ELABORATE

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Created by
gizmo ph

Cards (56)

  • Administering Oxygen by Nasal Cannula/Face Mask

    1. Check physician's written order
    2. Ask client to state name
    3. Explain procedure and rationale
    4. Review safety precautions
    5. Assist client in appropriate position
    6. Perform hand hygiene
    7. Prepare equipment and supplies
    8. Connect oxygen device
    9. Adjust flow rate
    10. Check oxygen flow
    11. Place prongs in patient's nostrils and adjust fit
    12. Place tubing over and behind ears
    13. Position face mask over nose and mouth
    14. Adjust elastic strap
    15. Encourage client to breathe through device
    16. Re-assess respiratory status
    17. Perform hand hygiene
    18. Document pre and post application
  • Nasopharyngeal and Oropharyngeal Suctioning
    1. Assess need for suctioning
    2. Ask client to state name
    3. Explain purpose
    4. Provide privacy
    5. Perform hand hygiene
    6. Prepare equipment and supplies
    7. Pour sterile water and lubricant
    8. Position client
    9. Place towel
    10. Turn on suction and adjust pressure
    11. Wear PPE
    12. Don sterile gloves
    13. Measure insertion distance
    14. Lubricate catheter
    15. Instruct deep breathing
    16. Insert catheter without suction
    17. Apply suction while withdrawing
    18. Wipe and flush catheter
    19. Allow interval between suctioning
    20. Repeat suctioning as needed
    21. Change to oral catheter
    22. Suction oropharynx
    23. Wipe and flush catheter
    24. Repeat oropharyngeal suctioning
    25. Turn off suction
    26. Offer oral hygiene
    27. Roll and remove gloves
    28. Re-assess patient
    29. Reposition patient
    30. Document procedure
  • Suctioning should be done only when secretions have accumulated or adventitious breath sounds are audible
  • Suctioning removes air from the patient's airway and can cause hypoxemia
  • Suctioning for longer than 10-15 seconds robs the respiratory tract of oxygen which may result in hypoxemia
  • Suctioning too quickly may be ineffective at clearing all secretions
  • Suctioning the oropharynx after the nasopharynx clears the mouth of secretions. More microorganisms are usually present in the mouth, so it is suctioned last to prevent transmission of contaminants
  • Single Rescuer Adult CPR (Out of Hospital Setting)
    1. Survey scene for danger
    2. Check for unresponsiveness
    3. Call 911
    4. Give 30 chest compressions
    5. Give 2 rescue breaths
    6. Continue cycles of 30:2
    7. Check for pulse and breathing
    8. Provide rescue breaths if no breathing
    9. Continue CPR until EMS arrives
  • Suctioning procedure

    1. Remove gloves pulling edge of the gloves from inside out
    2. Re-assess patient by auscultating lung fields
    3. Reposition patient comfortably
    4. Do after care
    5. Document the procedure as to pre suctioning findings, tolerance of the patient to the procedure and post suctioning findings
  • To reduce the transmission of microorganism
  • To assess the effectiveness of suctioning and the presence of complications
  • To ensure comfort of patient
  • To maintain cleanliness of the materials and to prevent spread of microorganisms
  • Ensures continuity of care and ongoing assessment record
  • Single rescuer adult CPR (out of hospital setting)
    1. Survey the scene for impending danger
    2. Check for unresponsiveness
    3. Call for help
    4. Instruct a responsible bystander to activate EMS, get an AED and to come back immediately
    5. Position victim on his back
    6. Position self at the victim's side near the neck and shoulders
    7. Quickly scan for any sign of breathing while checking for carotid pulse
    8. Put heel of one hand on the center of the victim's bare chest between the nipples and put the heel of other hand on top of the first hand
    9. Straighten arms and position shoulders directly over hands
    10. Push hard and fast, delivering 30 compressions
    11. Allow complete recoil in between each compression
    12. Push straight down on the victim's breastbone
    13. Avoid bending, jerking, rocking, "double crossing", bouncing and massaging during compressions
    14. Open victim's airway using head tilt, chin lift maneuver
    15. Deliver a breath by completely covering the mouth of the patient while pinching the patient's nose
    16. Repeat delivery of breath while observing the chest rise
    17. Completely perform 5 cycles of compressions and breaths (30compressions:2breaths) in 2 minutes
    18. After 5 cycles, determine if signs of life have returned by checking carotid pulse while observing for signs of breathing
    19. If with pulse and breathing, stop CPR
    20. Position to recovery position by rolling the patient to the side and supporting his back
  • Two-rescuer adult CPR (in-hospital setting)

    1. Check for responsiveness/Check rhythm in cardiac monitor/ If with flat line, check placement of ECG lead
    2. If no response or flat line in the cardiac monitor, call for help
    3. Check pulse and breathing
    4. Place the bed flat and at an appropriate and comfortable working height
    5. Remove pillow and place the cardiac board under the patient
    6. Position patient
    7. Position self at the patient's side near the patient neck and shoulders
    8. Position hands for CPR correctly
    9. Prepare to do CPR
    10. Perform compression: "push hard and fast"
    11. Completes 5 cycles (1 cycle 30:2) in 2 minutes if without advanced airway. If with advanced airway, perform 2 minutes period of uninterrupted CPR
    12. Rotate roles every 2 minutes (less than 10 seconds)
    13. After completing 5 cycles, reassess by checking cardiac rhythm and pulse
    14. If with pulse/normal cardiac rhythm, assist in positioning the patient to semi fowler's position
  • Assessing responsiveness prevents starting CPR on a conscious victim
  • Activating the emergency response system initiates a rapid response
  • AEDs make it possible for more people to respond to a medical emergency where defibrillation is required
  • The supine position is required for resuscitative efforts and evaluation to be effective
  • Provides easier access to the neck when checking for pulse and provides better access to the patient's chest
  • Provide information on the patient's breathing. Prevents doing CPR to a breathing patient. Quickly checking, prevents delay of provision of compressions during cardiac arrest
  • Proper hand positioning ensures that the force of compressions is on the sternum, thereby reducing the risk of rib fracture, lung puncture, or liver laceration
  • Ensures force of compressions
  • Direct cardiac compression and manipulation of intrathoracic pressure supply blood flow during CPR
  • Incomplete recoil in between each compression is associated wiith intrathoracic pressure and significantly decreased coronary and cerebral perfusion
  • This maneuver may be sufficient to open the airway and promote spontaneous respiration
  • Provides oxygen to the patient's lungs. Pinching the nose prevents the escape of breath delivered
  • Prevents hypo and hyperventilation. Hyperventilation results in increased positive chest pressure and decreased venous return. Blood flow to the lungs during CPR is only about 25% to 33% normal; patient requires less ventilation to provide oxygen and remove carbon dioxide. Longer breaths reduce the amount of blood that refills the heart, reducing blood flow generated by compressions. Delivery of large, forceful breaths may cause gastric inflation and distension
  • Breathing and compressions simulate lung and heart function, providing oxygen and circulation
  • To check ROSC (Return of spontaneous circulation). Checking quickly prevents delays for further CPR
  • Indicates ROSC (Return of spontaneous circulation)
  • Placing the patient in recovery position allows assistance of gravity for clearance of an obstruction of the airway by the tongue and also gives a clear route by which fluid can drain from the airway
  • Initiates rapid response
  • Facilitates chest compressions during CPR
  • A rigid surface allows effectiveness of compressions
  • Opens the airway and prevents obstruction by the tongue
  • Ensures adequate force of compressions and prevents early rescuer fatigue
  • Prevents rescuer fatigue which may reduce force of compressions
  • To assess ROSC (Return of Spontaneous Respirations)