IMPORTANT Flashcards
Nursing Care & Considerations for the patient in ICU or Acute Care Unit
Integumentary Personal Hygiene Diet & Fluids Bowel & Urinary Care Infection Control Considerations
Discuss nursing care of the patient with altered gas exchange
- Position patient with head of bed elevated, in a semi-Fowler’s position (head of bed at 45 degrees when supine) as tolerated as this allows increased thoracic capacity.
- Encourage or assist with ambulation as per physician’s order.
- Maintain an oxygen administration device as ordered, attempting to maintain oxygen saturation at 90% or greater.
- Support family of patient
- Provide reassurance and reduce anxiety
- Medications as prescribed – antibiotics, bronchodilators, anticoagulants, thrombolytics
- Monitor the effects of sedation and analgesics on patient’s respiratory pattern
- Encourage slow deep breathing using an incentive spirometer
What is preload and how is it measured
Pressure or stretch exerted on the walls of the ventricle by the volume of blood filling the ventricles at the end of diastole; used as an indication of volume status. Measured by the Central Venous Pressure (CVP).
What is contractility
The ability of a muscle to shorten when stimulated; in particular, the force of myocardial contraction.
What is afterload
The resistance to ventricular contraction; pressure the ventricles have to overcome to eject blood into the circulation.
What is Stroke volume:
volume of blood pumped with each heart beat. 50-100mL/beat
What is Mean Arterial Pressure (MAP):
Average pressure within the arterial system throughout the cardiac cycle. 70-90 mmHg
What is Central Venous Pressure (CVP):
Preload of the right ventricle measured by the CVP.
What is Cardiac output (CO):
the amount of blood pumped by the heart each minute (SV X HR = CO)
what are the 3 different shocks? how do they present? And treatment for shock (Fluids)
Mild (15-30% loss) - HR =/>100 - Neurological - Slightly anxious - Urine >30mls/hr - Resps >20 - Cap Refill Normal Moderate (30-40% loss) - HR =/>120 - Neurological – Mildly anxious/confused - Urine 20-30mls/hr - Resps >30 - Cap Refill Reduced >4 seconds
Severe (>40% loss)
- HR =/>140
- BP - Hypotensive
- Neurological – Confused/Lethargic
- Urine 5-15, negligible
- Resps >40
- Cap Refill Reduced >4 seconds
Management
• A-E assessment
• Once airway and breathing are secure then focus on minimising fluid loss and restoration of circulating blood volume
• Insert 2 large bore intravenous cannula as per hospital protocol and guidelines of fluid resuscitation and blood transfusion
• Monitor for signs of fluid overload e.g pulmonary oedema and escalating distress
• medical review
• FBC
Secondary Survey
• Full set of vital signs
• Reassurance
• Patient History
abg interperate result and interventions
A-E Assessment
o A – Assess airway for secretions Suction if necessary Positioning o B - O2 Therapy Humidifier/Nebuliser Titrate O2 if CO2 retainers Rest/work at breathing o C – Fluid & Nutrition input o D - Medication Antibiotics Paracetamol
Secondary Survey
o Full set of vital signs
o Reassurance
o History of patient
what is the advanced life support algorithm and what is the nurses role
The ALS represents the recommended assessment, intervention and management options for a patient in respiratory arrest.
CPR Defib/ monitor Assess Rhythm Shockable – shock – CPR 2mins 1mg adrenaline after 2nd shock, then every 2nd cycle. Amiodarone 300mg after 3rd shock.
Non-Shockable – CPR 2mins- 1mg of adrenaline immediately then every 2nd cycle
Return of spontaneous circulation
Post-Resus Care: 12 lead ECG, a-e assessment and treat the cause.
Assess Reversible Causes 4H’s • Hypoxaemia • Hypovolaemia • Hyper/hypokalaemia (&metabolic disorders) • Hypo/hyperthermia 4T’s • Tension pneumothorax • Tamponade • Toxins (poisns/drugs) • Thomboembolic (pulmonary/coronary)
Nurses role
2x CPR – 30 compressions : 2 breaths 1x Defib - monitor 1x Scribe 1x Oxygen 1x Medication – Adrenaline 1x Specialist
What are the diagnostic tests for pulmonary gas exchange, explain them
- Chest x-ray
- Capnography
- Mc&s
- ABG
- Pulse Oximetry
Discuss nursing care of a stemi
ECG within 10 mins presentation – repeat 6-8hr after presentation Cardiac specific Troponin – repeat 6-8hr after presentation Oxygen therapy • Only if SaO2 <93% • COPD Patients Maintain SaO2 88-92% Aspirin 300mg unless contra-indicated Vital signs Reassurance
Discuss the 5 anatomical difference in trauma care of a child vs adult
Gastrointestinal system Central nervous system Cardiovascular system Respiratory system Integumentary system Musculoskeletal system
ecg leads and what they show in the heart
A) Identify what the following leads are identifying;
a. II,III, aVF
b. I,Avl,v5,v6
c. V3, V4
d. V1,V2
a) Inferior
b) Lateral
c) Anterior
d) Septal
Primary Survey of burns:
A – Patient requires intubation due to smoke inhalation and burns to face.
B – Breathing requires to be monitored
C – Fluid replacement using formula
D -
Secondary Survey of burns
- Full set of vitals
- Give comfort measures
- History of patient & family
- Head to toe assessment
- Reassure Family
- Patient to be sent to Burns unit
- Early referral to a surgeon for Skin graphing
- Escharotomy may be required for circumferential full thickness & deep dermal burns of the chest or limbs with circulatory or for respiratory compromise
Top to toe assessment Thorough assessment for other potential injuries/symptoms Continued assessments (A-E, Obs) Further assessments Cardio, resp, neuro Documentation Medications Fluid Management
Local Effects of burns:
Zone of coagulation: Is at the center of the wound, where all tissue is damaged
Zone of stasis: surrounds the coagulation area, where some tissue is undamaged.
Zone of hyperaemia: is the unburned area surrounding the zone of stasis, but it is red due to increased blood flow through inflammatory response.
Systemic Effects of burns:
Cardiovascular:
Respiratory:
Metabolic:
Immunological:
Discuss some anatomical and physiological differences of the infant and adult
Newborn’s larynx one third diameter of adults Short maxilla and mandible Large tongue Floppy epiglottis Shorter trachea
Children compensate for hypovolaemia by vasoconstriction and tachycardia, and may lose up to 30% of blood volume before becoming hypotensive
Burns Criteria
Adults (>15%TBSA burn)
Children (>10%TBSA burn)
Burns formula
4mls/kg x %TBSA x Pre-burn body weight (in KG) = Volume in mls
Example for a patient that was 60kg pre-burn with 60% TBSA
4mls/kgx60x60= 14400mls
How much fluid is needed
50% of 14400 is required in the first 8 hours post burn. (7200mls) (900ml/ph)
25% of 7200mls is required in the second 8 hours post burn (3600mls) (450ml/ph)
25% of 7200mls is required in the third 8 hours post burn ( 3600mls) (450 ml/ph)
Note: On top of this fluid quantity the patient will also require the “normal” daily intake of hydration over 24/24. Average intake 2000mls thus 2000mls over 24/24 = 83mls/hr
In the first hour 983 mls/hour of CSL
