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
