Question

fall risk assessment:

SKILLNAME Fall Risk Assessment Description of Skill CONSIDERATIONS Indications Nursing Interventions (pre, intra, post) Outcomes/Evaluation Client Education Potential Complications Nursing Interventions TIVE LEARNING TEMPLATES

Answer 1

Description of Skill

Centreline insertion - a process in which a catheter is inserted into the internal jugular vein.

Indication:

1. For the administration of medicines in the critically ill patient.
2. Monitory central venous pressure measurement
3. Providing total parental nutrition
4. For administration of inotropic drugs
5. Providing fluid challenge in hypotension.

Outcome/ evaluation

1. Measurement of central venous pressure regularly.
2. Improvement in the patient's BP
3. Resolution of infective foci
4. Improvement in kidney function

Potential complication

1. Pneumothorax
2. Injury to the carotid arteries
3. Pleural effusion
4. Blooding diastasis.
5. Blood mis- Match.
6. Blockage of the tube.
7. Infection of the tube

Nursing intervention if complications occur

1. If a carotid is injured, apply the pressure of the injured vessel.till bleeding stops.
2. Pneumothorax or pleural effusion -
   1. stop all drugs being administered through the central line.
   2. Secure a peripheral line
   3. Keep the patient nill by mouth
   4. Inform the doctor and the respiratory physician on call
   5. Prepare the patient for ICD insertion.
3. Tube block - flush with saline or remove the line and insert a new line.
4. Blood mis- Match
   1. Stop the blood transfusion
   2. Inform the hematologist on call
   3. Consider giving steroid and antihistaminics
   4. Inform the blood bank.
5. Infected tube.
   1. Remove the C-line
   2. send the tip of the central line for culture and drug sensitivity.
   3. Do would pressing.
   4. Arrange for the insertion of a new central line.
   5. The site of insertion has will be different.

Nursing intervention:

1. regular measurement of central venous pressure
2. regular dressing
3. flush the central line everything a drug is injected
4. Flush the central line with heparin

Client education

1. Not to touch the central line
2. Inform the doctor or nurse if there is pus oozing out of the central line.
3. After the central line is removed, the wound within two days.