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Semester 2 OSCE
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- 1Clinical signs of internal haemorrhage:- no visible signs
- may appear as a firm lump
- may look blue - 2Clinical signs of external bleeding:- more obvious, obviously
- assess dressing
- check under patient's bedding/sheets
- bleeding can occur silently - 3How 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.
- 4What 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
- 5What 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 - 6What nursing action should you take for internal bleeding?- lie patient flat with feet elevated
- 7Haematemisisvomiting blood
- 8Haemoptysiscoughing up blood
- 9haematuriablood in urine
- 10haemothoraxblood in pleural cavity
- 11melenabowel, fecal matter
- 12epistaxisblood nose
- 13haematomableeding tissue
- 14What 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.
- 15What are we recording when we take a person's blood pressure?---
- 16What are we recording when we take a person's rest rate?---
- 17What do vital signs tell us about our patients? Temp, BP, HR, Resps, SaO2---
- 18Define syncope.The transient loss of consciousness (fainting) and tone in the body that results from inadequate blood supply to the brain.
- 19What are the common causes of syncope?- orthostatic hypotension (decrease in BP due to body's inability to adapt)
- micturition syncope
- vasovagal syncope(most common) - 20How should syncope be managed?- DRABC
- check the response
- call for help and note time
- lay pt down
-check pulse
- elevate legs
- monitor BP
- document - 21How should you position a patient who has fainted?Lie them down! initially elevate legs, get onto their side just in case they vomit.
- 22What 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. - 23What should you do if the patient is hypotensive?Get patient to sit or lie down. Elevate feet.
- 24How do you recognise a seizure?Sometimes they can feel it coming on. muscle spasms, drooling, frothing at the mouth, falling.
- 25What 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.
- 26What are the 6 rights?1. Right patient.
2. Right drug.
3. Right dose.
4. Right time.
5. Right route.
6. Right documentation. - 27Formula for IV infusions?Volume / hours x 20 dpm / 60 minutes
- 28Where is the most suitable IV placement positions?- non dominant hand
- avoid near joints
- veins large enough for IV catheter - 29What 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 - 30Define Type 1 diabetes.Usually juvenile onset or insulin dependent. results from the progressive destruction of pancreatic B cells due an autoimmune process
- 31Define Type 2 diabetesNon-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.
- 32How do you take a BGL?___
- 33What is the normal range for a BGL on a non-diabetic patient?Between 4-8
- 34What is the normal range for a BGL for a diabetic patient?4-10 (a bit higher than usual??? lecture)
- 35How do you prepare the pt for taking their BGL?wash their hands with a warm flannel (and not alcohol gel)
- 36Why do we monitor patients BGL's?it varies due to what the patient eats, is fasting, not their usual lifestyle, under stress.
- 37What is Hypoglycemia?Not enough glucose in the blood. Below 4.
- 38What are the symptoms of hypoglycaemia?Clammy, pale, thirsty, unconscious, feeling faint
coma - 39What is the treatment? Conscious? Unconscious?Conscious: fast acting sugar (lollies), then slow acting sugar (bread)
Unconscious: glycogen injection - 40What does the hypo kit contain?- electrodes
- lancing devices & lancets
- cotton balls
-glycogen injection
-fast/slow action sugars
-biscuits, drink - 41When 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).
- 42How 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 - 43What is the PQRST of pain assessment?Provocation, quality, region, severity, timing.
- 44What effect does pain have on the vital signs of a patient?Pain causes the heart rate, respiratory rate and blood pressure to rise.
- 45What 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.
- 46What is an acceptable oximetry reading for a healthy patient?97%-100%
- 47What 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.
- 48What does an oximetry reading tell us?It tells us what percentage of oxygen is in the blood.
- 49What can affect a correct oximetry reading?Cold hands, nail polish, dirty fingers.
- 50What 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.
- 51What are the signs and symptoms of hypoxiaChanges in the color of your skin, ranging from blue to cherry red.
Confusion.
Cough.
Fast heart rate.
Rapid breathing.
Shortness of breath.
Sweating.
Wheezing. - 52What 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.
- 53What 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.
- 54How 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. ----
- 55What does febrile / pyrexia mean?Febrile is showing symptoms of a fever. Pyrexia is a raised body temperature.
- 56What are the clinical signs and symptoms of pyrexia?Sweating.
Shivering.
Headache.
Muscle aches.
Loss of appetite.
Dehydration.
General weakness. - 57How do we treat pyrexia?Make room temperature comfortable. Cool sponge bath. Monitor vital signs. Promote rest & fluids to avoid dehydration.
- 58What 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. - 59Why 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.
- 60SIX RIGHTSPATIENT
DRUG
DOSE
ROUTE
TIME
DOCUMENTATION - 61What 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.
- 62AURICULARears
- 63BUCCALAdministration directed toward the cheek, generally from within the mouth.
- 64CONJUNCTIVALAdministration to the conjunctiva, the delicate membrane that lines the eyelids and covers the exposed surface of the eyeball.
- 65SUBLINGUALunder tongue
- 66IMintramuscular
- 67What is the difference between side effect and allergy?Side effects can be expected when taking certain drugs.
Allergies are unexpected/unpredictable events. - 68PO/Oorally
- 69IDintradermal (vaccines)
- 70IMintramuscular
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- Fichas sobre Semester 2 OSCE, creado por Ruby Dow el 28/10/2016.
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- Ruby Dow
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