ICU 1A Flashcards
Respiratory System
• Shape and size of chest,
• Chest movement /accessory muscles/work of
breathing
• Air entry R=L?, breath sounds (wheeze, stridor)
• Rate and rhythm of breathing, ventilated, FiO2
• ET placement/position/tubing/tape/cuff pressure,
• Other airways/tubes? (Nasopharyngeal, pleural)
• Sputum (character and amount, specimen?)
• Arterial Blood Gas results (ABG’s)
• Regular suctioning/physio/daily CXR / DB+C?
Cardiovascular System
- Heart rhythm, pulses (pedal and radial)
- BP and medications (inotropes)
- Heart sounds
- IV fluids and fluid status (CVP, UO, oedema / secretions /drains)
- Haemoglobin /? bleeding
- Colour, temperature
- Perfusion, capillary refill < or > 2 sec
Gastrointestinal System
- NG/PEG tube position, security, patency
- Free drainage /aspirate, character of asp.
- Abdominal distention, girth measurement?
- Bowel sounds
- Bowels; frequency, character of stool
- Rectal tube?
- Feeding regime (enteral or parenteral), tolerance
Genitourinary System
- Urine output
- Colour, odour, specimen collection
- IDC change / bag
- Weight
- Electrolytes
- Dialysis
- Integrity of genital area
Integumentary System
- Wounds/drains
- Sutures or clips
- Pressure area’s/ bony prominences /Braden Scale
- Oedema/Rashes
- Dressing change/line change due
- Limb stiffness /passive limb
- Temperature
Computerised documentation
These systems provide for “paperless” data
management, order entry, and nurse and
physician charting. If and when a decision is made
to utilise this technology, it is important to
integrate such a system fully with all ICU activities.
Bedside terminals
facilitate patient management
by permitting nurses and physicians to remain at
the bedside during the charting process.
Some more nursing considerations
- Physical hygiene (inc. eyes/mouth)
- Patient positioning/dignity
- Infection control
- Elimination (bladder/bowel)
- Impaired communication
- Nutrition
- Anxiety
- Pain
- Sensory-perceptual problems
Empathy
Often means caring for people that are having a really bad day/ week/ month; both patients AND significant others • Hearing is last sense to go, so even if unconscious, speak to your patient. • Be culturally sensitive • Respect privacy (patient gowns, family time)
Physical Hygiene
Routine in ICU’s vary • [Generally] pts are washed at the end of ND (around 6am) by +/- 2 RN’s • Lift rounds • Sheets/draw sheets changed frequently • Often need daily CXRs or weight • Use massage if indicated
Positioning
• Use of special devices (air beds) • Enough nurses to support patient and equipment • Careful use of lifters and manual aids • Regular PAC, use of pillowsmay not be haemodynamically stable enough to turn though • Massage back, feet • Active and passive limb exercises • Nurse with head of bed at 30 degrees unless contraindicated
Eye Care
• Regular eye care (0.9 % saline) to protect • Administration of artificial tears and/or lubricating ointment • Taping eyes closed (eye pads) • Witch hazel solution on eye pads (used to decrease orbital oedema)
Mouth Care
• Second hrly mouth care to moisten (oral hygiene sticks or gauze with saline or diluted mouthwash/H202) • Regular oral suctioning • Change position of tapes and tubes • Clean teeth as indicated • Apply lanolin to lips to avoid cracking • Other med’n (nystatin for oral candida)
Restraints
• Physical (hand/ ankle/
cervical spine)
• Medication (sedation)
Infection
Prevention
• HANDWASHING – most effective and least expensive! • PPE – including fit testing of masks • Alcohol hand-gel at every bed space • Dedication of equipment for bedspace and/or staff (E.g: stethoscope) • Cleaning of all equipment between use • Nurses to clean medical equipment around bedspace daily (including IV pumps, trolleys and equipment such as ventilators etc). • Reduces risk of nosocomial infection, including sepsis
