Assessment 1B - Response template

Course

HLT54115 Diploma of Nursing

Subject Code and Title

ACC114 Acute care

Unit(s) of Competency

HLTENN011 Implement and monitor care of a person with acute health problems

Performance criteria, Knowledge evidence and Performance assessed

PC: 1.1, 1.2, 2.1, 2.2, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 4.1, 4.2, 4.3, 4.4, 5.1, 5.2, 5.3

PE: 1

KE: 1.3, 1.4, 1.6, 1.10, 1.11, 1.12, 1.13, 1.14, 1.17, 1.18, 2, 3, 4, 5, 6, 7, 8.1, 8.2, 8.3, 8.4, 9.1, 9.2, 9.3, 10.2, 11.1, 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 11.12

Title of Assessment

Assessment task 1B - Case study

Type of Assessment

Case study with short answer questions

Submission

Assessment due at the end of Module 4 on Sunday 23:59 of week 8

Scenario Mr Jason McFarlane

I: Jason is 17 year old male

S:Presented to the accident and emergency department after a motor vehicle accident (MVA). An X-ray confirmed a fractured right (R) tibia and broken ribs. He also has concussion from a head injury sustained in the MVA.

B:Jason has no significant medical or surgical history. He has an allergy to Morphine.

Social History (SHx):

Lives at home with mother, step-father and siblings.

Recently completed high school, waiting to hear if he has a place in university

Recently obtained his drivers licence

Has a girlfriend Lucy

Spends a lot of time playing computer games, is not very physically active.

A:Jasonis 88kg and 172cm in height. Current vital signs Resp 28, O₂Sats 97% on room air (RA), BP 130/85, HR 110, Temp 37, and pain 6/10.

R:Jason is scheduled to havesurgery to repair his fractured tibia, an open reduction and internal fixation (ORIF). He needs to be prepared for surgery planned this afternoon.

Question 1

Outline your nursing actions for preparing Jason for theatre. Include in your answer:

What information is required to complete a pre-operative checklist, what nursing assessment should be completed, what education/ information would you give to Jason and his family?

Response:

Preoperative checklist:Make sure theatre bed is prepared, check oxygen supplements working, I>v pole should be place behind the head side of the bed, must have charts such as neurological, neurovascular, pain assessment, medication, urinalysis, Fluid balance chart, Braden scale. Arrange gown, cape and ted stockings.

Make sure surgeon has obtained the patient compliance statement from family or guardian because Jason is 17 years old. Make sure Jason and family members understands.

Identification check: Two identify bands non operative limb checked.

Ask for allergies and note down on medication charts.

Perform assessments such as vital signs, pain assessment neurological, neurovascular, urinalysis, skin assessments, VTE risk assessments and BGL if patient is diabetic.

Anathesia consent form completed and correct.

Operative site marked on patient and checked.

Ask Jason last time meal and fluid consumed (note down the time).

Check Bowel open.

Ask patient to remove any jewellery including piercing, glasses, dentures make up nail polish, hair clips should be removed. Any valuable item put them in bag handover to family members or we keep in safe if he agrees.

Premedication given time checked.

Pre operation shower.

Iv fluid treatment chart.

X rays

ECG

Blood test.

Blood group.

Pregnancy status.

Any other relative information.

Firstly, start with the preoperative teaching make sure Jason and his family members understands whats going on what would happen after surgery. We also talk to Jason and family members how pain will be controlled after he awakes from anathesia in PACU, teach some exercise needs to perform on order to heal fully as soon as possible.

References: Retrieved information from working notes in class by Georgie Abalos.

Brown, D. Ed. (2020). Lewiss medical surgical nursing: assessment and management of clinical problems. Retrieved from:https://lesa.on.worldcat.org?oclc?1107364401

Question 2 (word count no more than 100 - 200 words)

What is the current best practice in the prevention of venous thrombosis (VTEs) following major surgery?

Reference required

Response: we have to follow the Venous Thromboembolism prevention Clinical care Standard has been developed by the commission to provide high quality care to prevent VTE in hospitals.

1>Asses and document VTE risk: To ensure patient at risk of VTE timely assessed and results documented so that all clinicians in patient care have access to the result and aware of the patient VTE prevention needs.

2>Develop VTE prevention plan that balances the risk of thrombosis against the risk and consequences of bleeding.

3>Inform patient and family members about VTE: By providing knowledge about VTE patients play an active role in preventing VTE.

4>Document and communicate the VTE prevention plan to all clinicians involved in their care so that they can understand a particular VTE prevention needs.

5>Use appropriate VTE prevention methods to minimise the risk of adverse events. Such as medicines or mechanical methods according to patients preferences, clinical condition and evidence-based guidelines.

6>Reassess patient thrombosis and bleeding risk is reassessed and documented at interval no longer than seven days. The patient is also monitored for VTE related complications each time risk is reassessed.

7>A patient at risk of VTE following hospitalisation receives a written discharge plan before leaving hospital which provides information about individualised care to prevent VTE following discharge. The plan is discussed with the patient, make sure he understands the recommended care and follow up that may be required. The plan is also communicated to the patients general practitioner or ongoing clinical provider with in 48 hours of discharge so that ongoing VTE care can be completed according to plan.

References:

Kreutzer, L., Minami, C., & Yang, A. (2016).Preventing venous thromboembolism after surgery.JAMA, 315(19), 2136.Retrieved fromhttps://jamanetwork.com/journals/jama/fullarticle/2521971

WebMD. (2021).What is venous thromboembolism?Retrieved fromhttps://www.webmd.com/dvt/what-is-venous-thromboembolism

Question 3 (word count no more than 200 words)

Outline the difference between elective and emergency surgery.

Reference required

Response:

Elective surgery is a planned and booked in advance surgery after the special clinical assessment. Mainly private hospitals in Australia performed elective surgery. Moreover, elective surgery does not mean it is not needed, it all about timing which means something can be put off without causing permanent harm to your body. It may be a surgery you choose to have better quality of life, but not for life threatening condition. For example, Including removes a mole or wart, having kidney stones removed, Pain can be removed without opioids that is elective surgery.According to Australia Institute of Health and Welfare50% off patients waited at least 48 days for admission from elective surgery waiting lists in 2020-2021 due to impact of Covid -19 on health care system. Moreover. 754600 patients were admitted from public hospital on waiting lists for elective surgery in 2020-2021. (AIHW, 2022).

Emergency surgery:Emergency surgery is a stressful event for patients and their families. To prevent urgent medical conditions and life-threatening events sometimes surgery needs to be done immediately.

If patient is badly injured an ambulance may be called to transport a patient to hospital. A patient transported by an ambulance will be assessed and care will start immediately by paramedics or other trained emergency medical personnel.

Following are some examples of emergency medical surgery:

Severe trauma to the head, chest, abdomen, and extremities.

Invasive types of resuscitation and surgery for certain causes of acute respiratory failure.

Severe burns

Cardiac arrest events such as heart attacks, cardiac shock.

Brain conditions.

In emergency surgery once the physical assessment is done and the patient is as stable as possible diagnostic tests may be ordered. These tests include X rays, CT and MRI scans, ECG which helps to find out what is wrong with the patient and how serious is the problem.

Antibiotics are often given to prevent infection, along with medication to control pain. Recovery time will depend on the patients condition.

References:

https://www.aihw.gov.au/reports-data/myhospitals/sectors/elective-surgery

https://www.mainehealth.org/Services/Surgery/Emergency-Surgery#:~:text=Emergency surgery is designed to,post-operative and recovery procedures.

Question 4

Describe the following anaesthetics:

Reference required.

Question 5

Write a description below of the surgical procedures:

Reference required.

Question 6

Jason has returned from Theatre after having an ORIF (R) tibia, repaired under spinal anaesthesia. Outline what the immediate post-operative care would be when Jason returns to the ward. Discuss the enrolled nurses responsibilities of caring for a patient on return to the ward post anaesthetic.

Reference required.

Response:

Jason should be stabilised before transferred from PACU to the ward unit. Clients after operations are at more risk of complications related to airway, breathing and oxygenation. Other complications such BP, cardiac function, neurological status, bleeding from, pain DVT and urinary retention. The nurse must always be aware of the hospital policy and procedure for post operative care and follows surgeons specific post operative protocols for Jason.

Following are the responsibilities of the nurse

The bed area and room are prepared to receive the patient. Sphygmomanometer, stethoscope, thermometer, and pulse oximeter should be easily accessible for monitoring vital signs.

An IV stand is brought to the bedside (Usually behind the bed).

Vomit bag should be placed which is easily accessible.

Extra pillows to support the patient in appropriate manner. The room is cleared of untidy things so bed can be easily manoeuvred. Oxygen and suction equipments checked before patient is returned into the ward.

Following assessments should be done immediate when Jason return to the ward.

Vital signs

Neurological and neurovascular observations

BGL if patient is diabetic.

Pain assessment. Use 10-point scale and ask questions t to determine the type of pain and location.

Colour of the skin, location of dressing or sutures.

Muscle strength and response, fluid therapy, location of lines, type, and amount of solution infusing.

Level of physical and emotional comfort.

Depending upon the location of the surgery position of Jason like side with head extended head minimise aspiration and avoid stressing the incision.

Nurse must check drains and wound site if dressing have less fresh bleeding mark the extent with a pen and monitor it, if its in larger amount change dressing and reported it Register nurse, Surgeon may also notify and keep an eye.

Monitor fluid intake and output should be balanced to avoid urinary retention. To prevent urinary retention, make sure Jason void within 8 hours after surgery> if he does not then a urinary catheter is presented and notify to registered nurse.

Re asses the patient after pain relief interventions.

Provide person hygiene to Jason, change his operation clothes with in six hours after his surgery by doing this he feels more comfort.

Nurse also assists Jason with fluids and nutrition which helps the body return to normal functions.

Nurse also encourages Jason to do breathing exercise to at least every 2 hours when he awakes. To apply circulatory function appley ted stockings as ordered. Remove the stocking at least one hour daily to inspect the skin.

Deterioration related to Jason health notify to Registered Nurse and surgeon may also notify If bleeding is larger amount.

Reference:

Tollefson, J., Watson, G., & Jelly, E. (2018). Essential clinical skills: post-operative care. Retrieved from:https://ebookcentral-proquest-com.torrens.idm.oclc.org/lib/think/reader.action?dociD=57836127ppg=346

Question 7

Two hours after being admitted to the ward, Jason complains that the analgesia does not seem to be working.

a.What assessment could you do to determine Jasons pain?

b.What would you do in the situation that Jasons pain is not relieved? Who do you notify?

c.What are some non-pharmacological methods that can be used to help with Jasons pain?

Reference required.

Response:

A.To determine Jason pain, I do pain assessment using a numeric pain rating scale. Where Jason asked how would rate your pain on scale from 0 to 10. 0 means no pain, 10 means worst pain. We can also use Wong bakers faces pain rating scale to assess the pain and ask about the location and duration of the pain. Alongside we can observe the pain by looking at his face, from his speech and actions.

B.After giving pain relief medication if he is still complaining regarding pain I would talk to registered nurse or doctor about his current condition and obtained prescription to increase analgesic doses based on pain severity and comfort goal.

C.I used cold packs to reduce his swelling, whereas use heat packs for relieving chronic muscle. Massage, music therapy, repositioning, prayers (if applicable), respiratory and deep breathing exercise improves the Jason pain. Moreover, I can talk to him by holding his hand, rubbing on his hand give greater patient satisfaction and relief, distraction, relaxation and management techniques such as meditation and yoga can be used to provide relief to Jason.

Crozer Health. (2021).PQRST Pain Assessment Method.Retrieved fromhttps://www.crozerhealth.org/nurses/pqrst/

Better Health Channel. (2021).Pain Management in Hospital. Retrieved fromhttps://www.betterhealth.vic.gov.au/health/servicesandsupport/pain-management-in-hospital

Question 8

Describe the following post-operative complications:

Reference required.

Reference:

Question 9

A percutaneous indwelling central catheter (PICC) has been inserted into Jason for long term IV antibiotics and for fluid maintenance. What is the role of the enrolled nurse to prevent infection of the site and in the management of IV fluids?

Reference required

Response:

The role of an enrolled nurse in the management of IV fluids, blocked PICC line is most appearing thing while taking care of PICC line which can cause difficulty in giving medications and in taking blood for test, so to avoid this we have to flush the tube with solution before and after usage, if we are unable to clear the blockage we have to notify the RN about situation and stop using the PICC. Check for dressing covering the PICC line is intact, if it comes loose there are chances of the line comes out by accident which must reported to RN for replacement of dressing. Air must not enter the PICC line, so it is very important to keep the caps or clamps always must be closed to stop enter of air inside. If there is any sign of swelling, redness or tenderness in the arm, swollen hand, shortness of breath and tightness in chest, these are signs of presence of blood clots which must notified to RN. (MacMillan Cancer Support, 2020)

Visual infusion phlebitis Score must score 0 which means IV site is healthy. Document the infused volume per hour on fluid balance flowsheet. Check the solution is the prescribed one, rate of infusion and the amount infused is documented. Keep a check of fluid intake and electrolyte status to avoid fluid overload and electrolyte imbalance. (The Royal Childrens Hospital Melbourne, 2021)

To reduce the risk of infection, the caps at the end of the tube must be changed every week and change the dressing every week or before if required in cases such as it starts loosening up and become wet while taking shower. If there are any signs of Redness, swelling or pain around the entering of PICC, any discoloured fluid is coming out from the entry of line and elevation in the vital signs especially high temperature are signs of presence of infection which must be notified to RN in charge. (MacMillan Cancer Support, 2020)

Reference: -

MacMillan Cancer support (2020). PICC Illness. Retrieved fromhttps://www.macmillan.org.uk/cancer-information-and-support/treatment/types-of-treatment/chemotherapy/picc-lines

Question 10

Jason has been on prolonged bed rest due to his surgery and injuries from the MVA.

a.Discuss the possible complications associated with prolonged bed rest.

b.What information would you provide to Jason and his family to prevent these complications?

c.How would you ensure Jason is stable on his feet when he is able to begin mobilising? What member of the MDT would assist you with this?

Reference required.

Response:

A). Prolonged bed rest has an impact on the normal blood flow cause complications such as interrupted venous flow with prolonged immobility, edema, venous dilations. Moreover, inadequate fluid can affect normal bowel function of the body leads to constipation.

B). To prevent these complications, I instruct Jason to have at least 2-3 litres of fluid per day and increase fibre in his diet. i also educate him to do physical activities within limitation of pain to maintain bowel movement.

To avoid VTE, as client is confined in bed and unable to use, so we educate client about the need, use and benefits of Sequential Compression Devices and stocking which help in providing proper circulation of blood.

To avoid pressure injuries, we can educate family about the need, use and benefits to change the positioning of client every 2 hours to avoid development of pressure on area in contact to surface, place the pillow between the joint in touch with each other for example placing pillow between legs, and use of air matters can also reduce the risk of pressure injuries.

C). Patients start with range of motion exercise, active toe movements. Later advised by physio to do non- weight bearing walking then partial weight bearing walking. Later full weigh bearing walking under the supervision of nurse or physio until he feels comfortable. Physiotherapists may suggest walking aids such walking stick, four-wheel drive to maintain his balance while walking.

Reference: Kreutzer, L., Minami, C., & Yang, A. (2016).Preventing venous thromboembolism after surgery.JAMA, 315(19), 2136.Retrieved fromhttps://jamanetwork.com/journals/jama/fullarticle/2521971

The Royal Childrens Hospital Melbourne. (2019).Pressure injuries prevention and management.Retrieved fromhttps://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_injury_prevention_and_management/

Question 11

Jasons breathing difficulties from his fractured ribs have impaired his chest movements and he is now de-oxygenating despite having O₂administered at 10L/min via a Hudson mask. An X-ray shows that he has a pneumothorax. The doctor inserts an intercostal chest tube attached to an UWSD (under water seal drain)

Outline the care requirements for an UWSD, consider in your answer:

a.What are the monitoring requirements for an UWSD?

b.What are the possible signs of deterioration for a client with an UWSD?

c.The scope of practice for an EN caring for a client with an UWSD;

d.What education would you provide to Jason and his relatives relating to the UWSD?

Reference required.

Response:

(a)Monitoring Requirements for USWD are as follow (Agency for Clinical Innovation, 2021)

Check all the tubes are connected well and ensure that they are visible, tight and secure

Ensure that the underwater seal is activated, and the rod is immersed 2 cm under water.

Ensure that the pressure is low around 3-5 kpa.

Staff should take care to accurately read suction pressure when selecting low wall suction pressure is in mmHg or KPA units.

USWD has to be placed on its stand or hanged on the side of bed

Always keep the drainage unit below the chest level.

Always check for any signs of respiratory deterioration.

(b)The possible signs of deterioration for a client with an UWSD are as follow: - (Contributor, 2005)

Drop is oxygen saturation

Client complaining of chest pain

Increased breathing

Diminished breathing sound

Decreased chest movement

Signs of hypotension

Tachycardia or bradycardia

(c)As an enrolled nurse (Contributor, 2005)

Monitor the vital signs, respiratory assessment to check any signs of respiratory distress.

Educate the client and family about the procedure benefits and complication which may arise.

Check dressing is intact, clean, and dry if not replace it, otherwise it can cause infection.

A pain assessment must be performed.

Make sure that the water seal is always held at 2 cm.

UWSD is always placed below the chest height.

Monitor the colour, and volume of the drainage, any abnormality must report to RN.

Always follow infection control procedures, check the site of insertion for any redness or swelling which may indicate infection.

(d)As an enrolled nurse, we will educate the client about why UWSD is required and its benefits and also explain the procedure of using UWSD which will help in reducing anxiety, stress and discomfort in client and family. Teach them about requirement of infection control and its important in clients health. Teach them about the possible signs of deterioration, if they find any signs and symptoms immediately inform about it to the staff. Educate them to always place the drain unit below the chest level and there shouldnt be any knicks in tube to avoid further complications.

Reference

Agency for Clinical Innovation. (2021).Pleural drains in adults. Retrieved fromhttps://aci.health.nsw.gov.au/resources/respiratory/pleural-drains/pleural-drains-in-adults/section-3-management

Question 12

When you enter Jasons room to attend to his routine observations, you find that he is unresponsive.

a.What is your response to this situation?

b.Outline 2 members of the MET and discuss the roles and responsibilities of each?

Reference required.

Response:

According to the Australian and New Zealand committee on resuscitation recommends that in all emergencies first respondents follow ANZCOR basic life support guidelines. DRABCD approach.

First respondent firstly ensures the safety of both persons.

Assist Jason on the ground and position them on the side and make sure his airway is open. I would check breathing sounds pattern.

Press emergency button or start calling need help, need help loudly.

If I see any bleeding I would try to stop and stay with the Jason all the time start doing CPR until he gets responsive.

B) Bedside Nurse and charge nurse.

The rapid response Nurse

Bedside nurse and charge nurse:when bedside nurse enters into Jason room for routine observations, she found he is unresponsive immediately press emergency button or call-in charge nurse about Jason conditions. In charge nurse immediately responds to support bedside nurse. Then bedside nurse provides secondary assessment of the situation to the in-charge nurse. The bedside nurse calls the primary team while the charges nurse activates a rapid and calls for help and a monitor. In charge nurse will designate roles and responsibilities.

Bedside nurse also provides SBAR report to the rapid response team nurse and respiratory therapists. In charge call code Blue with patient bed number, ward name and room number. Code team is activated. CPR should be initiated within a minute of unresponsiveness of the patient. Then everybody comes to help Jason such as Doctor, rapid response team, monitor response team.

The rapid response nurse:

When rapid shifted to code blue then roles and responsibilities in the room also shifted. The rapid response nurse leads the code and coordinates with the critical care personnel by name which includes Anaesthesia, critical care physicians and critical care nurses. Whereas charge nurse coordinates local responders by name which include recorder who uses computer for documentation and security guard for crowd control.

The rapid response nurse gives a SBAR report to the code physician.

Reference:Hood. N., Considine. Spinal immobilisation in pre-hospital and emergency care: a systematic review of the literature. Australasian Emergency Nursing Journal 2015; 18:118-37.

Question 13

It has been determined after the emergency response that Jason has had an acute brain haemorrhage. He is unconscious and requires a tracheostomy and a nasogastric tube to be inserted for NG feeds.

Outline your care of a tracheostomy tube. In your response consider:

a.care of the tracheostomy including suctioning and dressing changes

b.your scope of practice as an EN caring for a client with a tracheostomy

Reference required.

Response:

(a)While caring for a client with tracheostomy, suctioning by removing mucus and other secretions and avoid blockages of tube to maintain airway is very important, it is performed by RN and EN with advanced skill. presence of secretion in tube, signs of respiratory distress, after vomiting, desaturation on pulse oximetry and changes in ventilation pressure are the sign of tracheostomy needs to be suctioning. Nurses always perform aseptic non-touch technique. Always use appropriate size of suction catheter and appropriate suction pressures which is between 80-120 mmHg to avoid any tracheal damage. The depth of insertion of the suction must be measured before suctioning, we can find the suction depth in the clients records. Procedure of suctioning must be completed within 5-10 seconds. Suctioning catheter must replace every 24 hours or at any time if contaminated or blocked and discard the used one in clinical waste. Changes in secretion such as blood stained, yellow and green secretions may indicate infection and trauma in airway which must be notified to RN immediately. (The Royal childrens Hospital Melbourne, 2014)

Care for dressing, if nurse find dressing intact, dirty, or wet it must be replaced immediately to avoid any infection using 0.9% sterile saline solution and aseptic technique. Suctioning must be completed before changing the dressing. In stoma care, nurse must maintain skin integrity by ensuring skin is clean and dry or any signs of injection such as redness, swelling and excessive exudate. (The Royal childrens Hospital Melbourne, 2014) Provide client with proper oral care to avoid any oral thrush and mouth ulcers.

(b)As an Enrolled nurse, we must monitor vital signs, PQRST pain assessment and look for any abnormal secretion such as blood stained, yellow and green secretions may indicate infection and trauma in airway which has to be reported to RN immediately. Check for any obstruction in pipe and report it to RN. Provide proper oral care to avoid Oral thrush and oral ulcers. If dressing is dirty, wet and intact replace it with a new one. Observe skin around the stoma and check for redness, swelling, evidence of granulation of tissue, exudate and any offensive colour are signs of infection which must be reported to RN. Look for any signs of respiratory distress such as increased work of breathing, decreased breathing sounds, oxygen desaturation, cyanosis, and agitation which can be caused by blockage of tube call for assistance and reported to RN.

Reference:

Tollefson, J., Watson, G., & Jelly, E. (2018). Essential clinical skills: post-operative care. Retrieved from:https://ebookcentral-proquest-com.torrens.idm.oclc.org/lib/think/reader.action?dociD=57836127ppg=355

The Royal Childrens Hospital Melbourne. (2014).Tracheostomy management.Retrieved fromhttps://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Tracheostomy_management/

Question 14

A nasogastric tube (NGT) is commonly inserted to provide nutritional support to individuals.

a.Describe the care required prior to using the NGT?

b.What actions do you take if you think the tube is blocked?

c.Describe your steps when giving a NGT feed.

Response: coughing and movement on bed can dislocate the location of the NGT tube. So checking is mandatory before administering feeding. We compare the length of the NGT tube at patient nares with length is recorded on the previous feeding and can also check position with the help of pen light by opening the mouth of the patient.

1.Before using NG feed we firstly assess patients need for eternal tube feedings, then auscultate for bowel sounds before assistance in feeding.

2.Assess patient for fluid volume excess or deficit electrolyte, metabolic abnormalities such as hyperglycaemia.

3 Double check the rate route and frequency of the fluid. Bedside assessment like finger stick blood glucose measurement may also be required.

4 e explain procedure to the pain and gain consent before administering.

5 wash hands to control cross contamination.

6 prepare required feed and should be warmed at room temperature. Time and frequency of feed, correct amount of kilojoules, fluids and nutrients stated at dietitian chart please double before administers. Connect tubing to container as needed or prepare ready to hang container.

7Ensure patient upper body raised at 45 degrees or at sitting position. After the feeding process complete patient remain seated for another 30-60 minutes to avoid reflux and aspiration during a feed and post feeding.

8 Aspirate gastric contents to check for gastric residual. It indicates that NGT tube is in the stomach. Measure pH of aspirate gastric contents fasting pH is usually equal or less than 4. Check the colour of the aspirates and results from pH testing indicates probability of gastric placement.

After taking care of all above requirements initiate feeding.

References:

Dougherty. L. & Lister. S. (eds). (2015). The Royal Marsden Hospital Manual of Clinical Nursing Procedure (9^thed.)

National health and medical research council (NHMRC). (2014). B4.2.4 enteral feeding tubes. Australian Guidelines for the prevention and control of infection in healthcare.https://www.nhmrc.gov.au/book/b4-2-4-eternal-feeding-tubes

Tollefson, J., Watson, G., & Jelly, E. (2018). Essential clinical skills: post-operative care. Retrieved from:https://ebookcentral-proquest-com.torrens.idm.oclc.org/lib/think/reader.action?dociD=57836127ppg=388

Crisp, Jackie, et al. Potter and perrys Fundamentals of nursing- Australian version- eBook. Retrieved from: https://ebookcentral-proquest-com.torrens.idm.oclc.org/lib/think/reader.ation/docID= 5709753&ppg=1080

Question 15

List three (3) nursing interventions that an enrolled nurse can do to care for the unconscious patient.Reference required.

Response:

1Firstly, I do respiratory assessment which includes monitoring patency of airway, assessing rate, breathing pattern, pulse oximetry checks and arterial blood gases to assess gaseous exchange. Positioning (the recovery or side lying positioning) is also very important for unconscious patient because they are not able to maintain their own airway. Some patients require oxygen therapy so meet the oxygen requirement of the patient using nasal cannula or ventilators.

2. monitor vital signs to know the baseline of the patient, cardiac monitoring may be ordered. There is risk of DVT dur to venous stasis in legs. So active and passive exercises should be completed to reduce this risk applied anti embolic stocking. Maintain fluid balance. Closely monitor fluid intake input urinary output of the patient. Regular uranalysis should be carried out. Range of motion exercise can be carried out so that joints can works in a functional position.

3. Regular change in positioning prevent him from pressure injuries. Personal hygiene such as eye drops applied to reduce the risk of cornea abrasion (Clarke et al.,2016). Teeth care with help of toothpaste and brush and yank Auer suction catheter should be used to remove the fluid. Ear care include checked earwax and cleansed with a washcloth. Finds out patient preference for music and play at least few hours to provide stimulations. Maintain patient dignity when providing care.

Clarke, l., Gray, S., white, L., Duncan, G& Baumle, W. (2016). Foundation of nursing: enrolled Division @ Nurses (ANZ ed). Melbourne

Tollefson, J., Watson, G., & Jelly, E. (2018). Essential clinical skills: post-operative care. Retrieved from:https://ebookcentral-proquest-com.torrens.idm.oclc.org/lib/think/reader.action?dociD=57836127ppg=401

Question 16 (no more than 100 words)

Discuss why it is important to check and know how to use all emergency equipment.

Response:

It is vital to check and learn the usage of all emergency equipments as this help in providing the medical assistance to patient in emergency which will be helpful in saving life as time is precious in emergency. Checking of and maintaining the suction equipments, wall oxygen and suction and resuscitator BMV unit are things to consider carefully. If we find any of such equipments not functional, we should document and notify to the concerned department so that they can either replace or repair it at the earliest. Checking of emergency trolley equipments as per the adult cardiac arrest equipment is must. If there is any equipment missing in trolley or not working well or expired, should be replaced, or repaired immediately. If we are a new person to the staff or workplace is new, we must ask the permanent staff about emergency equipment and their place and check ourselves is everything necessary present or not. Each worker at workplace should know how to perform basic life support and assist nurse or staff in it.