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
