W1 Essential Nursing care Flashcards
essential nursing care for a critically ill patient includes all of the following: (12)
> Pain Management > positioning > Pressure care > VTE prevention > Oral Hygiene > Eye care > Nutrition and fluids > Urine output > bowel management > Infection Control > Discharge planning > family centred care
Importance of Positioning (patient and devices)
o Support ventilation, prevention of VAP, reduce the risk of aspiration and associated infection during feeding.
o Easy assessment of drips and drains, ensure adequate flow with gravity, no potential for occlusion or pressure injury.
How often should pressure care be performed on an immobile patient?
what does pressure care/assessment include?
1) 2 hourly repositioning
2) assessment of skin condition (blanching, redness, skin integrity, colour, temperature)
3) Correct use of equipment when repositioning.
VTE Risk Factors? (9)
1) Surgery 2) immobility 3) HRT, 4) smoking,
5) Coagulopathy, 6) vein injury, 7) previous DVT,
8) family history, 9) over 40yrs
how can nurses aid in the prevention of VTE?
1) assess for risk factors
2) Medications: anticoagulants (heparin, Clexane, warfrin)
3) Non pharmacological: Teds and pumps, adequate hydration, ROM exercises, early ambulation
Oral Hygiene should be performed how often?
o 2 hourly suctioning
o 12 hourly teeth brushing, chlorhexadine mouthwash
How can nurse care for patient eyes?
Eye toileting
eye drops to keep moist,
may need to be tapped shut if on VAP
Delivery method of nutrition in patients who are NBM?
why may Patients need a high calorie intake?
o Enteral feeding (NGT, PEG, NJ), parentral feeding
o High caloric diet (energy for wound healing and recovery)
1) Volume of fluid intake pt (normally) requires in 24 hours?
2) What needs to be considered when determining the type of fluid the patient requires?
1) 2000mls/24hours fluid
2) patient may require specific fluids to meet electrolyte needs, glucose needs, correct fluid shift
What is involved in urinary care for a patient?
1) Monitoring urine output hourly, to evaluate fluid balance
2) catheter care: cleaning around catheter with warm soapy water, ensuring bag is patent and bellow level of bladder,
3) looking for signs of skin irritation,
4) monitoring colour and consistency of urine,
5) performing urinalysis for indication of infection, kidney impairment, glucose imbalance.
what assessment tool is used in bowel function?
Bristol stool chart
Infection control includes
o Standard precautions. appropriate PPE
o hand hygiene, Aseptic technique
o Safe disposal of sharps and equipment
O timely and appropriate isolation
the methods of infection transmission/ precuations
Droplet,
contact,
Airborne
Discharge planning involves:
1) Patient/family education, 2) appropriate support at home, 3) access to services in the community to promote recovery. 4) resources and supplies for self care (dressings) 5) follow up appointment 6) signs of infection, deterioration. 7) who to contact for questions or support.
how can nurses facilitate communication between the patient, doctor and family and provide support?
o Speak to doctor daily and relay to patient and family
o Inform family of changes in patient condition
o Discuss concerns to reduce anxiety
o Ensure information given is consistent.
o Do not provide false hope
- Involve patient and family in the decision making regarding their care
- Consider psychological, social, cultural and spiritual needs of family and patient
- Chaplin, indigenous support work, interpreter
- Education regarding condition and patients ongoing care needs
What are the different methods of communication?
- Verbal
- Body language
- Written
- Pictures
- Lip reading
- Typing boards
- Gestures
signs of anxiety:
Increased pain, Increased HR, RR, BP, SOB, Dry mouth, diaphoretic, pallor, cool, clammy, grimacing, Sleepless, restlessness, agitation rapid speech, Inability to retain information Seeking reassurance
How can Nurses reduce anxiety among patients?
- Appropriate pain management; Antianxiety medication
- Massage, music, aromatherapy,
- Discuss patient’s concerns, reduce over dependence on nurse.
what is delirium?
1) A reduced ability to direct, focus, sustain and shift attention and reduced orientation to environment.
- it develops over hours to days
2 types: There is hypoactive and hyperactive delirium.
Causes of delirium:
A consequence of medical condition, intoxication or withdrawal, lack of sleep, intense pain
How can nurse manage patients with delirium?
Adequate pain relief, reduce anxiety, careful use of sedatives and benzos, treat cause (hypoxia, hypo-perfusion or fluid and electrolyte imbalance) optimise sleep cycle
what are the pharmacological and non pharmacological interventions for pain management
what does nurses need to do after implementing intervention?
1) Pharmacological: multimodal, paracetamol, NSAIDs, opioids, antianxiety
2) Non pharmacological: repositioning, reassurance, information, massage, breathing exercises, visual imagery, music and family presence
3) reassess patients pain to evaluate the effectiveness of intervention
how can nurses optimise patients sleep during hospitalisation?
- pain relief, night sedition as required,
- relaxation techniques, adequate warmth,
- encourage family to provide personal belongings, - earplugs/eye mask, reduce noise, dim lighting, -
reposition/pressure support, - bed baths in the evening,
- plan care activities to allow for 1.5-2hour undisturbed sleep period.
when should sleep be assessed?
what information needs to be gained when assessing patients quality of sleep?
1) on admission
2) sleep habits at home, dissatisfaction with sleep, fatigue, snoring, apnoea
