418

• Objective data


  Empirical, measurable
• Subjective data


  Data that can be used for conscious patients
• Implicit data


  Covered information that needs to be uncovered by asking the patient questions
• OPPA assessment


  1. Observe/inspect

  2. Palpate

  3. Percuss

  4. Auscultate
• Mental assessment


  • Alert
  • Lethargic
  • Stuporous
  • Comatose
• Functional screening


  1. Orientation to person

  2. Orientation to other people

  3. Orientation to time

  4. Orientation to place

  5. Memory

  6. General knowledge

  7. Attention span and calculation skills
• Cranial nerves


  CODE: Oh! Oh! Oh! To Touch And Feel A Girl's Vagina So Heavenly! Try It!
• Sensory assessment


  • Pain
  • Touch
  • Position
  • Vibration
• Motor assessment


  1. Tandem Walking/Heel To Toe

  2. Romberg's Test

  3. Fingers-To-Nose Test

  4. Rapid Alternating Movement

  5. Heel-To-Shin
• Reflexes


  Deep tendon reflexes assessed using a hammer
• Breath sounds


  • Bronchial
  • Bronchovesicular
  • Vesicular
  • Crackles
  • Wheezes
• Electrolytes


  • H2O follows Na
  • Na affects mental function
  • K affects heart pumping
  • Ca affects bones
  • Mg affects muscles
  • PO4 has inverse relationship with Ca
• Respiratory process


  1. Ventilation

  2. Pulmonary Perfusion

  3. Diffusion

  
• Oxygenated blood can dissolve in plasma (PaO2) or bind with RBCs
• Buffer system


  Mechanism to maintain homeostasis by balancing acid-base
• Respiratory patterns


  • Tachypnea
  • Bradypnea
  • Apnea
  • Hyperpnea
  • Kussmaul
  • Cheyne-Strokes
  • Biots

  
• Chest inspection


  • Barrel
  • Pigeon
  • Funnel
  • Kyphoscoliosis
• Arterial blood gas


  • pH
  • PaCO2
  • HCO3
  • PaO2
  • SaO2
• Modified Allen's test


  Check perfusion of radial and ulnar arteries before arterial puncture

  
• Allen's test


  1. Ask patient to make a tight fist

  2. Apply pressure over the radial and ulnar artery

  3. Wait approximately 30 seconds

  4. Remove pressure from the ulnar artery

  5. Note color should return within 7 seconds with adequate ulnar artery supply

  
• Arterial blood sampling


  1. Wash hands

  2. Don apron

  3. Don gloves

  4. Gather a clean equipment tray

  5. Gather the equipment (Sharps Disposal Container, Alcohol Swabs, Gauze pad, Syringe, Needle)

  6. Introduce yourself

  7. Confirm the patient details

  8. Explain the procedure

  9. Gain Consent

  10. Check for any contraindications (Medication such as Warfarin or Aspirin, problems with clotting in the blood, problems with liver)

  11. Allen's Test

  12. Expel the heparin from the ABG syringe

  13. Withdraw the plunger slightly

  14. Attach the needle

  15. Palpate location of radial artery

  16. Clean the puncture site for 30 seconds

  17. Inject local anesthetic (Lidocaine 1%) subcutaneously over the planned puncture site, at least 60 seconds prior to ABG sampling (in non-emergency settings)

  18. Warn the patient of a sharp scratch

  19. Insert the needle at 30-45 angle

  20. Aim towards the maximum point of pulsation

  21. Observe for flashback

  22. Hold the needle still whilst the syringe fills

  23. Remove the needle

  24. Apply firm pressure immediately and continue to apply pressure for at least 5 minutes

  25. Insert needle into rubber block

  26. Dispose needle into appropriate sharps container

  27. Attach cap to syringe

  28. Thank patient

  29. Dispose of used equipment appropriately

  30. Wash hands
• Pulse oximetry (SpO2; SaO2)


  Used to monitor arterial oxygen saturation non-invasively
• Pulse oximetry


  • Performed either intermittently or continuously
  • Arterial oxygen saturation values are usually denoted with the symbol SpO2
  • Arterial oxygen saturation values measured invasively via ABG analysis are denoted by the symbol SaO2

  
• Pulse oximetry sites


  • Finger
  • Earlobe
  • Nose
  • Toe
• Normal pulse oximetry reading


  95-100% (within 2% of ABG)
• Venous O2 Sat (SvO2)

  Reflects the oxygen saturation level of venous blood
• Venous O2 Sat (SvO2) measurement

  1. Measured using central catheters placed in the brachial vein or at the chest part near the heart and pulmonary area

  2. Attached to a sensor that gives the SvO2 number

  3. SvO2 sample obtained from the most distal port of the pulmonary artery (PA) catheter, which contains the ideal mix of all venous blood in the heart

  
• End Tidal CO2 (ETCO2)

  Carbon dioxide concentration at end expiration
• ETCO2 monitoring


  1. A photodetector measures the amount of infrared light absorbed by the airway during inspiration and expiration

  2. ETCO2 monitor converts these data to a carbon dioxide value and a corresponding waveform, or capnogram
• ETCO2 monitoring categories


  • Colorimetric - use of pH sensitive strips
  • Capnometric - numerical display
  • Capnographic - wave display
• Normal ETCO2 range


  30-43 mmHg
• Mechanical ventilation


  Use of a machine to move air into a patient's lungs
• Indications for mechanical ventilation

  • Acute respiratory failure
  • Respiratory center depression
  • Neuromuscular disturbances

  
• Modes of ventilatory control

  • Volume-cycled
  • Pressure-cycled
  • Time-cycled
• Nursing considerations for mechanical ventilation

  • Provide emotional support to the patient
  • Turn on the ventilator alarms at all times
  • Assess cardiopulmonary status frequently, at least every 2 to 4 hours or more often
• Volume-cycled ventilation


  Delivers a preset volume of air each time, regardless of the amount of lung resistance; most common
• Pressure-cycled ventilation


  Generates flow until the machine reaches a preset pressure, regardless of the volume delivered or the time required to achieve the pressure
• Time-cycled ventilation


  Generates flow for a preset amount of time
• Nursing considerations for mechanical ventilation

  • Provide emotional support to the patient to reduce anxiety and promote successful treatment
  • Turn on ventilator alarms to alert to hazardous conditions and changes in patient status
  • Assess cardiopulmonary status frequently
  • Be alert for complications associated with mechanical ventilation
• Common mechanical ventilation complications

  • Barotrauma
  • Volutrauma
  • Atelectrauma
  • Hypotension
  • Gastrointestinal problems