NUR245 TOPIC 1 

Acute care nurse- they are generally critical care nurses/emergency care nurses (ICU, HDU (high dependency), ED), care for acutely unwell pts and care for pts with a wide variety of illness, from CVAs to AKIs, fractures and fibrillations, manage the acutely unwell pt- all body systems, and recognise the deteriorating pt- act on early warning signs

Recognition of the clinically deteriorating patient

o    Early warning charts ie ADDs for adults amd CEWT for children

o    A-E assessment

o    Systems based approach

o    Top to toe

o    Managing all areas- manage all body systems taking a system based approach

o    Sensory, oxygenation/ventilation/transport/perfusion,ingestion/digestion/absorption /elimination,endocrine,neurovascular

 Revision of the Primary survey, including basic anatomy and physiology

o    Immediate assessment and management of life threatening disorders (quick)

o    Fix issue prior to moving to next pt

o    Pneumonic: ABCDE 

o    Determine priorities of care 

A-    (airway and cervical spine stabilisation) 

- LOOK: Obstructions? Blood/vomit/saliva/loose teeth

- LISTEN: any adventitious sounds that could indicate an airway obstruction?

- Secure C spine if necessary 

- WHO IS AT RISK? Anaphylaxis, neurological condition ie CVA/seizures, submersion, foreign bodies, traumatic injury to face/neck

- Nasal pharangeal/oral pharyngeal if pt is unconscious 

- If there's a risk of skull fracture then nasal pharyngeal tube is not used, a larangel musk airway can be used 

- Always assume that pt has cervical spine trauma with any pt with face head or neck trauma and/or significant chest injuries 

- Spine stabilised and head maintained in a neutral position as well as C-Spine 

AIRWAY ANATOMY:

- Respiratory anatomy is divided into 2 zones, upper and lower airways. Physiological differences conduction (upper) and respiratory zone (lower)

- Conduction zone consists of nose, mouth, nasal passage, pharynx, larynx, trachea bronchi and bronchioles. These tubes have the function of warming filtering and humidifying air and facilitate movement of air to respiratory zone where gas exchange takes place

- Pharynx has 3 regions (nasopharynx, oropharynx, laryngopharynx, lined with ciliated mucosa for which the function is to warm and humify the air and remove foreign particles. The larynx is the junction between the upper and lower airways

- Upper airways contain all the structures from the start of the trachea and is what we think about when we consider A for airway. Conducting zone extends beyond this. Main purpose of larynx is vocalisation and direct food bolus and inspired air into the oesophagus and trachea. Formed from a scaffold of different cartilage pieces, that are supported by ligaments and membranes, most prominent of cartilage structure is thyroid cartilage. 

- Superior to larynx is epiglottis which prevents any food or liquid going into the lungs during swallowing 

SIGNS AND TX OF AIRWAY OBSTRUCTION: 

- SIGNS: stridor, dyspnoea, hoarse voice, agonal breathing, foreign body, facial trauma

- TX: open airways by headtilt/jaw thrust, recovery position, suctioning, airway device (eg nasopharyngeal airway)

B-    BREATHING 

-  Still in conduction zone- trachea is supported by a C shaped cartilage that connects larynx to bronchi, it’s made up of cartilage, connective tissue and smooth muscle which provides both strength and flexibility the trachea needs to remain open during breathing which is why it is so rigid however the posterior part of the trachea is felxibile so that is allows food boluses to pass through the oesophagus the trachea then braches into the 2 main bronchi in the corena. The corena has a very sensitive nerves and when stimulated by microorganisms a powerful cough is produced along with bronchospasms the bronchi separate and enter the lungs at the hila which means root of the lungs and individually are called hilum. Te hila are important because this is where the main pulmonary vessels majpr bronchi and lymphatic vessels are situated. Generally when someone aspirates the contents will end in the right lung as the right main bronchus is vertical wider and shorter than the left. Epithelial liing in bronchi have ciliated cells and single cell exocrine glands that secrete mucous. the main bronchi divide into lobular bronchi three on the right two on the left to leave room for the heart, then to the segmental bronchi, which have less cartilage and ciliated cells but more smooth muscle then into the bronchioles.

The respiratory zones consisted of structures that are involved in 

- Gas exchange, from the Bronchiols to the alveoli. 

- The alveoli are the primary area for gas exchange. (16.15mins) 

The pulmonary system has three primary functions. To ventilate the alveoli, to allow gas exchange in and out of the blood and to perfuse the lungs, which ensures the organs of the body are rich in oxygen and low in carbon dioxide.

The mechanics of breathing involves the major muscles, so your diaphragm and intercostal muscles and accessory muscles your sternocleidomastoid and scalene. the elasticity of the lungs and chest walls and the resistance to airflow through the conducting zone. 

 Revision of the Secondary survey

-  (EFHGI) 

- E – Exposure: still part of primary survey: look for other injuries—trashes, cuts, bruises—ensure pt is kept warm

- F – Full set vital signs; includes ECG, possible catheter or nasal gastric tube  family presence and further investigation

- G- Give comfort measure – eg pain relief, verbal reassurance, involves developing trusting relationship between pt and their loved ones

- H- History: full history of events; preferably from the pt, mechanism of injury  and Head to Toe: looking for any other injuries 

- Inspect posterior surfaces – involves rolling the pt and looking for further injuries on their back and back of their legs 

- Respiratory rates are often the first to deteriorate that is why it must be done for 60 secs

 Introduction to MET (medical emergency team call) calls and CARE calls

-  Any obs in purple area

-  ADDs score under or equal to 8

- Threatened airway

- Resp/cardiac arrest

- Sudden drop in SpO2 equal/under 90

- Sudden fall in conscious lvl (ie under or equal to 2 GCS)

 - Seizure

- CARE: care calls are for pts or their relatives to escalate care for themselves or their loved ones 

- Empowers family members/friends/carers to call for review if they feel loved one Is deteriorating/not receiving the right help

- Shown to improve mortality rates and decrease ICU admissions