232 quiz Flashcards

Question

primary survey letters meaning

Answer 1

``` Danger, Response, Send for help A – Airway with cervical spine control B – Breathing and ventilation C – Circulation with haemorrhage control D – Disability (eg neurological) E – Exposure with temperature control ```

Answer 2

Primary survey is conducted prior to a Secondary Survey (Secondary Survey as described in one of the NUR231 OLTs and 3rd Year) - Do everyday very quickly with all patients - Do in order of priority - Is a cycle - Each component MUST be fixed before moving onto the next - It is a dynamic process, you are constantly checking and re-checking - Conducting a Primary Survey is contextual - Unconscious patient in ED - Remote area nurse called to road accident - Collapsed patient on the ward - Requires sound assessment skills - Skills develop with experience - Grab your learning opportunities on Prac.

Answer 3

Danger- even in hospital;, response “hello can you hear me’’ 2.A= airway- any vomit, blood, secretions,loose teeth 3.Don PPE, suctioning, Head tilt chin lift, jaw thrust, oropharyngeal airway/ Guedel - Suction only as far as can see DOWN SIDES, go in without occluding the suction port- only occlude when going out (suctioning) - 2 fingers under chin and firm palm on forehead while gently tilting forehead backwards (chin tilt) - place thumbs either side of patients cheeks, find angle of jaw placing 2 fingers underneath there gently pushing that forwards (jaw thrust) - measure gudel from ear to middle of incisor, can use gudel to open airway 1) upside down then turn or use tongue compressor and place straight in Is patient gags, looks like they’ll vomit. REMOVE 4. B= Breathing- look, listen and feel for breaths - Bag valve mask delivers o2, put over nose and mouth, provide breaths for patient using it 5. C=Circulation- radial pulse on patient, feel for more central pulse such as carotid 6. D=Disability- use pneumonic AVPU (alert, to voice, to pain or unresponsive), GCS 7. E=exposure- little bit at a time. Face, top half of body, legs, genitalia (usually in conjunction with putting a catheter in if necessary), log roll if necessary and look over posterior surfaces

Answer 4

Danger- response- send for help. Out in the community- schools, shopping centre, the home, in a plane etc.

Answer 5

cervical spine. Look for danger, response, airway, etc. following DRSABC then escalating as required

Answer 6

Jaw thrust and chin lift/ tilt. And oropharyngeal airway (gudel)

Answer 7

2 fingers under chin and firm palm on forehead while gently tilting forehead backwards (chin tilt) The head-tilt chin-lift is the primary manoeuvre used in any patient when cervical spine injury is NOT a concern 7 [Level GPP]. • Place one hand on patient’s forehead and tilt the head gently back (the head, not the neck is tilted backwards) • The other hand is used to provide the chin lift. Placing the tips of the index and middle finger of the second hand, lift the mandible at the mentum, which lifts the tongue from the posterior pharynx 7 [Level GPP]. Refer to figures 3 and 4a • Alternatively, the chin is held up by the thumb and fingers in order to open the mouth and pull the tongue and soft tissues away form the back of the throat

Answer 8

place thumbs either side of patients cheeks, find angle of jaw placing 2 fingers underneath there gently pushing that forwards (jaw thrust The jaw thrust is an alternative manoeuvre, particularly in the patient in whom cervical spine injury is a concern. This manoeuvre moves the tongue anteriorly with the mandible, minimising the tongue's ability to obstruct the airway. With the patient supine and the clinician standing at the head of the bed 7 [Level GPP]: • Identify the angle of the mandible • Place index and other fingers behind the angle of the mandible and apply upwards and forward pressure to lift the mandible • Using the thumbs, slightly open the mouth by downward displacement of the chin

Answer 9

Vomit- suctioning Choking on foreign bodies- chest thrust and back blows, chin tilt/ jaw thrust Relaxation of airway muscles in unconscious person- oropharyngeal airway Anaphylactic reaction- oropharyngeal airway

Answer 10

a bag valve mask

Answer 11

oropharyngeal and nasopharyngeal airways

Answer 12

Vital signs, signs and sources of haemorrhage, mental status, peripheral pulses, skin pallour

Answer 13

11. The most common method of fluid replacement is via intra venous transfusion. If this method is not possible then intra osseous fluid transfusion may be conducted

Answer 14

Alert, voice, pain, unresponsive The pupil response should also be assessed (if possible depending on the situation).

Answer 15

13. ‘E’ for exposure means that the person has all of their clothing removed (an area at a time) so that a full visual assessment can be conducted. An awareness of the person’s temperature is important as full exposure of the body may quickly result in hypothermia.

Answer 16

14. Importantly, Primary Survey is what is called a dynamic process You are constantly checking and re-checking, and adapting to each person’s individual situation

Answer 17

6 rights- drug, dose, individual, time, route and documentation

Answer 18

identify indication verify validity of order wash hands Check patient’s identification (this may be patient sticker)- check for recorded allergies! Check drug name, dose, route, time, frequency, indications and prescribers’ signature Depending on the facility you are working at you may be required to scan or use key access to enter the medication storage room You will then need to locate the area where the medication you require is stored Assess the need for physiological observations or drug specific monitoring prior to medication administration. Consider the following: • Last dose and time medication administered (ensure documented) • Blood monitoring e.g. International Normalisation Ratio (INR), gentamycin level • Liaise with Shift Coordinator/MO/NP/Pharmacist as appropriate • Blood pressure e.g. prior to administering ace inhibitors, beta blockers • Heart rate e.g. when on beta blockers, or digoxin therapy • Administering medications pre or post food or fasting states • Effects on planned procedures e.g. no anti-hypertensives to be administered prior to haemodialysis Retrieve medications from a locked cupboard/drawer and key to be retained by nursing staff. • Right patient - i.e. check name/unit number/Date of Birth (DOB) on the patient’s identification (ID) band against Medication Chart AND ask patient to state their name and DOB (if able). If no ID band in situ, apply one immediately if applicable. • There are some situations where a patient may not be able to wear a patient identification band, including: mental health patients, patients who refuse to wear the patient identification band, patients who cannot wear a patient identification band because of their clinical condition or treatment 6 [Level GPP]. In these circumstances, identification confirmation to be sought in the order listed (1) photo identification, (2) verbal identification (incorporating the 3 point identification checks) or (3) visual identification confirmed by 2 clinical staff • For outpatients (no identification band in situ) the patient’s name, address and date of birth must be verbally confirmed by the patient/carer against the health care record identification label 6 [Level GPP] • If the patient requires any infusions or complex therapies an ID band must be in situ • Right medication/drug (including expiry date) • Right dose • Right route • Right time • Right documentation • Check for any allergies/adverse reaction/s Explain procedure to the patient. Provide specific medications education 1 [Level GPP] • Administer prescribed medication

Answer 19

Pay attention to drugs with similar names and varying doses Always check the foil strip inside the box is the correct drug and dose Check the expiry date on the package

Answer 20

Dispense required number of tablets into a medicine cup using non touch technique Check patient sticker on medication chart against patient identity band and/ or confirm with the patient verbally Remember to position the patient appropriately for taking medications and assess effectiveness of medication. Use …. Assessment tool (vital signs, pain assessment tool..?)

Answer 21

Finally, will need to sign for the medication, completing date and ensuring to sign for the correct time Many drugs have specific administration requirements. E.g. Ibuprofen should never e administered on an empty stomach ( always with milk or food). Mims has this information Sign Medication Chart and lock medication drawer (as appropriate

Answer 22

tablets, capsules, lozenges/pastilles, elixirs, linctus/syrups and mixtures.

Answer 23

Liaise with MO if patient is not able to tolerate or take oral preparations and seek alternative prescription • If patient is unable to swallow tablet (refer to Dysphagia SDLP as patient may be at risk of aspiration): • Consider use of liquid formula or alternative route • It is recommended that crushed medications are administered individually to avoid potential drug interactions/compatibility • Liaise with pharmacist if any concerns

Answer 24

Cytotoxic medications as causes chemotherapy exposure (e.g. methotrexate) • Modified release (enteric coated or slow release) tablets or capsules as this can alter the rate of release of drug 1 [Level GPP] Enteric coatings allow the medication to remain intact in the stomach and to pass unchanged into the small bowel where the coating dissolves and the drug is released and absorbed 1 [Level GPP]. Slow/sustained release- release the active ingredient over a period of time to extend the duration of effect

Answer 25

• If prescribed dose requires tablet to be halved or quartered, discard any remaining portion into the clinical waste/sharps container ensuring that the medication is not identifiable. Any remaining tablet fragments are not to be kept and/or administered

Answer 26

• Enteral syringes MUST be used if administering enteral liquid medications, (refer to figure 5) as the reverse Luer lock connection is NOT compatible with IV tubing Critical incidents have occurred when oral liquid medicines have been administered via both the IV and subcutaneous (subcut) routes

Answer 27

hand hygiene

Answer 28

``` Intramuscular injections (IMI) deposits medication deep into the muscle layer, where the vascularity of the muscle aids the rapid systemic action and the absorption of relatively large doses of up to 5mL in appropriate sites Sites: deltoid (upper arm), dorsoglutea 9buttocks)l, rectur femoris, vastus lateralis (thigh muscles) and ventrogluteal muscles (side of hip) ```

Answer 29

1. All meds should be drawn up in a blue tray, or as per the policy of the hospital Syringe size should be chosen to match the injection volume as close as possible -Drawing up (blunt) needles should be used in all cases where the syringe is not pre filled -Safety needles should always be used (come with caps that flick over the sharp end of the needle after insertion and prior to disposal 2. 6 rights- time, drug, dose, route, patient, documentation 3. Check local policy for cleansing solution to be used 4. Ensure needle is 90 degrees to the skin. Hold firmly down with one hand 5. Holding firmly in place with 1 hand, check local policy for drawing back on needle- recent evidence suggests not necessary 6. Ensure no blood in the syringe, this should be one smooth movement 7. Please note that manufacturers advice is to çlick’ the safety device over the used needle on a hard surface- not with your fingers. It is safer to keep your fingers away from the used needle at all times

Answer 30

IMI injections may be contraindicated in patients who/ have: • Are immunocompromised • Moderate /severe acute illness • Impaired coagulation mechanisms • Peripheral vascular disease, oedema, shock as these conditions impair peripheral absorption

Answer 31

Potential Complications • Fibrosis and contracture of the muscles • Nerve injuries/palsy • Arterial puncture/haematoma formation • Local irritation/infection/abscess • Neuropathy • Abscess

Answer 32

Thick muscle, relatively free of major nerves and blood vessels capable of absorbing large volume 2,3 [Level GPP]. Commonly used for antibiotics, antiemetic’s, deep IM and z-track injections in oil, opioids & sedatives 2 [Level GPP] • Ventroguluteal site is the safest site for an IMI injection and should be used for patients with no muscle wasting in this area 2 [Level GPP] • Locate ventrogluteal site by placing palm of hand against the greater trochanter of the femur and the index finger on the anterior superior iliac spine of the pelvis (right hand to left hip, left hand to right hip) 3 [Level GPP] • Extend the middle finger posteriorly along the iliac crest 3 [Level GPP] • Inject between the ‘V’ of two fingers 3 [Level GPP]. • Up to 2.5 mL can be injected

Answer 33

The most accessible site but small area limits the number and volume of injections that can be administered 3 [Level GPP]. • Locate the deltoid muscle - palpate the lower edge of the acromion process which forms the base of the triangle in line with the midpoint of the lateral aspect of the upper arm • The injection site is in the centre of the triangle, about 2.5–5cm below the acromion process • Recommended maximum volume of fluid injected into the deltoid is 2 mL5 [Level GPP].Exception: In InvegaTrinza (injection of Paliperidone that lasts for 3 months).The deltoid is the recommended injection site ,despite the highest dose being 2.6ml

Answer 34

Use of the dorsogluteal site for IMI injection is not advised, it is accompanied by complications including damage to sciatic nerve and superior gluteal arteries. Muscle mass may have atrophied in older or non-ambulant patients. This muscle has the lowest drug absorption rate and this can result in a build-up in the tissues, increasing the risk of overdose 3 [Level GPP]. It appears that there is a risk that the medication will not reach the muscle due to the amount of subcutaneous tissue in this area • Locate the dorsogluteal muscle in the upper, outer quadrant of buttock approximately 5–8cm below the iliac crest • Palpate the posterosuperior iliac spine/crest and the greater trochanter of the femur. An imaginary line is drawn between the two anatomical landmarks • The injection site is above and lateral to the line • Up to 3mL can be injected at this site

Answer 35

The rectus femoris - anterior quadriceps muscle is used primarily for antiemetics, opioids, sedatives, injections in oil, deep intramuscular and Z-track injections. This site is rarely used by nurses but is easily accessible for self-administration of injections The vastus lateralis - no major blood vessels or significant nerve structures are associated with the site. Used for deep IMI and Z-track injections GPP].Up to 5mL can be injected • The vastus lateralis is located on the anterior lateral aspect of the thigh and extends from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur • The middle third of the muscle is the best site for injection

Answer 36

This technique should be used for all intramuscular injections: • Pull skin at the injection site taught and to one side (~1–2cm) with the thumb or side of the non-dominant hand and maintain this firm traction of the skin throughout the procedure • Insert needle with dominant hand into muscle at 90° angle leaving 0.5 cm of shaft exposed. This method prevents back-tracking of medications into tissue, decreases pain and injection site lesions which is essential when administering cytotoxic, iron or oil IMI • Draw back on plunger to ensure that needle is not in a blood vessel • If blood returns with draw needle, discard the needle and syringe. Recommence the administration process using a different site 3 [Level GPP] • If no blood is aspirated, slowly administer medication 1 [Level GPP] to allow the muscle fibres to expand to accommodate the drug • Wait a further 10 seconds before removing the needle and once it has been removed, only then release the traction (Z Tracking) on the skin 4 [Level GPP]. • DO NOT massage the site 1 [Level GPP]. Sign Medication Chart

Answer 37

1. Find the trochanter. This is the knobby top portion at the top of the femur 2. Find the anterior iliac crest. This is the thick rounded upper part of the ileum 3. Position your right hand to the patients left side if using the ventrogluteal site. Place palm of hand over the trochanter, pointing index finger towards anterior iliac crest 4. Spread the second finger toward the back of the iliac crest, making a V with your fingers 5. The njection site is in the middle of this V, level with the knuckles of your fingles. The thumb should always be positioned towards the front of the patients body.

Answer 38

Subcutaneous (subcut) injections pierce the epidermal and dermal layers of the skin, and medication absorption is relatively slow because of the poor blood supply to the subcut tissue 5 [Level GPP]. Only small volumes of medication up to 2mL to be administer

Answer 39

1. gently squeeze the subcutaneous tissue, then inject at 45 degrees (can also be given at 90) 2. dispose in sharps bin Prepare medication according to Preparation of Ampoules and Vials section. Follow Pre-Administration Checking Procedure. • Select appropriate site for injection and position the patient appropriately • If the area is not visibly dirty use of chlorhex swab is not required 4 [Level IV] • If visibly contaminated, clean as appropriate then swab site with chlorhex swab and allow to air dry • Using 2 finger technique pinch up a skin fold to elevate subcutaneous tissue, and lifts the adipose tissue away from the underlying muscle 5,7 [Level GPP]. Refer to figure 10. NB: For insulin injections using patient pens with Autoshield® safety needle, DO NOT use pinch up technique, brace skin prior to inserting needle unless risk of IMI where 45 degree angle injection may be required. Refer to Blood Glucose Level Management NPS • Insert needle at a 90° angle 5,7 [Level GPP] • The needle may be inserted at 45° angle (the skin does not need to be pinched) if the patient is lean or to adjust for needle length (avoids inadvertent IMI administration) 7 [Level IV] • Depress plunger slowly • When all medication is injected withdraw the needle • Release skin fold • Place needle and syringe in receptacle for safe transportation to disposal Utilise safety needles/syringe if available. An engineered sharps injury prevention device is recommended 5,8 [Level GPP]. If no safety device available, do NOT re-cap used needle to avoid contaminated needle stick injury 5 [Level GPP]. Apply pressure using the gauze for 10-20 seconds till bleeding stops or ask the patient to apply pressure if able to prevent haematoma formation. NB: Do not apply pressure after administration of low molecular weight heparin as this can result in increased bruising

Answer 40

Potential complications can include: • Bruising • Inflammation • Tenderness • Swelling • Scarring • Abscess formation Report any adverse events to the MO and document in the patient integrated notes

Answer 41

Subcut injections may be given in the following sites (refer to figure 9): • Abdomen • The most commonly used site as it has thicker subcut tissue • Avoid the umbilicus by a 5cm radius as well as any scars 5 [Level GPP] • Anterior aspects of thighs • Outer aspect of upper arms • Upper aspect buttock • Upper back Where multiple injections required, other routes to be considered (e.g. oral, IV, nasogastric tube). Correct site selection is important to ensure absorption and comfort Ensure site is not bruised, tender, hard, swollen, oedematous, inflamed or scarred which could hinder absorption and cause discomfort

Answer 42

IM-90 SUCUT-45 IV-25 INTRADERMAL-10-15

Answer 43

Use non touch technique to add the drawing up (blunt) needle to the syringe If there is medication in the lid there are a couple of techniques you can use to move the medication down- tap bottle or slide on table There is usually a dot (or a number of dots) that indicate the weak part of the ampule. This is where you break the lid open. Carefully remove the blunt needle from the syringe at the base Discard the blunt needle in the sharps container Using non touch technique put a red cap on to the syringe so that it is safe and remains sterile Fill out identification sticker, these come in different colours depending on the route of administration. Other colours- blue,….?

Answer 44

Using non touch technique twist the drawing up blunt needle onto the syringe Gently twist the head off, making sure you do not squeeze the ampoule Draw up medicine Remove blunt needle from the syringe and discard in a sharps bin Apply red cap

Answer 45

Find info on what to mix antibiotics up in to on….? Always wear gloves to draw up antibiotics- to protect skin from absorbing if spills? Use a drawing up needle blunt to draw up from plastic saline or water for injections ampoule Some facilities have specific short needles for drawing up from ampules. Others use needles. Use local policy to identify what you should be doing. Don’t twist your needle on too tightly Push a small amount of mixing fluid in to the ampoule. Then allow air to come back in to your syringe.

Answer 46

The Mental State Examination (MSE) is a process of obtaining information about specific aspects of individual’s mental experiences and behaviour at the time of the interview. Mental State Examination is only one of a range of data gathering activities that are required to assess an individual. All clinicians should have a basic knowledge of mental state examination and be able to describe psychiatric phenomena. to be able to carry out their own assessment to determine the severity and nature of the individual’s problems and the risk to self and others.  MSE is a process of obtaining information about specific aspects of individual’s mental presentation & behaviour at the time of the interview  MSE is one method of gathering data required to assess an individual which is commonly used in Western Australia  Therefore all clinicians working in local mental health settings should be able to conduct a mental state examination using a standardised format  MSE is one of a range of measures  Determine medical/ psychiatric emergency  MSE can be completed in the course of taking the history  In emergency situations – MSE may sometimes be brief  MSE is observational & active listening  MSE is a routine part of any interaction with clients  MSE can help or hinder the establishment of rapport  Therefore MSE must be documented in a professional, sensitive & objective manner

Answer 47

 Identify signs & symptoms of mental illness  Monitor change or improvement in mental state  Recognise symptomatology which might assist diagnosis  Might inform treatment and interventions  Provides us with a record of a persons mental state at that particular moment.

Answer 48

 During admission  In the course of taking history  If there is any change in clinical presentation  Informally on one to one interaction Note: It’s important to recognise that although a formal MSE is conducted and recorded at specific intervals during a presentation, that informal MSE is a specific nursing skill which is used constantly when monitoring for even the slightest change in mental state.

Answer 49

```  Individual details  Identifying the presenting problems  History of presenting illness  Personal history  Previous medical/surgical history  Family history  Premorbid personality  Illicit drug use/ alcohol abuse history  Mental State Examination ```

Answer 50

 Please listen actively  Try to use open-ended question e.g Could you tell me about your relationship with your family?  Allow patients to express their concerns and emotions  Try not to interrupt patients or disagree with them about their experience.  Avoid asking “why” questions, as these can feel a little judgemental.

Answer 51

1. Appearance & Behaviour - 2. Speech 3. Mood & Affect 4. Form of thought 5. Content of thought 6. Perceptual disturbances 7. Sensorium & cognition 8. Insight 9. Formulation

Answer 52

```  Age  Gender  Race/ethnic background  Build  Hair style & colour  Apparent health  Level of hygiene  Mode of dress  Physical abnormalities/ striking features ```

Answer 53

 Eye contact- Most consumers maintain eye contact and their eyes track the movements of the interviewer. Wandering eyes may reveal distractibility, visual hallucinations, mania, or cognitive impairment. Avoidance of eye contact may express hostility, shyness or anxiety. Constant tracking with eyes may indicate suspiciousness.  Individuals reaction to present situation- e.g. hostile, friendly, withdrawn, guarded, co-operative, uncommunicative, seductive  Individuals motor activity- e.g. psychomotor retarded, restless, repetitive behaviours, hyperactive, hand- wringing, bizarre (include description)  Abnormality of movement- Movements with neuropathological basis are tremors, akathesia, tardive dyskinesia (TD), choreatic, athetotic movements, and tics. Fear and intention increase the tremor, distraction decreases it.  Expressive gestures

Answer 54

 Articulation disturbances- e.g. Stuttering, Dysarthria, aphasia or slurring of speech often indicates a neurological disorder, or intoxication?  Rate (rapid, pressured, slow)  Volume (loud, whisper, quiet)  Quantity (monotonous, mutism)

Answer 55

Mood and affect are sometimes difficult to distinguish from each other. The clinician can distinguish the two by defining mood as the patient’s subjective description of his or her feeling state while defining affect as the objectively observable manifestations of the feeling state. ```  Mood subjective/ internal feeling state use patients own words  Affect objective/ external feelings & observable manifestations moment to moment expression ```

Answer 56

 Affect is described by using: 1. Range & intensity 2. Stability 3. Appropriateness & congruity

Answer 57

 Variations may range from lack of emotional expression to emotional expressiveness e.g sadness, anger, happiness etc  Normal affect - variations in facial expressions, use hands, body movements or laughter  Restricted affect - decrease in intensity & range of emotional expressions  Blunted affect - severe decrease in intensity & range of emotional expressions  Flat affect - total or near absence emotional expressions

Answer 58

 Rate at which affect changes  Stable - no fluctuation in affect  Labile - excessively rapid changes in affect  Diurnal variation

Answer 59

 Appropriate & congruent to topic of conversation or situation e.g. sadness at funeral, laughter at joke  La belle indifference - a person may claim to be blind, paralysed yet shows no concern for his fate, or for the impact of symptoms on his life

Answer 60

Thought form/process refers to organisation, flow & production of thought & include:  Amount of thought & its rate of production  Continuity of ideas e.g., tangentiality, derailment / loosening of associations, distractible speech, illogicality, irrelevance, circumstantiality, perseveration, echolalia, thought blocking).  Disturbances of language - Refers to the use of words that do not exist (neologisms or word approximations) or conversations that do not make sense (incoherence or word salad, clanging).

Answer 61

 Poverty of ideas - absence or near absence of spontaneous speech or talk  Flight of ideas - abrupt changes in conversation, where there is no common connection in the ideas expressed  Slow or hesitant thinking - reduced amount of thoughts

Answer 62

 Poverty of ideas - absence or near absence of spontaneous speech or talk  Flight of ideas - abrupt changes in conversation, where there is no common connection in the ideas expressed  Slow or hesitant thinking - reduced amount of thoughts  Perseveration- persistent repetition of the same words or themes  Thought blocking - abrupt interruption to the flow of thinking where thoughts are completely absent for a period of time  Distractible speech - repeated changes of topic in response to nearby stimuli  Irrelevance - replies to questions are not related to main topic of discussion

Answer 63

Refers to use of language or words that do not exist & include:  Neologisms - creation of new words that have no significance or meaning to others  Word Salad / incoherence - communication is disorganised & senseless

Answer 64

```  Simply whether the persons thoughts are negative or positive  Suicidal thoughts  Thoughts to harm others  Perceptual disturbances  Delusions ``` ```  Religious delusions  Nihilistic delusions  Delusions of jealousy  Grandiose delusions  Delusions of guilt & unworthiness  Somatic delusions  Hypochondriacal delusions  Dysmorphic delusions Other unusual thought content include:  Overvalued ideas  Obsessions  Phobias ```

Answer 65

```  Delusions of persecution  Delusions of reference  Delusions of control/influence/passivity  thought broadcasting  thought withdrawal  thought insertion ```

Answer 66

```  Hallucinations:  auditory  visual  olfactory  gustatory  tactile Other perceptual disturbances:  Derealisation  Depersonalisation  Illusions ```

Answer 67

```  Level of consciousness – coma to stupor  Memory  Orientation  Concentration  Abstract thoughts ```

Answer 68

 Capacity to recognise own problems & symptoms  Knowledge of medication  Amenable to treatment  Likelihood of compliance with treatment  Judgement

Answer 69

```  Summary of signs & symptoms  Summary of risk features  Strengths & weaknesses  Prior life experiences  Current state of health  Attitude towards illness  Supports ```

Answer 70

Static - all the time and dynamic risks- occur anytime ( background/ current factors) Risk assessment done all the time Legal form Always on admission looks at absconding, suicide risk, violence and aggression etc.

Answer 71

Oxygen is a medication, but it must never be denied to a patient in an emergency

Answer 72

Indications- critical illness or injury eg. Trauma or shock, type 1 or 2 respiratory failure and special cases of poisoning- carbon monoxide or paraquat- which is a herbicide Arterial hypoxaemia (inadequate arterial oxygen content) OR Failure of the oxygen-haemoglobin transport system.  Used primarily to treat tissue hypoxia and hypoxaemia  Conditions that may decrease PaO2 include airway obstruction, hypoventilation or hypoperfusion  Typically: treatment of cyanosis, shock, severe haemorrhage, cardiac and respiratory arrest, and patient deterioration  Deterioration in patient condition demonstrated by:  Decreasing conscious state (may include restlessness/confusion)  Decreasing oxygen saturations (below target range/< 88%)  Patient demand for oxygen increasing (having to titrate up oxygen supply to maintain target oxygen saturation)

Answer 73

Arterial hypoxaemia is defined as an oxygen saturation of less than 90% or an oxygen tension (PaO2) of less than 60mmHg. It may result from impaired gas exchange in the lung, inadequate alveolar ventilation or a shunt that allows venous blood into the arterial circ

Answer 74

Tissue hypoxia may occur in the absence of arterial hypoxaemia because of a failure of the oxygen-haemoglobin transport system. This can result from a reduced oxygen carrying capacity in blood (e.g. anaemia, carbon monoxide poisoning) or reduced tissue perfusion (e.g. shock). Successful treatment of tissue hypoxia requires early recognition and correction of contributing factors

Answer 75

Hand hygiene Patient sat up in an optimal position- only if clinically able to do so (take into consideration spinal precautions, for example) Oxygenation is reduced in the supine posture so fully conscious hypoxaemic patients should be nursed in the most upright posture .possible unless (a) this is uncomfortable for the patient, (b) immobilisation is required for suspected or actual skeletal or spinal trauma, (c) the patient is hypotensive or (d) the patient is recovering from a seizure.

Answer 76

4 different devices frequently used- nasal prongs, Hudson mask, venturi mask and non-rebreather mask

Answer 77

- Can be used for type 2 (hypercapnoeic) respiratory failure and special cases of poisoning. Flow rate of 0.5-4L/m (if under 2L/min use low flow adapter) Approx FiO2 (%) 22-40 - Inner cannula into nares around both ears and gently done up at the bottom and then attached to the oxygen

Answer 78

```  Low Flow  22-28% - FiO2  Flow rate 0.25 - 2L/min  Simple system  24-40% - FiO2  Flow rate 1 - 4L/min  High Flow  21 - 100% - FiO2  Flow rate 6 – 60L/min ```

Answer 79

advantages of improved comfort, less claustrophobia, ability to eat and speak freely, less easily dislodged, less inspiratory resistance and no risk of CO2 rebreathing. Their disadvantages are that flow above 4L/min tends to cause nasal dryness and discomfort if maintained for several hours and they may not be effective in patients with severe nasal obstruction

Answer 80

Nasal cannulae should not be used in patients who have: • Nasal trauma. Further trauma is to be avoided • Nasal injury including epistaxis +/- packing • Nasal blockages

Answer 81

Insert the nasal cannulae into the opening of nares (figure 3B) • Ensure that a prong is inserted into each nostril. Cannulae can easily become dislodged. This may result in oxygen being directed into the patient’s eye which may cause corneal ulceration • Secure the tubing behind the ears. Ensure that it is not too tight to cause trauma behind the patient’s ears or in the nostril area. Gently secure under the chin using the sliding adjustment piece. Check areas behind ears and on cheeks for development of pressure areas • Turn the oxygen flow meter on to prescribed flow rate • Titrate the flow rate according to: • Patient’s saturation level in relation to the medical prescription • Select minimum flow rate to achieve target saturation • Assess mucosal dryness of nasal passages at least once per shift. Liaise with MO for ongoing management as indicated. Nasal irritation, soreness and trauma can occur. A vitamin E-based lotion (e.g. Nozoil®) that may be used to treat nasal areas. NB: The use of lanolin and petroleum jelly may accidentally block the nasal cannula and affect the pliability of the tubing

Answer 82

- Can be used for type 1 (hyoxaemic) respiratory failure. Use at a flow rate of 5-10L/ min to deliver at approx. FiO2 (%) OF 40-60 - Must be turned on prior to putting onto patient, goes around back of head and gently sit on face - To make better fit can pinch around the metal area on the nose - If you deliver less than 5L /min can cause the patient to rebreathe their CO2!!

Answer 83

 40 - 60% - FiO2 |  5 - 10L/min

Answer 84

A simple face mask has open side ports that: • Allow room air to enter mask and dilute the oxygen • Allow exhaled carbon dioxide to leave the containment space

Answer 85

Apply Hudson facemask to patient • Set the flow rate to a minimum of 5L/min 17 . Inspired oxygen concentration accuracy may vary depending on the mask fit and patient ventilatory variables 18 [Level GPP] • DO NOT occlude side ports • Titrate the oxygen flow rate to the minimum prescribed flow rate, to achieve the target saturation • Notify MO if patient’s condition deteriorates, or if patient is requiring increasing oxygen requirements to maintain prescribed saturation levels. Activate medical emergency as per criteria. See Management of Medical Emergencies and Cardiorespiratory Arrest CPS

Answer 86

is excellent for patients that are CO2 retainers eg. COPD patients Used for type 2 (hypercapnoeic) respiratory failure and some cases of poisoning such as paraquat. See flow rate on device to deliver an FiO2 (%) between 24- 60 Requires setting up, put pieces together and then choose delivery amount required. Doctor will tell you amount. The device tells you the amount at bottom. Deliver amount tool attached Protector put around side Oxygen tubing attached Turn on oxygen and put on around nose and mouth Different size mask sizes available

Answer 87

 Precisely regulated oxygen concentration  24 - 60% - FiO2  (depending on device) available in the following concentrations: 24%, 28%, 35%, 40%, and 50%

Answer 88

Apply facemask with appropriate nozzle to patient. Ensure hood in situ at all times and adjust elastic strap to ensure adequate fit obtained • Ensure that the nozzle vent is not obstructed and that the protector hood is in the correct place protecting the vent at all times. The Venturi mask requires the dilution of oxygen with room air. Any obstruction/occlusion to this nozzle vent may cause a decrease in flow towards the patient and can increase the percentage of oxygen being delivered • Set flow rate as specified on bottom of the nozzle air entrainment regulator (as prescribed). Refer to manufacturer’s guidelines to check the %

Answer 89

Used for major trauma, shock and carbon monoxide poisoning. Use at a flow rate of 10-15L/ min to get an FiO2 (%) of 60-90 Used in medical or traumatic emergency situation as it delivers a high level concentration of oxygen Must not be given at below 10l per min Make sure reservoir is filled prior to placing over nose and mouth Put around back of head and pinch nose metal area to fit For smaller patients smaller sized masks are available

Answer 90

 60 - 90% - Fi02 |  10 - 15L/min

Answer 91

A non-rebreather mask is similar to a simple mask but has multiple one way valves and a reservoir bag attached. The valves: • Prevent air being drawn into the mask • Enables CO2 to leave the mask, preventing a risk of rebreathing The reservoir bag: • Fills with greater concentration of oxygen available for the patient to inspire • Has a one way valve preventing exhaled air from being rebreathed

Answer 92

Apply facemask to patient • Set the flow rate from 10-15L/min 21 [Level GPP]. Inspired oxygen concentration accuracy may vary depending on the mask fit and patient ventilatory variables • Reservoir bag fills on exhalation and almost collapses on inspiration. Reservoir should not collapse completely. If reservoir does not inflate correctly, check tubing connections and oxygen supply. If still not inflated, increase the flow rate and liaise with MO. Should the bag deflate, the patient is at risk of not receiving prescribed oxygen and rebreathing CO2. A flow rate of less than 10L/min is ineffective oxygen delivery. If a flow rate of less that 10L/min is indicated to maintain target saturation, use alternate oxygen delivery system • Titrate the oxygen flow rate to the minimum prescribed flow rate, to achieve the target saturation. Notify MO if patient’s condition deteriorates, or patient requiring increasing oxygen requirements to maintain prescribed saturation levels • An ICU/ Respiratory review is suggested for any patient that requires a non-rebreather mask for longer than 8 hours • Activate medical emergency as per criteria

Answer 93

 An Oxygen Prescription Chart must be completed when the patient stabilises

Answer 94

 Vital signs with SpO2 must be conducted regularly  Oxygen supply must be titrated to meet oxygenation goals: 88–92% for patients with or at risk of hypercapnoeic respiratory failure (CO2 retainers) 94–98% for all other patients  Supply should be discontinued in patient maintaining stable oxygen saturation

Answer 95

Oxygen is a medication and therefore can has adverse effects with administration. One such complication is: Oxygen toxicity:  From exposure to high levels (80% to 100%) of oxygen for prolonged periods  Inflammatory response  destruction of the alveolar membrane  Symptoms – ache or burning behind sternum, respiratory distress with decreased vital capacity, nausea and vomiting, restlessness, tremors, twitching, paraesthesias, convulsions and a dry, hacking cough

Answer 96

```  An Oxygen Prescription Chart is required for all patient’s supplied oxygen (this may vary in different health facilities)  Includes:  Delivery system  Flow rate  Application  Target SpO2  Prescriber  Reviewed and renewed daily by medical officer  Signed by Nurse once per shift ```

Answer 97

All disposable oxygen equipment must have a patient identification label and date of commencement affixed.

Answer 98

Urgent medical review and ABG measurement is required if the patient develops signs of deterioration including any of the following: acute breathlessness, decreasing conscious state, rising or abnormal respiratory rate, oxygen saturations less than (

Answer 99

- Highly addictive, dangerous and closely monitored - In locked cupboard and only a registered nurse can hold the key for it - S8 (and S4 Restricted) drugs must be stored securely. Usually in a double locked cupboard. These are very strict storage requirements.

Answer 100

- 2 registered nurses to check out a schedule 8 medication. There are special exceptions to double RN checking procedure- including single nurse posts/ community health stations - Have order with them - Registrar for drugs of addiction linked to cupboard and drugs in cupboard - Pull out medication - Check that the balance matches registrar. Always double check you have correct drug/ dosage/ type. For example, there is abut a dozen different types/ mixes of morphine - Check each ampule- is it what it should be? Drugs are in the wrong place sometimes (sometimes through error or intentionally) - Double checker confirms balance. You may need to count medications individually. If the tray or box of 10 is incomplete. - Most facilities have booklet set out same way. Medication will be listed and will tell you what page to go to. Each medication has own page - Once know balance is correct check out patients medication - Both need to check drug, dose and expiry date of ampule required. Often the text is small so close inspection is often required. - Will not be any discarded if using all medication eg 10mg ampule administering 10ml - Keys are always held by RN (not doctor), never put down anywhere - Each medication storage area will have a schedule 8 and schedule 4 register - Register has an index page and there will be a page for each separate medication and dose. Find the medication and dose you need and turn to the relevant page number - Each page will detail the medication and dose and the balance remaining. Each time a new medication is received from the pharmacy it is written into the book in red pen and signed and counted by 2 nurses - Students can not be a second checker for schedule 8s while a student

Answer 101

- Follow six rights go to patient and administer medication- please refer t drawing up medications and injection technique videos to observe the procedure of preparing this medication for administration via subcutaneous injection. - All schedule 8s need 2 nurses to go to the bedside, always need to stay together with medication - Make sure to check identiy details/ sticker together, look for allergies - Check medication, dose, frequency, indication and prescribers signature on prescription - Apart from checking time interval since previous PRN doses you should also check Maximum dosage? Amount already had? To ensure you are not exceeding the maximum dose in 24 hours - The medication should be administered as directed, and the nurse who is second checking is required to observe this. The medication chart then needs to be signed by the nurse who is the second checker ( refer to local facility policy) Hand hygiene Check the medication against the prescription • Confirm the number in stock against the S8 register • Remove the prescribed amount returning the remaining stock to the cupboard • Register must record: • Date and Time (of administration) • Full name of patient • Dose administered • The correct entry in the dose administered to patient column is the dose of that form and strength administered to the patient (refer to example 1 for correct recording) • Amount discarded (if appropriate) • Amount issued from stock • Balance • Name of prescriber • Signatories of staff administering and witnessing (sign and print name)

Answer 102

“Schedule 8 drugs are 'poisons to which the restrictions recommended for drugs of dependence by the 1980 Australian Royal Commission of Inquiry into Drugs should apply'. These include morphine, hydromorphine, pethidine, methadone, codeine phosphate and oxycodone.” google

Answer 103

``` Dangerous and highly addictive drugs Schedule 8 (S8) medications to be kept in a locked storage cupboard/metal medication safe that complies with regulations ```

Answer 104

The Shift Coordinator or a designated RN /Midwife is responsible for the security of the schedule 8 (S8) and restricted schedule 4 (S4R) keys at all times. The Medication Competent Enrolled Nurse may accept the responsibility of holding the S4R key if delegated by a Registered Nurse/Midwife. Exception: If the S4R key is kept on the same ‘holder’ as the S8 key

Answer 105

• Document the appropriate code on the Medication Chart (MR246) • Inform the MO • Document in the patient integrated notes • Hand over to staff of the oncoming shift or when patient is transferred to a different area/ward

Answer 106

Undergraduate students with no recognised nursing/midwifery/medical qualification are not permitted to be the signatory in the Register of S8 medicines in accordance with OD 0141/08. THIS DOES NOT PRECLUDE A STUDENT FROM PARTICIPATING IN THE CHECKING PROCESS as the 3rd checker or as a requisite to the student administering the medication – WHICH MUST BE under the direct supervision of a registered nurse (RN) or registered midwife (RM).

Answer 107

Administer: to personally apply or introduce a medicine.

Answer 108

Signatory: a signer or one of the signers, of the Register. Assistants with no formal medical or nursing qualifications are not permitted to be involved in the checking of drugs.

Answer 109

When less than the entire ampoule, vial, liquid or tablets are administered to a patient, the remaining contents/portion is to be discarded (with a witness/ authorised person) into an appropriate receptacle (sharps or clinical waste container), ensuring that S8 medications cannot be identified. S8 tablets to be crushed prior to discarding Ensure the S8 register records the signatures, and printed identities of the individuals administering and discarding the S8 medication, including the volume discarded • If an S8 infusion is to be discarded by a nurse, it should be witnessed by authorised staff (Pharmacist, MO, RN/RM) 2 [Level GPP]. Both staff are to sign and print name on chart where S8 is prescribed. Discard S8 infusion and administration line into the designated S8 clinical waste receptacle • If S8 medication is dispensed from cupboard but not administered to the patient (e.g. patient refuses, or change in prescription) the reason for discarding medication and dose discarded is to be recorded in the register. Refer to Discrepancies and Making Alterations in the S8 Register section if preparation not administered and can be safely returned to stock • Where possible, the RN witnessing the medication removal from S8 cupboard to be the same RN to witness any discarded amount • Where this is not possible staff administering/discarding S8 are to ensure that the second authorised staff member witnesses the discarding • In ED discarding of S8 medications should be witnessed by the POD leader or Shift Coordinator in the event that the witnessing nurse is not available

Answer 110

DO NOT open sealed boxes • Check integrity of tablet/capsule blisters/glass ampoule (gently invert and shake)/plastic ampoules (squeeze) • Check the expiry date is not exceeded • Use a separate page for each strength and form of each S8 medication recorded • Count and record the total amount of the medication in stock • Compare stock balance against register balance • If no discrepancy – stamp/or write “Checked and Correct” on each page for each medication in the S8 register (including patient’s own) • If discrepancy – follow S8/S4R Discrepancy/Loss reporting process • Both parties to sign and print name in S8 register on each page. Clinical areas may have a separate S8 register for patient’s own S8 medications (if high volume) or use rear of register for this purpose (or note this under pts own meds) • Once all the S8 medications are checked: • Ensure all S8 medications are returned to the cupboard • Ensure storage area is locked

Answer 111

DO NOT alter or obliterate any entry in the S8 register, e.g. when a medication is written out of the register and not administered. A further entry to be made on the next available line to correct an entry, return the item to stock or state that the medication was discarded and the reason why. • If an error is made in the S8 register it is to be corrected with a new entry on the line beneath and counter signed by both parties. Refer to Example Making Alterations examples 1A, 1B, 1C in document ( Dose signed out but not administered, Dose signed out but not administered, Correcting mathematical errors) • When an S8 medication is returned to stock unused, a further entry is made on the next available line. E.g. intact ampoule of opioid. NB: DO NOT return opened tablets from strips or liquid preparations these are to be discarded into an appropriate waste receptacle 7 [Level GPP] • Report all medication discrepancies/losses as per Work Flow for Schedule 8 (S8) & Schedule 4 Restricted (S4R) Discrepancy/Loss Report Form Flowchart and complete the Schedule 8 (S8) & Schedule 4 Recordable Discrepancy/Loss Report Form –

Answer 112

Hand hygiene Introduce self Explain what about to do and why Consent Might in reality need to shave patches of patients chest and ensured it is dry with a towel to aid connection of the ECG leads Machine plugged in ECG Dots and leads Machine usually has diagram of what connects where and also textbooks Placement of ECG leads is generally standardised as per L and B and the majority of other texts, and ECG machine information Count intercostal spaces and palpate so that you do not connect ECG dots to the bone/ribs and connect to correct anatomical sites to make sure accurate reading is obtained Modern ECG machine – once the leads are connected will give you a wavefrmreadout and advice you if any leads are not connected well; allowing you to reconnect them ECG allows you to put in patient details, have computer on them and can take the information and data into account when recording data Identifying who ecg belongs to is essential. You must place a patient sticker on immediately before beginning The computer in the ECG machine has the ability to access the ECG waveforms and make a ‘diagnosis’. In most places the ECG needs to be ‘’read’’ by a health professional who will advise the patient of the outcome. Ypou may wish to advise the patient for this. Might find on computer screen theres bits of interference, will need touse tricks to avoid this

Answer 113

Leads charging battery in bed can interfer so may need to switch off To prevent interference on ECG readout you may need to disconect the bed, remove the patients mobile phone ( and yours!). move electric pumps and othersimilar devices away from the vicinity of the ECG machine. Important that you connecgt the leads properly to get readout that Is CORRECT and not misleading Most modern ECGs will advise you on the computer screen that the leads are not connected correctly

Answer 114

Take off, let him know will show doctor, make sure comfortable, low bed and make sure has the call bell and anything needed

Answer 115

ECG lead colour codes alward the same V1- RED, V2- YELLOW, V3- GREEN, V4- BLUE, V5- ORANGE, V6- PURPLE Limb leads left leg-red, rght leg- green. Right arem- white, left arm- black

Answer 116

Make sure you have shaved hair chests, ladies with larger breasts stickers can be placed under or over the top of the breast tissue, whatever gives the best landmarks Ensure all electrical devices, such as mobile phones are away from the ECG machine to limit interference. Ensur ethe chest is clean and dry

Answer 117

• Chest pain suggestive of ischemia • Known or suspected arrhythmias • Changes in rhythm (e.g. atrial fibrillation to sinus rhythm, new bundle branch block) • Post cardiac arrest/resuscitation • Post syncopal episodes to assess arrhythmia • ST/T wave changes consistent with metabolic and electrolyte disturbances • Pre and/or post-operative assessment • Post insertion of pacemaker (permanent or temporary) or following percutaneous coronary intervention (PCI) • Following cardioversion • Assessment of medications known to cause cardiac arrhythmias  Suspected or actual ischaemic chest pain  Suspected or actual cardiac arrhythmias  Routine pre and/or post operative management  Medication administration (where the drug is known to have cardiac effects)

Answer 118

No absolute contraindications to performing an ECG exist, other than patient refusal. Some patients may have allergies or, more commonly, sensitivities to the adhesive used to affix the leads; In these cases, hypoallergenic alternatives are available from various manufacturers

Answer 119

• 12 lead ECG machine • ECG electrodes • To be stored in the packet provided to prevent drying out of electrodes • Check expiry date on packet and discard if expired • One packet of electrodes per machine (minimum) • Spare ECG paper – change ECG paper when coloured indicator line is showing • Appropriate to machine model • Hair clipper (as required) for excessive hair 2-JBI 2016 [Level GPP] • Isopropyl alcohol 70% impregnated wipes

Answer 120

Hand hygiene • Explain the procedure to the patient and obtain verbal consent as appropriate • Maintain patient warmth, privacy and dignity • Expose lower legs and forearms for limb lead placement as required 6-JBI Electrocardiograph • Remove wrist watches and jewellery as necessary to facilitate lead placement and reduce electrical interference. Ensure that these items remain with patient • Position patient semi-fowler/supine on the bed with their arms relaxed at the sides and legs extended as clinical condition allows 4-Queensland Health Adult & Paediatric 2012, 7-Society of cardiopulmonary tech NZ. If the bed/trolley is too narrow to support patient’s limbs, consider placing patient’s hands under their buttocks to prevent muscle tension • Expose the patient’s chest • If body hair is very thick, spot clip the areas where electrodes will be placed as firm adherence of electrodes is vital 2- • Dry skin if moist. Oily skin to be cleaned with soap and water, bath wipes or a 70% isopropyl alcohol impregnated wipe 3-Society for CST Clinical Guidelines Time must be allowed for the alcohol to fully evaporate before the electrodes are attached or problems may be encountered with electrode adhesion 8-Crawford Filling in gaps. Clean, dry skin will enhance electrode adhesions 6-JBI Electrocardiograph 2016• Apply new ECG electrodes for each 12 lead ECG as per Placement of 12 Lead ECG Electrodes section. Electrodes that are left in place for long periods of time may produce skin rashes or irritation

Answer 121

* Choose sites over soft tissues • Avoid bony prominences, thick muscles or skin folds as these can produce artefact on ECG recording • Place ECG electrodes on patient’s limbs with the lead connection pointing in a superior direction (towards torso) Do not place limb leads on torso 6-JBI Electrocardiograph * Limb leads to be equidistant along the arms and leg as able. If limbs not accessible (e.g. amputee or dressings), place electrodes at the most accessible distal location for that lead. Moving the limb leads away from the distal limbs alters the appearance of the ECG, this can invalidate the use of the ECG for diagnostic purposes of acute coronary syndrome (ACS) 3-Society for CST Clinical Guidelines 2010 [Level IV] * Right Leg (RL) – on the inner aspect right leg (proximal to ankle) * Left Leg (LL) – on the inner aspect left leg (proximal to ankle) * Right Arm (RA) – on the inner aspect of the right forearm (proximal to wrist) * Left Arm (LA) – on the inner aspect of the left forearm (proximal to wrist)

Answer 122

V1 – at fourth intercostal space, right sternal margin V2 – at fourth intercostal space, left sternal margin V3 – midway between V2 and V4 V4 – at the fifth intercostal space, left mid clavicular line V5 – at the same transverse level as V4 on anterior axillary line V6 – at the same transverse level as V4 on the left mid axillary line

Answer 123

Female patients – electrodes can be placed either under or on top of the breasts depending upon which approach will allow electrodes to be placed in the correct position. Improper placement of the leads can yield a tracing that gives the appearance of disease where none is present or vice versa

Answer 124

Hand hygiene • Confirm correct patient identification • Attach leads from 12 lead ECG machine to corresponding electrode on patient • Instruct the patient to relax and breathe normally, refrain from moving/talking to reduce artefact caused by muscular movement 6-JBI Electrocardiograph • If respiratory movement interferes with an ECG recording, consider asking patient to briefly hold their breath/shallow breathe whilst the ECG is obtained • Ensure ECG cable is off the floor and clear of other electrical equipment and no tension on any of the leads 9-Jevon Recording accurate ECG • Observe the screen on the 12 lead ECG machine to ensure a clear signal obtained from each lead. See Troubleshooting section for how to correct artefact • A clear trace and straight baseline should be observed before pressing the record button 6-JBI Electrocardiograph • Press ‘start’ to obtain ECG recording as per machine operating instructions • ECG recording will commence once quality/steady baseline signal obtained Document on the 12 lead ECG print out • Patient name, date of birth and unit medical record number (UMRN) (sticker preferred) • Check automatic date and time details for accuracy, manually correct if necessary • Reason for ECG. e.g. pre-operative, chest pain • Pain score if chest pain is present • State any deviation from standard lead position E.g. V4R, V5R, V6R • Indicate any change in patient position from supine ...  Correct lead and electrode placement is essential  Decrease potential electrical interference (watches, mobile phones, power to electrically operated beds, call bells …)  Ensure lead adherence:  Remove excess chest/limb hair  Ensure skin is dry  Oily skin may require soap & water wash (and dry)  Limb leads should be applied over soft tissue, not hard bone  Limb leads should be equidistant and as distal as possible  Patient must be relaxed, lie still, not talking (as possible)  All ECG recordings must be labelled immediately with the correct patient identification

Answer 125

 An electrocardiograph is a graphical record of the electrical activity of each cardiac cycle of the heart  The electrical system coordinates the heart’s rhythm (beat)  Electrodes applied to the chest wall and limbs detect the strength and direction of the electrical currents  And represent these by waveforms on graph paper  The graph paper is marked at standard intervals which allow the measurement of strength and rate of the heart/pulse

Answer 126

The conduction system of the heart consists of the sinoatrial (SA) node, the atrio-ventricular node (AV) node, the bundle of HIS & the left & right Bundle branches then divide into the Purkinje fibres.. Pacemaker cells are situated all along the system but the SA node is usually the “pacemaker” due to it’s high rate of firing (60 -100 bpm) (the AV node 40-60bpm & bundles 30-40bpm)

Answer 127

```  An ECG records as a series of waveforms designated as PQRST, with each letter representing an aspect of atrial or ventricular electrical activity.  Each ECG lead gives you a different view of the heart conductivity  So a sinus (“normal”) rhythm will show as different on each lead  Each lead has a positive & negative pole which shows as an up or down waveform ```

Answer 128

 In practice - serial (repeated at standard intervals) ECGs monitor changes over time and response to medication/treatment  Reveal ischaemia/infarction  Reveals effect of medication and treatment  Useful to diagnose between Acute Coronary Syndrome (ACS) and Stable Angina; and if ACS, between unstable angina and acute MI  When used in conjunction with cardiac markers (troponins and enzymes)

Answer 129

1 small square equals 0.04 seconds 5 small squares equals 0.2 of a second 25 small squares equals 1 second A common length of an ECG printout is 6 seconds; this is known as a "six second strip." A 1 minute rhythm strip contains 300 large boxes and 1500 small boxes

Answer 130

 P wave = SA node firing and atrial depolarisation (contraction = atrial systole)  PR interval = impulse travel time  QRS complex = depolarisation from the AV node through the ventricles (contraction = ventricular systole)  ST segment = start of repolarisation  T wave = ventricular repolarisation (refill = ventricular diastole)  QT interval = total time for ventricular depolarisation & repolarisation  U wave = (if present) part of latter phase of ventricular repolarisation

Answer 131

Basic analysis of a rhythmic strip This is just one of many different methods  Step 1 – Determine rhythm  Step 2 – Determine rate  Step 3 – Analyse the P waves for (almost) identical size, shape & position  Step 4 – Measure the PR interval (count the number of small squares – 0.04 secs each)  Step 5 – Measure the QRS complex (count the number of small squares – 0.04 secs each)

Answer 132

Possible cause • Patient experiencing seizures, chills, anxiety or tremor due to medical condition • Improper electrode application • Dry electrodes or fractured leads • Electrical interference from electric beds, nurse call bells, electric foot-pumps and air mattresses, mobile phones Management • Keep the patient warm and encourage them to relax 2- JBI 2016 [Level GPP] • Ensure skin is clean and dry • Ensure electrodes are in contact with skin and connections secure, reapply prn • Consider light abrasion of the skin surface with dry gauze wipe • Ensure ECG cables are not twisted • ECG wires may require replacement – contact Technical Services/equipment managers/lodge Enterprise Maintenance Procurement and Costing (EMPAC) • If tremor due to a medical condition e.g. Parkinson’s, attached limb electrodes to where the limbs join the trunk to minimise interference • Turn off power supply to non-life support electrical equipment

Answer 133

So we know which patients it belongs to and doesn’t get lost

Answer 134

Hand hygiene 6 rights IV fluid treatment chart Need infusion set and bag

Answer 135

Need infusion set and bag Open packets on sterile trolley Make sure roller of infusion set is down pror to piercing the bag Pierce the bag on a clean, flat surface Hang bag Squeeze the chamber gently 2-3 times, until it is about half full Close roller shut once roller has reached the end of the line. Your line is now primed In order to increase the drip rate, pus the roller up In order to decrease the drip rate, push the roller down

Answer 136

Find out how many drops/ mL your set delivers- most deliver 20drops/ml Step 1- convert time to the same units eg. 24 hours x 60 = 1440 minutes Step 2- rate (drops/ minute)= (volume to be delivered x drops/ ml) divided by time in minutes Therefore a prescription 1L normal saline over 4 hours Step 1: 4x 60=240 Step 2: (1000 x 20)/ 240 =83.3 drops a minute (round down to 83)

Answer 137

PIVC insertion kit or equivalent containing: • Inner sterile procedure pack: • 3 gauze swabs • 1x sterile transparent semi-permeable IV dressing (e.g. Tegaderm) with insertion details sticker (for site) 5-Inf Nurse 2016, 9-Loveday EPIC3 2014 [Level GPP] • 1x plastic yellow tray (for sharps) • 1x sterile protective sheet • 1 x sterile field (plastic) • Outer bag • 1 x tourniquet (‘single patient use’) • 1 x isopropyl alcohol 70% and chlorhexidine 2% swab (chlorhex swab) • 1 x isopropyl alcohol 70% and chlorhexidine 2% solution impregnated swab stick 3-ACSQHC 2010 [Level I] NB: If known allergy to chlorhexidine, use povidone iodine in 70% alcohol Loveday epic3 2014 [Level GPP]. • Extension set (e.g. SmartSite®) Can be used for contrast injection and blood sampling • 1 x 10mL pre-filled sodium chloride 0.9% syringe (STERILE can be placed on sterile field) • Insertion details sticker (for patient integrated notes) • Intravenous (IV) cannula of pre-determined size. Refer to Appendix I: PIVC Selection • Sterile gloves • Personal protective equipment (PPE) as per standard precautions Optional: • Multi-lumen Luer lock port (if multiple infusions required) • Tubular bandage • Surgical adhesive tape • Topical lignocaine gel/cream • Surgical clipper (if required) Additional equipment if blood specimen collection is required: • Specimen request forms • Relevant vacuum specimen tubes • Vacutainer® holder x 1 (see figure 1) • Chlorhex swab

Answer 138

Hand hygiene • Inform patient of procedure and obtain verbal consent as able • Position the patient comfortably. Place the limb to receive PIVC below the level of the heart to improve venous filling of target vein 12-Phillips 2011 [Level GPP] • Consider need for local anaesthesia • Consider need for local heat or allow are to hang over the bed to facilitate venous filling of the target veins JBI PIVC Insertion 11/01/2016 • If required dry heat application is preferred JBI no author PIVC insertion .. • Explain the procedure to the patient and obtain consent Note: If using topical lignocaine, apply 30-60 minutes prior to procedure. • Utilising PIVC pack from IV trolley, select appropriate IV cannula, sterile gloves, non-sterile protective sheet, and blood tubes, chlorhex swab and local anaesthetic if required • Perform hand hygiene. Clean trolley with hospital grade detergent • Perform hand hygiene and open dust cover of PIVC pack. Place the inner pack on top of the trolley and all other items on the bottom of the trolley • Open sterile PIVC insertion pack aseptically. • Add sterile items (IV cannula, sterile gloves, adhesive dressing, extension set and sterile 10mL prefilled saline syringe, plus items for local anaesthetic as required) • Place non-sterile ‘underpad/ bluey’ under insertion site. Select appropriate site/vein. If required, remove hair using clipper. Apply tourniquet • Instruct patient to clench and unclench hand and palpate the vein • Swab a large area of skin around chosen insertion site liberally with alcohol and chlorhexidine swabstick (in concentric circles) ensuring total site for dressing is included ALLOW SKIN ANTISEPTIC TO AIR DRY (for 30 seconds) to ensure that resident bacteria are killed • While waiting for site to dry, perform hand hygiene and don sterile gloves • Place paper from sterile glove packaging over the tourniquet as an impervious barrier (to enable asepsis to be maintained during tourniquet release) • Prime extension set with prefilled sodium chloride 0.9% (loosen cap for ease of application). Option to disconnect sodium chloride 0.9% syringe or leave connected for flushing • Peel back liner of sterile dressing and place ‘adhesive side up’ on general aseptic field

Answer 139

* Position sterile drape over hand/arm (absorptive side up). Only sterile gloves to touch sterile drape (see figure 2) * If necessary, re-palpate the vein to confirm position (decontaminated area only). Whilst applying skin traction, insert the cannula into the prepared target vein at ~25° angle. Do not contaminate the key parts of the cannula * Check for flash in cannula. Advance cannula into the vein and activate safety device * Using paper from sterile glove packaging to cover non-sterile tourniquet, release tourniquet * Hold/secure IV hub with sterile hand * Apply gentle pressure to occlude the vein above cannula * Withdraw the stylus (do not touch internal surface of cannula) and place in yellow tray/or sharps container * Connect the extension set, touching only the outer surfaces of the cannula hub and the extension set * Secure cannula and extension set with dressing as per Securing section * Flush cannula using pulsatile motion (push-pause) assessing for.. * Resistance • Pain or swelling distal to the insertion site • Leaking around the insertion site

Answer 140

* Secure the cannula and extension set in place with one sterile hand and using a non-touch technique apply the transparent dressing over the insertion site, with the keyhole end of the dressing is positioned towards the extension set (step 1). Do not contaminate the adhesive of the dressing * Pinch the dressing firmly around the bridge where the cannula hub and extension set connect, ensuring that there is no tenting (step 2) * Gently lift the extension set and cross the wings of the dressing and fix to the skin beneath (step 3). * Apply pressure over entire dressing and peel away the paper frame (step 4) * Peel the securement strip from the dressing frame and fix across the bridge where the cannula hub and extension set connect (step 5) * Scrub the hub of extension set with alcohol and chlorhexidine swab and allow to airdry * Flush cannula (push/pause) with sodium chloride 0.9% 10mL syringe closing slide clamp prior to disconnecting syringe ( to maintain positive pressure and avoids blood return) * If blood samples are required after insertion, re apply tourniquet and perform sampling as per Blood Sampling via Cannula on Insertion section * Immediately post procedure, remove gloves and dispose of waste. Perform hand hygiene (prior to completing documentation) * Clean trolley with detergent. Perform hand hygiene

Answer 141

• If the sterile field on the trolley has been breached use a new PIVC insertion pack • If the sterile field on the trolley has been maintained then continue to use the already opened PIVC insertion pack, add new IVC, sterile gauze, sterile towel and sterile gloves. Use a new swabstick to prep skin NB: Under no circumstances should you reuse the same cannula from the previous insertion attempt.

Answer 142

PIVC site sticker to record date and time of insertion. Affix sticker to side of dressing ensuring visibility of PIVC entry site. Patient integrated notes (or Triage Nursing Assessment) to record insertion details (for each occasion): • Insert completed ‘blue’ PIVC insertion pack sticker indicating date and time of insertion and insertion site Additional documentation if applicable: • Number of attempts • If inserted under emergency conditions • If traumatic failed insertion, record Peripheral Intravenous Assessment Scale (PIVAS). Refer to section on PIVAS • Date and reason for dressing change Patient Care Plan to record PIVC management plan : • Date PIVC inserted • Specify site of PIVC where multiple cannulas are in situ (e.g. left arm, right arm) • PIVAS score. Refer to section on PIVAS

Answer 143

While PIVC in situ • Report redness, pain, swelling and discharge from site • Keep cannula well secured to avoid trauma to vein (which will increase risk of infection) • Provide PIVC patient education leaflet on insertion Post-removal • Remove dressing after 24 hours (ensure no bleeding) • Inform nursing staff/GP if any pain, redness, discharge or discomfort At discharge • Ensure all PIVC removed. • If patient discharged against medical advice and PIVC remains in situ, report to Shift Coordinator and MO • If PIVC previously removed because PIVAS ≥ 1 and patient discharged prior to 48 hour assessment period instruct patient to: • Keep dressing intact for 24 hours • Observe for redness, pain, swelling or discharge from site. Inform GP if any of these occur

Answer 144

``` yelloe blue pink green grey orange ```

Answer 145

• Consider the length of PIVC • Start distally in the upper extremities • Choose firm, round, elastic, well filled veins • Assess the length of the vein • Inspect and palpate for problems • Look at or ask the patient for their previous history of cannulation (if possible).

Answer 146

Rate (drops/minute) = Solution Volume x Drop Factor (drops/mL) divided by Time (in minutes)

Answer 147

Check local policy Hand hygiene Pre op checklist Right patient Allergies Patients going to surgery should always have 2 name bands on, with 3 idenitifying points (name, DOB, URMN). One on the wrist and one on the ankle Check local policy regarding preoperative washing as the requirement for this varies Vitals Patient should have a full set of vitals done and completed and many require an ECG done prior to theatre. Requirements for an ECG may vary depending on patient age and surgery consented for. Weighed patient and height Check patient fasting status and where they are on theatre list. This will dictate when they can eat and drink prior to theatre. This may vary for children with the..? Patients commonly take their own medication at their usual times regardless of fasting requirements, though this may depend on the surgery and the anaesthetist. Exceptions to this may be coagulants and diabetic medications. VTE (venous thromboembolis prophylaxis) check local policy re

Answer 148

Two (2) identification bands must be secured on the patient (wherever possible) • Ensure they do not interfere with IV access site or proposed procedure site • They must be placed on top of anti-embolic stockings if in situ • The patients micro-alert status must be present on addressograph If two identification bands cannot be secured on either the upper or lower limbs, the reason must be documented on appropriate chart (such as checklist/integrated notes)

Answer 149

The requirement to remove or tape jewellery depends on the booked procedure, the surgeon and facility. Usually wedding bands may be left on and taped over. Can you think of an exception to this/ when ring should definitely be removed- Surgery involving arms? Depending on facility, surgeon, surgery and anaesthetist the patient may or may not have to remove their makeup

Answer 150

Patient should fully understand and have consented to their operation with the surgeon. This should have included adverse outcomes (such as potential for infection). It is NOT the nurses role to obtain consent though the nurse may discuss procedure with patient depending on their experience in this area. Consent form should be signed by the doctor as well as the patient. In the case where a patient is unable to sign their own consent form, a legally authorised proxy (usually next of kin) can do this. If the obtained consent meets the criteria the Nurse will proceed with patient preparation. If the obtained consent form does not meet the criteria the Nurse will: • Liaise with the Shift Coordinator/MO for ongoing management plan Document in the patient integrated notes

Answer 151

Requirement not to remove underwear and wear theatre gown again depends on the facility and the surgeon/ surgery

Answer 152

Hand over from PACU nursing staff should be in ISOBAR format. It will include all details of the operation. Remember to check any drains prior to moving your patient. Your patient is not ‘accepted’ from PACU to return to the ward unless their vital signs are stable and criteria such as pain and wound bleeding is under control. Holly meets this criteria. Always check the wound site if there is any strike through on the wound dressing mark it. This way when you return to the ward you will know if there is any extra excaudate.

Answer 153

``` Full vitals Analgesia Antiemetics Maintain IV as ordered Check wound with all vital signs Check and mark all drains again They must be monitored closely as there is always the potential for ANY post-surgical patient to deteriorate. And don’t just depend on your equipment (e.g. Sat’s probe) use assessment skills ```

Answer 154

At a minimum, include: • Name of the patient (introduce nurse, advise patient of imminent transfer to ward/unit) • Procedure performed (including any adverse events) • Relevant medical, surgical and psychosocial history (past and present) including allergies • Vital sign status • Nausea and vomiting (PONV is addressed and anti-emetics are prescribed) • All medications administered (including anaesthetic agent, e.g. general/local anaesthesia) • Pain management plan in place, analgesia last administered and effect • Wound status/drains • Invasive access devices (such as venous access, indwelling catheters) • Fluids, medications infusing • Urine output • Post-procedure instructions/parameters • Requirement for transmission based precautions as applicable (e.g. micro alert and transmissible diseases). Refer to Infection Control Manual for further information

Answer 155

• Patient is able to respond to verbal stimuli (comparative to pre-procedure) • The last set/discharge from recovery vital signs have been documented on the AORC/MADDS (BHS) • All IV infusions (fluids and pumps delivering fluids) are checked and correct as per the written prescription with Recovery Room Nurse/Escort Nurse. Seek clarification from the prescribing Anaesthetist/Medical Officer whilst in the post-procedure area as needed • All wound sites and drains for type, patency and drainage volumes; ensure dressings are intact. There should be no excessive loss from drains or wounds. If the Recovery Room Nurse is unsure of bleeding origin, the Surgeon/Anaesthetist should review the patient prior to leaving the area 1 [Level IV] • All equipment, drains, catheters, tubes and IV attachments are secure • Patient is suitable for transfer to the post-operative ward • If the receiving Nurse determines that the patient may not be suitable for transfer they must express their concern with Recovery nursing staff and escalate as required to, recovery coordinator → Recovery CNC(RPH)/Theatre NUM (BHS) → contact the ward/unit Shift Coordinator and request review by clinical area CNS, CN or SDN or after hours CNS/CNM. Ensure suitability of patient transfer and alleviate Receiving Nurse concerns. Nurses must work within the Scope of Nursing Practice Framework • Ensure all documentation and patient belongings (dentures, hearing aids) accompany patient to the ward

Answer 156

5 moments of hand hygiene | Ensure you have sharps container close by

Answer 157

Need stich cutter, forceps Hand hygiene Open equipment onto sterile field and apply gloves Remove alternative sutures initially Lift knot with forceps and slide stitcher cutter underneath gently but to firmly cut suture Need to cut suture as close to skin as possible, so that minimal suture is pulled through. Have some gauze close by to place removed sutures on Continue removing alternate sutures, observing for any signs of the incision gaping. If woung has closed well,you can continue to remove sutures. If in any doubt about wound closure. It is best to get checked by the doctor or clinical nurse before continuing.

Answer 158

Staple or clip remover needed Again start by removing alternate staples, whilst assessing wound closure Place the curved edge of the staple remover under the centre of the staple Gently squeeze the handles of the staple remover, which will make the staple bend and lift. You can then gently lift the staple from the skin Continue removing alternative staples, observing the incision line for any opening. If the wound has healed and closed well, you can proceed toremoving all of the staples. Dispose of sharps as per clinical waste policy. Ensure your patient is left comfortable and education is given for the care of the skin. If a dressing is required, a dry island dressing is preferable to a waterproof one.

Answer 159

Resuscitation trolleys (also known as 'crash carts' or 'emergency trolleys') are used to store and transport essential resuscitation equipment. QLD Health (n.d.) defines this piece of equipment as "A trolley for the purpose of cardio- pulmonary resuscitation and management of other emergencies..." (p. 4). The stocking and set-up of equipment on resuscitation trolleys may vary from health facility to health facility but should be standardised within institutions, while making allowances for specialised areas such as paediatrics. Definition A trolley for the purpose of cardiopulmonary resuscitation and management of other emergencies in the Health Centre

Answer 160

Team has to have important skills in Airway interventions, including tracheal intubation • Intravenous cannulation, including central venous access • Defibrillation (advisory and manual) and cardioversion • Drug administration • The ability to undertake advanced resuscitation skills (e.g. external cardiac pacing, pericardiocentesis, intercostal catheter insertion) • Skills required for post- resuscitation car Team leader responsible for directing and co-ordinating the resuscitation attempt • the safety of the resuscitation team at the cardiopulmonary arrest • ending the resuscitation attempt when indicated, often in consultation with other resuscitation team members and medical staff otherwise in charge of the patient 11 • documentation (including audit forms) and for communication with the relatives and other healthcare professionals involved in the patient’s management • organising resuscitation team debriefing.

Answer 161

``` airway breathing circulation drugs extras ```

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