NCM 118 SKILLS FINALS PDF

CONTINUOUS AMBULATORY PERITONEAL WHAT IS DIALYSIS DIALYSIS (CAPD) Is the process of osmosis and diffusion This is a recent variation of peritoneal used to reestablish fluid and electrolyte...

CONTINUOUS AMBULATORY PERITONEAL WHAT IS DIALYSIS DIALYSIS (CAPD) Is the process of osmosis and diffusion This is a recent variation of peritoneal used to reestablish fluid and electrolyte dialysis. It involves infusing 500 to 1,000 balance ml of personalized dialysate through a To remove toxic substances and peritoneal catheter, clamping the metabolic wastes. catheter with the empty bag still attached, rolling the bag up, and placing DIFFUSION it in a waistband, with the client then going about his usual activities. Is the passage of ions from an area of high concentration across a Every 4 hours the client drains the fluid semipermeable membrane to an area from his peritoneal cavity into the of lower concentration. empty bag of dialysate, and repeats the infusion. OSMOSIS MAJOR COMPLICATIONS OF CAPD: Is the passage of water molecules across a semi-permeable membrane 1. Peritonitis from a less concentrated solution to a more concentrated one. 2. Fluid and Electrolyte Imbalance ALL ABOUT DIALYSIS: MAJOR COMPLICATIONS OF CAPD: PERITONEAL DIALYSIS 1. Peritonitis A commercially prepared sterile 2. Fluid and Electrolyte Imbalance dialysate, an electrolyte solution, flows 3. Dehydration by gravity through a catheter inserted through the abdominal wall into the 4. Catheter Sepsis peritoneal cavity. 5. Abdominal Pain and tenderness After the solution has remained in the peritoneal cavity for the prescribed 6. Organ Trauma time, the dialysate is removed. The 7. Hemorrhage physician will order this process repeated until the client’s fluid and electrolytes fall within acceptable limits. HEMODIALYSIS PERITONEUM Uses a machine that contains semi- Acts as the semipermeable membrane permeable membranes in a dialysate for osmosis and diffusion. solution prepared according to the client’s electrolyte values.  Diffusion and ultrafiltration occur after Dialysis fluid enters the peritoneum. the client’s heparinized arterial blood runs through the machine and returns The fluid remains in contact with the through one of the client’s veins. This peritoneum for 20 to 30 minutes while process continues until the client’s fluid dialysis occurs. and electrolyte values fall within the Post-dialysis waste products drain from limits set by the physician. the peritoneal cavity. NURSING MEASURES IN HEMODIALYSIS NURSING MEASURES IN PERITONEAL DIALYSIS 1. Observe carefully for breaks or kinks in 1. Ask the client to urinate before you membranes to prevent hemorrhage. insert the catheter into the peritoneum, 2. Monitor the chemical composition of to prevent bladder puncture. the dialysate solution, the fluid rate and 2. Warm the bottles of dialysate in warm pressure, and blood clotting time water. (anticoagulants are administered throughout hemodialysis). 3. Permit 2 liters of dialysate to flow unrestricted into the peritoneal cavity 3. Provide shunt care: (this should take about 10 minutes) Keep the area clean, dry and sterile. 4. Allow fluid to remain in the cavity for Observe the internal shunt for patency. the time ordered by the physician If it is working, you can feel a thrill on (about 20 to 30 minutes) palpation or hear a bruit with a 5. Reverse the bottles; allow fluid to drain stethoscope; if the shunt is discolored from the peritoneal cavity unrestricted patency is questionable. (about 20 to 30 minutes). Facilitate Immediately report clotting to the drainage by changing the client’s physician. position or massaging the abdomen. Avoid trauma to the extremity with the 6. Keep accurate intake and output records related to the amount of shunt (no blood pressure measurement, intramuscular or intravenous dialysis fluid entering the peritoneal medications, or blood drawn). cavity and the amount in the drainage. Have clamps available to prevent Important: Remove all dialysis fluid. exsanguination if the shunt disconnects. Nursing Consideration Before, During and After 4. Provide comfort for the client. Dialysis NURSING BEHAVIORS NURSING RATIONALE PERITONEAL DIALYSIS Before Dialysis:  infection, arrythmias. Explain the Explanations help and shock. procedure reduce the client’s After Dialysis: Arrhythmias pose a anxiety. Monitor the client’s threat. A client who pulse rate and blood loses fluid too rapidly. Weigh the client, This information pressure every 15 will go into using a bed scale, and establishes a baseline minutes until the hypovolemic shock. measure the client’s for future comparison client become stable, vital signs then every 4 hours.. Place the client in a. The client, must comfortable supine or remain in one position. Monitor the client’s This identifies when semi-reclining for 6 to 8 hours. weight daily and the client will need position. temperature every 4 dialysis again, and to During Dialysis: hours. monitor infection as it poses a possible Provide emotional. This will assist in complication reassurance to the decreasing their client and family anxiety. throughout the procedure. During peritoneal. This will prevent dialysis, carefully muscle stiffness and TRIAGE provide passive soreness. With range-of-motion hemodialysis, the arm -comes from the French word tier, meaning “to exercises to all the or leg with the shunt sort”. limbs of a client, and is left unexercised to during hemodialysis, avoid dislodging the It is used to sort patients into groups to every limb except catheter. based on the severity of their health problems the arm or leg with and the immediacy with which these problems the shunt must be treated.. Maintain aseptic. Aseptic technique technique in helps prevent This includes the identification of an peritoneal dialysis, infection, a potentially appropriate hospital destination and method of with care of the serious complication. transport and is based on the patient's age and peritoneal catheter medical problem or type of trauma, an and the area around objective measure of the acuity of the it, and in hemodialysis, with all condition, and the distance from an Emergency tubing connections Department. and at the shunt site.. Monitor the client’s. Monitoring the vital OBJECTIVES OF TRIAGE vital signs every 15 signs helps determine minutes (blood whether the client is The triage levels assist the nurse in precisely pressure will go down losing fluid too determining the needs of the patient and the as the body loses rapidly; early urgency for treatment. fluid). detection can prevent complications, such as  Triage is classifying clients according to interpretation of civilian emergency their need for care and establishing priorities of departments using triage care; the kind of illness, the severity of the problem and the resources available. Categories: Historical Perspective: Triage Emergent – Highest priority origin Urgent – have serious health problems but are not life-threatening; is still Non-urgent – those who have episodic unknown...... illnesses without increased morbidity “Fast-track”- requires simple first aid or basic primary care. Therefore, French studies and the origin of triage shown in domestic and foreign published works have been investigated and its significance reaffirmed. Standardized Triage System (5-level triage system) The etymology of the word “triage” means “to break into three pieces.” It TRIAGE LEVEL I: RESUSCITATION was suggested by a literature review that the rise of Napoleon led to military These are conditions requiring immediate tactical changes and that the prototype nursing and physician assessment. Any of triage arose from experience gained delay in the treatment is potentially life or in the difficult campaign in Egypt and limb-threatening. Syria. Conditions include: Subsequently, triage was refined by a. Airway compromise Napoleon's military surgeon, D. J. b. Cardiac arrest Larrey, who created the ambulance c. Severe shock transport system d. Cervical spine injury Multisystem Baron Dominique Jean Larrey - A trauma French military chief surgeon in e. Altered level of consciousness (LOC) Napoleon Bonaparte's imperial guard, (unconsciousness) developed a system based on the need f. Eclampsia to evaluate and categorize wounded soldiers quickly during battle Weinerman et al- 1964 - The triage system was first implemented in hospitals. Published a systematic  TRIAGE LEVEL II: EMERGENT These are conditions requiring nursing Conditions include: assessment and physician assessment Alert head injury Minor trauma within 15 minutes of arrival without vomiting Vomiting and diarrhea Earache in patient older than age 2 without Head injuries Chemical exposure to evidence of the eyes dehydration Severe asthma Severe headache Minor allergic reaction Corneal foreign body Severe trauma Chest pain Chronic back pain Pain in patients older Any pain greater than 7 than age 50 on a scale of 10 Lethargy or agitation Back pain Vomiting and diarrhea Any sexual assault with dehydration Conscious overdose GI bleed with unstable TRIAGE LEVEL V: NON-URGENT vital signs Fever in infants younger Any neonate age 7 days These are conditions requiring nursing than 3 months or younger and physician assessment within 2 Severe allergic reaction Stroke with deficit hours. Acute psychotic episode Conditions include: a. Minor trauma, not acute TRIAGE LEVEL III: URGENT b. Sore throat c. Minor symptoms These are conditions requiring nursing and d. Chronic abdominal pain physician assessment within 30 minutes of arrival Emergency Department Triage Conditions include: System a. Alert head injury with vomiting (may be according to individual hospital b. Mild to moderate asthma protocol) c. Moderate trauma d. Abuse or neglect e. GI bleed with stable vital signs f. History of seizure, alert on arrival TRIAGE LEVEL IV: LESS URGENT These are conditions requiring nursing and physician assessment within 1 hour.  except oral or topical refill medications, or Emergency Department Triage System: prescriptions NON-URGENT (GREEN): Priority 3 Emergency Assessment This classification is given to clients A systematic approach to the assessment of an with local injuries who do not have emergency patient is essential. immediate complications and who can wait for several hours for medical The most dramatic injury is not the most treatment. serious. Emergency Severity Index (ESI) The primary and secondary assessment provide the emergency nurse with a methodical The Emergency Severity Index (ESI) is a approach to help identify and prioritize patient five-level emergency department (ED) needs. triage algorithm that provides clinically relevant stratification of patients into A (Airway)- Does the patient have an open five groups from 1 (most urgent) to 5 airway? (least urgent) on the basis of acuity and resource needs. a. Is the patient able to speak? b. Check for airway obstructions such as loose teeth, foreign objects, bleeding, vomits or other secretions. LEVEL DESCRIPTION EXAMPLES NOTE: Immediately treat anything that Immediate, life- Cardiac saving intervention arrest compromises the airway. 1 required without Massive delay bleeding B (Breathing)- Is the patient breathing? Cardiac- High risk of related a. Assess for equal rise and fall of the deterioration, or 2 chest pain signs of a time-critical Asthma chest (Check for bilateral breath problem sounds), respiratory rate and pattern, attack Stable, with multiple skin color, use of accessory muscles, types of resources Abdominal integrity of the chest wall and position needed to investigate pain 3 or treat (such as lab High fever of the trachea) tests plus X-ray with cough imaging) NOTE: All major trauma patients require Stable, with only one supplemental oxygen via a non-re-breather Simple type of resource mask laceration 4 anticipated (such as Pain on only an X-ray, or only sutures) urination C (Circulation)- Is circulation in immediate Stable, with no Rash jeopardy? 5 resources anticipated Prescription  a. Can you palpate the central pulse? 2. Indwelling What is the quality (strong, weak, slow, urinary catheter rapid)? 3. Gastric tube b. Is the skin warm and dry? 4. Laboratory c. Is the skin color normal? studies d. Obtain a blood pressure (in both arms if 5. Pregnancy chest trauma is suspected). test (if applicable) D (Disability)- Assess level of F- Facilitate family presence consciousness and pupils (a more complete G- Give comfort measures neurologic survey will be completed in the secondary survey). Different Methods of Triage Assess LOC using the AVPU scale: A- Is the patient alert? V- Does the respond to voice? P- Does the patient respond to painful stimulus? U- The patient is unresponsive even to painful stimulus 2. Secondary Assessment Different Methods of Triage The secondary assessment is a brief but thorough, systematic START- Simple Triage and Rapid assessment designed to identify all Treatment injuries. SALT- sort, Assess, Life-saving Steps: (EFFGH) interventions, and Treatment/Transport E- Expose/ environmental ATS- Australasian Triage Scale control CTAS- Canadian Triage and Acuity Scale F- Full set of vital signs MTS-Manchester Triage System F- Five interventions: ESI- Emergency Severity Index 1. Pulse oximetry Method commonly used in triage is a triage method used by first responders to quickly classify victims during a mass casualty incident(MCI) based on the severity of their injury. It was developed at Hoag Hospital in Newport Beach, California for use by emergency services