lead to decreased nutrient absorption, constipation, and increased risk of malnutrition in older adults.</p> Signup and view all the answers

<p>The female reproductive system undergoes changes such as decreased estrogen levels, vaginal dryness, and decreased libido. These changes can lead to menopause, hot flashes, and increased risk of osteoporosis and heart disease in older adults.</p> Signup and view all the answers

<p>The male reproductive system undergoes changes such as decreased testosterone levels, decreased libido, and erectile dysfunction. These changes can lead to decreased muscle mass, bone density, and increased risk of chronic diseases such as diabetes and cardiovascular disease in older adults.</p> Signup and view all the answers

<p>Decreased glomerular filtration rate.</p> Signup and view all the answers

<p>Decreased renal filtration and efficiency.</p> Signup and view all the answers

<p>Older adults experience genitourinary changes such as decreased bladder tone, urinary incontinence, and decreased libido. These changes can lead to decreased quality of life, social isolation, and increased risk of urinary tract infections and other health complications.</p> Signup and view all the answers

<p>Age-related changes in the gastrointestinal system, such as decreased gut motility and reduced secretion of digestive enzymes, increase the risk of constipation and other gastrointestinal disorders such as diverticulitis and gastroesophageal reflux disease in older adults.</p> Signup and view all the answers

<p>Decreased production of digestive enzymes, such as hydrochloric acid, pepsin, and pancreatic enzymes.</p> Signup and view all the answers

<p>Decreased oestrogen production.</p> Signup and view all the answers

<p>Decreased sperm count.</p> Signup and view all the answers

<p>Decreased bladder tone and increased residual urine.</p> Signup and view all the answers

<p>Decreased motility and delayed gastric emptying.</p> Signup and view all the answers

<p>Atrophy of the epithelial lining of the vagina.</p> Signup and view all the answers

<p>Prostate enlargement.</p> Signup and view all the answers

<p>Changes in gut bacterial flora.</p> Signup and view all the answers

<p>Alleviate pain and discomfort, improve patient satisfaction and quality of life, and reduce risk of chronic pain and associated complications.</p> Signup and view all the answers

<p>Hand hygiene.</p> Signup and view all the answers

<p>Before and after patient contact, before and after invasive procedures, and after contact with bodily fluids.</p> Signup and view all the answers

<p>Improved patient safety, enhanced patient engagement and empowerment, increased efficiency and productivity for healthcare providers, and better data analytics and research capabilities.</p> Signup and view all the answers

<p>To monitor patient health and detect potential complications.</p> Signup and view all the answers

<p>To track infection rates and provide feedback to healthcare workers on infection prevention practices.</p> Signup and view all the answers

<p>Demographic and medical history information, medication lists and allergy information, laboratory and radiology results, and clinical notes and documentation.</p> Signup and view all the answers

<p>To monitor and prevent central line-associated bloodstream infections.</p> Signup and view all the answers

<p>To involve healthcare team, patient, and family in developing a comprehensive pain management plan.</p> Signup and view all the answers

<p>To provide a consistent and reliable method of assessing pain intensity and quality.</p> Signup and view all the answers

<p>S1 (lub) followed by S2 (dub)</p> Signup and view all the answers

<p>Mitral and Tricuspid valves</p> Signup and view all the answers

<p>To assess cardiac output, blood flow, and peripheral circulation</p> Signup and view all the answers

<p>3-5 small squares</p> Signup and view all the answers

<p>The right atrium receives deoxygenated blood from the body via the Vena Cava.</p> Signup and view all the answers

<p>To assess cardiac function and rhythm</p> Signup and view all the answers

<p>The right ventricle pumps deoxygenated blood into the lungs via the Pulmonary artery.</p> Signup and view all the answers

<p>To identify fluid retention and possible cardiac failure</p> Signup and view all the answers

<p>The left side of the heart has high O2 and low CO2 levels, while the right side has low O2 and high CO2 levels.</p> Signup and view all the answers

<p>The SA node acts as a pacemaker, initiating impulses in the right atrium.</p> Signup and view all the answers

<p>To assess peripheral circulation and cardiac output</p> Signup and view all the answers

<p>The bundle of HIS is located in the interventricular septum and transmits impulses from the AV node to the Purkinje fibers.</p> Signup and view all the answers

<p>To assess heart sounds and identify cardiac abnormalities</p> Signup and view all the answers

<p>To identify right-sided heart failure and fluid retention</p> Signup and view all the answers

<p>The Purkinje fibers transmit impulses to the myocardial cells, causing the heart to contract.</p> Signup and view all the answers

<p>To assess cardiac output and peripheral circulation</p> Signup and view all the answers

<p>64% of blood volume is in veins and venules, 13% in arterioles, 7% in capillaries, 9% in the pulmonary circulation, and 7% in the heart.</p> Signup and view all the answers

<p>Symptoms include colour change to lips, face, and nail bed, chest discomfort, palpitations, sweating, lightheadedness, and shortness of breath.</p> Signup and view all the answers

<p>Cardiac output regulation ensures that the heart pumps the right amount of blood to meet the body's needs, maintaining blood pressure and perfusion of organs.</p> Signup and view all the answers

<p>The pulmonary circulation receives deoxygenated blood from the heart and returns oxygenated blood to the heart.</p> Signup and view all the answers

<p>Between the lungs and above the diaphragm (in the mediastinum)</p> Signup and view all the answers

<p>To pump blood to all parts of the body, delivering oxygen, nutrients, and other substances to tissues and removing waste products of cellular metabolism</p> Signup and view all the answers

<p>Arterial pathways (distribution routes) and venous pathways (collection system returning blood to the heart)</p> Signup and view all the answers

<p>To receive blood returning to the heart and to contract to pump blood into the ventricles</p> Signup and view all the answers

<p>To pump blood out of the heart and into the circulatory system</p> Signup and view all the answers

<p>To transport deoxygenated blood from the heart to the lungs and to return oxygenated blood from the lungs to the heart</p> Signup and view all the answers

<p>To transport oxygenated blood from the heart to the body's tissues and to return deoxygenated blood from the tissues to the heart</p> Signup and view all the answers

<p>Intrinsic mechanisms (e.g., Frank-Starling mechanism) and extrinsic mechanisms (e.g., autonomic nervous system, hormones)</p> Signup and view all the answers

<p>Cardiac output is inversely proportional to peripheral resistance</p> Signup and view all the answers

<p>It provides a systematic approach to assessing and managing cardiovascular problems, promoting critical thinking and evidence-based practice</p> Signup and view all the answers

<p>Colour, Odour, Amount, Consistency of sputum; Spirometry/Peak flow; SpO2, respiration rate, and other vital signs</p> Signup and view all the answers

<p>Documentation is essential because 'if it wasn't documented, it didn't happen'</p> Signup and view all the answers

<p>To evaluate the severity of respiratory disease and monitor treatment effectiveness</p> Signup and view all the answers

<p>By identifying signs of respiratory distress, such as accessory muscle use and breathing pattern changes</p> Signup and view all the answers

<p>Accessory muscle use, breathing pattern changes, and signs of respiratory distress</p> Signup and view all the answers

<p>To identify abnormal breathing patterns that may indicate respiratory distress or disease</p> Signup and view all the answers

<p>Thoroughly documenting findings and thanking the patient when the exam is concluded</p> Signup and view all the answers

<p>Rapid assessment of the patient's airway, breathing, and circulation</p> Signup and view all the answers

<p>To determine the patient's oxygenation status and identify potential respiratory distress</p> Signup and view all the answers

<p>To gather objective data about the patient's respiratory system</p> Signup and view all the answers

<p>Crackles are scratchy breath sounds, and they are often caused by fluid in the alveoli and airways, such as in pneumonia or pulmonary oedema, and may also be associated with fibrosis.</p> Signup and view all the answers

<p>Dyspnoea is shortness of breath; it is assessed by asking about the patient's exercise tolerance and current symptoms</p> Signup and view all the answers

<p>To identify abnormalities in breathing rate, rhythm, and depth</p> Signup and view all the answers

<p>Rhonchi are gurgling breath sounds, often due to fluid in large and medium-sized airways, whereas wheezing is a whistling sound, typically loudest on expiration, and is often associated with asthma. Rhonchi may be caused by bronchitis or pneumonia, while wheezing may be caused by air forced through narrow airways.</p> Signup and view all the answers

<p>Stridor is an inspiratory whistling sound, often due to tracheal narrowing.</p> Signup and view all the answers

<p>To identify signs of respiratory distress or disease</p> Signup and view all the answers

<p>To identify signs of respiratory distress or disease, such as nasal flaring or retractions</p> Signup and view all the answers

<p>Assessing breathing pattern changes is important in patients with respiratory disease because it can help determine the severity of the disease and the effectiveness of treatment.</p> Signup and view all the answers

<p>Spirometry is a lung function test that determines the level of respiratory function, including lung volume and capacity, and is used to monitor the progression of respiratory disease and response to therapy.</p> Signup and view all the answers

<p>To identify the patient's current symptoms and determine the focus of the examination</p> Signup and view all the answers

<p>To provide objective data about the patient's respiratory status</p> Signup and view all the answers

<p>Common signs of respiratory effort include the use of accessory muscles, such as the neck and shoulder muscles, and changes in breathing pattern, such as rapid or shallow breathing.</p> Signup and view all the answers

<p>Dyspnoea assessment is important in managing patients with respiratory disease because it helps to determine the severity of the disease, monitor treatment effectiveness, and identify potential complications.</p> Signup and view all the answers

<p>Assessing for pleural friction rub is important in patients with respiratory disease because it can indicate pleural inflammation or other underlying conditions.</p> Signup and view all the answers

<p>Limb leads: I, II, III, aVR, aVL, aVF; Chest leads: V1-V6</p> Signup and view all the answers

<p>5th intercostal space midclavicular line</p> Signup and view all the answers

<p>Thumb side of wrist, medial to radial artery</p> Signup and view all the answers

<p>Closure of atrioventricular valves (mitral and tricuspid)</p> Signup and view all the answers

<p>Heart rate</p> Signup and view all the answers

<p>Percussion</p> Signup and view all the answers

<p>Breath sounds</p> Signup and view all the answers

<p>Vibrations (tactile fremitus) over lung fields and chest expansion</p> Signup and view all the answers

<p>Assessing risk factors for falling, including intrinsic, extrinsic, and socioeconomic factors.</p> Signup and view all the answers

<p>The ESR is increased in the presence of inflammation, but it is not specific to a particular condition and therefore does not establish a diagnosis on its own.</p> Signup and view all the answers

<p>To assess pain in patients who are unable to verbalize their pain, such as those with dementia.</p> Signup and view all the answers

<p>Identifying potential health issues and relating back to the data for relevance and direction</p> Signup and view all the answers

<p>Mobility issues can increase the risk of falling due to decreased balance, strength, and flexibility.</p> Signup and view all the answers

<p>Comorbidities, such as hypertension and anaemia, can increase the risk of falling by affecting balance, strength, and cognition.</p> Signup and view all the answers

<p>To assess pain in patients who are unable to verbalize their pain</p> Signup and view all the answers

<p>Identifying mobility issues that can increase the risk of falls</p> Signup and view all the answers

<p>Certain medications, such as sedatives and antidepressants, can increase the risk of falling by causing dizziness, drowsiness, and confusion.</p> Signup and view all the answers

<p>To assess a patient's risk of developing a pressure ulcer</p> Signup and view all the answers

<p>Vision impairment can increase the risk of falling due to reduced visual acuity and increased risk of tripping.</p> Signup and view all the answers

<p>Socioeconomic factors, such as literacy and dependency, can affect access to healthcare and fall prevention strategies.</p> Signup and view all the answers

<p>Identifying musculoskeletal changes that can contribute to falls and mobility issues</p> Signup and view all the answers

<p>To provide optimal pain relief and improve the patient's quality of life</p> Signup and view all the answers

<p>Impaired physical mobility can be caused by ineffective use of walking aids, decreased muscle strength due to pain, stiffness, and osteoarthritis. Addressing these factors through non-pharmacological and pharmacological methods can improve mobility and reduce the risk of falls.</p> Signup and view all the answers

<p>Assessing pain and comfort levels is crucial in identifying the impact of pain on daily activities and developing effective pain management strategies. This information can help healthcare providers tailor interventions to address pain, improve mobility, and enhance quality of life.</p> Signup and view all the answers

<p>A comprehensive musculoskeletal examination should include an assessment of joint mobility, muscle strength, and gait analysis. This information can inform fall prevention strategies by identifying potential risks and developing targeted interventions to improve mobility and reduce the risk of falls.</p> Signup and view all the answers

<p>The 'related to' factor helps healthcare providers identify the underlying causes of impaired physical mobility and chronic pain. This approach enables targeted interventions that address specific needs and improves overall quality of life.</p> Signup and view all the answers

<p>Common barriers to effective pain management include inadequate pain assessment, inadequate dosing, and inadequate pain management strategies. Healthcare providers can overcome these barriers by using non-verbal pain assessment tools, regularly assessing pain levels, and developing tailored pain management strategies.</p> Signup and view all the answers

<p>Accurate documentation is essential in geriatric care, as it informs care planning, tracks patient progress, and identifies potential risks. Accurate documentation can improve patient outcomes by enabling targeted interventions and improving quality of life.</p> Signup and view all the answers

<p>A comprehensive fall prevention strategy should include an assessment of risk factors, environmental modifications, and targeted interventions to improve mobility and reduce the risk of falls. Healthcare providers can implement these strategies by developing individualized care plans that address specific needs and promote fall prevention.</p> Signup and view all the answers

<p>Subjective and objective data provide a comprehensive understanding of a patient's condition, enabling healthcare providers to develop targeted interventions and inform care planning. This information can improve patient outcomes by addressing specific needs and promoting overall quality of life.</p> Signup and view all the answers

<p>Eyes Opening, Best Verbal Response, and Best Motor Response</p> Signup and view all the answers

<p>The patient's alertness and response to stimuli, with scores ranging from 4 (spontaneous) to 1 (none)</p> Signup and view all the answers

<p>To identify brain damage and assess the level of consciousness in a person following a traumatic brain injury</p> Signup and view all the answers

<p>Eyes opening, best verbal response, and best motor response</p> Signup and view all the answers

<p>To identify potential brain damage and assess the patient's level of awareness of themselves and their environment</p> Signup and view all the answers

<p>The patient's orientation to person, place, and time, with scores ranging from 5 (oriented) to 1 (none)</p> Signup and view all the answers

<p>To identify neurological deterioration or improvement</p> Signup and view all the answers

<p>6</p> Signup and view all the answers

<p>Apply painful stimuli</p> Signup and view all the answers

<p>The verbal response is modified to include developmental milestones</p> Signup and view all the answers

<p>To assess the patient's response to environmental stimuli</p> Signup and view all the answers

<p>To identify potential neurological deterioration and guide treatment</p> Signup and view all the answers

<p>To assess the patient's response to painful stimuli</p> Signup and view all the answers

<p>The primary purpose of the GCS is to assess the level of consciousness. It is scored by adding the scores of three components: Best Eye Response (1-4), Best Verbal Response (1-5), and Best Motor Response (1-6), with a total score ranging from 3 (minimum) to 15 (maximum).</p> Signup and view all the answers

<p>To assess the level of consciousness and neurological function</p> Signup and view all the answers

<p>Common causes of altered neurological status in children include changes to the neurological system, trauma, and infection. Manifestations may include listlessness, unresponsiveness to surroundings, and altered muscle and limb tone.</p> Signup and view all the answers

<p>A GCS score of 3 indicates brain death, and the corresponding level of consciousness is unresponsive.</p> Signup and view all the answers

<p>Possible causes of a GCS score of 6 include spinal cord injury, and the corresponding level of consciousness is locked-in syndrome.</p> Signup and view all the answers

<p>The GCS scoring system assesses neurological status by evaluating three components: Best Eye Response, Best Verbal Response, and Best Motor Response. The scores from each component are added to obtain a total score.</p> Signup and view all the answers

<p>A GCS score of 8-10 indicates a permanent vegetative state, and the corresponding level of consciousness is unconscious but reactive to stimuli.</p> Signup and view all the answers

<p>Common causes of altered neurological status in adults include intoxication, organic causes, and increased intracranial pressure. Manifestations may include lethargy, confusion, and altered level of consciousness.</p> Signup and view all the answers

<p>Moderate interrater reliability in ED departments indicates that the GCS scoring system is clinically useful for assessing neurological status, but may not be entirely reliable for individual patient decisions.</p> Signup and view all the answers

<p>It is estimated that 70% of older people have skin problems including wounds such as skin tears, leg ulcers and pressure injuries.</p> Signup and view all the answers

<p>Skin colour, bleeding, lesions, hair distribution, colour and quantity, nail length, colour, configuration, symmetry and cleanliness.</p> Signup and view all the answers

<p>To assess skin temperature, texture, moisture, tenderness, oedema, and skin changes.</p> Signup and view all the answers

<p>Warmth, redness, swelling, exudate or odour.</p> Signup and view all the answers

<p>To reduce anxiety, ensure adequate lighting, and provide a stable temperature.</p> Signup and view all the answers

<p>On admission and at regular intervals.</p> Signup and view all the answers

<p>It helps identify potential skin problems and prevent further complications.</p> Signup and view all the answers

<p>It helps identify patients at risk of developing pressure injuries or other wounds.</p> Signup and view all the answers

<p>To identify potential skin lesions and pressure injuries, and to develop strategies for prevention and management.</p> Signup and view all the answers

<p>To assess the risk of pressure injury in patients, particularly older adults.</p> Signup and view all the answers

<p>To ensure privacy, comfort, and hygiene, and to facilitate a thorough and accurate assessment.</p> Signup and view all the answers

<p>To identify potential skin lesions and pressure injuries, and to prevent complications.</p> Signup and view all the answers

<p>To identify any abnormalities, such as skin lesions, pressure injuries, or signs of aging.</p> Signup and view all the answers

<p>To establish a baseline for future comparisons and to identify any changes or abnormalities.</p> Signup and view all the answers

<p>To prevent the transmission of infection and to maintain patient safety.</p> Signup and view all the answers

<p>To identify potential skin lesions or pressure injuries.</p> Signup and view all the answers

<p>To identify potential skin lesions or pressure injuries, and to develop strategies for prevention and management.</p> Signup and view all the answers

<p>To maintain accurate records and to facilitate continuity of care.</p> Signup and view all the answers

<p>Limited mobility, use of wheelchairs or other mobility aids, cognitive impairment, poor nutrition, polypharmacy, and sensory loss</p> Signup and view all the answers

<p>To classify and document skin tears</p> Signup and view all the answers

<p>To identify patients at risk of developing pressure injuries</p> Signup and view all the answers

<p>Immobility or reduced physical mobility, loss of sensation, impaired cognitive state or level of consciousness, urinary or faecal incontinence, poor nutrition or recent weight loss, dry skin, and acute or severe illness</p> Signup and view all the answers

<p>Daily</p> Signup and view all the answers

<p>To ensure a safe and comfortable environment for the patient and healthcare provider</p> Signup and view all the answers

<p>To standardize the description and staging of pressure injuries</p> Signup and view all the answers

<p>To document the assessment and monitor healing progress</p> Signup and view all the answers

<p>An alternative classification tool for skin tears, commonly used in QLD Health Facilities</p> Signup and view all the answers

<p>To ensure consistent and accurate documentation and treatment of skin tears</p> Signup and view all the answers

<p>Skin, hair, and nails</p> Signup and view all the answers

<p>To assess for tenderness, warmth, or swelling in joints and muscles, and to evaluate muscle tone and strength</p> Signup and view all the answers

<p>36.5°C - 37.5°C (97.7°F - 99.5°F)</p> Signup and view all the answers

<p>Assessing level of consciousness and neurological function</p> Signup and view all the answers

<p>To assess cranial nerve function, cognitive function, and motor and sensory function</p> Signup and view all the answers

<p>To evaluate muscle strength, range of motion, and joint function</p> Signup and view all the answers