Complete Flashcards
What is the definition of “Assessment”
The action of assessing someone/gathering information
What is the definition of ‘problems’ (actual and potential)?
Signs or warnings of serious complications
What is the definition of ‘interventions’?
Actual treatments and actions/changing the course of action
What is the definition of ‘clinical manifestations/signs & symptoms’?
Results that are either objective or subjective
What is Aetiology?
The underlying cause of a condition or contributing factors
What is pathophysiology?
Altered physiological processes associated with disease or injury - changes in the tissue that result from injury or disease
What is the definition for ‘rationale’?
The explanation/reason for a course of action i.e why something is done
Is the Rapid Assessment Framework considered to be an assessment?
NO
What does the Rapid Assessment Framework Cover
Your ABCDE’s (Airway, Breathing, Circulation, Disability, + environment/exposure) + actual/potential risks
What should the core body temperature of a person be?
Adult: Between 36.5 and 37.7
Older Adult: Between 35 and 36.4
Pedeatrics: Between 37 and 38
What is the expected pulse range for a patient?
10yrs-adult: 55-90bpm
2-10 yrs: 70-110
0-2yrs: 80-150
What is the expected respiratory rate for a patient
Typical: 12-20bpm
3-10yrs: 20-28
0-3yrs: 20-30
What is the expected systolic range for a patient?
<120 mmHg
What is the expected distolic range for a patient?
<80 mmHg
What does 02 stand for?
Oxygen
What does COPD stand for?
Chronic Obstructive Pulmonary Disease
What are red flags?
Signs or warnings of serious complications
What does RR stand for?
Respiratory Rate
What does NZEWS mean?
New Zealand Early Warning Score
What does PaCO2 stand for?
Arterial Carbon Dioxide Tension
What does Sp02 stand for?
Peripheral Oxygen Saturation
What is an intervention?
Actual treatments and actions
What does NP stand for?
Nasal Prongs
What does SOBOE stand for?
Shortness of Breath on exertion
What does V/Q stand for?
Ventilation/Perfusion Ratio
What does TB stand for?
Tuberculosis
What does HC03 stand for?
Bicarbonate
What does PEFR stand for?
Peak Expiratory Flow Rate
What does CPAP stand for?
Continuous Positive Airway Pressure
What does the abbreviation EF stand for?
Ejection Fraction
What does the abbreviation AKI stand for?
Acute Kidney Injury
What does the abbreviation CVA stand for?
Cerebrovascular Accident
What does the abbreviation ARF stand for?
Acute Renal Failure
What does the abbreviation HTN stand for?
Hypertension
What does the abbreviation IHD stand for?
Ischaemic Heart Disease
What does the abbreviation CAD stand for?
Coronary Artery Disease
What does the abbreviation MI stand for?
Myocardial Infarction
What does the abbreviation UAP stand for?
Unstable Angina Pectoris
What does the abbreviation STEMI stand for?
ST-Elevation myocardial infarction
What does the abbreviation AF stand for?
Atrial Fibrillation
What does the abbreviation CHD stand for?
Coronary Heart Disease
What does the abbreviation NSTEMI stand for?
Non-ST-Elevation myocardial infarction
What does the abbreviation HF stand for?
Heart Failure
What does the abbreviation CVD stand for?
Cardiovascular disease
What does the abbreviation PVD stand for?
Peripheral Vascular Disease
What does the abbreviation TIA stand for?
Transient Ischaemic Attack
What does the abbreviation UA stand for?
Unstable Angina
What does the abbreviation CKD stand for?
Chronic kidney disease
What does the abbreviation ACS stand for?
Acute Coronary Syndrome
What does the abbreviation CRF stand for?
Chronic renal failure
What does LOC stand for?
Level of Consciousness
What does ICP stand for?
Intracranial pressure
What does CVA stand for?
Cerebrovascular accident
What does CPP stand for?
Cerebral perfusion pressure
What does TBI stand for?
Traumatic brain injury
What does SCI stand for?
Spinal Cord injury
What does SCBF stand for?
Spinal Cord Blood Flow
What does MAP stand for?
Mean Arterial Pressure
What does SAH stand for?
Subarachoid Haemorrhage
What does BBB stand for?
Blood Brain Barrier
What does CSF stand for?
Cerebrospinal Fluid
What is a pressure injury?
A localised damage to the skin and underlying soft tissue thats usually, but not always, over a body prominence
What type of devices can pressure injurys be caused by?
External medical devices, these wounds are then referred to as medical device-related pressure injurys (MDRPIs)
Can mucous membranes (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?
Yes. Although the anatomy of mucous membrane sites isn’t consistent with pressure injury staging guidelines. For this reason, pressure injuries to mucous membranes can’t be staged using the pressure injury staging system.
What are two examples of where mucous membranes can (such as the nose, mouth, lungs, and stomach) sustain pressure injurys?
- From endotracheal tubes
- From nasogastric tube stabilisers
When does shear occur?
When layers of tissue move in opposite, parallel directions, resulting in stretching, occluding or the tearing of blood vessels and disruption of blood flow to the affected area.
Disrupted blood flow can lead to what?
Tissue ischemia and tissue death
How long can it take to notice a shear injury?
It can take several days for the tissue damage to ‘surface’ and show itself, typically by changes in colour, temperature, and texture
Pressure injurys are staged using what system?
The NPUAP staging system
Do we backstage pressure injurys? I.e saying that an S3PI is healing to an S2PI?
No, once a pressure injury is characterised i.e “S3PI”, it is always that, it can either be a healing S3PI or a non-healing S3PI. If a wound is worsening it can be restaged.
What does HAPIs stand for?
Hospital-acquired pressure injuries
What are the disadvantaged for a patient with a HAPIs?
Higher mortality rate, longer length of stay, and a higher chance of readmission + increased cost of care.
Determining the stage of a pressure injury comes down to what factors?
Presence of fluid in the wound
Colour of the area
Type of tissue exposed or directly palpable.
What are some things we can do as nurses to prevent a HAPI?
Turning and repositioning the patient frequently
Padding bony prominences (pillow between knees ect)
Keeping the elevation of the head at 30 degrees
Ensuring the surface the patient is on allows them to move side to side
Floating the heels off the mattress
Promoting PH-balances skin cleansers followed by moisturisers and protectants
Containing fecal and urinary incontinence to the best we can (pads)
Optimising patients nutritional status
Provide a pressure redistribution mattress and chair pad for those at high risk
Assess for tissue breakdown
Collaborate with the MDT to optimize care interventions.
What is the acronym to use when preventing pressure injuries and what does it stand for?
S - Surfaces and Devices
S - Skin inspection
K- Keep moving
I - Incontinence and moisture
N - Nutrition and hydration
Where on the body are pressure injuries most likely to occur?
Can happen anywhere but Heels, sacrum and ankles are more common
Describe key points to the acronym SSkin inspection to prevent pressure injuries
Carried out regularly (identify any discolouration, change in temperature, swelling and any pain or discomfort)
Pressure mapping can be used to identify the intensity of pressure
Too much bedding can cause pressure and make sure the chair they are using is the chair (sit with knees at a 90 degree angle)
Watch where the feet of tall people are, as the feet might be touching the end and cause pressure
What is the knee break technique?
When moving a client in bed, bring their knees up so there feet are braced on the bed before lifting the head of the bed, so their heels don’t slide along the sheets and cause friction and also help reduce pressure on the sacrum and heels.
Describe key points to the acronym Keep moving to prevent pressure injuries
Having a mobility plan in place helps ensure care is received to meet a person’s needs
The plan should include a repositioning schedule, or walking schedule, aides and people required
Shower and toilet chairs can lead to pressure damage
Describe key points to the acronym Incontinence and moisture to prevent pressure injuries
Incontinence products such as pads, ensure they are changed if full prior to position change as they increase the risk of pressure and skin damage
Someone who experiences incontinence is 40% more likely to sustain a pressure injury
Ensure incontinence products are the right size and shape for the person
Describe key points to the acronym Nutrition and hydration to prevent pressure injuries
Nutrition plays a major part in maintaining optimum skin health. Malnutrition screening and observing what, and the quantity of food and drink taken, and a regular weight check is vital for pressure injury prevention
Overweight people are also at risk. Research suggests in the over 65 age group, as many as 40% are malnourished
How many stages of pressure injuries are there?
4 stages
Stage 1
Stage 2
Stage 3
Stage 4
Characteristics of a stage 1 pressure injury?
Skin is intact with an area of nonblanchable erythema, Meaning when you press on the reddened area, it doesn’t turn white or become pale
Stage one doesn’t describe the layer of tissue that has been impacted, only that localised skin is intact, red and doesn’t blanch
Characteristics of a Stage 2 pressure injury
Partial skin loss with exposed dermis
A wound that is pink or red in colour, consisting of moist, viable tissue
Alternatively, stage 2 pressure injuries can present as an intact or ruptured fluid-filled blister
What stages do nurses confuse with deep tissue pressure injuries?
Stages 1 and 2
How can deep tissue injuries present?
Deep tissue pressure injuries can present as a blood-filled blister or they may have epidermal separation and a darkened wound bed. A deep tissue pressure injury can progress to an unstable wound. When this happens, the wound is recategorised as an unstageable pressure injury
What are deep tissue pressure injuries?
Localised areas that:
Have intact or non-intact skin
Don’t blanch
Are deep red, purple or maroon in colour
What are impairments?
A physical, sensory, neurological, psychiatric, intellectual, or other form that is something an individual has.
What is Disability?
The process which happens when one group of people create barriers by designing a world for only their way of living, taking no account of the impairments other people have
What is a health passport used for?
Its used by people with impairments that may be going from home/care facility to a hospital, its used to communicate the needs of that individual and allows the nurse to provide individualised care to that patient.
What do we need to ensure when working with a patient with an impairment?
Find out about their condition, take the time to find out how to meet their needs, and involve the person with the impairment in planning their care.
What are some examples of types of impairments?
Cerebral palsy, depression, and down syndrome.
what are some things that are important for the safe discharge home of a person with visual impairment?
- Asking the patient about any factors that might affect their ability to preform ADLs or post-hospital recommendations when they are back home. - Then asking this patient about their preferences for accomodating their needs.
- Observe the patient preforming manual tasks independently and without coaching before discharge
- Follow up with the patient shortly after their discharge to determine whether they are successfully preforming self-care activities and to identify any questions or problems.
Define what a long term condition is
- A condition than can be treated and managed, however NOT cured
- A condition that is ‘non-communicable disease’ meaning you can’t catch it
Name some long term conditions
- Autoimmune conditions like diabetes, rheumatoid arthritis
- Chrons disease - not autoimmune however does affect the immune system - inflammatory
bowel condition - Cardiovascular disease
- Cancers
- Respiratory disease
- Mental Illness
- Chronic Pain
- Chronic Kidney disease
- Dementia
- COPD (Chronic Obstructive Pulmonary Disease)
What is the difference between a Long Term Condition and an acute illness?
Therefore Long term conditions are conditions that cannot be cured, however can be managed. An acute illness if treated correctly can be cured. Patients with Long Term conditions can still be admitted to hospital with acute exacerbations of their long term condition. For example Chronic Obstructive Pulmonary Disease (COPD) - acute exacerbation (change in cough or sputum), or heart failure - acute exacerbation
What can empowering patient self-management of their long-term condition do for patients?
- Reduce disease progression - improve their quality of life (QOL)
- Increase the patients understanding of their ‘triggers’ - when they need to get medical help
and from where - Reduce readmission to hospital-reduce costs to health system
Why is it important to understand long term conditions?
- “Chronic illness is the leading cause of morbidity, mortality and inequitable health outcomes in NZ”
- “Reducing the impact of long term conditions is a priority of the NZ health system. Service funders and providers need to be more flexible, innovative and able to measure the difference they are making for their populations. This high-level approach is people/whānau focused, not disease specific.”
What is COPD?
Progressive, chronic disease characterised by irreversible airway obstruction, hindering expiratory flow
Umbrella term encompassing emphysema, chronic bronchitis and other conditions
Each has their own pathophysiology but all contribute to airway inflammation initiated by a noxious irritant
What is Emphysema?
Lung disease which makes it harder for clients to breathe out. The Alveoli are damaged making it harder for effective gas exchange to occur as the air sacs enlarge, Emphysema causes big baggy alveoli (increased volume) so pressure drops – this makes it hard for CO2 to be expelled
What are the 4 major causes/risk factors for COPD cited by WHO
- Tobacco smoking (Cigarettes, pipes, cannabis, second hand smoke)
- Indoor pollutants (Biomass fuel used for cooking and heating (wood and coal) most common in developing countries)
- Outdoor pollutants (Occupational dusts/chemicals, Particulate matter, ozone, sulpha dioxide, nitrogen dioxide, carbon monoxide, and lead (industrialised areas) forest bush fires, agricultural burning, transport
- Genetics, history of respiratory infections
What is Pursed lip Breathing?
It is a ventilatory strategy frequently adopted spontaneously for patients with COPD to relieve dyspnoea (difficultly breathing): it helps to counteract gas trapping. It generates an increased pressure in the airways to allow for expiration (airflow will move from an area of high to low pressure)
How does Pursed Lip Breathing help?
Pursed lip breathing works by moving oxygen into your lungs and carbon dioxide out of your lungs. This technique helps to keep airways open longer so that you can remove the air that is trapped in your lungs by slowing down your breathing rate and relieving shortness of breath
Emphysema causes big baggy alveoli (increased volume) so pressure drops – this makes it hard for CO2 to be expelled. Pursed lip breathing generates increased pressure so that intraluminal pressure exceeds atmospheric pressure and the breath can flow out of the lungs more easily. It is to aid expiration and decrease WOB (work of breathing).
What is Rheumatic Fever and why is it important to discuss?
Rheumatic fever may develop if strep throat or scarlet fever infections are not treated properly or after strep skin infections. Rheumatic fever is thought to be caused by a response of the body’s immune system. The immune system responds to the earlier strep throat or scarlet fever infection and causes a generalised inflammatory response. Strep throat is caused by the bacteria Group A Streptococcus.
If rheumatic fever is not treated promptly, rheumatic heart disease may occur. Rheumatic heart disease weakens the valves between the chambers of the heart. Severe rheumatic heart disease can require heart surgery and result in death.
Is Rheumatic Fever a long term condition?
Rheumatic fever is not a long term condition. Getting a precise diagnosis soon after symptoms show up can prevent the disease from causing permanent damage and can develop into rheumatic heart disease
- Rheumatic Heart Disease is a long term condition
What populations does rheumatic fever impact on more than others?
Although anyone can get Rheumatic fever, It is more common in school aged children (age 5-15), Māori and Pacific children. Rheumatic fever is very rare in children younger than 3 years old and adults. Infectious illnesses, including group A strep, tend to spread wherever large groups of people gather. Crowded conditions can increase the risk of getting strep throat or scarlet fever, and thus rheumatic fever if they are not treated properly. These settings include:
- Schools
- Day-care centres
- Military training facilities
Someone who had rheumatic fever in the past is more likely to get rheumatic fever again if they get strep throat or scarlet fever again
What are the three steps health professions can do for long term condition?
- Primary Prevention
- Reduce disease progression
- Empower patients/whānau
What happens during primary prevention?
Screening - like cardiovascular disease risk assessment, Smear, Well man check, Mammography, vaccinations. Importance of education for primary prevention
What happens during reduce disease progression?
If there are early warning signs of type 2 diabetes, then lifestyle changes can be put into place for example to reverse the high levels of HbA1c back to within normal
What are some important strategies to help support someone with a LTC?
Therapeutic relationship
Acknowledge their challenges, include family
Understand the patients ‘motivators’
Collaborative care approach, education and support.
Look at barriers for the patient
Use a interpersonal approach, use GP, notes, ect
Show compassion and empathy
Empower the patient
Provide patient with as much knowledge about the condition as possible (education)
Support strategies that work for them
What is important steps of discharge planning for a patient with acute exacerbation of LTC?
If patient is admitted with an acute exacerbation of their LTC, the following is important:-
Discharge planning starts as soon as possible following admission
All the correct services are alerted to the admission and kept updated of possible discharge date- INTERPROFESSIONAL COLLABORATION
Community services are restarted on patient discharge.
What does GCS stand for?
Glasgow Coma Scale
What does AEIOU TIPSS stand for? and what is its purpose?
A: Alcohol
E: Epilepsy
I: Insulin
O: Opium
U: Uraemia
T: Tumour
I: Injury
P: Psychiatric
S: Sepsis
S: Stroke
These are some common causes of altered consciousness
What are 7 common causes of falls?
Delirium, cardiac/neurological/muscular-skeletal condition, side-effects from medications, balance/strength/mobility, poor eyesight, poor memory, and incontinence/urinary urgency.
What are the two components that we can divide consciousness into?
Alertness/wakefulness: the appearance of wakefulness
Alertness/cognition: content of cognitive mental functions.
What is the first stimuli assessment we do in the GCS?
Eye opening
Does eye opening mean the patient is aware of their surroundings?
NO
How do we do the first 3 steps of an ‘eye opening’ assessment in the GCS?
Observe the patient before speaking to them. (If their eyes are open, or they open as you approach score a 4 - spontaneous)
Next, talk to the patient with a normal voice, say their name or ask them to open their eyes. (If they open their eyes - score a 3 for speech)
If this fails speak louder or shout. Not touching the pt. (If the patient opens their eyes score a 3 - to speech)
What are the steps after (to speech) that we preform for an “eye opening” assessment?
Next, touch or shake the patient (if the patient opens their eyes score 2 - to pain)
If this fails, use noxious stimuli.
Explain to the patient and family what you are going to do and why, apply a peripheral painful stimulus (applying pressure with barrel of pen to the lateral outer aspect of the second or third interpharangeal joint, gradual pressure 10-15 secs) If the patient opens their eyes score 2 - pain.
If this fails and the patient has still not opened their eyes score 1 - none.
Note: if the patients eyes are closed due to facial injurys or swelling document “C” and a score cannot be assigned for this category.
Verbal responses depend on what in the brain?
Wernickes speech centre which in in the temporal lobe and on broca’s speech centre in the frontal lobe.
What are the steps involved for a “Best verbal response” assessment?
First ask the patient the following questions: ‘Who are you’, ‘Where are you’, and ‘Why are you here’ + ‘What is the current month’ and ‘What is the current season’. - don’t use closed questions. If the patient answers all of these correctly, score 5 - orientated.
If the patient answers one or more of the above questions wrongly but is able to talk in sentences, score 4 - confused. (Orientation to time is often lost first)
If the patient tries to respond to the questions but is unable to talk in full sentences and uses random words or repeats the same phrase or work, score 3
If you hear no intelligible words - score 2. If the patient doesn’t produce any sounds - score 1.
Note: if the patient is unable to respond verbally due to an endotracheal tube, document ‘T’
What are the steps involved for a “Best motor response” assessment? (1-6)
1st. Ask the patient to obey at least two simple commands
Examples: Lift your arms up, hold up your thumb, stick out your tongue. If the patient follows the command, score 6 - obeys commands
If this fails move on. Observe the patient, are they trying to pull their O2 supply ect moving their hand above chin level. This would be ‘localising to pain’ - score a 5.
If both of these are not present we move to applying a painful stimulus. Firstly explain to the patient what you are going to do and why. Apply supra-orbital pressure gradually for 30 seconds, then try the trapezius squeeze for up to 30 seconds.
If the patient try’s to locate the stimulus in an attempt to remove the source of pain, score 5 - localises to pain (note: the patient must bring arm above chin level and across bodys midline). If the patient flexes their arm towards the source of pain but fails to localise or remove it, score 4 - withdrawal from pain/normal flexion. If the patient flexes the arm at the elbow and rotates wrist in response to pain, score 3 - abnormal flexion. If the patient straightens the arm at elbow and rotates it inwards with legs extending and the feet plantar-flexed, score 2 - extension.
If no movement is observed, score 1 - none.
What are some recommendations for clinical practice? GCS
- Listen to the patients family’s concerns
- When communicating a GCS score, state each component of score not just total
- Ensure the same staff member carries out all observations during shift
- at shift handover, observations should be done together with nurse leaving and nurse arriving
- Ask for second opinion when in doubt
- Mark dots not lines on chart
- A drop of one point in motor response is of clinical significance and must be reported to the medical team immediately
- During the night shift, do not assume the patient is asleep and omit assessment
- Clarify with the team the freq of the GCS obs and how long these should be continued for.
How do you do supra-orbital pressure? Are what are the considerations with this type of painful stimulus?
Apply pressure above the eye gradually for a maximum of 30 seconds.
This targets the trigeminal nerve (cranial nerve V), and is contraindicated by orbital damage, skull fracture and glaucoma. This method is also risky for patients with reduced awareness due to potential sudden movement that may cause injury to their eyes.
How do you do the trapezius squeese? Are what are the considerations with this type of painful stimulus?
Apply pressure by grasping approximately 3cm of the muscle between the thumb and forefingers and twisting for up to 30seconds.
This targets the spinal accessory nerve and is documented as the most suitable method. Especially in the presence of orbital damage, skull fracture or glaucoma. Although this method could be difficult on a large or obese patient.
Why are sternal rubs and nail-bed pressures no longer used?
These methods cause prolonged discomfort and damage
Failure to assess the level of consciousness accurately and take appropriate action in a timely manner could lead to what?
Irreversible and devastating consequences
Oxygen (02): monitoring
Sp02, RR, Pa02 (ABG), colour
Oxygen (02): patient education
should include correct administration and use of oxygen delivery devices
Oxygen (02): Adverse effects
toxicity with prolonged exposure to high 02 concentrations; decreased affinity of Hb for C02 in C02 retainers (haldane effect)
Oxygen (02): precautions
oxygen therapy devices should not be used near an open flame due to its high combustibility
Oxygen (02): Pharmacodynamics
oxygen therapy improves effective cellular oxygenation. it acts to restore normal cellular activity at the mitochondrial level and reduce metabolic acidosis
Oxygen (02): pharmacokinetics
oxygen is largely inhaled into the alveoli and diffused into the capillary bed. oxygen combines with haemoglobin, with a small amount being dissolved in the plasma. oxygen is metabolised in the tissues almost entirely in the mitochondria, where oxidase enzymes reduce the oxygen in the formation of adenosine triphosphate (ATP).
excretion of oxygen metabolites (C02 and H20) is via the lung renal system
Oxygen (02): reason
treatment of hypoxaemia by increasing alveolar oxygen tension. The aim is achieve a normal or near normal oxygen saturation for an individual patient
Salbutamol (short acting B2 adrenergic agonist (SABA): reason
bronchodilator - relief of symptoms during maintenance treatment of asthma and COPD; prevention of treatment of exercise/allergen induced bronchospasm
Salbutamol (short acting B2 adrenergic agonist (SABA): monitoring
peak flow measurements before and after administration can help determine effectiveness
Salbutamol (short acting B2 adrenergic agonist (SABA): patient education
what common side effects to expect
appropriate delivery of inhaler (including spacer, mouth care)
asthma and COPD action plan
Salbutamol (short acting B2 adrenergic agonist (SABA): adverse effects
tachycardia, headache, nervous tension, fine hand tremor, hypotension
hyper/hypokalemia (which may cause weakness, fatigue, tremors, muscle spasm)
Salbutamol (short acting B2 adrenergic agonist (SABA): contradictions
caution with CVD, diabetes and HTN
inhaler may contain lactose
Salbutamol (short acting B2 adrenergic agonist (SABA): pharmacodynamics
salbutamol is a B2- adrenergic agonist and stimulates B2 adrenergic receptors. binding to these receptors in the lungs results in relaxation of bronchial smooth muscles
Salbutamol (short acting B2 adrenergic agonist (SABA): pharmacokinetics
onset by inhalation is rapid (5-15 min) peak effect reached in 1-2 hours
metabolised in liver and excreted in kidneys
GTN (Glyceryl Trinitrate Antianginal): Indications for use
Chest Pain/Angina
GTN (Glyceryl Trinitrate Antianginal): Monitoring Requirements
BP and HR
GTN (Glyceryl Trinitrate Antianginal): Patient Education
Sit down, Stand up slowly
GTN (Glyceryl Trinitrate Antianginal): Side Effects
Flushing, Headache, Dizziness, Dry mouth (rare)
GTN (Glyceryl Trinitrate Antianginal): Contra-indications
VIAGRA, ETOH (ethanol), HR <50
GTN (Glyceryl Trinitrate Antianginal): Pharmacodynamics
Antagonises NO receptors = relaxes smooth muscle. Dilates veins and arteries. Reduces BP
GTN (Glyceryl Trinitrate Antianginal): Pharmacokinetics
Sublingual, dermal, rapidly metabolised short duration
Morphine Sulfate: ADDITIONAL NAMES INCLUDE:
Morphine Sulfate (IV), Oxynorm, Sevredol, MS Contin
MORPHINE SULFATE: Indications for use
Analgesia/sedation
MORPHINE SULFATE: Monitoring Requirements
RR, BP, HR
MORPHINE SULFATE: Patient education
Careful mobilising. Avoid ethanol and other opiates
MORPHINE SULFATE: Side Effects
Sedation, Dizziness, Nausea, constipation, hallucinations
MORPHINE SULFATE: Contra-Indications
Respiration rate, depression, severe asthma, acute abdomen pain, traumatic brain injury (TBI)
MORPHINE SULFATE: Pharmacodynamics
Opioid mu-receptor antagonist. Targets CNS opiate receptors. Depresses CNS, RR, GI. Vasodilation
MORPHINE SULFATE: Pharmacokinetics
Oral, IM, IV, Per rectum. Short half life
Define Hypoxia
- Less than normal levels of 02 in the body tissues
Define Hypoxemia
less than normal levels of 02 in the blood
Pa02 <80mmHg (<60mmHg significant hypoxaemia)
Define Hypercapnia
- Greater than normal levels of C02
- PaC02 > 45mmHg
Define Hypocapnia
- Less than normal levels of C02
- PaC02 < 35mmHg
What is the normal range of PaC02?
35-45mmHg
What is the normal range of Pa02 levels?
75-100mmHg
What is the normal range of Arterial Oxygen?
75-100mmHg
What are 12 signs and symptoms of hypoxaemia?
- Changes in the colour of your skin
- Confusion
- Restlessness
- Anxiety
- Increased heart rate
- Increased respiration rate
- Shortness of breath
- Sweating
- Wheezing
- Use of Accessory muscles
- Flaring of nostrils or pursed lips
- Decreased oxygen saturation levels
What are 8 clinical manifestations that a person would experience with COPD?
- Frequent chest infections
- Persistent wheezing
- Persistent chesty cough which can be dry or with sputum
- Difficulty breathing
- Dyspnea
- Decreased energy levels
- Tightness of the chest
- Swelling in the lower extermities
What is efficient gas exchange dependent on?
Adequate Ventilation and Perfusion
What is shunting?
When blood flow can be redirected from poorly ventilate alveolus (one air sac) to a well-ventilated alveolus through vasoconstriction
What is a dead space?
Poor perfusion and a well ventilated alveolus
What is a silent unit?
Poor ventilation AND Poor perfusion (no air moving through the lungs)
What are the two areas of Gas Exchange Insufficiency?
Mechanical
Functional
What are the three areas of Mechanical Insufficiency of gas exchange?
- Structural damage
- Airway obstruction
- Medication
Describe how structural damage impacts on gas exchange
- Nervous system (spinal injury high up, anything that impacts the nerve pathways)
- Intercostal Muscles
- Diaphragm (injury which impacts taking a deep breath to expel CO2 effectively, or on
inspiration with the intake of O2) - Abdominal muscles (Pushing diaphragm out to push the air out)
Describe airway obstruction for gas exchange
- Physiological and foreign objects (asthma, mucous)
Describe how medication can impact on gas exchange
CNS Depressants (Alcohol, benzodiazepines, sedatives. Anything which effects the
respiration rate)
What functional factors can impact on gas exchange?
- Cardiac Compromise (Poor venous return)
- Pulmonary Embolism (Block off blood vessels and lungs - ventilated but not perfused)
- Tumour (blockage which effects perfusion)
- Hb (Haemoglobin) (Not enough Haemogolbin = not enough red blood cells to carry
enough oxygen as Haemogolbin has 4 oxygen particles) - Infection (pus, anything in the lungs which block the perfusion in the lungs)
- COPD
- Compliance (the ability for the lungs to inflate and recoil)
- Resistance
- Surface area (hold the alveolus open, if you lose this, the alveoli might collapse more
easily as the surface area will be reduced - smoking)
What are 4 problems with ventilation (air in/out)?
- Inflammation of Bronchial walls causing epithelial oedema = decrease air entry, decrease gas exchange
- Exudate in lower airways causing obstruction to air flow = decrease air entry, decrease gas exchange
- Exudate in alveoli causing increased diffusion distance = decrease gas exchange
- Inflammation in alveolar wall causing increased diffusion distance = decreased gas exchange
What are 2 problems with perfusion (blood to lungs and body)?
- Partial or complete obstruction to pulmonary artery (could be a clot and partially close off the artery) causing reduced blood flow = decreased gas exchange
- Ineffective functioning alveoli (from exudate or oedema) causing vasoconstriction of surrounding pulmonary capillaries = further decrease gas exchange
What clinical presentations are we observing with the respiratory rate?
- Tachypnoea/bradypnoea (fast and slow breathing)
- Orthopnoea (have trouble breathing lying down, but can breathe normally when sitting up
heart not pumping efficiently) - Dyspnoea (subjective feeling of breathing, reporting they are struggling to breath)
- Rhythm and depth (are they breathing in a normal rhythm? Gasping? Breathing shallow?)
What clinical presentations are we observing with breath sounds?
- Wheeze
- Crackles
- Stridor (usually on inspiration, sounds like a barking type sound. Inflammation or
obstruction of the airway) - Reduced Air entry
- Cough
What accessory muscles are we observing for within the clinical presentation?
- Sternocleidomastoid
- Scalenes
- Trapezius
- Pectoralis minor/major
- Abdominals (on expiration)
What clinical presentation are we observing for the patient’s positioning?
- Upright
- Tripod (leaning forward, supporting upper body with hands on knees/similar)
- Chest symmetry
What are body tissues?
a group of cells that have similar structure and that function together as a unit.
Which usually comes first? Hypoxia or Hypoxaemia?
Hypoxaemia.
We can assess and use interventions to prevent this from going to hypoxia hence preventing cell death
What is a common cause of Hypocapnia?
Hyperventillation.
Taking in too much O2, and not being able to balance this with CO2
What is the cause of Hypoxia?
Often caused secondary to Hypoxaemia.
Which is caused by any condition that reduces the amount of oxygen in your blood or restricts blood flow can cause hypoxia. People living with heart or lung diseases such as COPD, emphysema or asthma, are at an increased risk for hypoxia
What are the medical causes of Hypoxaemia?
ventilation-perfusion (V/Q) mismatch, diffusion impairment, hypoventilation, low environmental oxygen and right-to-left shunting.
What is Ventilation/perfusion mismatch?
Ventilation-perfusion mismatch is mismatched distribution of ventilation (airflow) and perfusion (blood flow)
When does ventilation/perfusion mis match occur?
Ventilation-perfusion (V/Q) mismatch occurs when either the ventilation (airflow) or perfusion (blood flow) in the lungs is impaired, preventing the lungs from optimally delivering oxygen to the blood
What does VQ ratio stand for?
ventilation/perfusion ratio
What is vasoconstriction?
Vasoconstriction is the narrowing (constriction) of blood vessels by small muscles in their walls. When blood vessels constrict, blood flow is slowed or blocked
What is an alveolus?
a small air-containing compartment of the lungs in which the bronchioles terminate and from which respiratory gases are exchanged with the pulmonary capillaries.
What are bronchioles?
A tiny branch of air tubes in the lungs
WOB: 5 signs of respiratory distress
DiapHRaGM
- Diaphoresis (excessive sweating) different to normal sweating, clammy al over dripping in sweat and they feel cold. increased metabolic effort. hypocapnia
- Hypoxia (less than normal level of 02 in the cells
- Respiratory rate
- Gasping associated with running out of breath, RR starts to drop and they start gasping, rhythm changes too)
- Accessory muscle
Need to intervene quickly or they can go into respiratory arrest
what we can measure: RR, depth and pattern
can be measured but a degree of subjectivity depending on how it is calculated
what we can measure: Work of breathing
- accessory muscle use
nasal flaring/ pursed lip breathing - speaking long/short sentences, single words only, not speaking
- intercostal indrawing
what we can measure: peak flow measurement
- measurement of maximal forced exhaled air flow (L/min)
- baseline and to measure effectiveness of interventions
- useful for people with asthma
- used to keep an eye on maximal force
what we can measure: specialist tests
- CXR (chest X-ray)
- spirometry
- CT/MRI
- ABG (arterial blood gas)
Airway assessments
patency is it open and is it fully open, partial obstruction?
- is the airway patent
- partial obstruction- snoring, stridor, you can hear something
- complete obstruction- silence, no extra sounds
- under threat?
- what your assessing for, patency, expecting to find the airway patent, or patent and concern that it is under threat.
possible cause of obstruction
- tongue
- vomit
- epiglottis
- uvulitis
- secretions
- inflammation
- neurological impairment
- foreign body
What is the rationale for “Sitting’ the patient up to increase lung expansion”
In doing this we are increasing ventilation hence increasing gas exchange in the lungs.
What are the 7 things that we can clinically observe when thinking about a patient with a respiratory issue?
Respiratory rate
Breath sounds
Accessory muscles
Positioning
Neurological changes
Skin
Sputum
What are we observing in terms of the Respiratory rate when we are assessing a patient?
Tachypnoea/bradypnoea
Orthopnoea
Dyspnoea
and
Rhythm & Depth
What is Tachypnoea?
abnormally rapid breathing.
What is bradypnoea?
abnormally slow breathing.
What is orthopnoea?
Orthopnea is the sensation of breathlessness that affects a person when they are lying down and subsides in other positions, such as standing or sitting up.
What is Dyspnoea?
difficult or laboured breathing that is self reported by the patient
If we notice cyanosis what is an important factor to assess?
Cyanosis is the blue tinging of the skin so assess capillary refill of peripherals.
What is a peak flow measurement test?
Peak flow is a simple measurement of how quickly you can blow air out of your lungs. Normal adult peak flow scores range between around 400 and 700 litres per minute
What can we use a peak flow measurement for?
as a baseline and to measure the effectiveness of interventions (useful for diagnosing asthma)
What are clinical presentations of neurological changes?
Anxiety
Agitation
Confusion
Drowsiness
Pain
What are clinical presentations of Skin?
Diaphoresis
Pallor
Cyanosis
Flushing
What are clinical presentations of Sputum?
Colour
Odour
Haemoptysis
Airway interventions:
Positioning:
- maintaining head and neck alignment (chin tilt/jaw thrust)
- Consider elevating head of bed/side positioning in OSA
- Recovery position
Clear secretions:
- Encourage airway clearance with coughing
- Consider suctioning (Yankeur/suction catheter)
- Promote hydration to thin secretions for expectoration
Breathing assessments:
General appearance:
Work of breathing
Rate, depth and pattern
Accessory muscle use
Nasal flaring/pursed lips
Cough
Colour
Skin moisture
Positioning:
Supine/erect
Tripod
Pillows to support
Level of activity:
What is your patient doing?
Chest:
AP measurement
Symmetry
Paradox
Drains?
Supplemental oxygen use:
Nasal cannula
Airvo (humidified O2)
CPAP/BiPAP machine
Posterior chest auscultation:
Air entry
Quality of breath sounds
Wheeze
Crackles
Adventitious sounds
Percussion:
Resonance
Hyper resonance
Dullness
Breathing interventions:
Positioning:
Sit the patient upright
Support with pillows if required
Mobilise as able
Regular turns/repositioning
Cough techniques:
Huff coughing
Incentive spirometry
Deep breathing
Administer prescribed medications:
Bronchodilators (inhalers with spacer
Oxygen
Physiotherapy referral:
Education
Loosen secretions
Secretions:
Promote hydration to thin secretions
Consider humidification of O2
Anxiety reduction:
Education and reassurance to reduce respiratory effort and SNS response
Circulation assessments:
General appearance:
Skin colour
-Flushed
-Cyanotic
Temperature
-Raised (core)
-Peripherally cool
Capillary refill time
Diaphoresis
Heart rate:
Tachycardia/bradycardia
Rhythm (regular/irregular)
Quality (weak/bounding)
Blood pressure:
Hypertension
Normotension
Hypotension
Renal function:
Urine output
eGFR
Fluid balance
Circulation interventions:
Hydration:
Oral
Intravenous fluid as prescribed
Administer prescribed medication:
Consider DVT prophylaxis
Mobilising:
Foot pedalling
Frequent mobilisation as able
Regular repositioning
Disability assessments:
Level of consciousness:
AVPU
Orientated to time, person & place?
Restlessness/agitation (hypoxaemia)
Anxiety:
Breathlessness
Fear of dying
Dyspnoea
Increased work of breathing
Mood
SNS response
Pain:
COLDSPA
Pleuritic pain will contribute to alveolar hypoventilation (decreasing gas exchange)
Opioid analgesia causing ↓ RR and LOC
Disability interventions:
Pain management:
Select appropriate analgesia
Administer analgesia as prescribed
Anxiety reduction to reduce SNS response:
Patient education
Communication of plan
Involve family/whānau
Not “reassure patient” – what does this mean?!
Environment assessment:
Patient risk assessment:
Falls
Braden
Smoking
Past medical/surgical history:
Previous respiratory issues (COLDSPA)
Medications
Drug reactions
Allergies
Early Warning Score:
Trends
Action required?
Other assessments:
Occupation (hazards)
Living situation
Family/whānau supports
Self-management of health issues
Alcohol and drug use
Cultural needs
Spiritual needs
Define Heart Failure
An acute or chronic condition in which the heart doesn’t pump blood as well as it should resulting in congestion (CHF) of blood backing up and unable to meet the demands of the body
- The heart’s inability to consistently pump enough blood to organs and tissues
- Cardiac output is insufficient to meet the metabolic demands of the body and accommodate venous return
- Occurs from either a structural or functional abnormality of the heart
- The resulting decreased blood supply to body impairs organs and tissue function
- The dominant feature is inadequate tissue perfusion
What is a structural abnormality of the heart?
Valve problem/dysfunction, ventricle thickness, rigidity
What is a Functional abnormality of the heart?
Following a MI, cardiomyopathy, CAD (coronary artery disease)
Define Cardiac Output (CO)
Stroke Volume x Heart Rate (3.5-5L/min)
Define Stroke Volume (SV)
Amount of blood pumped out per heartbeat
Define Preload
(Volume) amount of ventricular stretch at the end of diastole. The greater the stretch the stronger the contraction (Starling’s Law)
Define Afterload
(Pressure) resistance to the ejection of blood from the ventricle
Define Ejection Fraction, what the normal is and how it is measured
- The ejection fraction (EF) is the amount of blood that is pumped out of the left ventricle (LV) with each heartbeat
- A decreased EF = decreased amount of blood being pumped out = decreased perfusion
- It is measured in percentages
- Normal range is 55-70%
- An EF of 40% or less indicates HF
- Calculated from an echocardiogram
What is Systolic Heart Failure?
- Shortened to HFrEF which stands for Heart Failure reduced Ejection Fraction
- Pumping problem of the heart
- Inability of the Left ventricle to contract effectively
( Ventricles can’t pump hard enough during systole )
What is diastolic heart failure?
- Shortened to HFpEF which stands for Heart failure Preserved ejection fraction
- It is a relaxing problem
- Inability of the Left ventricle to relax and fill effectively
( Not enough blood fills into ventricles during diastole )
Define systole and diastolic
Systole = The ventricles eject blood (pump)
Diastolic = The ventricles fill with blood (relax)
What is Right-Sided Heart Failure?
- The right ventricle cannot eject sufficient amounts of blood - blood backs up in the venous system and may result in:
- Peripheral Oedema
- Weight gain but anorexia/nausea may be present
- Hepatomegaly/Splenomegaly
- Liver is the last place to send blood back to the heart
- Ascites
- Jugular vein distention
- The blood can back up to the rest of the body via the right atrium and manifest as oedema, legs/ankles/feet, sacrum/penis (dependent areas) around the eyes, organ oedema
(Could experience Anorexia, GI distress, Weight loss, signs related to liver function impairments)
What is Left-Sided Heart Failure?
- The left ventricle cannot pump blood effectively to the systemic circulation. The blood backs up in the pulmonary system so the pulmonary venous pressure increases in:
- Decrease EF
- Pulmonary congestion/oedema with dyspnoea
- Cough
- Crackles
- Impaired oxygen exchange
- LHF is the most common form (from left ventricular dysfunction). Blood cannot get out and around the body, so it backs up in the lungs via the left atrium and pulmonary vein
- It causes pulmonary congestion and oedema in the lungs
(cough with frothy sputum, Cyanosis and signs of hypoxia, orthopnea)
What is the patho for Heart Failure?
- MI or cardiac dysfunction/structural abnormality impairs ability of L) ventricle to fill with or eject blood
- Poor ventricular function/myocardial damage leads to decreased stroke volume and cardiac output
- Leads to a neurohormonal response
- Either sympathetic system is activated to increase cardiac workload, or RAAS pathway is activated
- Results in vasoconstriction and sodium + fluid retention
- Further stress on the ventricular wall and remodelling leads to heart failure
What are some signs and symptoms of heart failure?
Pale, grey, SOBOE, orthopnea (unable to lie flat and breathe), nocturia (increased urination overnight due to lying flat and kidneys being well perfused), oedema, confusion, tachycardia, hypotensive, dry cough, dyspnoea, weak pulse, tachypnoea, fatigue, anxiety, ECG abnormalities, palpitations, restlessness, hypoxaemia, moist cough, diaphoresis, cyanosis, dizzy, light-headed, nausea, weight-gain, SOB, crackles on auscultation, ascites, exercise intolerance
What are some risk factors/aetiology for Heart Failure?
- Ischaemia - Myocardial infarction (elevated Troponin)
- Valve disease
- Cardiomyopathy
- Pericarditis
- Fluid overload (renal failure, Intravenous fluid (IVF))
- Hypertension
- Smoking
- Type 2 Diabetes
What is an echocardiogram?
a test of the action of the heart using ultrasound waves to produce a visual display, for the diagnosis or monitoring of heart disease.
What is an LVEF?
Left ventricular ejection fraction (LVEF)
Ejection fraction typically refers to the left side of the heart. It shows how much oxygen-rich blood is pumped out of the left ventricle to most of the body’s organs with each contraction.
