The assessment of critical care pt’s personal hygiene should be undertaken on 2 levels. What are they?
- Determining what the pt is able to do and wants to do for themselves.
- The nurses assessment of what is required
The International Skin Tear Advisory Panel classification system uses 3 categories to describe skin tears. What are they?
- Skin tear without tissue loss
- Skin tear with partial tissue (flap) loss
- Skin tears with complete (flap) tissue loss
How often should an eye assessment be undertaken?
Every 12 hrs, even for conscious pt’s who are able to blink.
Pt’s who are unable to close their eyelids should receive 2hourly eye care
What is Catheter-associated urinary tract infection (CAUTI)?
This is primarily caused by contamination from the healthcare worker or from the pt’s own flora during catheter insertion or management of the urinary drainage system or via reflux of contaminated urine.
When would you use a a large diameter catheter?
This may be required to drain haematuria or clots
Sleep deprivation in pt’s who are critically ill are often attributed to?
- bed baths during the evening shift
- untreated pain and anxiety
- family visiting
- altered melatonin levels
Essential nursing care includes?
- assessing the integumentary system for: pressure area care, positioning of pt, VTE
- personal hygiene - oral, eye care, washing
- diet and fluids
- bowel and urinary care
- infection control considerations
- discharge planning
What is MRO?
Multi-drug resistant organisms= collective term for a number of infections from multi resistant organisms.
What is CAUTI?
Catheter-associated urinary treat infection= primarily caused by contamination from healthcare worker or from the pt’s own flora during catheter insertion or management of the urinary drainage system or via reflux of contaminated urine.
What is constipation?
It is describe as fewer than 3 BM per week; incomplete evacuation; hard or difficult to pass stools.
What is DVT?
Deep vein thrombosis = blood clot in a major vein of the lower body ie-leg, thigh, pelvis causing interruption of venous blood flow.
What is pulmonary emboli?
Occurs when a part of the thrombus moves through the circulation and lodges in the pulmonary circulation.
When it comes to bariatric considerations what does R-E-S-P-E-C-T stand for?
R=respect E=environment/equipment S=Safety P=privacy E=encouragement C=Caring And compassion T=tac
What is bronchoconstriction?
Narrowing of the airways by contraction of the muscle fibres
What is a tracheostomy?
Surgical procedure in which an opening is made into the trachea.
what are the general principles for transporting a critically ill pt?
- a careful assessment of risk of adverse events during transported should be evaluated
- primary focus should be on pt safety and prevention of adverse events
- risk/benefit assessment
- equipment check prior to transport
- informing pt and family
- essential care during transport
What are some appropriate resources to enhance pt nurse communications?
Body language
- lip reading
- pictures
- writing
- gestures
What are some precipitating factors of anxiety?
- concern about illness/underlying chronic disease
- current feelings and experience
- concern of impact of illness on recovery
- side effects of medications
Describe strategies to reduce pt pain and anxiety to promote sleep and rest in the critically ill.
- Pharmacological treatments = treat pain and any other reversible physiological causes
- non-pharmacological treatment: noise reduction, music therapy, heat therapy, massage
Sleep deprivation in pt who are critically ill is often attributed to?
- bed baths during night shift
- untreated pain and anxiety
- family visitations
What is a nebuliser?
A nebuliser is compressed air/oxygen, it is a fine mist in aerosol form that can deliver large doses of a drug over long periods
