Summary Chamberlain College of Nursing NR340 Exam 1

Chamberlain College of Nursing NR340 Exam 1 Overview of CC Critical Care Nursing • Deals with human responses to critical illness or injury o Physiological o Psychological • Focus on both the patient’s and family’s responses • Critical Care Overview • Not always centered in an “ICU setting” o Inpatient o Outpatient o Home Care o eICU o Tele-stepdown o Post anesthesia o Flight nursing-transport • Professional Organizations o American Association of Critical-Care Nurses o Society of Critical Care Medicine Trends and Issues • Critical care patients more complex • Increasing costs for care • Facilities for long term ventilators • Reduces stays in hospitals: more risk for infection • Better for patient to be at home Focus on Quality and Safety • Errors and harm must be prevented o Communication is a big error o On record where to find items o Medication errors o Documentation errors o Handwashing o Falls • Nurses are challenged to reduce errors and promote a safe environment • Several initiatives o Joint Commission National Patient Safety Goals o Institute for Healthcare Improvement o Quality and Safety Education for Nurses (QSEN) National Patient Safety Goals • The Joint Commission National Patient Safety Goals • Examples relative to critical care nursing o Communication o Medication safety o Reduce infections o Reconcile medications o Telephone orders- SAY BACK o TALL letters for similar drug names Harms Targeted for Reduction • Adverse drug events • Infections o Catheter-associated urinary tract infections (CAUTI) o Central line–associated bloodstream infections (CLABSI) o Surgical site infections o Ventilator-associated pneumonia (VAP) • Injuries from falls and immobility • Obstetric adverse events • Pressure ulcers • Venous thromboembolism (VTE) Communication • Communication important for safe care • Standardized approaches o SBAR and SBAP  Situation  Background  Assessment  Recommendation (Plan) • Collaboration o Nurse/ doctor o Debreifing Other Trends and Issues • Reducing hospital readmission rates o Chronic illness (HF) • Increasing use of technology o Electronic medical records o Physician order entry • Ethical issues associated with prolonging life and futile treatment • Telemedicine and eICU • Aging population and workforce • Shortage of CC nurses The Critical Care Environment • Stressful • Noisy • Sleep Deprivation • Concerns of the Critically Ill Patient o Patients responses do vary • Loss of control (even breathing) • ↓ Communication (d/t vent) • ↓Mobility, ↓Comfort Psychosocial Support (HIGHEST CONCERN) • Ensure safety • Reduce sleep deprivation • Reduce noxious sensory overload • Increase pleasant sensory input • Provide reorientation o Strategies  Mimic night/ day  Calendar/ clock  Tell them what you are doing  Talk to the patient  Allow for rest periods  Provide pleasant area Geriatric Concerns • Diminished ability to adapt to, or cope with, stressors of critical illness • At greater risk for negative outcomes • May not bounce back Ethical Issues • Critical care nurses confront in everyday practice o Informed consent and confidentiality o Withholding or withdrawal of treatment o Organ and tissue transplantation o Distribution of healthcare resources o Appropriate use of technology • Greater frequency in critical care Ethical Principles • Autonomy o Body o Ability to make decisions for self • Beneficence o To do good o To benefit the patient • Nonmalificence o To do no harm • Justice o People getting what they deserve/ need • Veracity o Be truthful • Fidelity o Be faithful • Confidentiality Nurse Involvement in Ethical Decision Making • Advocacy o Open communication of patient’s wishes and ethical concerns o True collaboration with healthcare team members • Dilemmas can result in moral distress • Formal mechanisms (The Joint Commission) o Bioethics committees o Ethics consultation • Opportunities for critical care nurses o Ethics forums and rounds o Peer review o Institutional review boards (research) Selected Issues • Informed Consent o Have to insure that patient is actually informed o No remaining questions about procedure/outcome • Advanced Directives • Organ and tissue donation o Call gift of hope – Nurses only responsibility • Life-sustaining treatment Forum to Resolve Issues • Bioethics Committees • Ethics Consultation Concerns of the Critically Ill • Pain o Physiology o Predisposing Factors  Disease process can cause pain  Changing dressing, movement, etc.  Ischemia o Assessment  Subjective  Pain is what the patient says it is  Objective  Vital signs  Non-verbal  Facial expressions  Moaning/Groaning  Grimiacing  Guarding  Body Movement • Pain Management (acute pain) o Nonpharmacologic  Heat, cold, massage, breathing, guided imagery, etc. o Prevention  Opioids  Fentanyl  Dilaudid  Morphine  Concern is respiratory depression  Antidote is narcan o Epidural o NSAIDS o PCA • Anxiety o Prolonged stated of apprehension in response to fear  Either actual or perceived fear o Marked by  Apprehension  Agitation  Automatic arousal o Physiology  Activation of sympathetic nervous system  Flight or Fight o Predisposing Factors  Fear  Uncertainty  Loss of control o Assessment  Subjective  Objective  Increases BP  Increased RR  Fidgety  Agitation • Anxiety Management o Pharmacological treatment for anxiety  Sedatives  Benzodiazepines  Reversal agent – Romazicon (Flumazenil)  Lorazepam(Ativan) – Intermediate acting  Midazolam (Versed) – short acting  Propofol – Short acting  Continuous drip  Mechanical vent  Dexmedetomidine o Titrate to an end point (sedation scales or tools)  Level of sedation- calm, follow commands o Everyday turn off sedation – Sedation Vacation  Sedation may not be metabolized/excreted  Builds up in body • Delirium o Acutely changing mental status  Can’t make decisions  Hypoactive/ hyperactive o Multiple types  Hyperactive  Hypoactive o Multiple causes  Sleep deprivation  Pain  Fever o Goal—keep the patient safe o Medication—Haldol  Give antipsychotic meds o Nonpharmacologic Interventions  Awaken them – establish normal sleep cycle  Breathing  Choice of sedation – certain sedatives contribute to delirium  Delirium screening Respiratory Alterations Nursing Goals • Maintain patent airway • Ensure adequate ventilation • Ensure adequate oxygenation Respiratory Anatomy o Upper  To bring air into the body  Filter, humidify, warm  Carnia is the beginning of the lower airway o Lower  Bronchi, bronchioles, alveoli Physiology of Breathing • Involuntary/ voluntary • Rest • Ventilation o Inspiration  Negative pressure o Expiration  Longer, passive • Gas Exchange o Alveoli- higher concentration PaO2to lower o Ventilation is CO2&O2 out of alveoli  Controlled by CNS • Regulation of Breathing o Chemoreceptors o Medulla and Pons Terminology • Work of breathing o Should NOT be work