What is frequency a head to toe assessment should be performed
100
The approach to responding to a patient complaining of chest pain.
What is: Perform vital signs assessment, chest assessment, Pain assessment, stat ecg, inform MRP - administer medication as ordered (ASA, Nitro, Morphine, O2 if sPo2 < 92%)?
100
A person must be oriented to these three things in order to have a GCS of 15
What is Person, Place and Time?
100
This has been known to cause confusion in older adults, with no other overt symptoms.
What is urinary tract infection?
100
Respiration refers to the act of breathing, this refers to the exchange of gases during respiration.
What is ventilation?
200
This is the order in which assessment actions should be performed.
What is Inspection, palpation, percussion then Auscultation?
(except abdominal assessment when auscultation comes after inspection)
200
Three signs or symptoms that can occur during myocardial infarction.
What are: chest pain/pressure/heaviness (referred pain); tachycardia / bradycardia; hypertension / hypotension; shortness of breath; diaphoresis; nausea; weakness / dizziness;
200
Sudden onset of these signs or symptoms would prompt the nurse to initiate a code Teal.
What is: unilateral arm/leg weakness; slurred speech/inappropriate words/mute; unilateral facial droop; loss of vision?
200
These signs/symptoms are associated with upper and lower gastrointestinal bleeding.
What is coffee ground emesis and melena stools?
200
This is a must for auscultation of the lung fields.
What is auscultating the anterior, medial and posterior chest?
300
This vital aspect of the "head to toe" assessment occurs prior to systems based assessment.
What is the "critical look" - the first impression, observation of the patient's general clinical appearance.
300
This can be a sign of impaired circulation and/or coagulation often seen in sepsis.
What is skin mottling?
300
The approach to caring for a person having a seizure.
What is prevent injury, ensure airway protection (call RT), inform MRP for medication/administer medication to halt the seizure? call code if necessary!!
300
This can result in pulmonary edema, elevated blood urea nitrogen and creatinine, hyperkalemia and hyponatremia.
What is acute renal failure?
300
This is a must for auscultation of the lung fields.
What is auscultating the anterior, medial and posterior chest?
400
This must be done first in order to fully assess your patient.
What is removing the patient's clothing / uncover the patient?
400
The response to a patient with tachycardia.
What is Vital signs / cardiac assessment (stable or unstable), ECG, Pain assessment, review meds / PMHx, inform MRP as necessary.
400
The post-fall procedure for ED or admitted patients.
What is performing neurovitals, q 30-60 min, notifying MRP and family, observing for change in patient condition, completing diagnostics (prn), placing yellow wristband on patient and falling star in room, completing MORSE assessment and IRS
400
Observing this is an indicator of internal bleeding, and should be immediately reported to the MRP.
What is Cullen's sign?
400
Patient's with this often present with increasing shortness of breath, chest pain worsening on deep breath, cough and may be associated with skin discolouration and new onset arrhythmia.
What is pulmonary embolism?
500
This is a very important but often neglected area of the body to assess during physical assessment.
What is the posterior aspects of the patient? (posterior lung fields, skin (e.g. back, buttocks, heels) for integrity and colour...)
500
A delay in this evidence based intervention is associated with reduced change of survival.
What is effective (hard and fast) chest compressions, (followed by early defibrillation of shockable rhythms)?
500
An acutely disturbed state of mind that occurs in fever, intoxication, and other disorders and is characterized by restlessness, illusions, and incoherence of thought and speech.
What is Delirium?
500
This disease can result in ascites, encephalopathy and coagulopathies which can be lethal.
What is cirrhosis of the liver?
500
This is the difference between and pleural effusion and pulmonary edema.
What is fluid accumulation in the pleural space and fluid accumulation within the lungs?