critical care Flashcards
CPR
unconscious, check carotid/neck pulse, chest compressions, open airway using chin lift, give breaths
airway obstruction
stand behind pt, place arms around waist, make fist, thumb side of fist above belly-button, 5 in and up thrusts
- IF pregnant/obese, chest thrusts
- IF infant, place over arm with head lower than rest of body, 5 back slaps with heel of hand in between shoulder blades, turn infant over and 5 chest thrusts
- ONLY remove object if visible
inflated cuff trach
for pts at risk of aspiration (e.g. unconscious, mechanically ventilated), not used for conscious patients because uncomfortable
nursing trach care
semi-Fowler’s for pt, wear PPE (e.g. mask, goggles, clean gloves), remove soiled dressing, sterile gloves, remove old canula, put new one, clean around stoma with sterile water, dry, replace with sterile gauze
nursing impaled object
stabilize object, NEVER remove
deflated cuff trach
used for pts not at risk of aspiration
SIRS/systemic inflammatory response syndrome
inflammatory response (e.g. high HR, high RR, fever)
sepsis
SIRS + infection source (e.g. UTI, pneumonia)
septic shock
sepsis + hypotensive DESPITE adequate IV fluid resuscitation
MODS/multiple organ dysfunction syndrome
septic shock + multiple organ damage (e.g. low platelets, AKI, ARDS/acute respiratory distress syndrome
nursing triage: red
life threatening injury that pt may survive if treated within next hour
nursing triage: yellow
pt can wait 1-2 hours without loss of life/parts of body
nursing triage: black
unlikely to survive
nursing triage: green
“walking wounded”
ex. of yellow situations that nurses should triage
abdominal wounds without hemmorhage, fracture requiring open reduction/pieces of a broken bone put back into place using surgery, debridement, external fixation/rods are screwed into bone and attached to a stabilizing structure on the outside of the body, eye injury, CNS injury
