Acute Care Nursing 1 Flashcards
What are the requirements of a medication prescription?
Must be legible Must contain: - start date - medicine - route - dose - frequency / dose times - indication (if appropriate) - prescriber name, signature, contact details
What are the high risk medications as specified by APINCHS
A - antimicrobials
P - potassium and other electrolytes / psychotropic medication
I - Insulin
N - narcotics/opioids
C - chemotherapeutic agents
H - heparin and other anticoagulants
S - systems (eg safe administration of liquid medications)
What are the 6 rights of medication administration?
1 - right patient 2 - right medication/drug 3 - right dose 4 - right route 5 - right time 6 - right documentation
Sites for subcutaneous injections
- anterior abdominal wall (5cm clear of umbilicus and any scars)
- anterior aspects of the upper arms
- anterior aspects of the thighs
- scapulae
Sites for intramuscular injections
- deltoid (upper arm)
- dorsogluteal (buttock)
- rectus femoris (anterior quadricep)
- vastus lateralis (lateral anterior quadricep)
- ventrogluteal (hip)
How to locate the ventrogluteal injection site
- place palm of hand against the greater truncator of the femur and index finger on the anterior on the anterior superior iliac spine of the pelvis
- abduct the middle finger posteriorly along the iliac crest
- inject between the V of the two fingers
Potential complications of IMI
- fibrosis and contractures of the muscles
- nerve injuries/palsy/neuropathy
- arterial puncture/haematoma formation
- local irritation/infection/abscess
What is the maximum injection volume for each injection site
- deltoid = 2mL (EXCEPT Invega Trinza, 2.6mL)
- ventrogluteal = 2.5mL
- dorsogluteal = 3mL
- vastus lateralis = 5mL
- rectus femoris = 5mL
What vital signs should be conducted?
- respiration rate
- oxygen saturation
- heart rate/rhythm/strength
- blood pressure
- temperature
- level of consciousness
- pain
- cognition
What aspects of respiration should be assessed?
- rate (breaths/min)
- rhythm
- depth and symmetry
- effort
- audible sounds
Types of audible/abnormal breath sounds
- stridor: high-pitched breath sound
- stertor: laboured snoring sound
- wheezing: high-pitched and squeaking
- crackles, bubbles, gurgles
Types of abnormal breathing patterns
- apnoea: absence of breathing
- tachypnoea: resp rate greater than 20 breaths/minute
- bradypnoea: resp rate less than 10 breaths/minute
- dyspnoea: shortness of breath, difficulty breathing
- hypoventilation: reduced rate and depth of breathing
- hyperventilation: rapid deep breathing
- Cheyne-Stokes: slow and increased depth of breathing with periods of apnoea. Sign of dying
Clinical conditions affecting oxygen sats
- severe hypoxia
- abnormally high pH
- hypotension
- arrhythmias
- hypothermia
- pharmacological vasoconstrictions
- peripheral oedema
- jaundice/hyperbilirubinaemia
- low perfusion states/poor peripheral circulation/peripheral vascular disease
- anaemia
- carbon monoxide exposure
- medical conditions such as COPD
Pulse sites
- temporal pulse
- carotid pulse
- apical pulse
- brachial pulse
- radial pulse
- femoral pulse
- popliteal pulse
- posterior tibial pulse
- pedal pulse
How to locate the apical pulse
5th intercostal space, left mid-clavicular line
Mean Arterial Pressure (MAP)
the average blood pressure throughout the cardiac cycle.
NOT the average of the diastolic and systolic pressures as diastole exceeds systole.
MAP = (2xDBP + SBP) / 3
MAP needs to be greater than 60mmHg to perfuse tissue
What is the AVPU scale?
Rapid/simplified assessment of level of consciousness A = alert V = responds to voice P = responds to pain U = unresponsive
What is acute compartment syndrome?
pressure increases within any confined space in the body, resulting in a reduction of blood flow to the tissues contained within that compartment space; resulting in muscle, nerve and tissue ischaemia.
What are the early findings for neurovascular deficit?
Pain (and related oedema/swelling) - with passive stretch, out of proportion to the injury, unrelieved by narcotics
Paraesthesia (pins and needles) - diminishing sensation
Palpation - tense compartment with a tight, firm feeling
What are the late findings of neurovascular deficit?
paralysis - decrease or loss of movement
pallor - pale skin is a sign of decreased blood flow. May also become cyanosis or mottled
pulses - reduced or absent peripheral pulses
temperature
Colour descriptions during neurovascular obs
- natural
- pale
- mottled
- cyanotic
Assessing neurovascular obs
- Pain - is it relieved by opioids?
- colour
- temperature
- capillary refill (should be <2 secs)
- pulses (pedal pulse unpalpable in ~ 10%)
- sensation (was there a nerve block?)
- movement
Assessment tools for neurological obs
- vital signs
- glasgow coma scale
- neurological signs:
- pupil size and reaction to light
- upper limb motor function
- lower limb motor function
What are the three sections of the glasgow coma scale
- eyes open
- best verbal response
- best motor response
GCS - eyes open scores
4 - spontaneously
3 - to speech
2 - to pain
1 - none
GCS - best verbal response
5 - oriented 4 - confused 3 - inappropriate words 2 - incomprehensible sounds 1 - none
GCS - best motor response
6 - obeys commands 5 - localise 4 - withdraw 3 - abnormal flexion 2 - extension 1 - none
order of vital signs during a neurological assessment?
1 - respiration
2 - temperature
3 - blood pressure and pulse
Abnormal breathing patterns assessable on neurological assessment?
Ataxic - completely irregular, random deep and shallow resps, irregular pauses
Biot’s - irregular rate and depth, alternating patterns of deep gasping and apnoea
Cheyne-Stokes - regular pattern of alternating deep breathing and apnoea
Central neurogenic hyperventilation
Apneustic breathing - prolonged inspiration, pause at full inspiration
