HM, TRACHE & GCS Flashcards
heimlich manEUver
Apply for victim who is choking
Abdominal Thrust
5 back blows (using heel of the hands)
Benefits of HM
1 Conscious who choke
2. Pregnant who choke
3. Child or Infant under a year old
4. Own self
Indicator of HM
1 A person appears to be choking
2. Coughing (if conscious encourage to cough)
3. Not coughing (Perform Heimlich Maneuver)
4. Universal sign - Clenching of the neck (indicator to perform Abdominal Thrust)
is surgical incision into the trachea via the throat with a tube inserted
Tracheostomy
Reasons for trache
1 For exploration
2. For removal of foreign body
3. For obtaining specimen
4. For gaining access to the airway for assisting in inspiration
Types of trache
Permanent and temporary
Purpose of trache
- To facilitate prolonged artificial ventilation
- To bypass serious upper respiratory obstruction
Obj of tracheostomy care
- To keep tracheostomy tubes patent and free from mucus
- Prevent infection
- Prevent trauma to the ostomy
- Develop skills in tracheostomy care
Purpose of trache care
- Maintain airway patency by removing mucus and encrusted secretions
- Promote cleanliness and prevent infection and skin breakdown
Assessment for tracheostomy care
Inadequate nutritional status
Respiratory infection
Fluid status
Humidity
Assess for excess peristomal secretion
Assess for respiratory status
Identify tyoe of trache tube
Assess cl ability to understand and perform independent trache care
Suctioning
5-10
Perform before eating
Do while cleaning
Hyper oxygenation
When to clean
2 a week
When to change trache tube
Every 28 days
-The scale was established in 1974 by Graham Teasdale and Bryan Jennett at University of Glasgow Institute of Neurological Sciences
GCS (GLASGOW COMA SCALE)
a reliable scale that aims to give reliable way of recording the conscious state of the person.
GCS (GLASGOW COMA SCALE)
3 components of GCS
Eye Response (1-4)
Verbal Response ( 1-5)
Motor Response ( 1-6)
arms ike C’S move toward the cord
Decorticate (Flexor)
arms like E’s
Decerebrate ( Extensor)
used during the assessment can range from verbal or audible stimuli to painful /pressure or stimuli
Stimuli
2 types of painful stimuli
Central stimuli
Peripheral Stimuli
pressure or pain is applied to the center of the body to create pain
Central stimuli
Generally brain injury classifed as:
Severe
Moderate
Minor
Severe GC
<8 -9
Moderate GCS
8 or 9 -12
Minor GCS
> 13
Eye opening response
4 spontaneous
3 to speech
2 to pain
1 no response
Verbal response
5 oriented to time, person and place
4 confused
3 inappropriate words
2 incomprehensible sounds
1 no response
Motor response
6 obeys command
5 moves to localised pain
4 flex to withdraw from pain
3 abnormal flexion
2 Abnormal extension
1 no response
