NUR205 acute Flashcards
describe wet dressings
placing dressings that are moist with NS or prescribed liquid. Common use eczema. provide hydration, relief and cooling while preventing scratching.
Describe moisture retentive dressings
gel based, expand to fill wound caverties,
Occlusive dressings
air and water tight, used to enhance absorption of creams
Week 2 Q1Often the simplest method of establishing an airway is …?
deep coughing, deep beathingmove patient on side tilt head back, open mouthif these two fail endotracheal tube (ETT) suctioning, tracheostomy (hole in throat) or Guedel
Week2 Q2. How is an oropharyngeal (Guedel) airway measured prior to insertion? And what is it’s purpose?
measuring from the middle of the persons mouth to the angle of the jaw.prevents the tongue from covering the epiglottis maintains a clear airway and optimise respiratory functions
Week Q33. What are the indications for suctioning an airway?
Patients inability to adequately clear the airway by coughing.VomitObtaining a specimen for diagnosesWhen adventitious breath sounds are heard When secretions are present Unexplained increase in shortness of breath, respiratory rate or heart rate.
Week 2 Q4 4. List & briefly explain the indications for inserting an ICC/intra-pleural drain
Post operative management for improving gas exchange and breathingTreatment of spontaneous or trauma pneumothorax.Used to re-expand the lung and remove excess air, fluid and blood.
what is Pneumothorax?
Pneumothorax: abnormal presence of air in pleural cavity( collapsed lung)
what is Hemothorax:
accumulation of blood in the pleural cavity( space between lungs and walls of chest).
week 2 Q 5. It is good practice to have 2 padded clamps & 250ml of sterile water (depending on facility policy) at the bedside of all patients with ICCs in. Explain why & how they may be used.
The water is to create a water seal if you need to move the patient or for emergency when the equipment is not working properly.Clamps provide a seal and prevents air from entering the pleural space.
week 2 Q6 On your clinical prac. you are caring for a patient with a hemothorax who has a right-sided chest tube in place. • Discuss nursing management, assessments, care priorities of nursing a patient with a chest tube
Nursing management:position patient frequently n semi-fowler positionEncourage patient to turn, cough and take deep breaths. Assessments: 1hrly, under water seal chamber is below bed level Tube free of kinks, securely taped and intact. Asses lung sounds rate and rhythm and depth. Assess O2 sats Asses capillary refill, surgical site and dressing
what is a P wave
atrial depolarisation. increased P wave - hypokalemia decreased P wave - hyperkalemia
What is a PP interval
the space between consecutive P wave
What is a PR interval
the time between first deflection of P wave and first deflection of QRS complex (identifies Pathology of AV node)
What is a QRS complex
ventricular depolarization
what is a QT interval
the measurement between the start of the QRS complex and the end of the T wave. This indicates the time it takes depolarise and repolarise
What is a RR interval
time between each R wave (in QRS) and used to calculate the heart rate
What is a ST segment
The time between end of QRS and beginning of T wave, it reflects the period of zero potential
What is a T wave
ventricular repolarisation
identify V1
4th intercostal space, right sternal boarder
identify V2
4th intercostal space, left sternal boarder
identify V3
5th intercostal space, left sternal border
identify V4
5th intercostal space, left midclavicular line
identify V5
5th intercostal space, left anterior axillary line
indentify v6
5th intercostal space, left mid-axillary line
describe any precautions you need to make when attaching an ECG
take off jewellery, ensure muscles are relaxed, clothing waist up removed, electrodes are accurately placed, privacy
