Xu_xum08266299_Assess Client Case Study

nursing assessment

board and keep the limb on the top of the sheet (visible) at all times it's a useful strategy to secure a connection (Sir Charles Gairdner Hospital 2012).

Catheter related infection may occur since the arterial line insitu is an invasion equipment. Apply aseptic infection control standard when inserting the line and assessing the site (Sir Charles Gairdner Hospital 2012). Regularly monitor the site for any redness or swelling.

Ensure the pressure bag is inflated to 300mmHg to prevent clot forming. Also

flushing the line with a fast flush device is another prevention strategy (Sir Charles Gairdner Hospital 2012).

Regular assessment of distal pulses and capillary refill can detect any potential interruption to peripheral circulation (Sir Charles Gairdner Hospital 2012).

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4. CPAP provides continuous gas flow to open the throat and airway for

spontaneously breathing patients which makes their breathing easier (Sleep Health Foundation 2011). It creates a positive pressure into the lungs and opens the collapsed alveoli membranes in order to maximize the surface of alveoli for gas exchange (Falcone et al 2014). The positive pressure remains in the lungs to keep alveoli inflation at the end of expiration, therefore, energy will not be consumed during the next inhalation. In this way, CPAP assists patients in breathing with

minimized effort and less respiratory muscle fatigue to achieve desired oxygenation (Falcone et al 2014).

The increased intrathoracic pressures created by CPAP impairs the venous return which can create a potential risk for the patient with increased intracranial pressure. Precaution strategy should be applied in such a circumstance by keeping the

positive end expiratory pressure (can be controlled by a valve attached to the CPAP mask) under 10cm H2O(Falcone et al 2014) .

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5. The purpose for an inter-costal catheter is draining air, fluid or blood accumulated in the plural space caused by the patient's chest trauma as a result of MCA (Lanyon 2014).

Frequent observation is required when nursing patients with ICC insitu. Bubbles present in underwater seal drainage is important because it indicates the air has been sucked from the pleural space and being prevented to re-enter the chest cavity