Summary Nursing Critical Care

Nursing Critical Care Chapter 3 Laws: EMTALA: Emergency room law - everyone who comes in ER room must be treated whether they have insurance or not. Torts: Doing something legally wrong Intentional: Assault (Verbal threats), battery (Physical harm, putting your hands on them without permission), false imprisonment (medical restraint is a necessity) (Haldol to sedate them is chemical restraint) Unintentional: Negligence (no harm to patient we just didn’t do what we were supposed to), Malpractice (when harm is done to the patient). ON TEST Dilemmas: No right or wrong Principlism is a widely applied ethical approach based on four fundamental moral principles to contemporary ethical dilemmas: respect for autonomy, beneficence, nonmaleficence, and justice. • Autonomy states that all persons should be free to govern their lives to the greatest degree possible. This implies a strong sense of self-determination and an acceptance of responsibility for one's own choices and actions. To respect autonomy of others means to respect their freedom of choice and to allow them to make their own decisions. • Beneficence is the duty to provide benefits to others when in a position to do so and to help balance harms and benefits. In other words, the benefits of an action should outweigh the burdens. Actions intended to benefit the patients or others. • Nonmaleficence is the explicit duty not to inflict harm on others intentionally. • The principle of justice requires that health care resources be distributed fairly and equitably among groups of people. Other principals • The principle of veracity states that persons are obligated to tell the truth in their communication with others. • The principle of fidelity requires that one has a moral duty to be faithful to the commitments made to others. These two principles, along with confidentiality, are the key to the nurse-patient relationship. Bioethics committees – Address ethical concerns. Typical membership of a bioethics committee includes physicians, nurses, chaplains, social workers, and, if available, bioethicists. Informed consent: Three elements must be present. Informed consent is not a form. It is a process that entails the exchange of information between the health care provider and the patient or patient's proxy. 1. Competence (or capacity) refers to a person's ability to understand information regarding a proposed medical or nursing treatment. Patients providing informed consent should be free from severe pain and depression. Critically ill patients usually do not have the mental capacity to provide informed consent because of the severe nature of their illness or their treatment (e.g., sedation). If the patient is not mentally capable of providing consent, informed consent is obtained from the designated healthcare surrogate or legal next of kin. Advance directive: Witnessed written document or oral statement in which instructions are given by a person to express desires related to healthcare decisions. Living will: A witnessed written document or oral statement voluntarily executed by a person that expresses the person's instructions concerning life-prolonging procedures. Proxy: A competent adult who has not been expressly designated to make health care decisions for an incapacitated person, but is authorized by state statute to make healthcare decisions for the person. Surrogate: A competent adult designated by a person to make health care decisions should that person become incapacitated. Life-prolonging procedure: Any medical procedure or treatment, including sustenance and hydration, that sustains, restores, or supplants a spontaneous vital function. Does not include the administration of medication or treatments deemed necessary to provide comfort care or to alleviate pain. In hospice AND (allow natural death) - don’t treat just about comfort y DNR in hospice (you do treat like antibiotics but if they code you do nothing) Extraordinary care includes complex, invasive, and experimental treatments such as resuscitation efforts by CPR or emergency cardiac care, maintenance of life support through invasive means, or renal dialysis. Experimental treatments such as gene therapy also are extraordinary therapies. Ordinary care usually involves common, noninvasive, to tested treatments such as providing nutrition, hydration, or antibiotic therapy. In the critical care setting the noninvasive criterion does not apply; ordinary care is defined as usual and customary for the patient's condition. Maintenance of hydration and nutrition through a tube feeding is an example of a treatment that falls somewhere between ordinary and extraordinary care and is a highly debatable issue. Therefore it is important for individuals to document their wishes rather than relying on the members of the healthcare team to assist in the decision-making process related to nutrition and hydration. ON TEST Withholding or stopping extraordinary resuscitation efforts is ethically and legally appropriate if patients or surrogates have previously made their preferences known through advance directives. It is also acceptable if the physician determines that resuscitation is futile or has discussed the situation with the patient, family, and/or surrogate as appropriate, and there is mutual agreement not to resuscitate in the event of cardiopulmonary arrest. In brain death, complete and irreversible cessation of brain function occurs, whereas in irreversible coma or persistent vegetative state, some brain function remains intact. ON TEST Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations would indicate some brain function. All orders except antibiotic adjustment may be considered withdrawal or withholding of life support and should be written only after informed consent from the healthcare surrogate or family has been obtained. Because the patient has expressed a request to not have food or fluids withdrawn, it would not be appropriate for the physician to write an order to discontinue the tube feeding. Patient Self-Determination Act: This act requires that all healthcare facilities that receive Medicare and Medicaid funding inform their patients about their right to initiate an advance directive and the right to consent to or refuse medical treatment. Chapter 4 Nursing care in the critical care setting at the end of life is focused on five dimensions. These dimensions of nursing care consist of alleviation of distressing symptoms (palliation); communication and conflict resolution; withdrawing, limiting, or withholding of therapy; emotional and psychological care of the patient and family; and caregiver organizational support. Signs of suffering include dyspnea, tachypnea, diaphoresis, grimacing, accessory muscle use, nasal flaring, and restlessness. Chapter 5: Comfort, Sedation, and Delirium in Critical Care Hospitals and healthcare accrediting agencies have recognized that pain and anxiety are major contributors to patient morbidity and length of stay. Defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is whatever the patient says it is. Anxiety is a state marked by apprehension, agitation, autonomic arousal, fearful withdrawal, or any combination of these. It is a prolonged state of apprehension in response to a real or perceived fear. Anxiety must be assessed in the same way used to assess pain. Anxiety may contribute to pain perception by activating pain pathways, altering the cognitive evaluation of pain, increasing aversion to pain, and increasing the report of pain. Anxiety stimulates the SNS response. SNS activation is known as the “fight-or-flight” response. If the patient is mechanically ventilated, an increased respiratory rate leads to feelings of breathlessness. As the patient “fights” the mechanical ventilator (dyssynchrony), further alveolar damage ensues, and the endotracheal or tracheostomy tube creates a “choking” sensation and increased anxiety. Manifestations of inadequate pain control and anxiety management • Patient feeling of powerlessness • Suffering • Psychological changes (such as): • Agitation • Delirium • Elevating BP indicates pain When possible, patients should be asked about any herbal remedies used as complementary and alternative medical therapies and whether they take them along with prescription or over-the-counter medications. These products may lead to adverse herb-drug interactions, especially in the elderly who are more likely to be taking multiple drugs. Interventions to manage pain may differ from those used to manage anxiety. If pain is being treated in a patient who is experiencing anxiety only, the anxiety may worsen while potentially ineffective management strategies are used. Pain is managed with anti-inflammatory and analgesic medications, whereas anxiety is treated with sedative medications. • Physiological responses to pain and anxiety: Tachycardia, Tachypnea, HTN, Increased cardiac output, Pallor and/or flushing, Cool extremities, Mydriasis (If the patient is mechanically ventilated, an increased respiratory rate leads to feelings of breathlessness. As the patient “fights” the mechanical ventilator (dyssynchrony), further alveolar damage ensues, and the endotracheal or tracheostomy tube creates a “choking” sensation and increased anxiety, pillary dilation), Diaphoresis, Increased glucose production (gluconeogenesis), Nausea, Urinary retention, Constipation, Sleep disturbance • The RASS is a 10-point scale, from 4 (combative) through 0 (calm, alert) to −5 (unarousable). The patient is assessed for 30 to 60 seconds in three steps, using discreet criteria. The RASS has strong interrater reliability, is useful in detecting changes in sedation status over consecutive days of critical care unit care, and correlates with the administered dose of sedative and analgesic medications RASS: for adequate sedation (RASS value of 0 to -3). 0: alert and calm, 1: drowsy: awakening, with eye contact to voice, 2 Light sedation- sustains awakening with eye contact to voice, 3 moderate sedation-any movement (but no eye contact) to voice • The Ramsay Sedation Scale was developed for evaluation of postoperative patients emerging from general anesthesia. The scale includes three levels of wakefulness and three levels of sedation. The nurse makes a visual and cognitive assessment of the patient. Scores range from 1 (awake) to 6 (asleep/unarousable). • The Sedation-Agitation Scale describes patient behaviors seen in the continuum of sedation to agitation. Scores range from 1 (unarousable) to 7 (dangerously agitated). There is no objective tool considered goal standard for determining a patient’s level of anxiety which produces hyperactive function for instances, tachycardia, HTN, and movement. Typically patients are sedated to limit hyperactive. The electroencephalogram (EEG) records spontaneous brain activity that originates from the cortical pyramidal cells on the surface of the brain by placing electrodes on patient's head. To obtain a signal, an electrode is placed across the patient's forehead and is attached to a monitor. The monitor displays the raw EEG and the BIS or PSI value. A value greater than 90 typically indicates full consciousness, a score of 40 to 60 represents deep sedation, and a score of 0 represents complete EEG suppression. A BIS value of greater than 60 is associated with patient awareness and recollection. A BIS value of less than 60 should be the goal in critically ill patients who require sedation. A score is usually documented with each set of vital signs. These devices are especially useful for critically ill patients who are treated with medications that produce deep sedation or neuromuscular blockade. They provide a continuous evaluation of sedation that may also be less affected by rater bias. However, care must be taken when evaluating the BIS scores, as some patients with greater facial muscle activities during routine care or procedures may overestimate BIS scores. Therefore BIS may not be ideal as a single method of sedation assessment in the critically ill. LEARN THIS – MIGHT BE ON TEST Delirium (acute brain dysfunction) is an acute change or fluctuating mental status, inattention, disorganized thinking and Altered LOC. Patients in a critical setting develop some form of delirium result in longer duration of the Mechanical Ventilation and longer ICU stays than those without delirium. • Patient can have hyperactive (agitated, combative, and disoriented) Pure hyperactive delirium is rare, occurring in less than 1% of patients. These patients place themselves or others at risk for injury because of their altered thought processes and resultant behaviors. Psychotic features such as hallucinations, delusions, and paranoia may be seen. Patients may believe that members of the nursing or medical staff are attempting to harm them. • Hypoactive (quiet delirium): Often goes undiagnosed and underestimated when there is no active monitoring with a validated clinical instrument; it is also the most prevalent, occurring in more than 60% of patients. (they have a little bit of hallucinations, they pull at things ) • Mixed (both): describes the fluctuating nature of delirium. Some agitated patients with hyperactive delirium may receive sedatives to calm them, and then may emerge from sedation in a hypoactive state Delirium may be related to imbalances in the neurotransmitters that modulate the control of cognitive function, behavior, and mood. Risk factors for the development of delirium include hypoxemia, metabolic disturbances, electrolyte imbalances, head trauma, the presence of catheters and drains, and certain medications. Neurotransmitter levels are affected by medications with anticholinergic properties. Benzodiazepines, opioids, and other psychotropic medications are associated with an increased risk of developing delirium INTERVENTIONS FOR DELIRIUM: A. Keep patient safe B. Reorient them C. Give them something to do B. Least restrictive measure, for instance restraints and medication. Unnecessary use of restraints or medication may precipitate or exacerbate delirium. C. Splints or binders may be used to restrict patient from pulling at catheter, drains or dressing D. Any type of tubing should be removed as soon as possible, particularly nasogastric tubes, which are irritating to agitated patients. E. If these measures are not successful, medication may be necessary to improve cognition, not to sedate the patient. E. ON TEST- Haloperidol (neuroleptic): (Recommended medicine for delirium) it improves cognition, not sedate. It produces mild sedation without analgesia or amnesia. It has few anticholinergic and hypotensive effects. In the critically ill patient, the intermittent intravenous route of delivery is preferred because it results in better absorption and fewer side effects than the oral or intramuscular routes. It may cause prolonged QT interval on the electrocardiogram and may be seen and can result in torsades de pointes. Patients with cardiac disease are at higher risk for this dysrhythmia. Side effects are neuroleptic syndrome, anxiety, tachycardia, tachypnea, diaphoresis, fever, muscle rigidity, increased creatine phosphokinase, hyperglycemia. F. Preventing delirium and weakness associated with critical illness has resulted in the development of the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle. Implementation of the ABCDE bundle focuses on improving communication among team members, standardizing care of the critically ill patient, and avoiding oversedation, which can lead to prolonged mechanical ventilation, delirium, and weakness. • Neuromuscular blockade: (induced paralysis) – They have to be intubated because it suppressed respiratory muscles 1. NMB are typically used in an operating room, to help facilitate endotracheal intubation and mechanical ventilation, control increased ICP and bedside procedures (bronchoscopy, tracheostomy). The goal of NMB is complete chemical paralysis. ON TEST 2. NMB agents do not possess any sedative or analgesic (pain) properties. Patients who receive effective NMB are not able to communicate or to produce any voluntary muscle movement, including breathing, so patients must be sedated. Many institutions start continuous infusions of sedative medications before they administer an NMB agent. Long-acting NMB agents may improve chest wall compliance, reduce peak airway pressures, and prevent the patient from ventilator dyssynchrony. The result is improved gas exchange with increased oxygen delivery and decreased oxygen consumption. In patients with elevated ICP, suctioning, coughing, and agitation can provoke dangerous elevations in ICP. NMB agents diminish ICP elevations during these activities. • Nursing care of the patient receiving neuromuscular blockade o Perform train-of-four testing before initiation, 15 minutes after dosage change, then every 4 hours, to monitor the degree of paralysis. ON TEST o Ensure appropriate sedation. o Lubricate eyes to prevent corneal abrasions. o Ensure prophylaxis for deep vein thrombosis. o Reposition the patient every 2 hours as tolerated. o Monitor skin integrity. o Provide oral hygiene. o Maintain mechanical ventilation. o Monitor breath sounds; suction airway as needed. o Provide passive range of motion. o Monitor heart rate, respiratory rate, blood pressure, and oxygen saturation. o Place indwelling urinary catheter to monitor urine output. o Monitor bowel sounds; monitor for abdominal distention. 3. Patients are closely monitored for respiratory problems, skin breakdown, corneal abrasion and development of venous thrombi. If a patient experiences pain or anxiety while receiving an NMB agent, an increase in heart rate or blood pressure may be noted. 4. Tests – Train of four (Neuromuscular blockade) and paralysis One important intervention is assessing level or degree of paralysis by using a peripheral nerve stimulator to determine TOF. TOF evaluates the level of neuromuscular blockade to ensure that the greatest amount of NMB is achieved with the lowest dose of NMB medication. Ulnar nerve and the facial nerve are the most frequently used sites for peripheral nerve stimulation. Peripheral nerve stimulator delivers four low-energy impulses, and the number of muscular twitches is assessed. Four twitches of the thumb or facial muscle indicate incomplete NMB. The absence of twitches indicates complete neuromuscular blockade. The TOF goal is two out of the four twitches Nonpharmacological pain management: • Frequent reorientation • Providing patient comfort, and optimizing the environment. For example, a nurse's explanation to the patient and family of the different types of alarms heard in the critical care unit may lessen anxiety levels. • The most commonly used complementary therapies in the critical care unit are environmental manipulation, guided imagery, and music therapy. Guided imagery with gentle touch or light massage has shown to decrease pain and tension in critically ill patients. • The presence of calendars and clocks is helpful. For a patient experiencing delirium, continual reorientation and repetition of explanations and information is helpful. • Family involvement is one of the most important strategies to decrease the patient's anxiety or pain. • Pictures of family members and other small keepsakes provide diversions from the stressful critical care environment. In some critical care units, it may be possible to move the patient's bed so it faces a window. • Physically moving the patient to a different location prevents the patient from becoming tired of the surroundings, and it may provide some sense of clinical improvement for the patient and family. There are also critical care units in which the monitoring equipment is concealed behind cabinetry to provide a homelike atmosphere. Pharmacological pain management: The most commonly used opioids in the critically ill are fentanyl, morphine, and hydromorphone. • Fentanyl has the fastest onset and the shortest duration, but repeated dosing may cause accumulation and prolonged effects. Fentanyl patches are not recommended for acute analgesia because it takes 12 to 24 hours to achieve peak effect and, once the patch is removed, another 12 to 24 hours until the medication is no longer present in the body. Watch for breathing and hypotension. ON TEST LEARN THIS • Morphine has a longer duration of action, and intermittent dosing may be given. However, hypotension may result from vasodilation; vasodilation can also help pulmonary edema. Its active metabolite may cause prolonged sedation in patients with renal insufficiency. (Hydromorphine dilaudid - longest acting) • PCA: When the patient feels pain or just before any pain-inducing therapy, the patient can depress a button on the pump that will deliver a prescribed bolus of medication. PCA management is rarely appropriate for critically ill patients because most are unable to depress the button, or they are too ill to manage their pain effectively. However, some critically ill patients may benefit from PCA therapy to manage postoperative incisional pain. • Anxiety in the critical care setting is typically treated with benzodiazepines, propofol,(THESE ARE IMPORTANT DRUGS TO LEARN THEY SHOW UP A LOT) or dexmedetomidine. o Benzodiazepines are sedatives and hypnotics that block new information and potentially unpleasant experiences at that moment. Benzodiazepines should be titrated to a predefined end point, for example, a specific level of sedation using a standard sedation scale. Sedation may be maintained with intermittent doses of lorazepam, diazepam, or midazolam; however, patients requiring frequent doses to maintain the desired effect may benefit from a continuous infusion by using the lowest effective dose. o Propofol is an intravenous general anesthetic; however, sedative and hypnotic effects are achieved at lower doses. It has a rapid onset and short duration of sedation once it is discontinued. Adverse effects include hypotension & Respiratory depression, bradycardia, and pain when the drug is infused through a peripheral intravenous site. Propofol is available as an emulsion in a phospholipid substance, which provides 1.1 kcal/mL from fat, and it should be counted as a caloric source. Long-term or high-dose infusions may result in high triglyceride levels, metabolic acidosis, or dysrhythmias. Propofol requires a dedicated intravenous catheter for continuous infusion because of the risk of incompatibility and infection. The infusion should not hang for more than 12 hours. Michael Jackson drug. Has short half-life. As soon as you turn this drip off the patient is wide awake. (As a nurse you can start drips for this but you can never push propofol)