Critical Care Nursing Flashcards
What should a primary survey include?
- immediate assessment of stability
- identifying any life-threatening conditions (if there are, start resuscitation & stabilisation)
- check: Airway patent, Breathing (adequate oxygenation?), Circulation (tissue perfusion)
- Also check the level of consciousness and mentation using the Small Animal Coma Score
What can be done to maintain airway?
Intubation
Change positioning of patient
Remove any obstructions or by-pass
What can be done to check if the patient is breathing?
- Look for condensation, chest movements, movement of cotton held in front of nose
- Check MM colour
- SPO2
How can we check the circulation of a patient? What can we do to rectify it?
- CRT, BP, HR..etc
- Rapid infusion of fluids/oxyglobin (using pressure infuser)
- Compressions if no HR
- Stopping any bleeding or loss of fluids!
What should be done in a secondary survey?
Patient is stable at this point:
- Evaluate major body systems: respiratory, cardiovascular, neurological, renal (in that order!)
What is the main difference in a care plan for a critical patient compared to a standard patient??
Much shorter time frames for goals e.g. 5-10 minutes for breathing goals
How can we maintain CV function from a nursing point of view?
- Restore blood volume
- utilise central line, check dosage, check venous access, flush with hep saline every 4 hours.
- evaluate hydration status
- control any haemorrhage - Maintain body temperature
- care with vasodilation - Ensure timely administration of medications
- Walking/physio every 4 hours to maintain circulation and reduce risk of embolus
What nursing care is needed for a patient with a tracheostomy?
If fitted, need to remove inner tube Q2h to clean, nebulisation, suction to remove any mucus build up that will cause obstruction
What care is needed for a patient on a ventilator?
- monitor respiratory effort, body temperature, listen to chest… etc
- deflate and move cuff every 4hours to relieve tracheal pressure
- clean mouth with antiseptic solution every 4 hours (prone to oral ulceration due to lack of saliva)
- ventilation tubing replaced every 24 hours to avoid bacteria build up
What can be done for a respiratory critical patient in terms of positioning?
- Alter body positioning every 2-4 hours, monitor to see if new position causes any respiratory distress
- Postural drainage (used for pneumonia or pleural fluid), various positions depending on lung area needing drained - use wedges! Care with dyspnoea in dorsal.
What nursing care is needed for a patient with a chest drain?
- aspirate fluid every 2-4 hours
- use an aseptic technique
- inspect and clean stoma site twice daily
What patients is coupage contraindicated in?
- chest tubes
- rib fracture
- open chest wounds
- chest pain
- thrombocytopenia
- arrhythmias
What can be done to nurse a patient with head trauma?
Elevate the head to 30 degree angle to encourage drainage from the head and not worsening intra-cranial pressure
What could make intra-cranial pressure worse?
Occluding any jugular veins etc that help drain the head
What should you do for a patient that is suspected to have a spinal trauma
Use pad and wedges to keep spine parallel and secure to a spinal board
