Professional organizations that support critical care practice - ANSWER American Association of Critical Care Nurses (AACN), Society of Critical Care Medicine What is the mission of AACN? - ANSWER assisting acute and critical care nurses to attain knowle

Professional organizations that support critical care practice - ANSWER American Association of Critical Care Nurses (AACN), Society of Critical Care Medicine What is the mission of AACN? - ANSWER assisting acute and critical care nurses to attain knowledge and influence to deliver excellent care What is the vision of AACN? - ANSWER supports creating a healthcare system driven by the needs of patients and families in which critical care nurses make their optimal contributions...synergy What are the values of AACN? - ANSWER accountability, advocacy, integrity, collaboration, leadership, stewardship, lifelong learning, quality, innovation, commitment Explain the synergy model and recognize how it is used in practice - ANSWER - framework that aligns patient needs w nurse competencies - needs of patient drive nurse competencies for patient care What types of certifications are available for ICU nurses? - ANSWER CCRN - critically ill adult, pediatric or neonatal pts PCCN - acute care in progressive care, telemetry AACN - nurse managers and leaders Why are certifications important? - ANSWER validates knowledge of critical care nursing, promotes professional excellence, helps nurses to maintain current knowledge base What are three specific projects/organizations in place to assist nurses in providing safe care? - ANSWER Quality and Safety Education for Nurses (QSEN) Institute for Healthcare Improvement (IHI) Rapid response teams/joint commission (?) What types of measures do safe care organizations implement? - ANSWER Safety, reduce infections, bundles of care What is a bundle of care? Give an example. - ANSWER Set of 3-5 EBPs that when put together significantly improve pt outcomes ex - ventilator bundle -- HOB elevated, DVT prophylaxis, holding a sedative to determine pt readiness to get off vent What are some barriers to effective handoff communication? - ANSWER physical setting, social setting, language, communication medium ex - background noise, different languages, email vs text vs paper, status issues What standardized measures have been implemented to help prevent communication breakdown at shift change? - ANSWER SBAR, checklists What are examples of things you may need to communicate during multi-professional rounds? - ANSWER D/C needs, greatest safety risk, assessment and followup, implementation of bundles, assess need for all ordered meds, identify whether central lines & catheters can be removed, code status, family needs, advance directives, when to call MD, tx goals What types of things contribute to sensory overload/deprivation in a critical care environment? - ANSWER noise level, environment different than surroundings causing hallucinations, lighting What types of interventions can nurses implement to combat sensory overload/deprivation? - ANSWER Noise: place pt in private room, soundproof ceiling tiles, sedative music, quickly assess alarms Hallucinations: post family photos, encourage visitation, interact w pt Use natural lighting help design optimal and safe environment What types of stressors do patients identify from their critical care experience? - ANSWER difficulty communicating, pain, thirst, difficulty swallowing, anxiety, lack of control, depression/fear, lack of family/friends, physical restraint, feelings of dread, inability to get comfortable, difficulty sleeping, loneliness, thoughts of death What age-related demographic is at high risk for negative outcomes in the ICU? - ANSWER older adults 65 yo What types of situations contribute to family conflict being present? - ANSWER feelings/concerns of family; unresolved family issues How can nurses best support the family members of patients and assist them in coping? - ANSWER evaluate, plan, involve, communicate, support family-centered interventions see if family can help w care so they feel more in control What is the main cause of emotional outbreak or inappropriate responses from family members? - ANSWER lack of communication What does research say about family visitation in the ICU? - ANSWER results in better patient outcomes, liberal visitation is encouraged What are the benefits to allowing family presence during codes? - ANSWER promotes increased knowledge of pt condition/removes doubts witness everything possible was done decrease anxiety and fear about what is happening to their loved one sense of closure autonomy - ANSWER respect for individual and ability of the individual to make decisions with regard to their own health and future (informed consent) Beneficience - ANSWER actions intended to benefit the patient or others Nonmaleficience - ANSWER do no harm Justice - ANSWER being fair or just to the wider community in terms of the consequences of an action; fair allocation or distribution of healthcare resources What are bioethics committees? - ANSWER physicians, nurses, chaplains, social workers and bioethicists work together to provide ethics on a case by case basis What types of situations may warrant an ethics consult? - ANSWER disagreement/conflict exists on whether to pursue aggressive life-sustaining tx in a seriously ill pt (CPR, or emphasize comfort/palliative care) family demands to provide life-sustaining tx (ventilation, tube feedings) which nurse/MD consider futile seriously ill pt is incapacitated and does not have surrogate decision maker or advance directive Identify what must be present for patient to provide consent for themselves - ANSWER competence, voluntariness, disclosure of information, free from severe pain/depression What basic information must be present for decision making? - ANSWER Diagnosis of specific health problem/condition Nature, duration, purpose of proposed tx probable outcome of any intervention benefits of intervention potential risks that are common/hazardous alternative tx & their feasibility short-term and long-term prognoses if proposed tx are/are not provided What is the order of decision makers in SC? - ANSWER 1. guardian appointed by court 2. Attorney-in-fact appointed by patient 3. spouse of pt (unless they're separated) 4. Adult child of patient 5. parent of patient 6. adult sibling of patient 7. grandparent of patient 8. any other adult relative by blood or marriage who reasonably is believed by HCP to have close personal relationship w patient 9. Person given authority to make healthcare decisions for the patient by another statutory provision 10. If none of the above are available, then a person who has an established relationship w the patient who is generally familiar with their healthcare views When would a healthcare proxy/next of kin be used for decision making? - ANSWER When patient can't make decisions for themselves Advanced Directive - ANSWER Witnessed written document or oral statement in which instructions are given by a person to express desires r/t healthcare conditions living will - ANSWER witnessed written document or oral statement voluntarily executed by a person that expresses the person's instructions concerning life-prolonging procedures proxy - ANSWER competent adult who has not been expressly designated to make healthcare decisions for incapacitated person but is authorized by state statue to make decisions for person surrogate - ANSWER competent adults designated by person to make healthcare decisions should that person become incapacitated terminal condition - ANSWER A condition in which there is no reasonable medical probability of recovery and can be expected to cause death without treatment Persistent Vegitative State (PVS) - ANSWER A permanent, irreversible unconsciousness condition that demonstrated the absence of voluntary action or cognitive behavior, inability to communicate or interact purposefully with the environment brain death - ANSWER complete and irreversible cessation of brain function DNR - ANSWER do not resuscitate order Allow Natural Death (AND) - ANSWER basically the same as DNR but without the negative connotations Withholding or Withdrawing Life support - what it is & role of advanced directive - ANSWER comfort measures maintained, decisions based off open communication w/ family, advance directive w indications if one becomes critically ill is key medical futility - ANSWER situation in which therapy or interventions will not provide a foreseeable possibility to improve the patient's health Palliative care - ANSWER Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family. hospice - ANSWER Providing care for terminally ill pts What distressing symptoms does palliative care address? - ANSWER pain, hunger, anxiety, thirst, dyspnea, diarrhea, nausea, confusion, agitation, disturbance in sleep patterns How would you educate families on what withdraw/withhold of care looks like? - ANSWER dyspnea if ventilator withdrawal assess and ensure pt comfort, what meds to give to ensure comfort What types of therapies are held/stopped during withdrawal of care? - ANSWER ventilator, vasopressors, abx, blood & blood products, dialysis, nutritional support How is withdraw of care different from euthanasia? - ANSWER minimal mortal distress, agreed decisions In what manner should we communicate with families? - ANSWER consistent, professional, accurate, clear, culturally sensitive, calm manner and voice What types of things should we allow/provide for family members? - ANSWER social workers, chaplains, tissues, refreshments, chairs S/sx of pain - ANSWER what the pt says it is! inadequate sleep, anxiety, agitation, disorientation; unpleasant sensory or emotional experience tachycardia, tachypnea, HTN, diaphoresis, nausea & sleep disturbance, decreased tissue perfusion, cardiac events, nightmares isolation, PTSD, delirium s/sx of anxiety - ANSWER state of apprehension, fearful withdrawal -- subjective! What should you do prior to administration of pain or anxiety medication? - ANSWER assess patient, ID what the cause is & treat the cause What does a neuromuscular blockade do? What must be given beforehand? - ANSWER therapeutic paralysis (ex - tracium, sucinylcholine, rocuronium) ADMINISTER SEDATION BEFOREHAND - no sedative or pain effects! Train of four - what it is, what specific number of twitches indicate - ANSWER ensures proper amount of paralysis is achieved delivers 4 impulses to get specific number of twitches -- always get baseline number 0 twitches = too much 4 twitches = too little 2 twitches = perfect BPS - if given pt situation, be able to score - ANSWER Scores range from 3 (no pain) to 12 (maximum pain) Facial Expression - 1 Relaxed - 2 partially tightened (brow lowering) - 3 - fully tightened (eyelid closing) - 4 - grimacing Upper Limb Movements: - 1 - no movement - 2 - partially bent - 3 - fully bent with finger flexion - 4 - permanently retracted Compliance with mechanical ventilation - 1 - tolerating movement - 2 - coughing but tolerating ventilation most of the time - 3 - fighting ventilator - 4 - unable to control ventilation ARDS: underlying patho - ANSWER causes: aspiration of gastric contents, pneumonia, pulmonary contusion, multisystem trauma, sepsis all direct insult to inflammatory response **look at diagram from class* Lung injury -- capillary membrane damage -- inflammatory mediators increasing permeability of surrounding tissues -- "leaky membranes"/influx of RBC, WBC, protein into alveoli -- pulmonary edema -- diffusion defect, hypoxia -- resp failure lung injury -- alveolar membrane damage -- damage to pneumocytes -- decrease in surfactant -- impaired compliance, alveoli collapse, atelectasis -- V/Q mismatch -- resp failure ARDS: s/sx - ANSWER respiratory distress that does not respond to O2 therapy!! early signs: initially alkalotic (breathing harder to compensate for O2), neurological (restlessness, disorientation, decreased LOC), tachycardia late signs: hypoxia, SOB, use of accessory muscles, central cyanosis, crackles, lungs are hard to ventilate -- resp acidosis & metabolic acidosis r/t lactic acid buildup ARDS: diagnostic criteria - ANSWER P/F ratio of /= 300 bilateral infiltrates on CXR acute onset w/in 1w of initial insult no evidence of L atrial hypertension as cause ARDS: meds/tx - ANSWER oxygenation - mechanical ventilation with high PEEP sedation & comfort therapeutic paralysis F&E -- conservative! don't want to overload nutrition prone positioning Normal ABG levels - ANSWER pH: 7.35-7.45 PCO2: 35-45 HCO3: 22-26 PaO2: 75-100 (measurement of whole body oxygenation) SaO2: Pulse ox (95-100?) ABG change in hypoventilation - ANSWER low RR, going hypercapnic! High CO2, low bicarb -- retaining CO2 ABG changes in hyperventilation - ANSWER high bicarb, low CO2 -- blowing out CO2 Alveoli - purpose, what happens when fluid fills them? - ANSWER facilitates gas exchange, when fluid fills -- diffusion deficit -- poor gas exchange! PE: common causes - ANSWER VTE/DVT virchow's triad -- venous stasis, hypercoagulability, damage to vessel walls s/sx -- anxiety, SOB, impending doom, chest pain PE: nursing interventions to prevent - ANSWER heparin/lovenox SCDs mobilize PE: diagnosis - ANSWER CTA chest/pulm angiogram d-dimer (for kidney pts that can't get contrast) VQ scan (for kidney pts that can't get contrast) PE: tx - ANSWER heparin drip when indicated, embolectomy, vena cava filters PaO2/FiO2 ratio - ANSWER PaO2/FiO2 (FiO2 in decimal form) /= 300 is bad, 500 is normal What are the priority nursing interventions for a prone patient? - ANSWER maintaining airway patency, no kinks in airway, skin breakdown -- use proning kits on bony prominences! Ventilator bundle of care - ANSWER - HOB 30-45 degrees - Sedation vacations to assess readiness to wean - DVT prophylaxis w/ SCDs/heparin - PUD prophylaxis w/ pepcid - daily oral care (minimum q4h) w/ CHG/peroxide PEEP - what is it, how it helps pts, SE if too much - ANSWER Positive End Expiratory Pressure -- keep alveoli open to promote gas exchange too much -- hypotension (puts pressure on heart & heart can't pump), lung pops SIMV - indications, benefits, risks, associated ABG changes - ANSWER Synchronized Intermittent Mandatory Ventilation - set volume, set rate, variable pressure; pt breath allowed but not supported - Advantages: pt conditions muscles by attempting to breathe, could potentially wean pt off vent - Disadvantages: extra breaths not supplemented when they may need t obe - blood gas changes -- resp acidosis (?) PS - indications, benefits, risks, associated ABG changes - ANSWER Pressure Support - right before tube comes out! - patient initiating breaths themselves - volume: pt dependent, rate: pt initiated & dependent, pressure: set & given on inspiration; pt makes all breathing effort - advantages: weaning mode (stimulates normal breathing), comfortable for patient - disadvantages: pt has to trigger every breath!can't be on this if pt can't control breathing/can't make themselves breathe enough times - ABG changes: ? show tolerance; respiratory acidosis Risks if ETT is placed improperly or if it becomes unsecured - ANSWER unplanned extubation -- call for help, 100% O2 on NRB, manually ventilate if not breathing on their own complications of ETT: laryngeal/tracheal injury, damage to mucosa, acid/base disturbances, dysphagia/aspiration, hypotension (too much PEEP), stress ulcers, psychosocial complications Causes for high pressure alarms - ANSWER vent is trying to force air in but it can't -- caused by secretions, biting tube, kink in tube Causes for low pressure alarms - ANSWER vent is not meeting expected resistance -- air leak, apnea alarm, detached from ventilator or pt self extubates order of events when ventilator alarm goes off - ANSWER 1. assess pt & see what problem is 2. if you can't find problem -- take pt off vent & bag them manually 3. Call RT for help