PART A

Q1. List the routine daily clinical observation you would perform on a patient as part of their care plan.

A. As you enter the room, observe the patient for signs of distress, e.g. pallor, laboured breathing, and
behaviours indicating pain or emotional distress.

B Scan for safety hazards, e.g. are there spills on the floor?

C Look at the equipment, e.g. urinary catheter, intravenous pumps, oxygen, monitors.

D Scan the room who is there and how do these people interact with the patient?

E. Observe the patient more closely for data such as skin temperature, breath sounds, drainage/dressing
odours, condition of dressings, drains, need for repositioning (Wilkinson 2007).
Source:www.royalmarsdenmanual.com/.../pdfs/RMM_Stud_c02

Q2. Name the group of observations you would perform on a patient who has a head injury. Identify the
parameters measured during this clinical assessment.

1. Short attention span, easy distractibility and inability to concentrate.

2. Impulsive, impatient, low tolerance for pain or frustration.
3. Uncooperative, resistant to care, demanding.
4. violent and/or threatening violence towards people or property.
5. Explosive and/or unpredictable anger.
6. Rocking, rubbing, moaning or other self stimulating behaviour.
7. Pulling at tubes, restraints etc.
8. wandering from treatment areas.
9. Restlessness, pacing, excessive movement.
10. Repetitive behaviours, motor and/or verbal.
11. Rapid, loud or excessive talking.
12. Sudden changes of mood.
13. Easily initiated or excessive crying and/or laughter.
14. Self abusiveness, physical and/or verbal.

Source: www.sign.ac.uk/pdf/sign110

Q3. Name the group of observations you would perform on a patient who has had a pin and plate inserted
for a fractured radius. Identify the parameters measured during this clinical assessment.
 Q4. Lists 5 causes of errors in blood pressure measurement in relation to the cuff?

1. Youre using the wrong-sized cuff

2. Youve incorrectly positioned your patients body
3. Youve placed the cuff incorrectly
4. Your readings exhibit prejudice
5. Youre not factoring in electronic units correctly
Source : www.ems1.com/ems-products/Medical-Monitoring/articles/1882581-5-errors-that-are-
giving-you-incorrect-blood-pressure-readings/

Q5. Complete the basic life support flow chart.

D Check for DANGER- Hazards / Risks / Safety. To self, casualty or others

R Check for RESPONSE Non Responsive or Unconscious?
S SEND for help Ring Emergency Triple Zero (000) ask for Ambulance
A Open AIRWAY Look for signs of life = conscious or responsive or breathing normally or
moving
B Normal BREATHING? If unresponsive & not breathing normally
C Start CPR 30 compressions : 2 breaths if unwilling/unable to perform rescue breaths
continue chest compressions
D Attach DEFIBRILLATOR (AED) as soon as available and follow its prompts

Q6. How might the protocol for cardiac arrest differ from an acute care setting to an aged care
facility? Expalin your answer.

A cardiac arrest is an emergency. If you witness a cardiac arrest, you can increase the persons
chances of survival by phoning 911 immediately and giving CPR, while in an acute care setting, one must
ensure that aged-friendly principles are in place. Care needs to be taken to ensure quality use of
medicines. When an older person comes into acute care, a whole range of data must be collected
in a standardised and comprehensive way. For this reason, an assessment tool is usually used.

Q7. Identify and explain 5 signs and symptoms you would expect to see if a patient was
suffering from hypoxia?

Signs:

Rapid Breathing
Cyanosis
Poor Coordination
Lethargy/Lassitude
Executing Poor Judgment

Symptoms:

Air Hunger
Dizziness
Headache
Mental and Muscle Fatigue
 Nausea
Hot and Cold Flashes
Tingling
Visual Impairment
Euphoria

Other symptoms of hypoxemia may include cyanosis, digital clubbing, and symptoms
that may relate to the cause of the hypoxemia, including cough and hemoptysis.

Q8. FIGURE

Q9. Discuss the dangers of oxygen therapy.

Answers

A. Oxygen is a blood vessel constrictor or vasoconstrictor. As blood vessels are constricted,

circulation in the peripheral blood vessels is significantly reduced, an effect that was previously
thought to increase the risk of stroke. However, according to Henrys law, the additional oxygen is
dissolved in the blood plasma, which enables a compensating change to occur where oxygen
supports neurons that may be starved of oxygen, as well as reducing inflammation and post-stroke
edema in the brain.

B. A form of oxygen therapy called hyperbaric oxygen therapy has been widely used in the treatment
of stroke since 1990. The therapy has occasionally caused seizures but due to the effect of
dissolved oxygen on neurons, the seizure is not usually followed by any further negative effect. Such
seizures usually occur as a result of oxygen toxicity. Hypoglycemia can also contribute to the risk but
careful monitoring of the patients food intake can usually prevent this being a factor.

C. Patients with chronic obstructive pulmonary disease are at a particular risk of accumulating
carbon dioxide if they are administered supplemental oxygen and these patients needs to be
carefully monitored to prevent supplemental oxygen becoming dangerous rather than beneficial.

Source : http://www.news-medical.net/health/Oxygen-Therapy-Side-Effects.aspx

Q10. What is the minimum flow rate of oxygen in liters/minute when using non-rebreathing oxygen mask?
Answer:
A nonrebreather mask can deliver oxygen concentrations of 60% to 95% with flow rates from
10 to 15 L/min. When using a nonrebreather mask, do not allow the reservoir bag to deflate. If it
does deflate, the patient is likely to breathe in large amounts of exhaled carbon dioxide.
Source http://www.atitesting.com/ati_next_gen/skillsmodules/content/oxygen-
therapy/equipment/delivery-devices.html
Q11. What is the appropriate amount ( percentage ) of oxygen that nasal prongs should deliver at
2L/min?

Source:http://www.atitesting.com/ati_next_gen/skillsmodules/content/oxygen-
therapy/equipment/delivery-devices.html

Q12. What is a Tracheostomy?

Answer: A tracheotomy or a tracheostomy is an opening surgically created through the neck into the
trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating
room under general anesthesia. A tube is usually placed through this opening to provide an airway
and to remove secretions from the lungs. Breathing is done through the tracheostomy tube rather
than through the nose and mouth. The term tracheotomy refers to the incision into the trachea
(windpipe) that forms a temporary or permanent opening, which is called a tracheostomy, however;
the terms are sometimes used interchangeably.
Source : http://www.hopkinsmedicine.org/tracheostomy/about/what.html

Q13. Give 3 reasons why a patient might have a Tracheostomy?

a. They have obstructed upper airway;

b. They have dirty secretions from the airway;
c. lack of air getting to the lungs and some lung problems (e.g Chest wall injury,
Diaphragm dysfunction etc)
Source : http://www.hopkinsmedicine.org/tracheostomy/about/reasons.html

Q14. What safety measures are taken when cleanng a tracheostomy tube and changing the
dressing ?

A. Perform hand hygiene, verify physician orders for tracheostomy care, and collect supplies.
B. Perform hand hygiene, ID patient using two identifiers, explain procedure to patient, and
create privacy if required. Ensure patient has a method to communicate with you during the
procedure.
C. Apply non-sterile gloves and cover chest with waterproof pad.
D. Organize all supplies and set up sterile tray field; add cleaning solution to sterile tray.
E. Remove oxygen mask to clean dressing but replace frequently as required by patient.
F. Using forceps, remove the soiled dressing around the tube and discard in garbage bag.
G. Assess the stoma site for bleeding, appearance of stoma edges, and peristomal skin for
evidence of infection or redness
H. Clean the stoma site with a gauze or cotton-tip applicator soaked in normal saline. Be careful
not to disturb the tracheostomy tube. Dry surrounding area if required.
I. Assess the site to determine if barrier film is required.
J. Apply new manufactured pre-cut tracheostomy dressing to tube using sterile forceps.

Source : https://opentextbc.ca/clinicalskills/chapter/10-6-tracheostomies/

Q15. Define endotracheal intubation?

Endotracheal intubation is a procedure by which a tube is inserted through the mouth down
into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often
done under deep sedation. In emergency situations, the patient is often unconscious at the time
of this procedure.

Q16. Identify 3 situations when this would be performed.

You may need this procedure for one of the following reasons:

A. to open your airways so that you can receive an anesthetic, medication, or oxygen
to protect your lungs
B. Youve stopped breathing or youre having difficulty breathing
C. You need a machine to help you breathe and when you have a head injury.

Source: http://www.healthline.com/health/endotracheal-intubation#overview1

Q17. What is a Bellovac drain ? Identify 3 surgical procedure it may be used in .

Answer
Large Volume Drainage. Efficient drainage but with diminshed blood loss compared to a
high vacuum drain
Surgical procedures
Orthopaedics
Gynaecology
General Surgery
Source :
https://secure.dentsplyimplants.com/Main.aspx?Item=459337&navt=68686&navl=83954&nav
a=83974

Q18. What is the difference between an open drain and a closed drain ?

Answer :
closed drainage
drainage of an empyema cavity carried out with protection against the entrance of outside air
into the pleural cavity.
open drainage
drainage of an empyema cavity through an opening in the chest wall into which one or more
rubber drainage tubes are inserted, the opening not being sealed against the entrance of outside
air.

Source : http://medical-dictionary.thefreedictionary.com/closed+drainage

Q19. Define Enteral Feeding.

enteral feeding
a mode of feeding that uses the GI tract, such as oral or tube feeding.

Q20. Describe 3 reasons for enteral feeding being used.

A. When a patient has difficulty eating for whatever reason, and if the GI tract is working.
B. When patients who cannot obtain nutrition by mouth
C. unable to swallow safely, or need nutritional supplementation

Q21. List 5 complications associated with enteral feeding .

Feeding delivered by enteral tubes can cause the following complications:

 A. food entering the lungs, constipation, diarrhea, improper absorption of nutrients,
nausea, vomiting, dehydration, electrolyte abnormalities, high blood sugar, vitamin and
mineral deficiencies, and decreased liver proteins.

B. Infection- Bacterial contamination of enteral feed can cause serious infection

C. Feeding tubes inserted through the nose, such as nasogastric or nasoenteric tubes,
can cause irritation of the nose or throat, acute sinus infections, and ulceration of the
larynx or esophagus.

D. Feeding tubes inserted through the skin of the abdominal wall, such as gastrostomy
or jejunostomy tubes, can become clogged (occluded) or displaced, and wound infections
can occur.

E. Re-feeding syndrome- This occurs in previously malnourished patients who are fed
with high carbohydrate loads.

Source : https://patient.info/doctor/enteral-feeding

Q22. What does the word stoma mean?

1. a mouthlike opening.
2. an incised opening that is kept open for drainage or other purposes, such as
the opening in the abdominal wall for colostomy, ureterostomy, and ileal conduit

Q23. Explain the difference between an lleostomy, colostomy and a urostomy. Describe a chronic
disease associated with each and the impact having one of these stomas might have on a
patients ADL.

Ileostomy: This type of ostomy is made with a part of the small intestine (or ileum). It
may be what-is-an-ileostomy-imageused when the entire colon has been removed (like mine)
or it may be temporary following a resection or to allow the colon to heal before being
reconnected. It is commonly used in patients with ulcerative colitis, Crohns disease, Familial
Polyposis (FAP) and colon cancer. It is most often located at the lower right side of the stomach.
The poop is usually in liquid form and can be water or more of the consistency of applesauce.
The individual does not have any control on the activity of the ostomy and must wear an ostomy
bag, which needs to be emptied approximately 5-8 times a day.

Colostomy: This ostomy is formed with a part of the large intestine. It is used when only
part of the colon is removed or when a section of the colon needs time to rest and heal and can
also be either permanent or temporary. It is often used for patients who have diverticulitis, colon
cancer, bowel obstruction, paralysis, injury or birth defects. There are 2 common types of
colostomy that affects its placement: A transverse colostomy is on the upper part of the stomach
and a descending/sigmoid colostomy on the lower left of the stomach.

Urostomy: This type of ostomy is used for the urinary tract. It is actually a little more
complicated than the other types of ostomies as it requires the removal of the bladder, as well
as a section of the small intestine. The intestine is sewn back together, but the piece that was
removed is then attached to the ureters that extend from the kidneys and is also used the create
a stoma. It is only done as a permanent solution. A urostomy is most often needed due to
bladder cancer, but also inflammation of the bladder or birth defects. It is usually placed on the
right side of the stomach.

Source: http://stolencolon.com/ileostomy-colostomy-urostomy-difference/

Q24. Describe the post operative assessment of a newly formed stoma.

Answer:
A new stoma must be kept moist to ensure tissue integrity, so the nurse should place a
petrolatum gauze over the stoma. As soon as possible, a pouch system needs to be placed over
the ostomy and monitored for proper fit and signs of leakage. Besides monitoring the stoma
color, the nurse needs to continuously assess functioning of the stoma and notify the physician
of complications such as stoma retraction, unusual bleeding or presence of necrotic tissue and
compromised stoma vasculature. Waste matter should never be allowed to remain on the skin,
so nurses should diligently empty an ostomy pouch when one-third full and perform skin care
on the peristomal area. According to the National Kidney and Urologic Diseases Information
Clearinghouse, urostomies can get infected, so nurses should monitor and teach the patient
signs of symptoms of infection. These are dark urine with foul odor, increased mucus in urine,
lower back pain, nausea and vomiting.
Source: http://www.livestrong.com/article/121611-nurse-tips-ostomy-care/

Q25. What factors might influence a patients decision when choosing a type of stoma bag?
Answer:
The length of the stoma, abdominal firmness and shape, the location of the stoma, scars
and folds near the stoma, and your height and weight all must be considered. Special changes
may have to be made for stomas near the hipbone, waistline, groin, or scars.
Source : https://old.cancer.org/acs/groups/cid/documents/webcontent/002823-pdf.pdf

Q26. Explain the role of a nurse who specialises in Stoma-therapy?

Preoperative services include:

counseling regarding planned surgical procedure, the impact of an ostomy on the
patient's life, and the basics of ostomy management; sexual counseling; and stoma site
selection.
Postoperatively:
The nurse instructs the patient and family in ostomy care, dietary and fluid
alterations, and ways to incorporate ostomy management into the patient's life

The nurse also provides long-term follow-up care in outpatient settings; such care includes
ongoing counseling, education, and surveillance for complications requiring medical intervention.
Nurses can recommend appropriate measures to prevent and manage skin breakdown that is
related to immobility, friable skin, incontinence, and/or radiation therapy. They also can assist
in correcting or containing fecal or urinary incontinence and in cost-effective management of
draining wounds and fistulas.

Source : https://www.ncbi.nlm.nih.gov/pubmed/1511389

Q27. What is the difference between an indwelling and intermittent urinary catheters.

Intermittent catheterization (also known as self-catheterization) involves draining the

bladder on a regular schedule. The catheter is inserted into the urethra, and the contents of the
bladder are drained directly into the toilet. The catheter is then removed.
An indwelling catheter is a catheter that is inserted into the bladder. There are two ways
that it can be inserted: through the urethra (usually called a Foley catheter) and through the
abdomen (usually called a suprapubic tube). This is often the last resort when other catheters
havent worked.

Source : https://ahmexposed.wordpress.com/2016/02/18/catheter-basics-the-
difference-between-condom-intermittent-and-indwelling/

Q28. Identify 3 complications associated with indwelling and intermittent urinary catheters.

Odor many users report a light smell, which may come from the collection bag.
Highest risk of infection chronic infections are most common with this catheter type.
Urethra swelling inserting and removing the catheter can cause the urethra to swell.

Q29. Define intravenous therapy and identify 3 invasive devices for delivering it.
 Intravenous therapy is the infusion of liquid substances directly into a vein. Intravenous
(IV) means "within vein". Intravenous infusions are commonly referred to as drips. The
intravenous route is the fastest way to deliver fluids and medications throughout the body.

Peripheral intravenous device (PIV)/catheters

X-ray detectable, non-absorbable internal sponge
Vascular occluder
Suturing needle

Q30. List 5 reasons for giving intravenous therapy.

rehydration after becoming dehydrated from illness or excessive activity

treatment of an infection using antibiotics
cancer treatment through chemotherapy drugs
management of pain using certain medications
Fluid and electrolyte replacement

Q31. Provide a definition for extravasation ,phlebitis and air embolism.

Extravasation- it occurs when fluid seep out from the lumen of a vessel into surrounding tissue.
Phlebitis- inflammation of the veins
air embolism - Air enters vascular system and is propelled in to the heart creating an air lock at
the pulmonic valve. Blood unable to exit right side of heart.

Q32. What would you expect to see from an infected peripheral intravenous catheter(IVC) site?

Swelling, discomfort, burning, and/or tightness

Cool skin and blanching
Decreased or stopped flow rate
Blistering and/or skin sloughing
Redness or tenderness at the site of the tip of the catheter or along the path of the vein
Puffy area over the vein
Source : http://www.nursingcenter.com/ncblog/february-2015-(1)/complications-of-
peripheral-i-v-therapy

Q33. What observations would you make on a patient complaining of 7/10 post- operative pain?
Fever (temperature higher than 100F [38 C])
Nausea, vomiting, or both
Constipation
Diarrhea
Pus or discharge from the wound
Redness or swelling
Shortness of breath

Q34. They have just been given 10 mg of Endone. What observations would you perform on the
patient after administration of the medication?

Observations to be observed
dizziness, light-headedness, and confusion
drowsiness
hypotension
constipation
vomiting
nausea.
Q35. Identify 2 side effects of long term use of Endone.

A. A decreased level of testosterone or enlargement of the prostate. Other long-term

effects include excessive sweating, swelling in the arms and legs, and chronic
constipation.
B. Addiction that is characterized by greater dependence on the drug and tolerance to
the dosage.
Source : http://www.livestrong.com/article/79119-longterm-effects-taking-oxycodone/

Q36. What is an electrocardiogram (ECG)?

An electrocardiogram (EKG or ECG) is a test that checks for problems with the electrical
activity of your heart.

Q37. Describe 3 signs/symptoms that would indicate the need to perform an ECG?

Symptoms of heart disease. Symptoms include shortness of breath, dizziness, fainting,

and heartbeats that are rapid and irregular (palpitations).

Check the health of the heart when other diseases or conditions are present. These
include high blood pressure, high cholesterol, cigarette smoking, diabetes, and a family history
of early heart disease.

Unexplained chest pain or pressure. This could be caused by a heart attack, inflammation
of the sac surrounding the heart (pericarditis), or angina.

Q38. Which non-medical staff would you notify if you observed one of these signs/symptoms
and why?
A. Red cross staff or Any person who knows first aid in any cardiac arrests.
B. Assistant medical representative .

Q39. Identify the positions of the chest electrodes for a 12 lead ECG on the following diagram
sOURCE
http://www.emtresource.com/resources/ecg/12-lead-ecg-placement/

Q40. Provide an anatomical description of all electrodes locations V1,

V2,V3,V4,V5,V6,RA,LA,RL,LL.

Q41. How do we measure a 12 lead ECG with only 10 electrodes ?

Make sure the electrode conducting gel is fresh and adequately moist. A dry electrode
with inadequate gel reduces the conduction of the ECG signal.
 Often, electrode gel dry-out is a result of incorrect storage. Store electrodes as instructed
by manufacturer and do not remove from their pouch until theyre ready for use.
Do not place electrodes on skin over bones, incisions, irritated skin, and body parts where
there is lots of possible muscle movement.
Use 10 electrodes of the same brand. Using different brands with dissimilar composition
can hinder an accurate ECG trace.

Q42. List 4 things that can interfere with the quality of an ECG reading .

A. CONDITION OF THE SKIN

Impedance
Diaphoresis
Dryness
Oilyness
EMG, respiration and other biopotentials (physiological electrical signals)
Skin preparation techniques
Obesity
Skin stretch.

B. Electrodes
Adhesion
Conductor
Gel
Backing
Size
Design
Motion
Shelf life
Application technique
Electrical/mechanical properties
Location on the body

C. Environment
Electrical field (60 Hz)
Humidity
Temperature
Static electricity
Magnetic field
Radiofrequency
Vicinity of other machines (nebulizers, fans, power cords, etc.)

D. Cables & Lead Wires

Mechanical/electrical properties of materials
Shielded cable and shielded lead wires
Open lead wires (avoid loops)
Triboelectric effect (generated by cable movement)

SOURCE :multimedia.3m.com/.../factors-affecting-ecg-trace-quality.pdf