Critical Care Test 1 Questions and Correct Answers.

Critical Care Test 1 Questions and Correct Answers Two main professional organizations mentioned that support critical care practice. - Correct Answers: American Association of Critical-Care nurses (AACN) and Society of Critical Care Medicine (SCCM) Which organization best supports critical care nurses out of the two mentioned? - Correct Answers: The AACN's mission is to assist acute and critical care nurses to attain knowledge and influence to deliver excellent care using the "synergy model". The SSCM is targeted more toward the entire health care team in critical care, so AACN would serve nurses more. What is the mission of AACN? - Correct Answers: assisting acute and critical care nurses to attain knowledge and influence to deliver excellent care What is the Vision of AACN? - Correct Answers: a. creating a health care system driven by the needs of patients and families in which critical care nurses make their optimal contributions (described as synergy) What is the Values of AACN? - Correct Answers: Accountability, advocacy, integrity, collaboration, leadership, stewardship, lifelong learning, quality, innovation, and commitment Explain the Synergy Model and how it is used in practice? - Correct Answers: Patient needs (medically, emotionally, culturally, etc.) drive the nurse competencies required for patient care - when competencies stem from patient needs, and the characteristics of the nurse and patient match, synergy occurs and enables optimal outcomes - Many organizations use this model as a basis for developing frameworks for nursing practice, this is also used to implement appropriate staffing by ensuring the best nurse is matched with the patient that matches that nurse's competencies What types of certifications are available for ICU nurses? - Correct Answers: CCRN (nurses who provide care for critically ill adult, peds, or neonatal populations) and PCCN (nurses who provide acute care in progressive care, telemetry, and similar units) Why are critical care certifications important? - Correct Answers: They validate knowledge of critical care nursing, promotes professional excellence, and helps nurses to maintain a current base of knowledge What 3 specific projects/organizations are in place to assist nurses in providing safe care? - Correct Answers: i. Quality and safety Education for Nurses (QSEN) project ii. Joint Commissions National Patient Safety Goals iii. Institute for Healthcare Improvement (IHI) Quality and Saftey Education for Nurses (QSEN) - Correct Answers: defines 6 core competencies that provide a foundation for safe nursing care - patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety Joint Commission- National Patient Safety Goals - Correct Answers: goals updated annually to ensure facilities implement actions and protocols to address safety - ex. improve accuracy of patient identification, improve communication among HC providers (report critical values/test results), improve medication safety (labeling meds, contraindications, harmful side effects), use alarms safely, reduce risk of healthcare-associated infections (hand hygiene, aseptic techniques), identify safety risks (self-harm patients, fall risks), and prevent complications associated with surgery and procedures Institute for Healthcare Improvement (IHI) - Correct Answers: produced an action plan for reducing healthcare-associated infections and preventing infections with multidrug-resistant organisms - action plan includes bundles of care to reduce harms Explain what a Bundle of Care is? - Correct Answers: Care bundles are a set of 3-5 EBP (interventions) that when used together cause significant improvement in patient outcomes 1. All elements of the care bundle must be performed in a series of steps by 1 healthcare team within a single time frame Bundles of Care Example at Bedside - Correct Answers: Ex: caring for central lines, practicing meticulous hand hygiene, using full barrier precautions during central line insertion, applying chlorhexidine to the patient's skin as a cleansing agent, avoiding central line insertion into femoral vein, removing unnecessary IV caths What are some barriers to effective handoff communication? - Correct Answers: 1. Physical setting- background noise, lack of privacy, interruptions - ex. giving report in a noisy/busy hallway causing the recipient of the handoff to miss important information due to noise 2. Social setting- organizational hierarchy and status issues - ex. a nurse needing to communicate a critical value to a MD but they aren't answering the page or a new nurse feeling anxious to call the MD promptly 3. Language- differences between people of varying racial or ethnic backgrounds or geographical areas - ex. different languages between healthcare providers or even patient-to-healthcare provider 4. Communication medium- limitations of communications via telephone, e-mail, paper, or computerized records vs. face-to-face communication - ex. a peer missing a page, computer glitch causing messages to fail sending What standardized measures have been implemented to help prevent communication breakdown at shift change? - Correct Answers: i. Ask-Tell-Ask (a strategy for encouraging nurses to assess concerns before providing more information, especially when discussing stressful issues with patient and families) ii. Tell Me More (tool that encourages information sharing in challenging situations) iii. SBAR (useful tool with especially physicians) Can you give examples of things you may need to communicate during multi-professional rounds? - Correct Answers: Discharge needs, greatest safety risk, critical care "bundles", assessment and recommendation follow-up (Head to toe status), assess needs for all meds ordered, identify central lines and caths and tubes and if they can be removed, issues that need to be addressed (family needs, code status, advance directives), treatment goals and strategies, and plans for discussing care/needs with families What types of things contribute to this sensory overload/deprivation? - Correct Answers: i. Noise level (call-bell, oxygen or chest tube bubbling, loud conversations, voices over intercoms, telephones ringing, Tv, raising or lowering the bed, cardiac monitor, ventilator sounds, pneumonic tubes) ii. Environment is very different from their usual surroundings iii. Lighting issues (not enough natural light= deprivation and too much artificial light= overload) - Sensory deprivation in critical care unit due to the increase in perceptual disturbances (hallucinations), lack of interaction with family, introduction to a foreign environment, and artificial light disrupting a patient's circadian rhythm What types of interventions can nurses implement to combat sensory overload/deprivation? - Correct Answers: i. Placing patients in private rooms, providing "sedative" music, avoid excessively loud talking, responding to phones quickly, assessing alarms quickly ii. Encourage friends and family visitations, posting family photos and providing music or TV that the patient usually enjoys iii. Utilizing natural light in rooms, diming artificial lighting What types of stressors do patients identify from their critical care experience? - Correct Answers: Difficulty communicating, pain, thirst, difficulty swallowing, anxiety, lack of control, depression, fear, lack of family and friends, physical restraint, feelings of dread, inability to get comfortable, difficulty sleeping, loneliness, and thoughts of death and dying What age-related demographic is at a high risk for negative outcomes in the ICU? - Correct Answers: Age 65 and older and 33% die within 6 months after discharge from a critical care unit - Older patients have a decreased ability to adapt and cope with major physical and psychosocial stressors of critical illness What types of situations do you think could contribute to family conflict being present? - Correct Answers: a. The patient's family role, families coping strategies, socioeconomic issues, and if the family members are feeling angry, guilty, or have unaddressed concerns regarding the patients condition and care. b. Illness within the family may uncover underlying conflicts among family members, especially if they are estranger or have other unresolved issues. How can nurses best support the family members of patients and assist them in coping? - Correct Answers: i. Decision Making- involve family members in decision making, communicate the patient's status and explain all options for future care, hold meetings with health care team and family within 48 hours of admission to ICU ii. Family Coping- assign consistent nurses and physician staff, provide information to family members in various formats, provide family support through support groups, consult, etc. iii. Staff Stress- keep all healthcare members informed of treatment goals IV. Cultural Support of Family- culturally competent care Spiritual and Religious support of appropriate Family Environment of V. Care- allow family to be present during rounds, regular visitations, and allow family to be present during CPR VI. Palliative Care What is the main cause of emotional outbreak or inappropriate responses from family members? - Correct Answers: Lack of communication - Always be truthful, prompt, and communication in a jargon the family can understand - Facilitate open communication with family members to keep them involved in the patient's care What does research say about family visitation in the ICU? - Correct Answers: Family presence has a positive impact on the patient's condition What are the benefits to allowing family presence during cardiopulmonary resuscitation (codes)? - Correct Answers: i. Increases family knowledge of the patient's condition ii. Able to witness "everything possible" being done as well as the extreme stress CPR has on the body iii. Decreases anxiety and fear about what is happening IV. Gain a sense of closure and grieving, should death occur Autonmy - Correct Answers: respect for the individuals and the ability of individuals to make decisions with regard to their own health and future (the basis for the practice of informed consent) Benefience - Correct Answers: Actions intended to benefit the patient and others Nonmaleficence - Correct Answers: Actions intended not to harm or bring harm to others Justice - Correct Answers: Being fair or just to the wider community in terms of consequences of an action. In healthcare, it is described as the fair allocation or distribution of health care resources. What are bioethics committees? - Correct Answers: i. a multiprofessional committee that can serve as an education and policy-making body and provide ethics consultation on case-by-case basis ii. purpose: improve the process and outcomes of patient care by helping to identify, analyze, and resolve ethical problems - should be used when the issues cannot be resolved among the health care team, patient, and family What types of situations may warrant an Ethics consult? - Correct Answers: i. Disagreement or conflict exists on whether to pursue aggressive life-sustaining treatment in a seriously ill patient (like CPR) or emphasize comfort and palliative care ii. Family demands to provide life-sustaining treatment which physician and nurses consider futile iii. Competing family members are present and want to make critical decisions on behalf of the patient IV. A seriously ill patient is incapacitated and does not have a surrogate decision maker or advance directive Identify what must be present in order for a patient to provide consent for themselves? - Correct Answers: Competence, voluntariness, and disclosure of information What basic information must be present for decision making? - Correct Answers: i. A diagnosis of the patient's specific health problem and condition ii. The nature, duration, and purpose of the proposed treatment or procedures iii. probable outcome of any medical or nursing intervention IV. benefits of medical or nursing intervention V. potential risks that are generally considered common or hazardous VI. alternative treatments and their feasibility VII. short term and long term prognosis if a proposed treatment is or isn't provided What is the order of decision makers in South Carolina? - Correct Answers: i. A guardian appointed by the court pursuant ii. An attorney-in-fact appointed by the patient in a durable power of attorney iii. A spouse of the patient unless they are separated iv. An adult child of the patient, or if they have more than one child, then a majority decision by all children v. A parent of the patient vi. An adult sibling of the patient vii. A grandparent of the patient viii. Any other adult relative by blood or marriage (who has a reasonably personal relationship with the patient) ix. A person given authority to make HC decision by another statutory provision x. If 1-9 are not available/suitable then a person who has established a relationship with the patient who is acting on behalf of the patient When would a healthcare proxy/next of kin be used for decision making? - Correct Answers: If the patient is not mentally capable of providing consent advanced Directive - Correct Answers: Witnessed written document or oral statement in which instructions are given by a person to express desires related to health care decisions. It may include, but not limited to, the designation of a health care surrogate, a living will, or an anatomic gift. Living Will - Correct Answers: A witnessed written document or oral statement voluntarily executed by a person that expresses the person's instructions concerning life-prolonging procedures. Proxy - Correct Answers: A competent adult who has not been expressly designated to make health care decisions for an incapacitated person, but is authorized by the state statue to make health care decisions for the person Surrogate - Correct Answers: A competent adult designated by a person to make health care decisions should that person become incapacitated Terminal Condition - Correct Answers: A condition in which there is no reasonable medical probability of recovery and can be expected to cause death without treatment. Persistent Vegetative State - Correct Answers: A permanent, irreversible unconsciousness condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment Brain Death - Correct Answers: complete and irreversible cessation of brain function DNR - Correct Answers: A medical order that prohibits the use of cardiopulmonary resuscitation and emergency cardiac care to reverse signs of clinical death. The DNR order may or may not be specified in a patients advance directives. Allow Natural Death - Correct Answers: An alternate with less negative connotations, but essentially meaning DNR Withholding or Withdrawing Life Support - Correct Answers: Not initiating hemodialysis (withholding) to terminal weaning from mechanical ventilation (withdrawing). - an ethical decision-making approach is used to decide on the best action to take, - if conflict arises, ethics consult, ethics committee, and risk managers can provide assistance. an advance directive is key to avoiding treatment given or not given against one's wishes Medical Futility - Correct Answers: Situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient's health condition, or a lack of attainable goals of care Palliative vs. Hospice Care - Correct Answers: a. Palliative care is the provision of care interventions that are designed to relive symptoms of illness or injury that negatively affect the quality of life of the patient or family. This is in supplement to care and can be used during any point of illness, not just at end of life. b. Hospice care is generally reserved for those with a prognosis of less than 6 months to live and usually in place of aggressive life-sustaining or restorative care What distressing symptoms does palliative care address? - Correct Answers: Pain, anxiety, hunger, thirst, dyspnea, diarrhea, nausea, confusion. Agitation, and sleep disturbance in patters How would you educate families on what withdraw/withhold of care looks like (think: symptoms, order of events, what nurses are assessing)? - Correct Answers: i. The nurse will medicate to alleviate symptoms associated with the withdrawal of each therapy ex. for ventilator withdrawal, the patient will experience symptoms similar to respiratory distress and the nurse will medically sedate the patient to alleviate distress symptoms iii. Therapies that are commonly held/stopped during withdrawal of care: mechanical assistance, vasopressors, antibiotics, blood and blood products, dialysis, and nutritional support How is withdraw of care different from euthanasia? - Correct Answers: It is different in you're withdrawing the care that is keeping them alive, but are not doing anything to kill them or speed the process along (such as euthanasia and assisted suicide) In what manner should we communicate with families? - Correct Answers: i. needs are as variable as family situations, use non-judgmental assessment to become aware of patient's and family's personal feelings and values about the situation - keep in mind that the family can consist of different persons and different feelings ii. coordinate the communication process between patient, family and healthcare team to ease anxiety and ensure the most peaceful death possible What types of things should we allow/provide for family members? - Correct Answers: Adequate staffing for family, helpful organizational behaviors include bereavement programs for families and assistance or guidance in making funeral arrangements. Use cultural sensitivity, maintain patients dignity**, allow unrestricted family presence, provide items of comfort (tissues, refreshments, and chairs), maintain a respectful presence. Nursing Interventions to Support Care at the End of Life - Correct Answers: i. Assess patient's and family members' understanding of condition and prognosis to address educational needs. ii. Educate family members about what will happen when life support is withdrawn to decrease their fear of the unknown iii. Assure family members that the patient will not suffer iv. Assure family members that the patient won't be abandoned v. Provide for any needed emotional support and spiritual care resources (grief counselors and spiritual care providers) vi. Facilitate physician communication with family vii. Provide visitation and presence of family and extended family s/sx of pain - Correct Answers: tachycardia, diaphoresis, restlessness, agitation, which can lead to anxiousness, fearful, apprehension. (most of the time activated by SNS) s/sx of anxiety - Correct Answers: Apprehension, agitation, fearful, hyperventilation, sweating, tachycardia, trembling, feeling weak/tired, social withdrawal What should you do prior to administration of pain or anxiety medication? - Correct Answers: - depending on anxiety medication (the respiration rate) - Assess the level of anxiety as well, what is causing it (pain and anxiety can cause each other, and it can become cyclic) What does a neuromuscular blockade do? What must be given beforehand? - Correct Answers: Blocks all muscular function, but not a sedative or analgesic i. MUST GIVE A SEDATIVE beforehand!! Train of Four - what it is, what specific number of twitches indicate? - Correct Answers: An electrode machine that is used before and during NMB to ensure the proper amount of paralysis is given Delivers 4 impulses and must assess the number of twitches on the thumb and pinky you see i. Always get a baseline number (energy & twitches) ii. 0 twitches = too much NMB iii. 4 twitches = not enough NMB iv. 2 twitches = jusssssst right BPS (Behavioral Pain Scale) - Correct Answers: Patho of ARDS: Acute Phase - Correct Answers: uncontrolled inflammation in the alveoli (leading to inflammatory response and capillary damage and leaky membranes) Patho of ARDS: Proliferative Phase - Correct Answers: Occurs between 4-21 days after onset. The pulmonary edema resolves leaving the scarring of lung tissue to form, resulting in progressive hypoxemia Patho of ARDS: Fibrotic Phase - Correct Answers: occurs 2-3 weeks after initial insult. Lungs become completely fibrotic (scar tissue) which causes decreased functional capacity, severe right to left shunting, edema, and narrowing of the airway Hallmark S/Sxs of ARDS - Correct Answers: s/sx of respiratory distress (tachypnea, hypoxia, etc.) that DOES NOT respond to O2 therapy (injury in lungs cannot do gas exchange) Early Signs of ARDS - Correct Answers: alkalotic (initial signs of RD and hyper ventilating), neuro signs (restlessness, agitation, confusion), Cardiac (HR increases tachycardia to try to compensate) - Make blood alkalotic Later Signs of ARDS - Correct Answers: hypoxia will get worse (worsen Pts shortness of Breath), significant work of breathing (accessory muscles, use neck and stomach muscles), cyanosis (centrally), crackles in lungs (pulmonary edema), Acidotic (no gas exchange b/c of fluid in their lungs), metabolic acidosis as well because of build up of lactic acid What does the CXR look like for an ARDS patient? - Correct Answers: bilateral infiltrates (ground glass appearance) - white out appearance Medications ordered for ARDS - Correct Answers: 1) Oxygen Therapy through mechanical ventilation with high PEEP 2) Sedation & comfort (do not want SNS stimulated) 3) Therapeutic paralysis (Sedation 1st and then paralytic) 4) Fluids & Electrolytes (be conservative, may need to use lasixs) 5) Nutrition (TPN may be needed) Specific Diagnostic Criteria for ARDS - Correct Answers: 1) PaO2/FiO2 /= 300 (indicative of severe respiratory distress) 2) Bilateral infiltrates on CXR 3) Acute onset within 1 week of initial insult 4) No evidence of L atrial hypertension as cause Hypoventilation ABG Changes - Correct Answers: Respiratory acidosis (holding on to all that CO2 is acidic) - EX= drug OD, brain injury, abdominal or chest trauma/surgery, broken ribs Hyperventilation ABG changes - Correct Answers: Respiratory alkalosis (blowing off too much CO2) -EX= anxiety attack, anaphylactic shock, one-sided collapsed lung Alveoli - Correct Answers: Air Filled Sacs in which gas exchange occurs in them What happens when fluid fills alveoli? - Correct Answers: Diffusion of CO2 and O2 cannot occur (membranes become leaky and alveoli start to collapse) Early Signs of Hypoxemia - Correct Answers: Neuro symptoms (#1 restlessness!!!, anxiety, decreased LOC) pulmonary embolism (PE) - Correct Answers: When a DVT forms or a embolism travels and becomes lodged in the pulmonary vasculature Common Causes of PE - Correct Answers: - Lack of perfusion (V/Q mismatch) *Lack of gas exchange which causes IM to be released * inflammatory mediators * Virchow's Triad (venous stasis= #1 cause) PE Prevention - Correct Answers: Heparin or lovenox, SCDs, and mobilize them Common S/sx of PE - Correct Answers: tachypnea, SOB, impending doom, extreme episode of anxiety, acute change in HR (super tachycardic) Diagnostics for PE - Correct Answers: CTA chest with contrast (looks at lung vasculature and blood flow) and pulmonary angiogram PaO2/FiO2 ratio - Correct Answers: take the PaO2 and divide it by the FiO2 (in decimal form) - Less than or equal to 300 is indicative of ARDS - 500 or greater = normal 2 Main Priorities for patients who are going to be Proned - Correct Answers: #1 Maintaining a patent airway/protection & #2 pressure injury IHI's Ventilator Bundle of Care - Correct Answers: 1) HOB 30-45 degrees (based on pt tolerance) 2) Sedation vacations to assess readiness to wean (pausing sedation and seeing how well pt can breathe on their own and monitor ABGs) - you can do your best neuro assessment 3) DVT prophylaxis (heparin, lovenox, SCD, repositioning) 4) PUD prophylaxis (Pepcid to prevent ulcers) 5) Daily oral care (minimum q4h) with CHG/Peroxide (around the tube, on their mouth and teeth) PEEP (positive end expiratory pressure) - Correct Answers: Keep the alveoli open and maximizing the number of alveoli open for gas exchange - SE: an increase in intrathoracic pressure leading to decreased CO, trauma to surrounding tissues, increased intracranial pressure, hypotension Suctioning Procedure - Correct Answers: Most of the time you want to pre oxygenate your patient, then you tell them you're about to inline suction and insert the line down the ET and then once you meet resistance, pull up about an inch and then start suctioning all the way up. This should be for no longer than 15 seconds and then allow your patient to rest. Suctioning Indications - Correct Answers: ****Nurse is only to suction pt when they need it!!! (not on a schedule)**** - If pt is coughing, hear secretions, crackles in BS then you suction, but if pt is fine then DO NOT SUCTION SIMV (synchronized intermittent mandatory ventilation) - Correct Answers: A weaning mode that is a good setting for pts to exercise their lungs - Benefits: 1. Patient is able to condition their lung muscles by attempting to breath 2. Could possibly help patients wean off the ventilator - Risks: Extra breaths not supplemented when they may need to be - ABG changes: Respiratory acidosis because all the CO2 may not be fully blown off due to the ventilator not supporting the patient's breaths PS (Pressure Support) - Correct Answers: Best mode to put a patient on to stimulate spontaneous breathing (with a set pressure given on inspiration to give support when the vent recognizes that the patient is inspiriting) - Benefits: 1. Weaning Mode- stimulates normal breathing 2. Comfortable for pt - Risks: Patient has to trigger every breath won't be able to use this mode if the patient cannot breathe enough times - ABG Changes: Respiratory acidosis can occur due to the lack of breaths the patient may take Risks if ETT is place improperly - Correct Answers: 1. may be placed upward resulting in the cuff being positioned between or on vocal cords 2. too far in the airway causing a right mainstem bronchus (absent or diminished breath sounds in L lung and unequal chest expansion) 3. could go down esophagus and ventilate stomach rather than lungs Risks of unplanned ETT extubation - Correct Answers: - most frequently because the patient takes the tube out or comes out when moving a patient - this causes the patient inadequate ventilation - risk factors include agitation, inadequate surveillance, higher consciousness level, and presence of physical restraints High-and-low Pressure Alarms - Correct Answers: 1. HP alarms: vent Is trying to force air in, and it cannot Ex: secretions, pt biting on the tube (2 main ones) 2. LP alarms: lower resistance than what is expected Ex: Leak in tube, disconnected, or apnea alarms Order of Events when the ventilator alarm goes off - Correct Answers: #1: ASSESS the patient first and figure out why the alarm is going off NEVER TURN OFF ALARM! (only silence it if you know the problem) #2: When in doubt, manually ventilate your patient with an ambu-bag ABGs - Correct Answers: - Respiratory Acidosis: retention of CO2 hypoventilation, CNS depression - Respiratory Alkalosis: hyperventilation hypoxemia, anxiety, pain/fever, CNS irritation - Metabolic Acidosis: increased acids or loss of base DKA, lactic acidosis, drug overdoses, diarrhea - Metabolic Alkalosis: fain of base or loss of acids vomiting, NG suction, diuretics, low K+/chloride