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safety to the ill
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Presenter: Lisa E. McDonaldDate: September 2o12
LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
At the end of this two (2) hour session the participants will be able to:Define the term the critically ill patientDescribe the measures taken to maintain airway patencyCompare the nursing management of the critically ill patient to the non critical patientDiscuss three priority nursing diagnosis with interventions and rationale
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
This is a patient who requires close physiologic monitoring because of a life- threatening disruption of the normal haemodynamic mechanisms of one or more body systems; special monitoring devices/ assist devices and a complexity of catheters are used.*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Arterial Blood Gases (ABGs)Arterial lines ( Invasive blood pressure monitoring)Pulse oximetersCentral venous catheter (CVC)Swan Ganz catheter
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Mechanical ventilatorsEndotracheal tubeOro/nasopharyngeal airwayCardioscopeTransducers
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Persons requiring airway management include (i) Post anaesthesia patients (ii) Patients with seizure disorders (iii) patients with decreased level of consciousness *LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
(iv) Post head and neck surgery patients (v) Patients with respiratory disorders eg Asthma*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Maintenance of an adequate airway is critical in these patientsObstruction can be sudden and dramatic or may occur slowly over the course of several hoursLoss of a patent airway may usually be mechanical.
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Reasons for non patent airwayKinking of tubes, inappropriate placement of an edotracheal / tracheostomy tubeObstruction by blood or secretion ( bleeding and haematoma under skinflaps may compress trachea)
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
(iii) Aspiration ( may be seen in head and neck procedures)(iv) Swelling (v) displacement of the tongue, epiglottis *LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Airway obstruction is best treated by preventionPosition patient in the lateral position with head slightly down (unless contraindicated eg. head and neck surgery)If thorocotomy position head 30-45 ( in this position abdml organs do not impair motion of diaphragm)*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Suction prn via oropharynx and nasopharynxDeep breathing and coughingAscultate lungs Check position of endotracheal tube (ETT)Insert airway if lax epiglottis*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Monitor respiratory rate and patternUse jaw thrust , head tilt to open and maintain airwayAdminister bronchodilators as prescribed*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Central Nervous System (i) Assess level of consciousness using GCS(ii) Assess power grades(iii) If drainage tubes in assess amt, colour and consistency of drainage (iv) Monitor intracranial pressures (ICP)*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
(v) Observe for signs of raised intracranial pressure (normal 0-20mm hg)*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Respiratory (i) Monitor respiratory rate and pattern (ii) Ascultate chest (iii) Monitor oxygen saturation (iv) Monitor ABGs (v) Assess colour of mucous membranes
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Respiratory (vi) Position to facilitate ventilation (vii) Assess for use of accessory muscles (viii) Monitor for decrease in mentation/CL *LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Cardiovascular (i) Monitor BP ( invasive/non-invasive) and HR (ii) Monitor temperature (iii) Assess peripheral pulses (iv) Monitor central venous pressure (CVP)
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Cardiovascular (v) Assess jugular vein for distension (vi) Assess perfusion and capillary refill (vii) If chest tubes present assess amt. colour, consistency of drainage, airleaks blockage, change bottle using asepsis
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Cardiovascular(viii) Monitor lab. values eg. CBCs, tests specific to disease condition eg amylase levels-Pancreatitis (ix) Monitor IV fluid intake (x) Monitor urine output*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
GastrointestinalAssess bowel soundsAsses Ng tube for placement prior to feeds, aspirate q4hrlyIf being given Total Parenteral Nutrition, assess IV sites, maintain aseptic technique in administering and dressing site*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Gastrointestinal(iv) Monitor drainage from Gastrostomy, Jeunostomy, tubes amt., colour, consistency(v) Monitor lab. values - U&Es(vi) Monitor blood glucose levels, administer insulin if required (vii) Assess abdomen for distention, girth
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
GenitourinaryStrict intake and outputDo urinalysisAdvocate for urinary catheter change, sen tip of catheter for culture
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
MusculoskeletalDo pressure area carePassive exercisesAssess skin integrityAssess for oedemaReposition q2hrly
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Alteration in breathing pattern related to the effects of anaesthesia, stasis in secretionsIneffective airway clearance related to inability to cough effectivelyImpaired cardiac output related to hypovolemic state, decreased Potential for decreased cerebral perfusion related to raised intracranial pressure*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Carpinito, L. J. (1995) Nursing diagnosis: application to clinical practice. Lippincott:PhiladelphiaGolden, D. M. Intensive care of the surgical patient. Yearbook medical publishers: Chicago
*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
Hudock, C.M., Gallo,B.M., Morton, G.P. (1998) Critical CareNursing. Lippincott: Philadelphia*LEM/2010 NSDD Revised08/2012/CSON/UTech
LEM/2010 NSDD Revised08/2012/CSON/UTech
*Hudock, C.M., Gallo,B.M., Morton, G.P. (1998) Critical Care Nursing. Lippincott:Philadelphia
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