NUR356- COMPLEX NURSING CARE
1- WEEK 1 08-02
Chain of Prevention - answer Education- Education provided by the hospital/workplace
in regards to early deterioration
Monitoring- performing vitals signs and documenting acurately in the ADDS chart.
Recognition- Adding up score in ADDS chart and following track and trigger chart. Any
concerns about patient
Call for help- Escalating care appropriatley as per ADDS chart eg). review by
coordinator and notifying doctor. MET call. Anyone can "call for help".
Response- ALS trained staff
ADDS CHART AND THE DETERIORATING PATIENT - answer- Recognise failing
respiratory, cardiovascular, and neurological.
- Allocates points to measure routine vital signs. The total score indicates the level of
intervention required
- An increased score indicates an increased risk of deterioration and death.
- The purpose of these charts is to support timely recognition of clinical deterioration,
and prompt action when deterioration is observed.
- The score also determines the frequency of observations
ALS VS BLS - answerBLS relates to basic emergency procedures including CPR, basic
first aid and an automated defibrilator. ALS involves advanced interventions including
resus medications, advanvanced airway management and a manual defib that can be
overrided. The nurse will analyse the rythm and decide if it is a shockable rythm and
how mant jules to use.
ALS flow chart - answer•ALS is a standardized approach to cardiac arrest management
•Nurse to analyse the rhythm and decide if it's a shockable rhythm such as VF or
pulseless VT or to continue with CPR if it's Asystole or PE
Adrenaline - answerShockable and Non-Shockable
1mg bolus (10ml of 1:10,000) or (1ml 1:1000 with 20 ml flush)
•Vasoconstriction leads to an increase in coronary and cerebral perfusion
•Increases coronary and cerebral blood flow
Amiodarone - answerShockable Only
300mg bolus diluted in 20ml of 5% dextrose
•Anti-arrhythmic
•Increases the duration of the action potential and refractory period in atrial and
myocardium
, •AV conduction is slowed
Ventricular Fibrillation (VF) - answerShockable rhythm. A condition in which the heart's
electrical impulses are disorganized, preventing the heart muscle from contracting
normally.
Ventricular Tachycardia (VT) - answerShockable rythm with a rate usually above 100
bpm. rhythm usually regular. no P wave or it appears after QRS complex with
retrograde conduction.
Asystole/PEA - answerNON- SHOCKABLE
Always check for pulse
CPR
PEA- nil pulse and electricity still in heart.
4Hs and 4Ts and importance in resusitation - answerHYPOXIA- Ventilation adequedtly
during CPR
HYPOVOLAEMIA- Hemorage, obvious trauma, less obvious trauma AAA. Anaphylais
and sepsis
HYPER/HYPOKALAEMIA- metabolic disorders
HYPO/HYPERTHERMIA- drowning or trauma
TENSION PNEUMOTHORAX- trauma or pt's with mertaseses
TAMPONADE- compression of heart due to collection of fluid around heart.
TOXINS- deliberate/ non deliberate igestion of toxins
THROMBOSIS- pulmonary/ heart or lungs.
Post resuscitation care - answerROSC (Return of spontanious circulation).
Re-eveluate A-E assessment
12 lead ECG
Treat precipitating causes- 4H/4T- regular ABG's
Aim for 94-98 SP02%- hypoxia
Normocapnia (acceptable level of C02 in blood) and normoglycemia (acceptable blood
glucose level).
Endotracheal tube indications - answer•Upper airway obstruction
•Apnea
• High-risk aspirations
•Ineffective clearance of secretions
•Respiratory distress
•Respiratory/cardiac arrest
Endotracheal tube equipment - answer•Suction
•Laryngoscope
•Cuffed ETT tube
•Lubricant
•Syringe for cuff inflation
1- WEEK 1 08-02
Chain of Prevention - answer Education- Education provided by the hospital/workplace
in regards to early deterioration
Monitoring- performing vitals signs and documenting acurately in the ADDS chart.
Recognition- Adding up score in ADDS chart and following track and trigger chart. Any
concerns about patient
Call for help- Escalating care appropriatley as per ADDS chart eg). review by
coordinator and notifying doctor. MET call. Anyone can "call for help".
Response- ALS trained staff
ADDS CHART AND THE DETERIORATING PATIENT - answer- Recognise failing
respiratory, cardiovascular, and neurological.
- Allocates points to measure routine vital signs. The total score indicates the level of
intervention required
- An increased score indicates an increased risk of deterioration and death.
- The purpose of these charts is to support timely recognition of clinical deterioration,
and prompt action when deterioration is observed.
- The score also determines the frequency of observations
ALS VS BLS - answerBLS relates to basic emergency procedures including CPR, basic
first aid and an automated defibrilator. ALS involves advanced interventions including
resus medications, advanvanced airway management and a manual defib that can be
overrided. The nurse will analyse the rythm and decide if it is a shockable rythm and
how mant jules to use.
ALS flow chart - answer•ALS is a standardized approach to cardiac arrest management
•Nurse to analyse the rhythm and decide if it's a shockable rhythm such as VF or
pulseless VT or to continue with CPR if it's Asystole or PE
Adrenaline - answerShockable and Non-Shockable
1mg bolus (10ml of 1:10,000) or (1ml 1:1000 with 20 ml flush)
•Vasoconstriction leads to an increase in coronary and cerebral perfusion
•Increases coronary and cerebral blood flow
Amiodarone - answerShockable Only
300mg bolus diluted in 20ml of 5% dextrose
•Anti-arrhythmic
•Increases the duration of the action potential and refractory period in atrial and
myocardium
, •AV conduction is slowed
Ventricular Fibrillation (VF) - answerShockable rhythm. A condition in which the heart's
electrical impulses are disorganized, preventing the heart muscle from contracting
normally.
Ventricular Tachycardia (VT) - answerShockable rythm with a rate usually above 100
bpm. rhythm usually regular. no P wave or it appears after QRS complex with
retrograde conduction.
Asystole/PEA - answerNON- SHOCKABLE
Always check for pulse
CPR
PEA- nil pulse and electricity still in heart.
4Hs and 4Ts and importance in resusitation - answerHYPOXIA- Ventilation adequedtly
during CPR
HYPOVOLAEMIA- Hemorage, obvious trauma, less obvious trauma AAA. Anaphylais
and sepsis
HYPER/HYPOKALAEMIA- metabolic disorders
HYPO/HYPERTHERMIA- drowning or trauma
TENSION PNEUMOTHORAX- trauma or pt's with mertaseses
TAMPONADE- compression of heart due to collection of fluid around heart.
TOXINS- deliberate/ non deliberate igestion of toxins
THROMBOSIS- pulmonary/ heart or lungs.
Post resuscitation care - answerROSC (Return of spontanious circulation).
Re-eveluate A-E assessment
12 lead ECG
Treat precipitating causes- 4H/4T- regular ABG's
Aim for 94-98 SP02%- hypoxia
Normocapnia (acceptable level of C02 in blood) and normoglycemia (acceptable blood
glucose level).
Endotracheal tube indications - answer•Upper airway obstruction
•Apnea
• High-risk aspirations
•Ineffective clearance of secretions
•Respiratory distress
•Respiratory/cardiac arrest
Endotracheal tube equipment - answer•Suction
•Laryngoscope
•Cuffed ETT tube
•Lubricant
•Syringe for cuff inflation
