Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing 3002 > Assessment and haemodynamic monitoring > Flashcards

Assessment and haemodynamic monitoring Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

What is a primary assessment?

A

DRSABCDE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are you assessing in Airway?

A

conscious state, ability to speak or cry, skin color, foreign bodies / facial or neck injury, Patent or obstructed airway, c-spine,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are you assessing in Breathing?

A

chest wall inspection, chest wall movement, respiratory rate and work of breathing, 02 sats, signs of injury.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are you assessing in Circulation?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are you assessing in Disability?

A

AVPU, GCS, BSL, Pain, PEARL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are you assessing in Exposure?

A

Temperature, removal of cloths to see whole patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is a secondary assessment?

A

Is a systematic process to ensure the detection of ALL injuries / concerns, Complete head-to-toe examination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is involved in a secondary assessment?

A

FGHIJ

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are you assessing in Freezing? What types of nursing management can be implemented?

A

Temperature

Warm blankets, fluids and o2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What are you assessing in Get Vitals?

A

Obtain full set of vital signs

BP, HR, RR, Spo2, Temp, GCS,

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What information do you need for history?

A 
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are you assessing in Inspect the back

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Jot it down- Documentation should include?

A 
–mechanism of injury
–pre-hospital care and interventions
–patient assessment on arrival / ongoing
–patient management and interventions
–results of investigations / procedures
–management plan
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is a focused assessment?

A

Detailed assessment of the symptom / affected body system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is haemodynamic monitoting

A

The ability to real time monitor and measure pressures within the cardiovascular system including:
–central venous pressure CVP
–Arterial blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is a CVC

A

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)

17
Q

What are the indications for CVC

A 
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
18
Q

What are the most common veins used in CVC insertion?

A

–subclavian
–internal jugular
–external jugular
–femoral (rare)

19
Q

What are the complications of CVC during insertion and post insertion?

A 
DURING:
pneumothorax
haemothorax
air embolus
arterial cannulation
incorrect positioning
arrhythmia
cardiac injury
bleeding
nerve injuries
AFTER:
extravastion
haemorrhage
subcutaneous emphysema
thrombosis
sepsis
Infection
20
Q

What intervention must be done post insertion of a CVC

A

chest xray

21
Q

List types of long term CVC

A

peripheral inserted central cannula (PICC)- long term used > 12 months
Hickmans
Port-a-cath

22
Q

What is CVP

A

The pressure within the right atrium or superior vena cava

23
Q

If a patient has an elevated CVP they would be experiencing what types of conditions

A 
Right ventricular failure
Volume overload
Tricuspid valve stenosis
Constrictive pericarditis
Pulmonary hypertension
24
Q

If a patient has an decreased CVP they would be experiencing what types of conditions

A

Dehydration

Shock

25
Q

Can you inject into an arterial line
A. YES
B. NO
C. Only when injecting medications

A

B. NO

26
Q

List 5 complications of an arterial line

A 
Dampened wave form
Loss of wave form
Haemorrhage
Emboli
Infection
Ischemia
27
Q

What is an arterial line used for?

A

Arterial pressure monitoring allows accurate

measurement & monitoring blood pressure (BP).

28
Q

What arteries are the common sites used in arterial line insertion?

A

radial

femoral

29
Q

what are the nursing considerations for patients with a CVC?

A

Check tubing connections regularly
All infusions must run via a pump
Flush ports not in use as per policy
Ensure dressing is intact
–change immediately the integrity of the dressing is compromised
Carefully palpate around the catheter site
Assess surrounding area for signs of infection
If patient has a PICC assess the entire arm & don’t use this arm for BPs
Sterile technique
Assess insertion site for infection and haemorrhage

30
Q

How should you flush a PICC line?

A
  1. Always flush in a pulsatile (stop/start) manner to create turbulence in the lumen of the catheter, remove debris and avoid blockage of the catheter
  2. On accessing the PICC, flush with Normal Saline 10ml when determining patency.
  3. Flush before and after drug administration with 10ml normal saline.
  4. After blood sampling flush with 20ml of Normal Saline.
  5. Flush weekly when not in use
31
Q

List the S&S of PICC line infection

A 
Inflammation on site
fever
chills 
malaise ( feeling of general discomfort) 
vomiting 
light headed
32
Q

3 indications for a PICC line

A

Hydration
drug administration
poor peripheral veins

33
Q

Where does a PICC line lie?

A

Superior vena cava

34
Q

List 6 complications of a PICC line

A 
haemorrhage
infection
cellulites around insertion site 
thrombosis 
endocarditis 
mechanical (unable to flush)
35
Q

What size syringe should be used when accessing a PICC line

A

10ml or larger

Nursing 3002 (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions