PP3 Study notes .pdf

Primary phase: Evaluate A-E: Airway- pt A +O, maintain c spine, jaw thrust head tilt?, obstructions (vomit/blood/tongue/teeth) Breathing- Is the patient breathing, RR, depth, rise and fall of the chest, is the breathing symmetrical, WOB? Circulation- external haemorrhage? HR, warmth of skin,...

Primary phase: Evaluate A-E: Airway- pt A +O, maintain c spine, jaw thrust head tilt?, obstructions (vomit/blood/tongue/teeth) Breathing- Is the patient breathing, RR, depth, rise and fall of the chest, is the breathing symmetrical, WOB? Circulation- external haemorrhage? HR, warmth of skin, cap refill, ECG?, IVF, bloods?, IVC insertion Disability- LOC, BSL, Exposure- remove clothing, rash?, external bleeding?, maintain pt warmth, core temp Secondary phase Full set of OBS History- Ask pt or family Get monitoring devices and give comfort- Bloods, telemetry?, NGT/OGT?, SP02?, pain assessment, History and head to toe- Inspect and palpate the body; Head to chest, Abdo, Pelvis and perineum and Extremities Monitor- vital signs, injuries, primary assessment? And manage pain Documentation  Pain assessment OPQRST Onset: when did it start? What was the pt doing when it started? Provocation: what makes the pain better or worse? Rest? Repositioning? Medication? Quality: describe the the pain, sharp? dull? constant? Radiation: does the pain spread? Severity: how pain is the pain? 0-10? Timing: how long? getting better or worse over time? Pain assessment - FLACC Face: 0= no expression 1= frown or withdrawn 2= clenched jaw and frown Legs: 0= relaxed 1= restless 2= kicking Activity: 0= normal 1= squirming 2= jerking Cry: 0= no cry 1= moans 2= crying Consolability: 0= relaxed 1= touching and needs a hug 2= difficult to console HIPPA History : pt history Inspection: sight, sound and smell Palpation: touch and sound Percussion: touch and sound Auscultation: sound via stethoscope  Respiratory assessment IPPA assessment- Systematic approach Inspection: RR- SP02 needed? shape of thorax, symmetry of chest- sign of distress? normal r pattern? , superficial veins- IVC? Nasal flaring? Pursed lips? Tracheal tug? Palpation: chest wall tenderness? Pain? Feel bilateral- note any differences Percussion: normal- hollow dull- pe or consolidation note; pitch and duration Auscultation: listen to whole breath in and out, SOB? Words or sentences? Loud? Crackles or rhonchi? Wheeze? Cough- dry or moist? Breath sounds: Normal lung sounds Bronchial sounds: high pitched, loud and blowing Vesicular sounds: breezy sounds Bronchovesicular sounds: loud and medium-pitched, 1st and 2nd ICS Breath sounds: abnormal sounds Crackles: fine sounds indicating fluid Wheeze: high pitched Pleural rub: creaking Rhonchi: low pitched  Additional assessments Imagaing: CXR, CT, MRI, VQ scan Pathology- FBC, UES, BC AND ABG Spiromtery Hypoxia= low levels of oxygen in body looks like; decrese in LOC, tachypnoea, pallor, unstable OBS, WOB, cyanosis Mangement: Assessment, est airway + breathing, positioning, oxygen, reverse the cause, chest physio Croup= upper airway obstruction looks like; narrowing of airway, barking cough or voice, SOB, wheeze Asthma= inflammatory disease of lower airways (chronic) looks like; chest pain, SOB, changes in LOC, febrile, clammy, cough, wheezing treat with bronchodilators COPD= inflammation of bronchitis causing swelling that lints airway in + out of lungs looks like; cough, fatigue, SOB, dyspnea, wheeze Pneumonia= infection that causes inflammation and fluid within the alveoli HAP= occurs >48hrs post-admission, due to immobility, Post-op aspiration or aspiration PE= Blockage of pulmonary arteries by thrombus, fat or air embolus, or tumour tissue Pneumothorax= air leaking into the pleural space resulting in a partial or complete lung collapse  Cardiac assessment IPPA assessment- Systematic approach Inspect: inspection of chest wall, cyanosis? Pallor? Inspect JVD, look at extremities- peripheral oedema? DVT? Palpation: peripheral pulses- rhythm, rate, strength, oedema?, base of heart- pulsations, epigastric AAA+? cap refill 30mmHg = fasciotomy Signs and symptoms: Pain- limbs can cause extreme pain Pressure- increased pressure within muscles, limbs tight on palpation Pulses- normal, no pulse= late stage Paraesthesia- numbness, tingling or loss of sensation Paralysis- decreased movement Palllor- skin becomes pale and cool Poikilothermia- decreased core temp  Pre and post op assessment Pre-op prep ID band + allergies Dentures / contact lens / dental prosthesis ECG Implantable devices Special prep shave? Bowel prep etc NBM- solids 6 hrs and water 2 hour prior to surgery Post-op care A- patent B- RR, breath sounds, oxygen? And pulse oximetry C- ECG, OBS, cap refil, temp D- LOC, GCS, sensory and motor status, PEARL G- IVF, urine output, EBL Preventing post-op complications intake and output, blood results, VTE, pain management, prevent nausea Fluids and electrolytes- Maintenance of homeostasis Electrolytes= sodium, potassium, magnesium, phosphate, sulfate IVT= sustaining fluids, electrolytes and medications Types of IVF Isotonic (having same concentration of solutes as blood plasma = Restore vascular volume) Hypertonic (greater concentration of solutes than plasma) Hypotonic (lesser concentration of solutes than plasma) History- presenting problem and past medical hx PQRST Inspection- contour, symmetry, scars, reps movement 7 Fʼs of distension ‒ fat, fluid, fetus, flatus, faeces, ʻfilthyʼ big tumor, ʻphantomʼ pregnancy. Auscultation- RLQ, RUQ then LUQ, LLQ normal bowel sounds = 5-35 times per min Abnormal= 5 mins 0 sounds, high pitched, tinkling Percussion- Detects position, size and density of the abdominal organs Dullness over- fluid or mass Palpation- tenderness, guarding, swelling and masses NGT= decompress stomach by emptying accumulated gas and fluid People who are unable to take adequate nutrition: dysphagia Unresponsive anorexia Seriously ill Special considerations on an NGT= decreased LOC, cervical spinal cord injury, nasal injuries, skull fractures, active upper GI bleed, abnormalities of the oesophagus Measure from nose to tragus to middle of abdomen for NGT size Post insertion= X-ray to indicate NGT is in the stomach not the lungs Documentation: type and size, ease of insertion, confirmation of placement, what is it connected to eg suction, Complications Re-feeding syndrome= fluid retention and electrolyte imbalances in pts with serve malnutrition when referring beings Consider the pt situation: person and context Collect cues and information: review information, gather new information, recall knowledge Process information: analyse cues, narrow down information Identify the problem and issue: facts to make a nursing diagnosis Establish goals: what you want to happen Take action: course of action Evaluate outcomes: effectiveness of outcomes Reflect on precess and new learning: what have you learnt