انت هنا الان : شبكة جامعة بابل > موقع الكلية > نظام التعليم الالكتروني > مشاهدة المحاضرة
الكلية كلية التمريض
القسم قسم التمريض العام
المرحلة 2
أستاذ المادة حسام عباس داود السلطاني
6/25/2011 10:13:46 AM
ASSISTANT LECTURER/ HUSSAM ABBAS
Cardiovascular Diseases/Second Stage
Nursing care Post Cardiac Surgery in cardiac Intensive care unit CICU(CCU,ICU,RCU)
I. Preparation of patient before discharging from operation room
1. Prepare monitor setting
2. Connect ventilator with oxygen center and air center
3. Prepare ventilator setting
4. Prepare cables of arterial line
5. Prepare cables of central venous line
6. Prepare bed and sheet
7. Prepare suction machine for chest drains
II. Monitoring
A- Cardiovascular
1.Check and Record Blood pressure hourly
2. Record pulse [rate, pulse deficit every 15 min until it be stable]
3. Check cardiac output hourly by stroke volume and heart beat
4. Check central venous pressure CVP hourly
5. Record Electrocardiography for signs of any abnormalities
(dysrhythmias, VF, AF)
6.Check and Record body temperature hourly
7. Check skin color
8. Check central venous line [transducer setup]
9. Check signs of hypovolemia (decrease CVP, decrease cardiac output)
10. Check arterial lines (transducer setup).
11. Check signs of cardiac tamponade (cessation of chest drainage restlessness, decrease blood pressure, increased CVP, increased PAP and LAP)
12. Auscultate heart sound for quality, extra sounds, murmurs
13. Record chest tube out put hourly
14. Check any oozing or bleeding from incision of operation
B- Respiratory
1. Assess respirations: rate, depth if the ventilator don’t control
2. Check breath sounds
3. Check that endotracheal tube [ET] is connected to the ventilator. ET patency and position
4. Recording ventilator reading hourly [tidal volume, frequency Of breathing/ min]
5. Record arterial blood gases hourly.
6. check weaning process while intubation.
C- Neurologic
1. Check level of consciousness hourly
2. Check papillary size and reaction to light hourly
3. Check orientation level hourly
4. Check sensation and movement of extremities hourly
5. Check any sign of seizures
6. Record any abnormal signs and symptoms.
D- Gastrointestinal
1. Record the sings of nausea and vomiting
2. Auscultation bowel sound
E- Urinary
1. Record urine out put amount hourly
2. Check the urine color and any signs of renal insufficiency
3. Monitor laboratory results
4. Report laboratory results
5. Record any abnormal signs and symptoms.
F- Fluid and electrolyte balance
1. Check and record intake and output flow sheets hourly
2. Check serum potassium, calcium and sodium levels hourly
3. Record signs of edema
4. Check any changes in serum electrolyte
H- Record location, nature of pain
I- Observe ability to sleep while intubation and after extubation
J- Record signs of stress from environment
III. Promoting oxygen exchange
1. Suction during intubation
2. Suction as necessary after extubation
3. Elevated the head of patients slightly and turn side to side
4. Encourage breathing exercise.
5. Give analgesics before breathing and coughing exercise as order
6. Encourage patient for coughing
IV. Promoting fluid and electrolyte balance
1. Give maintenance fluid as prescribed
2. Give maintenance intravenous fluid as prescribed
3. Give supplemental potassium chloride as prescribed
4. Give calcium glyconate as order.
5. Give blood and blood product as order
V. Promoting comfortable and Rest
1. Give the narcotic analgesic every 3 hours during the first hours
2. Give frequent mouth care
3. Provide quiet and warm environment
4. Change bed lines when patient needed
5. Encourage patient to share feelings and expression
6. Encourage patient to incision support during coughing
7. Apply plan activities to permit period of sleep
8. Put the patient in the semi-fowler position
VI. Promoting measures for control of infection
1. Assess the sternal wound
2. Record any signs of infection
3. Maintain a sterile dressing for the first 48 hours after surgery
4. Give antibiotic in the time as order
5. Obtain a culture of wound drainage as order
6. Apply aseptic technique while remove chest drainage tube
7. Change dressing of wound as order
8. Use sterile technique when performing wound care
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المادة المعروضة اعلاه هي مدخل الى المحاضرة المرفوعة بواسطة استاذ(ة) المادة . وقد تبدو لك غير متكاملة . حيث يضع استاذ المادة في بعض الاحيان فقط الجزء الاول من المحاضرة من اجل الاطلاع على ما ستقوم بتحميله لاحقا . في نظام التعليم الالكتروني نوفر هذه الخدمة لكي نبقيك على اطلاع حول محتوى الملف الذي ستقوم بتحميله .
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