Assessment and haemodynamic monitoring Flashcards
What is a primary assessment?
DRSABCDE
What are you assessing in Airway?
conscious state, ability to speak or cry, skin color, foreign bodies / facial or neck injury, Patent or obstructed airway, c-spine,
What are you assessing in Breathing?
chest wall inspection, chest wall movement, respiratory rate and work of breathing, 02 sats, signs of injury.
What are you assessing in Circulation?
Ensure adequate perfusion, blood pressure & adequate fluid volume.
•sources of uncontrolled external haemorrhage
•conscious state
•skin color, warmth, moisture
•heart rate
•pulses (carotid / femoral / brachial / radial)
•blood pressure
•capillary refill (< 2 seconds)
•urine output
What are you assessing in Disability?
AVPU, GCS, BSL, Pain, PEARL
What are you assessing in Exposure?
Temperature, removal of cloths to see whole patient
What is a secondary assessment?
Is a systematic process to ensure the detection of ALL injuries / concerns, Complete head-to-toe examination
What is involved in a secondary assessment?
FGHIJ
What are you assessing in Freezing? What types of nursing management can be implemented?
Temperature
Warm blankets, fluids and o2
What are you assessing in Get Vitals?
Obtain full set of vital signs
BP, HR, RR, Spo2, Temp, GCS,
What information do you need for history?
Biographical – name, DOB etc. Reasons for seeking healthcare History of current problem- PQRST Past medical history – medical, surgery, immunisations, accidents, allergies Family history – illness and ages
What are you assessing in Inspect the back
Spinal immobilisation and log roll patient
PR examination to assess anal tone
Palpate the spine and costo-vertebral angles for tenderness and deformity
Control bleeding
Jot it down- Documentation should include?
–mechanism of injury –pre-hospital care and interventions –patient assessment on arrival / ongoing –patient management and interventions –results of investigations / procedures –management plan
What is a focused assessment?
Detailed assessment of the symptom / affected body system
What is haemodynamic monitoting
The ability to real time monitor and measure pressures within the cardiovascular system including:
–central venous pressure CVP
–Arterial blood pressure
What is a CVC
central venous catheter
A long catheter inserted under local anaesthetic by experienced MO into a large vein until the tip reaches the superior vena cava (near the right atrium of the heart)
What are the indications for CVC
Monitor fluid status (CVP) Administer large volume of fluids Administer fluids/medications rapidly Long term access Multiple drug administration Administer irritating medications Administer TPN Difficulty obtaining other access
What are the most common veins used in CVC insertion?
–subclavian
–internal jugular
–external jugular
–femoral (rare)
What are the complications of CVC during insertion and post insertion?
DURING: pneumothorax haemothorax air embolus arterial cannulation incorrect positioning arrhythmia cardiac injury bleeding nerve injuries AFTER: extravastion haemorrhage subcutaneous emphysema thrombosis sepsis Infection
What intervention must be done post insertion of a CVC
chest xray
List types of long term CVC
peripheral inserted central cannula (PICC)- long term used > 12 months
Hickmans
Port-a-cath
What is CVP
The pressure within the right atrium or superior vena cava
If a patient has an elevated CVP they would be experiencing what types of conditions
Right ventricular failure Volume overload Tricuspid valve stenosis Constrictive pericarditis Pulmonary hypertension
If a patient has an decreased CVP they would be experiencing what types of conditions
Dehydration
Shock
