Acute care Nur 203 Flashcards
What does the term negligence mean in nursing?
Failure to provide care or perform a duty reasonably expected of a nurse
What is highlighted in the ANMC code of conduct in relation to negligence, and how does this relate to nursing practice?
Failure to act in a professional manner, and providing care to a standard that is considered negligent, is considered a breach of conduct.
When do we gain consent from our patient?
before any procedure, as without consent all procedures could be considered assault.
Who has a duty of care?
Nurses have a duty of care for pt safety pt privacy and hospitals have a duty of care to their staff.
What are the most common conditions in which an intermittent catheter would be used?
- Abdominal, pelvic or rectal surgery/investigation.
- determine residual urine _urinary retention.
- To empty the bladder-post prostate surgery or bladder trauma.
- bypass an obstruction, tumour , bladder stones.
- reduce moisture and promote healing in genitourinary area.
What are the principles of aseptic technique?
To minimise the presence or pathogenic organisms as much as possible.
What are some reasons for nasogastric intubation NGT?
For administration of fluids, nutrients and drugs.
To allow drainage of contents of the stomach.
To allow removal of air from the stomach.
What type of pt would have NGT and why?
Long term pt for nutrient support.
surgical pt to remove gastric content and gas. pancreatitis pt to remove gastric acid/ stomach content.
preterm baby due to lack of swallow/suckling reflex.
Name examples of complications of enteral feeding and how to prevent these occurring.
No more than 3 attempts of inserting to prevent epistaxis (pain on insertion).
xray to prevent Aspiration, due to tube mygration or blockage. secure tube with tape and change daily. measure external length of tube afterevery shift .
flush tube before and after use.
Sit pt up 30 degrees to prevent cough and aspiration. Regular blood and urinalysis due to altered electroytes, hyperglycaemia, over hydration,
What lifestyle changes can pt take to help reduce GORD and peptic ulcer disease
Avoid food and drink that trigger symptoms.
Avoid large or late meals and lying down immediately after eating.
if symptoms are worse at night raise the head of the bed.
Lose weight if appropriate.
Reduce alcohol intake.
Stop smoking.
What medications can be taken to help with symptons of GORD
Antacids, PPIs and H2 receptor antagonists
Certain antacids are not recommended to pts with?
impaired kidney function or failure. Heart failure, High levels of calcium in their blood, hyperthyroidism or phenylketonuria.
what are the steps to carrying out a swallowing assessment?
Perform mouth care and decontaminate mouth.
ensure pt is able to swallow saliva and cough on demand.
assess for gag reflex and control of mouth/tongue if impaired refer to speech pathologist.
Have pt swallow a few spoons of water If it causes cough or gurgle refer to speech therapist
Why is acute pancratitis so painful?
Increased pressure within the ductal system. inflammation of the pancreatic nerve.
Elevated levels of neurotransmitters in pancreatic nerves. Obstruction of common bile duct.
Duodenal narrowing or obstruction
.
What would you implement to reduce symptons of pancreatitis?
Analgesia and antiemetics.
NGT to remove acid build up.
Regular liver function test to monitor risk of biliary obstruction.
Controlled fluid and nutritional replacement.
Nil by mouth to reduce pancreatic enzymes.
What advice would you give pt discharged after pancreatitis?
avoid alcohol.
high carb low-fat diet. eat small regular meals.
monitor blood sugar levels.
discuss possibility of cholecystectomy.
Describe nursing care of pt with bowel obstruction
NBM until bowel sounds are heard.
NGT for drainage checking colour and consistency. pain management.
frequent obs.
iv fluids and monitor output.
IV antibiotics if ischaemic bowel suspected.
What is an ileus and what are the signs?
Painful obstruction, symptoms include: N&V abdominal discomfort, diminished/absent bowel sounds, accumulation of gas on xray, CT scan can differentiate between ileus and obstruction.
what helps prevent constipation?
adequate dietary fibre, adequate fluid intake, increasing activity, going to the toilet after meals while the gastrocolic reflex is maximal
Describe one step questioning and when you would use it
For pt with a cognitive impairment use one point clear questions such as: pick up a pen, now right your name. We ned to order you lunch, do you want chicken? how about beef? would you prefer a sandwich?
What are some signs of raised ICP
oedema causes the optic nerve to be compressed resulting in impaired pupillary responses.
A fall in score on GCS.
Changes in BP, pulse and respiration are usually late signs of raised ICP
describe the trajectory of deterioration if S&S of ICP are missed and there is a failure to act
failure to act on elevated ICP can result in higher risk of mortality and permanent neurological impairment. delayed treatment worsens tissue hypoxia within the brain increasing oedema and injury.
What tis the Monro-kellie-hypothesis?
the relationship of pressures maintained in the cranial cavity, between the volume of blood, tissue, and Cerebrospinal Fluid. If one alters another is altered ie, If the intracranial blood increases this will result in the displacement of CSF.
How would you assess the neurological functioning using the Acronym AVPU?
A = alert, is pt alert and responsive? V = verbal. does pt respond to verbal commands? P= pain. does pt response to painful stimuls? U= unconscious. no response to any of the above
what interventions would you put in place to minimise the risk of falls for elderly in hospital?
falls risk assessment. Mini mental state exam. Nonslip socks. aids and equipment nearby (hearing aids, walking aids, glasses). call bell within reach. bed lowered to the floor. room near nursing station.
describe Alzheimer’s disease and the common manifestations of the disease.
progressive mental deterioration that can occur in middle or old age, due to degeneration of the brain
describe multiple sclerosis and the common manifestations of the disease.
progressive disease involving damage to the myelin sheaths of nerve cells effects the brain and spinal cord, and optic nerve. symptoms include numbness and tingling, muscle weakness and spasms, impairment of speech, and blurred vision and severe fatigue.
describe Parkinsons disease and the common manifestations of the disease.
It is a progressive degenerative disorder of the brain that causes a deficiency in the availability of dopamine which is needed for smooth muscle control. symptoms are tremor/ shaking, slow movement and rigid muscles.Freezing. stooped posture and staggered gait.
