exam Flashcards
the difference between critical care patients
Higher degree of illness
Greater dependance on nursing care
Potentially recoverable condition
Compromised airway
Head injuries
Polytrauma
Post major high risk surgery
Organ failure
Drug substance overdose
Mean age is 64 years
59% male
Higher mortality rate in ICU
Hemodynamically unstable
what is the nurses role in the CC setting
patient adovcate
routine assessment
Other essential nursing care
FBC monitoring
Wound pressure area care
Analgesia
Bowels
Operate maintain life support
Life saving medication delverly
BLS and ALS
Liaison between patient, family and other healthcare professionals
Evaluate interventions and treatment
Escalate care if patient is deteriorating
examples of verbal communication
Handover
Dialogue - patient family medical staff allied health
Feedback other staff
examples of non verbal communication
Body language
Gestures
Facial expressions
Touch
examples of written communication
Legal patient notes
Checklist charts
Research
Document everything
types of roles in team allocation
Resus nurse
Team leader
Scribe
what to inspect someones airway
Observer overall appearance alert oriented active drowsy etc
Colour
Respiratory rate rhythm and depth (shallow, normal or deep)
Respiratory effort work of breathing
Use of accessory muscles
Symmetry and shape of chest
Tracheal position tracheal tug
Audible sounds: vocalization wheeze stridor grunt cough paroxysmal
Monitor oxygen saturation
respiratory auscultation
Listen for absence/equality for breath sounds
Wheezes crackles
respiratory palpation
Bilateral symmetry of chest expansion
Skin condition
Cap refill
Fremitus
Subcutaneous emphysema : AIR trapped under the skin common in cardiac or pulmonary patients, sounds like bubble wrap
What is an airway obstruction
What is an airway obstruction
Blockage in the airway may partially or totally prevent air from getting into lungs
Types
Upper
Lower
Partial
Complete
Acute
Chronic
Causes
Frogien body
Coins
Toys
infection
Epiglottis
Retropharyngeal abscess
Bacterial tracheitis
Laryngotracheitis
Diphtheria
Tetanus
Lock jaw
Tongue obstruction: most common in unconscious patients
Immune angioedema
Anaphylaxis
Tumor
Trauma - neck hematoma
Poison and toxic exposure
Laryngospasm
Drug induced
Assessment of airway
vocalisation : can the patient talk
Tongue obstruction
Loose teeth of foregin objects
Bleeding
Vomitus
Secretions
Oedema
how to establish an airway
The first method for maintaining a patent airway is correct head position
Head tilt/ chin lift
Remove any foreign objects
Suction
Insert an airway
Endotracheal intubation
Needle or surgical airway
when and why do people need airway management
Apnea
Obstruction
Tongue epiglottis soft palate
Foreign body vomit food
Laryngeal swelling spasm
Gsc
Unstable midface trauma
Airway injuries
Respiratory failure
High aspiration risk
Inability to maintain airway or oxygenation
Oropharyngeal nasopharyngeal airways
Designed to overcome soft palate obstruction
Backward tongue displacement in an unconscious patient
Head tilt and jaw thrist may also be required
guedel
Laryngeal mask airway
Limitations
Great for short cases surgery and resus
However risk of leak with high airway pressure or poor lung compliance
Theoretical risk of aspiration of stomach contents
LMA insertion can cause coughing straining and laryngeal spasm
Uncommonly airway obstruction caused by epiglottis folding down
Short term device
Does not protect against aspiration
Unlikely to be seen intensive care
nurses role in intubation
Being familiar with intubation procedure
Being familiar and aware of equipment needed
Preparing the equipment is functioning
Ensure patient is monitored
And know post intubation care of the patient
what is cricoid pressure
pressing on pressure point for uncocnous patients
In situations where the patient has a know full stomach or if fasting times are unknown
Pressing on the cricoid
what would cause intubation complications
Facial burns and trauma
Upper airway pathology
Insecure loose teeth
Gastric reguaration
Clenching of teeth
Esophageal intubation
Possible cervical spine injury
what are post intubutation complications
Trauma to the lips teeth vocal cords
Transient arrhythmia related to vagal or sympathetic nerve
Aspiration
Infection
Reduced cough reflex
Tracheal ulceration
Tracheal stenosis \laryngeal oedema
Biting on the ETT tube
Discomfort
Bronchospasm
nursing responsibilities in intubation
Tube security tube marking
Cuff pressure
Co2 monitoring ventilation
Suctioning
Positioning
Pain relief and sedation
Gastric tube insertion
Oral hygiene
Humidification
What is a tracheostomy
Open pt airway small incision
Pressure injuries can occur
For prolonged ventilation
Head injuries
Respiratory distress syndrome
Sepsis
Neurological disease
Upper airway obstruction
advantages to a tracheotosmy
Minise WOB
Changed without sedation
Comfort
Secured effectively
Improved access to oral cavity
Patient communication
complications that can occur in trachostomy
Tube obstruction
Chest infection
Loss airway if dislodged
how to take care of a patient with a trachostomy
Security of the tube : tapes and padding
Inner cannula changes
Adequate humidification
Adequate suctioning
Stoma care
Facilitating communication
NIL by mouth
Ensure
Secure
Patency
Suctioning
Humidity
Regular airway and breathing assessments
chain of sruvival in advanced cardiac life support
early recognition and call
early cpr
early advanced care
basic life support DRSABCD
danger
responsive
send for help
open airway
normathing brething
start cpr
attach defib
what is a precordial thump
Only used for witness arrest
Slam fist down to where we give cpr
If defib is not available immediately
Should not be used if unwitnesd ventricular fibrillation and patients with recent sternotomy or chest trauma
CAB in CPR
compression
airway
breathing
Chest compression in children
15 CC to 2 breaths
120 CC per min
Two fingers not going that deep
what is a shockable rhythm
ventricular fibrillation
ventricular tachycardia
nonshockable rhythms
pulseless electrical activity
asystole
what is a shockable rhythm
ventricular fibrillation
ventricular tachycardia
nonshockable rhythms
pulseless electrical activity
asystole
defibrillation
sequence
1rst shock 2 mins cpr check rhythm
2nd shock 2 mins cpr check rhythm then adrenaline 1 mg
3rd shock 2 mins cpr check rhythm then amiodarone 300 mg
4 T and 4 H reversible causes of cardiac arrest
hypoxia
hypothermia
hyperkalemia
hypovolemia
tamponade
tension pneumothroax
thrombosis
toxins
4 Ts
Tamponade
Fluid in pericardial space
Chest trauma
Post cardiac surgery
Procedural
Take out with big needle
Thrombosis
Clot in pulmonary vein
Often cause by dvt / inactivity
Sob
Hypoxia
Fibrinolytic therapy
Toxins
Seek evidence history
Review medications
Act early
Some drugs have antidotes
As per cardiac arrest until toxin identified
Tension pneumothorax
Air in pleural space
Asthma
Procedural
Check tube position if intubated
Must perform examination
Difficult to ventilate
Unilateral chest rise/fall
Decreased breath sounds
Tracheal deviation
Trauma
Asthma procedural ICC
Tjroacostomy
Follow up with ICC chest drain
Initial treatment needle decompression needle 5th intercoastal space
4 Hs
Hypoxia
Pre arrest spo2
Consider advanced airway
Avoid hyperventilation use capnography
Assess and cause?
Hypothermia
Spinal shock
Exposure
Active rewarming technique
Warm iv fluids as per protocol
Consider cardiopulmonary bypass
Hyperthermia
Drugs
Surgery
Marathon
Heat stroke
Metabolic acidosis
Can cause mutli organ failure
Cooling matts
Fluid treatment
Dantrolene 0 muscle relaxant
Hyperkalemia
Vomiting
Kidney disease
Hypoglycemia
Hypovolemia
Internal
Surgical drains
Wounds
History of trauma
Sepsis
Anaphylaxis
Gastro
cardiac arrest drugs
Adrenaline
After every 2nd shock
Increases HR simulation
Amiodarone
VF/pulseless VT
Lignocaine
Antiarrhythmic drug
Atropine
Conduction of heart and accerlartales transmission
For bradycardia
Potassium
Persistent VF
Magnesium
Torsade de pointes, digoxin toxicity
Calcium chloride
Hyper K hypo ca overdose ca blockers
members in resus team
If possible role allocated in advance eg MET/PACE teams
Team leader clear
Airway management
Compressions
Defib person
Drugs 2 x people drawing up
Scribe very important
Runner
Someone to look after family
Someone to look after the ward
Importance of non technical sills
Structure communication
Task management
Team working
Situational awareness
Think about family
Patient wishes
legal/ethical
Mechanical compression devices if available
Transport
Faciltate safe angiography
What is a Tbi
Sudden trauma causes damage to the brain
Head suddenly and violently hits an object or when an object pierces the skull
Leading cause of death and disability
Huge financial, social, and emotional DALYS on the community
Cerebral blood flow
Brain has ablity to control blood supply to match its metabolic requirements
Vasoconstriction and dilation
Chemical or metabolic by products of cerebral metabolism
what is cerebral spinal fluid
Purpose
Buffer
Constitution
Production
Absorption
Pressure
500 mls produced a day
Pathophysiology of tbi
Rigid compartment skull
3 components
Csf
Blood
Brain tissue
Monroe kellie doctrine
V intracranial vault
Buildup of pressure nowhere to go
what is intracranial pressure
Norma icp <20 mmHg
Herniation syndromes
Central herniation
Uncal herniation
Tonsillar herniation
what is intracranial pressure
Norma icp <20 mmHg
Herniation syndromes
Central herniation
Uncal herniation
Tonsillar herniation
penerating tbi
MVC
Falls
Smoke inhalation
Burns
Explosion
Hanging
what is primary injury
Irreversible
At the time of injury
Only prevention
what is secondary injury
Follows intial event
Can prevent secondary brain injury
Hypoxia
Hypotension
Metabolic insults to the brain
Multifactoral
Time dependent
paediatric epidemology of tbi
Age
Falls
Misadventure
Maltreatment
5 times more children die from head trauma than leukemia
Cerebral perfusion is different
Brain is immature
Head and body proportions are different
Skull is thin
Neck muscles are weaker
Accurate history is often unavailable or inaccurate
A lot more water and more fattier therefore diminished shearing resistance
More susceptible to mechanical loas
Thin one layer
Skull elasticity is increased
Mechanical load is more easily transferred to the brain though a relatively compliant skull
paediatric cerebral perfusion
CPP prediction of outcome
lower pressures
recovery and impacts from sports tbi
Recognise injury
Removal from play
Rest
Return to play
Assess SCAT 3
Adult/paeds
Imaging
Neuropsychological
Physical LOC amnesia headache
Cognitive impairment
Sleep disturbances
Encephalopathy cognitive impairment early onset dementia
GSC defintitions
GSC defintitions
Mild GSC 13-15
Moderate GCS 9-12
Severe less than 8
what is a concussion
Direct blow
Acceleration or deceleration injury
Reticular activating system disrupton
Transient amnesia/ LOC
Nausea, vomiting, amnesia, headache, brief vision loss, concentration
what is a diffusional axonal injury
Severe type of tbi mild- severe
Acceleration/ decerlaration
Microscopic damage
Injury damaging the integrity of axon
Shearing and disruption of neuronal structures
Mainly white matter
what is subdural hematoma
Most common tbi
Bleeding into the subdural space
Rupture of bridging veins
Between dura mater + arachnoid
Rupture of parenchymal small vessels
Slower onset of symptoms
Loc hemiparesis fixed dilated pupils
what is a cerebral contusion
bruise to the surface of the brainOccurs in 20-30% of TBI
Caused by movement within the cranial vault
Acceleration/deceleration injury
Evolves over time 12-14 hours to develop on ct
what is a Subarachnoid hemorrhage
Bleeding into the subarachnoid space
60% of patients have injury pattern of cerebral contusions or lacerations of blood vessels
Causes hydrocephalus cerebral vasospasm
contributors to poor outcomes in tbi
Hypoxia
Deliver oxygen
Intubate
Rsi with c spine protection
Mechanical ventilation
hypoperfusion/hypovolemia
Hypotension
Adverse outcome
Decreased cerebral perfusion pressure
Bp over 90
Decrease in oxygenation to cerebral tissue - prevent
Inotropes
Prevent hyperthermia
Use active cooling
Driving temp down
Prevent coagulopahty
Defect in clotting cascade
Worsens injury
Increases with iv fluid
Risk factors
Increased temp
Trauma
Iss injury severity scale massive transfusion
treatment of severe tbi
Sedation
Fluid management
Osmotherapy - iv mannitol taking fluid out of the space
Hypothermia
Surgery
Hyperventilation
Steroids
Treatment to reduce ICP
Reduce cerebral oedemia: hyperosmolar therapy
Promote venous reutrn
Reduce activity associated with elevated
Manage pain
Risk of hypotension
Neurological exam
Management of movement
nursing care for patients with tbi
Gsc horly
Head to 30 degrees
Temp
Cervical collar clearance
Cluster care
Adequate analgesia
Dvt prophylaxis
Teds
Calf compressors
Chemical prophylaxis
Avoid nsaid
Positioning
Foot splints
Bed rails
Pillows- blankets
Regular passive movement
Families are importance
Rest
Aggressive
Grizzly
Stay calm
Soft reassuring voice
Dont argue
Try to distract
Maintain safe distance, lanyards
Develop plan
what do end of life decisions require
Family conferences
Ceiling of care
Advanced medical planning
Organ donation
Medication planning
observations in tbi patients
Vital signs
Including resp effort
Gsc
Oxygen saturation
Appearance
Central painful stimuli
Limb movement
Listen to the patient
Handover specifics
Nutrition bowels
Energy (trauma hyper caloric demand
Alerted metabolic state
Increased oxygen consumption
Increased nutrition
Post traumatic amnesia
Modified westmead
Apta
Naming
New memory
Recall new memory
Score out of 12
Biu
Eye care
High flow oxygen
