Erythema - Answers redness of the skin
Blanching - Answers when skin is pressed + turns white due to obstruction of blood flow to area
Localised heat - Answers inflammation, swelling
Oedema - Answers fluid retention in the body
Induration - Answers abnormal hard spot of skin
Skin breakdown - Answers dermis are damaged
Identify 2 PPE items & provide example. - Answers Gloves - to prevent exposure to bodily fluids
Mask - to prevent inhalation of toxic emissions
Identify 8 steps of clinical reasoning cycle. - Answers 1. Consider the patient.
2. Collect cues/information.
3. Process information.
4. Identify problems/issues.
5. Establish goals.
6. Take action.
7. Evaluate outcomes.
8. Reflect on process and new learning.
Identify 6 essential links in chain of infection. - Answers 1. Causative agent.
2. Reservoir.
3. Portal of exit.
4. Means of transmission.
5. Portal of entry.
6. Susceptible host.
List 3 things a nurse needs to consider before mobilising a patient. - Answers 1. Physical ability - if
they need assistance (walking aid)
2. If they've had any surgeries
3. Orthostatic hypotension (drop in bp going from sit to stand)
4. Medication
5. Privacy
Name for a safety device that is secured around waist and is used during mobilisation. - Answers
Walking belt.
Hypoxaemia - Answers low o2 in blood
Cyanosis - Answers discolouration (dusky coloured skin + nail beds)
Pressure injury - Answers damage to skin + underlying soft tissue usually over a bony prominence
Resident flora - Answers organisms residing on skin, rarely cause infection unless introduced into
body tissue by trauma or in conjunction with foreign bodies such as intravenous catheters
Transient flora - Answers can include pathogens responsible for infection, responsible for most HAIs
resulting from cross infection, easily removed by hand cleansing
Standard precautions - Answers HH before + after every episode of contact, PPE, safe use & disposal
of sharps, environment cleaning, respiratory & cough hygiene, ANTT, waste management, and
appropriate handling of linen.
5 moments of hand hygiene - Answers 1) before touching patient
2) before clean/aseptic procedure
3) after procedure/body fluid exposure risk
4) after touching patient
5) after touching patient surroundings
(HH before and after using gloves)
Nurse precautions - Answers Remove rings, watches, earrings, etc.; short fingernails; hand drying;
hands free of lesions & cuts.
PPE - Answers Personal Protective Equipment i.e. gloves, mask, safety glasses (protective eyewear),
gowns, and clinical attire
Correct "donning" - Answers HH, apron, mask, eyewear, gloves.
Correct "doffing" - Answers Gloves, HH, glasses, apron, mask.
When to perform vital signs: - Answers On admission; change in health status; symptoms arise (chest
pain, hot, faint, etc.); before during & after surgery; before & after medications affecting heart; before
& after interventions affecting vital signs; following accident, injury.
, Tachycardia - Answers fast heart rate
Bradychardia - Answers slow heart rate
dysrhythmia/arrhythmia - Answers Abnormal heart rhythm
Hyperthermia - Answers Abnormally high body temperature
Hypothermia - Answers abnormally low body temperature
Hypertension - Answers high blood pressure
Hypotension - Answers low blood pressure
Systolic - Answers Blood pressure in the arteries during contraction of the ventricles.
Diastolic - Answers occurs when the ventricles are relaxed; the lowest pressure against the walls of an
artery
Acceptable BP range - Answers 120/80 - ideal BP
Acceptable temperature range - Answers 35-37 degrees
Tachypnoea - Answers rapid breathing
Bradypnoea - Answers slow breathing
Apnoea - Answers absence of breathing
Acceptable respiration range - Answers 12-20 breathes
arterial oxygen saturation - Answers SaO2
peripheral oxygen saturation - Answers SpO2
Normal O2 saturation - Answers 95-100%
What is clinical reasoning? - Answers process that uses knowledge + thinking strategies + evidence to
gather + analyse parent information + diagnosis
What is critical thinking? - Answers Cognitive thinking process during which an individual reviews data
+ considers potential explanations + outcomes before forming an opinion or making a decision
DRSABCD - Answers Danger, Response (COWS), Send for help, Airway, Breathing, CPR, Defibrillation
Wound types - Answers superficial - epidermis (surface wound)
partial thickness - epidermis and dermis (deeper wound)
full thickness - epidermis, dermis, subcutaneous fat, muscle + potentially bone (deep wound)
Assessing + wound care - Answers Wound type, smell, amount + type of exudate, surrounding skin
(colour, heat, integrity, oedema), pain, using moist dressing + changing when necessary
Exudate types - Answers Serous, haemoserous, sanguinous, purulent
Serous - Answers Clear, thin, watery (normal)
Haemoserous - Answers Clear, pink, thin, watery (normal + bit of blood)
Sanguinous - Answers red, thin, watery (pertaining blood)
Purulent - Answers Yellow, grey, green, thick, infection (containing/producing pus)
Wound healing phases - Answers Phase 1 = inflammation phase (0-3 days)
Phase 2 = proliferative phase (3-24 days)
Phase 3 = maturation phase (24-365 days)
Signs of a wound infection - Answers Heat, increasing exudate, increasing pain, slow healing, cellulitis,
odour, fever.
Investigations for infected wounds - Answers Microbiological analysis, swab (sample taken after
wound is cleaned + taken form deep site), need aspiration, wound biopsy, blood tests, imaging -
detect osteomyelitis (infection in bone).
Elements of normal movement - Answers - proper body alignment/posture
- joint mobility
- balance
- coordinated movement
Flexion - Answers movement that decreases the angle of a joint
Extension - Answers movement that increases the angle of a joint
Abduction - Answers movement away from the midline
Adduction - Answers movement toward the midline
Preventing immobility complications - Answers Reposition to reduce pressure over vulnerable areas
(body prominences + heels); ensure heels are free of bed surface; low fowler's position = head + trunk
raised between 15 - 45 degrees; high fowler's position = head + trunk raised 90 degrees.