fundamentals of nursing 112

common bedside risk

falls, burns, poor manual handling, medication errors

bedside checks

check oxygen, air, suction equipment, remove clutters, dispose of sharps,

safety huddle

Brief discussion away from patient at start of shift, patient & family not present

Bedside handover

Conducted at patient bedside involves patients

risk assessment

screens for falls, pressure injury, malnutrition, delirium

WHat is the purpose of falls risk assessment?

Identifies patient at risk of falls and guides prevention planning

WHen should a falls risk assessment be completed?

upon admission and when patient condition changes

WHat does a falls risk score about 9 indicate?

A high risk of falling

WHat factors are assessed for falls risk?

previous falls, medical history, medication, mobility,

Purpose of waterlow scale?

identify risk of developing PI

Purpose of Malnutrition Screening tool and what does it assess?

Early identification of patients at risk of malnutrition, recent unintentional weight loss or reduced appetite

WHy is MST important

Increases risk of poor wound healing, infection, falls and PIs

Purpose of Delirium screening tools (4AT)?

Rapid screening for delirium and cognitive impairment

four areas assessed by 4AT?

Alertness, attention (months backwards), acute change, AMT4

WHy is DST important

increase risk of death, falls, functional decline

Subjective assessment include…

Symptoms, feelings, perceptions, health history, surgeries.

Objective assessments include…

measurable and observable data (eg. vital signs, risk assessment tools)

10 rights of med

1. right patients, 2. right medication, 3. right dose, 4. right route, 5. right time, 6. right education, 7. right documentation, 8. right refusal, 9. right assessment 10. right evaluation.

Purpose of airway assessment?

identify signs of airway obstruction and escalate if required

WHat does breathing assessment involve?

RR, breathing effort, SPO2, Respiratory distress

What does OPQRST stand for?

O - onset of symptoms

P - provocation

Q - quality

R - radiation

S - severity (0-10 scale)

T - timing

What does cultural safety look like?

1. language and communication

2. health literacy

3. cultural and spiritual considerations

4. aboriginal and torres strait islanders

5. CALD and LGBTQ+ patients

6. older adults and disability

Objective assessment (airway assessment)

Can patient speak clearly, any abnormal sounds (snoring, gargling), visible signs of obstruction, head positioned correctly

WHat is Tachypnoea?

RR more then 24bpm

What is Bradypnoea?

RR less then 10bpm

What do you assess during respiratory inspection?

• Respiratory rate and effort

• Accessory muscle use and posture

• Chest symmetry and shape

What do you assess during respiratory palpation?

• Tracheal position

• Chest expansion (front and back)

• Tenderness or crepitus

What do percussion sounds indicate?

• Resonant = normal lung tissue

• Dull = fluid or consolidation

• Tympanic = air-filled are

What are the 3 normal breath sounds and where are they heard?

• Vesicular: Soft, low-pitched; peripheral lungs.

• Bronchovesicular: Moderate-pitched; between scapulae.

• Bronchial: High-pitched, harsh; over trachea.

What are the inspiration and expiration characteristics?

Vesicular: Inspiration longer.

Bronchovesicular: Equal.

Bronchial: Expiration longer.

What is a pleural friction rub?

Grating sound caused by pleural inflammation, often heard laterally.

What should you assess during auscultation?

• Listen for normal and abnormal sounds.

• Compare both sides.

• Identify findings requiring escalation.

What symptoms may indicate reduced cardiovascular function during mobilisation?

fatigue, dizziness and reduced excercise tolerance

What should be assessed about sleeping? (cardiovascular assessment)

Orthopnoea (difficulty breathing when lying flat) & fatigue

WHat are normal circulation indications?

pinkskin, warm peripheries, no swelling, strong and equal pulses, HR in range, BP in range

WHat are abnormal circulation indications?

Pallor, cynosis, mottling, visible oedema, cool skin, weak or unequal pulses, tachycardia, bradycardia, hypotension, hypertension.

What is neurovascular assessment?

Performed on limb, evaluate circulation and neurological function, tissue perfusion

Symptoms during mobilisation may indicate compromised circulation? ((cardiovascular assessment)

pain, weakness, impaired movement in limb,

symptoms patient may report about circulation problems? (cardiovascular assessment)

tingling, numbness

WHat is at risk? (cardiovascular assessment)

Fracture or limb trauma, burns, crush injuries, oedema, vascular injury,

Compartment Syndrome (5 Ps)

Pain, pulse, pallor, parethesia, paralysis

WHat do neurological assessment include?(neurological assessment)

ACVPU, glasgow scale, pupil size and reaction, limb strength. and behaviour responsibilities.

How can neurological changes affect mobilisation?(neurological assessment)

Weakness, paralysis, poor coordination

What communication indicate neurological changes?(neurological assessment)

CHnage in speech, understanding or responsiveness.

How can neurological changes affect eating and drinking?(neurological assessment)

Dysphasia, increase aspiration risk.

WHat can change in sleep pattern indicate? (neurological assessment)

Neurological deterioration or increase intracranial pressure

What does ACVPU

1. Alert

2. Confusion

3. Voice

4. Pain

5. Unresponsive

What does the GCS Eye Opening (E) score assess?

• 4 = Opens eyes spontaneously

• 3 = Opens eyes to speech

• 2 = Opens eyes to pain

• 1 = No eye opening

What does the GCS Verbal Response (V) score assess?

• 5 = Oriented (person, place, time)

• 4 = Confused conversation

• 3 = Inappropriate words

• 2 = Incomprehensible sounds

• 1 = No verbal response

What does the GCS Motor Response (M) score assess?

• 6 = Obeys commands

• 5 = Localises pain

• 4 = Withdraws from pain

• 3 = Abnormal flexion (decorticate)

• 2 = Abnormal extension (decerebrate)

• 1 = No motor response

Core components

1. Glasgow coma scale

2. Pupil size and reaction

3. Limb strength

what does PEARL stand for? (pupil assessmet)

Pupils Equal and Reactive to Light

4 stages of pain

1. Transduction: convert harmful stimulation electrical signals

2. transmission: carries pain signals through nerves (a-delta & C fibres) to spinal cord and brain

3. Perception: brain recognises and interprets pain

4. Modulation: Body increases or reduces pain signals

Where do pain signals travel after activiation?

Through the spinothalamic tract to the thalamus

WHat influences pain perception?

The central nervous system

WHat is nociceptive pain?

Pain caused by tissue damage or inflammation

WHat is neuropathic pain?

Pain caused by injury or dysfunction of nervous system.

WHat is acute pain?

SHort-term pain that acts as warning

WHat is chronic pain?

Long-term pain involving changes in nervous system.

Three components of pain ?

1. Sensory

2. emotional (cognitive)

3. function components

Main things to assess when asking about pain?

Location, quality of pain, severity (0-10), aggravating and relieving factors, impact on daily function

How can pain affect mobilisation?

Pain may reduce limb use and limit movement

How might a patient communicate their pain?

Sharp, burning or pressure-like and children pay present as crying

How can pain affect eating and drinking?

Reduce appetite and prevent engagement in daily activities

WHat is the role of hypothalamus in temp regulation?

Acts as body thermostat, detecting temp chnages and triggering responses to maintain body temp

What can cause body temp to change?

• illness

• infections

• environment

• inflammation

What happens when the body becomes to cold

Body activates physiological responses to consev