- Hospitals and other health care institutions have a duty of care. List 3 major areas that must be attended to.
- patient safety
- patient confidentiality
- patient privacy
- Discuss the principles of good pain management in the care of acute pain.
- Pain is subjective- only the patient can describe it
- Working out any obstacles determine to combat
- Nurses have the responsibility to assess pain – pain scale , using the P,Q,R, S, T approach = provoking (what makes it better or worse),quality (what does it feel like), radiation (does your pain radiate), severity (pain intensity=1-10),time (when did it first start)
- Multimodal effect = using analgesic ladder to combat pain
- Non-pharmalogical comfort measures= music, TV, cold pack, heat pack.
- When is consent required from a patient and who can consent for a patient?
Consent to treatment is the principal that a person must give their permission before they receive any type of medical treatment or examination. This must be done on the basis of a preliminary explanation either verbally or written. Consent should be from the patient or guardian if under age or those in which are acting on their behalf (power of attorney).
If unconscious consent is informed consent is surpassed in these situations
- Skeletal fractures or soft tissue injury of limbs can result in the development of compartment syndrome. Using the lower leg as an example.
a) Explain what compartment syndrome is at cellular level, and what factors contribute to the development of compartment syndrome?
- Pressure rises in the compartment
- Decrease in perfusion and oxygenation
- Interstitial pressure overcomes intravascular pressure of capillaries
- Vessel walls collapse
- Local tissue ischaemia
b) Explain the signs and symptoms of compartment syndrome.
- Pain-persistent, progressive and out of proportion to the injury
- Pallor- the limbs may be pale
- Pulselessness- pulse absent or diminished
- Paraesthesia- nerves become ischaemic
- Paresis- feelings of weakness in limb or it’s extremities
c) What is the rationale of all observations in the early detection of compartment syndrome?
• Obs are done – to determining what nursing interventions should be implemented
- to try to save the limb
- identify that there is a problem occuring
- Describe the features of a person who has decerebrate posturing.
The pt lies in rigid extension with arms internally rotated at the shoulders, elbows, knees and hips extended and fingers, ankles and toes flexed.
- Describe the features of a person who has decorticate posturing.
A unilateral or bilateral postural change, consisting of the upper extremities flexed and adducted and the lower extremities in rigid extension
- Describe the nursing care of a patient with a bowel obstruction. Where possible provide rationales for your interventions/actions
- Pain & symptom management – provide medication if required
- Fluid balance monitoring
- Monitor for signs and symptoms of deterioration
- Administration of IV fluid, electrolytes and antibiotics
- Insertion of a nasogastric tube – nil by mouth
- Treatment of nausea and vomiting
- Radiograph or ultrasound required
- Prepare for surgery (if required)
- Discuss the differences between ischemic and haemorrhagic stroke
- Ischaemic stroke= sudden blockage or occlusion of cerebrovascular blood flow
- Haemorrhagic stroke= rupture of a blood vessel within the brain
- The acronym RICE is used in nursing. Explain what this means and to whom you would apply it
RICE is used for the treatment of strains and sprains.
R-rest – prevent additions injury and promotes healing
I-ice-moist/dry cold applied intermittently for 20-30 min
C-compression- controls bleeding, reduces oedema and provides support for injured tissue
E-elevation- controls the swelling.
- Describe the risk factors and the principles of prevention for the development of pressure ulcers.
- Surgery (THR, back injury) and bed bound for to long, immobile (quadriplegic)
- Turn or moving pt 2hrly
- Dry sheets
- Compression mattress
- Wedges, booties,
- Creams
- Brandon and Norton scale
- Neurological observations are an important nursing responsibility; describe what the assessment of the patient will be and how you will conduct this?
- GCS would be performed
- Assess the patient’s eye response, verbal response and motor function
- Score would be 3-15. 3 being the lowest score possible and 15 being normal function
- Cerebral function, cranial nerves, motor function, sensory function, reflexes
- Describe the management and nursing care of a patient with a suspected CVA?
- They need to get a scan to determine type of CVA= ischaemic or Haemorrhagic stroke.
- ECG/CT scan
- find out as much information as possible / medical history
- Start an antithrombotics/anti platelets = aspirin, clopidogrel
- Monitor BP
- Medication management- antiarrthymics, antihypertensives
- Normal obs
- Discuss when a nasogastric tube may be required and the rationale for aspiration of the tube.
A nasogastric tube may be required for:
• Short term administration of medications of feedings - infants
• To treat an obstruction
• To remove fluid and gas from the upper GI tract
The rationale for aspirating the tube is to be able to identify and confirm the position of the NGT and rule out the possibility of respiratory tract placement
- Why is it important that the patient cease taking aspirin and NSAIDs prior to surgery?
• Can cause excessive bleeding as aspirin is a blood thinner
- Name 3 different types of oxygen delivery systems
- Face mask (Hudson mask)
- Venturi mask – for COPD patients
- Non rebreather mask – stops exhaled gas from returning
- Nasal prongs
- Nurses can prescribe and administer O2 to patients whenever it is required? T or F
• False we cannot prescribe however we are able to administer oxygen in an emergency.
- Which patients must you deliver O2 with caution and why?
- All patients need to be monitored as too much O2 given can result in retention of carbon dioxide.
- Those that are maintaining it at home as it can pose a fire risk
- What are some management principles that can be used to minimize the risk of peristomal issues and skin complications such as dermatitis, skin stripping, denuded stomas, hyperplasia, folliculitis associated with stoma therapy
- Keep area clean
- Change dressing as needed using aseptic technique
- Watch for signs of inflammation
- Protect the skin with a protective skin – Vaseline, skin barrier
- Why is nutritional support an important consideration when caring for a patient with an ileostomy
• Patients are at risk of malabsorption due to the inability to absorb nutrients from food prior to expulsion
- List 4 signs that someone may not be tolerating enteric feeding?
- Respiratory distress
- Nausea, vomiting, diarrhoea
- GORD
- Abdominal distention
- Blood sugars/ glucose fluctuations
- What is aspiration pneumonia? Why are stroke patients at increased risk? What can be done to reduce the risk of aspiration pneumonia?
- Aspiration pneumonia is an inflammation of the lungs and bronchial tubes caused by the inhalation of oropharyngeal or gastric content.
- Stroke patients are more at risk due to the attribution of dysphagia.
- To reduce risks of aspiration happening stroke patients should be made NPO till a swallow assessment has been performed. Enteral tube feeding may be required if the patient fails to meet their nutritional need orally. Modifying food and fluid textures to promote safe oral intake. Sitting the patient up and using modified equipment to help prevent complications from arising. pH measurement should be performed routinely. Measurement of exposed tube length and should be checked often especially after coughing or vomitting.
