Medsurg_3_Exam STUDY GUIDE

The Synergy Model 1) Basic Concepts a) AACN Synergy Model for Patient Care i) The needs or characteristics of clients and families influence and drive nurse’s competencies ii) Synergy results in the needs & characteristics of a client, clinical unit or system are matched with a nurse’s competencies iii) It is about the patient and the family not about you! iv) The goal of the nurse is always to return the patient to optimal level b) Client Characteristics are Unique to Each Care Situation i) 8 Client Characteristics (1) Resiliency* (a) Capacity to return to a restorative level of functioning using compensatory/coping mechanisms (b) The ability to bounce back quickly after an insult (c) Some patients are very resilient and some are not (d) Nurse must assess patient’s resiliency and the factors that affect it (e) What are factors that affect resiliency? Age, immunocompromised, strong or weak? (f) What was their baseline before? (g) What mechanisms do they use to cope? (2) Vulnerability (a) Susceptibility to actual or potential stressors that may adversely affect outcomes (b) Comorbid conditions (3) Stability (a) Ability to maintain a steady-state; equilibrium (b) External and internal factors affect stability (c) Determine why they are not returning to optimal level (d) Many times this is beyond medical reasons (4) Complexity (a) Entanglement of 2 or > systems (i) Body, family, therapies (ii) Ex: CV and renal disease (iii) Become more complex to take care of (iv) Family issues- who is primary caregiver? (v) Therapy- ex: dialysis patient who has to go 3x a week (5) Resource Availability (a) Extent of resources the client/family/community bring to situation (i) Technical (ii) Fiscal (iii) Personal (iv) Psychological (v) Social: social worker (vi) What resources do they have when they get home? (vii) What if they need help working equipment? Ex: Meals on wheels (6) Participation in Care (a) Extent to which client/family engages in aspects of care (b) Try to get the family engaged; it may decrease their stress level (c) Have families and the patient participate in care; does not have to be hands on (d) How does patient take care of themselves? (e) Functional assessment (f) Can they make decisions? (7) Predictability (a) Allows one to expect a certain course of events or course of illness (b) Examples (i) A healthy 40-year-old female undergoing a pre-employment physical 1 (ii) A critically ill infant with multi-system organ failure 2) Nurse Competencies: Concern to Clients, Clinical Units and Systems LEVEL 1,3,5 a) Level 1: novice nurse, less than < 1 year experience b) Level 3: some experience, about 3 years c) Level 5: expert d) Clinical Judgment i) Clinical reasoning-ability of nurse to use their knowledge to change patient outcome ii) Decision makingiii) Critical thinking iv) Global grasp of situation e) Advocacy & Moral Agency i) Working on another’s behalf & representing concerns of the client/family & nursing staff ii) Serves as an agent in resolving ethical & moral dilemmas f) Caring Practices i) Creating a compassionate, supportive, & therapeutic environment for clients & staff ii) Aim of promoting comfort & healing g) Collaboration i) Working with others (1) Clients/families (2) Health care providers ii) Promotes each individual’s contributions iii) Involves intra- and inter-disciplinary work with colleagues & community h) Systems Thinking i) Body of knowledge & tools that allow the nurse to manage environmental & system resources available (1) What do you know about your chain of command? (2) Who will you call if patient scheduled at 8:30 am for surgery and transportation doesn’t come? OR i) Responsiveness to Diversity i) Sensitivity to recognize, appreciate, & incorporate differences into provision of care. ii) Difference may include: (1) Culture (2) Spiritual (3) Gender (4) Race (5) Ethnicity (6) Lifestyle (7) Socioeconomic status (8) Age (9) Values j) Facilitation of Learning i) Ability to facilitate learning for: (1) Clients/families (2) Nursing staff (3) Members of health care team (4) Community ii) May include both informal & formal learning k) Clinical Inquiry/Evaluator i) Ongoing process of questioning & evaluating practice ii) Creating practice changes through research utilization & experiential learning 3) The goal of nursing is to restore a client to an optimal level of wellness as defined by the client. Hemodynamic Monitoring 1) Hemodynamic Monitoring a) Critically ill patient require continuous assessment of the cardiovascular system to diagnose and manage medical conditions 2 b) Critical Care unit Patients c) Achieved via direct pressure monitoring systems i) Central venous pressure (CVP) ii) Pulmonary artery pressure (PAP) iii) Intra-arterial blood pressure (Arterial line) d) Nursing care i) Ensure system is set up and maintained properly (1) For example, the pressure monitoring system must be kept patent and free of air bubbles ii) Ensure stopcock is at level of atrium before measurements obtained (1) This landmark is referred to as the phlebostatic axis (2) Use a marker to identify this level on the chest wall, which provides a stable reference point for subsequent pressure readings iii) Establish zero reference point in order to ensure that the system is properly functioning at atmospheric pressure measurements (1) This is accomplished by placing the stopcock of the transducer at the phlebostatic axis, opening the transducer to air, and activating the zero-function key on the bedside monitor (2) HOB at 60 degrees This is where BP, CVP, and pulmonary artery pressures can be measured e) Complications i) Uncommon ii) Pneumothorax (1) Observe for signs during insertion of catheters using a central venous approach iii) Infection (1) Longer catheters left in place the greater risk for infection iv) Nurses must demonstrate competence prior to independently caring for a patient requiring hemodynamic monitoring (1) See care bundle, page 687 (a) Hand hygiene (i) Soap and water or alcohol based rubs before and after contact with catheter (b) Dressing (i) Wear clean or sterile gloves when changing dressing (ii) Cleanse the skin during dressing changes with a >0.5% chlorhexidine preparation with alcohol (iii) Dress site with sterile gauze or sterile transparent semipermeable dressing (iv) Change gauze dressing every 2 days or transparent every 7 days and whenever damp, loosened, or soiled (v) Do not use topical antibiotic ointment or creams (c) Catheter site (i) Assess regularly (ii) Remove dressing if patient has tenderness, fever without source, or other signs of infection (d) Pressure monitoring system (i) Keep all components sterile (ii) Replace transducers, tubing, and continuous flush device, and flush solution evert at 96-hour interval (iii) Do not infuse dextrose containing solutions through monitoring systems (e) Bathing (i) Do not submerge the catheter in water (ii) Showering is permitted if the catheter and tubing are placed in impermeable cover (f) Patient education (i) Report any new discomforts v) Air embolism (1) If stopcocks attached the pressure transducers are mishandled during blood drawing, administration of meds, or other procedures open to air 2) Hemodynamic monitoring: what does it measure? a) Hemodynamic monitoring measures: i) Heart chamber pressures 3 ii) Cardiac output iii) Preload iv) Afterload v) Contractility b) Cardiac Output= Stroke Volume x HR i) Cardiac Output (1) Total amount of blood ejected by the ventricle in liters per minute (2) Resting adult: 4-6L/min (3) Varies based on metabolic need (4) Decrease cardiac output results in decrease perfusion to target organs ii) Stroke Volume (1) Total amount of blood ejected by the ventricle per heartbeat (2) Resting adult: 60-130 mL 3) Effect of heart rate on cardiac output (c0) a) CO responds to changes in metabolic demands of tissues associated with stress, physical exercise, illness i) To compensate: CO enhanced by increases in SV and HR b) HR affected by CNS and baroreceptor activity c) Baroreceptors: aortic arch, right and left carotid arteries; sensitive to changes in BP i) Chronotropy ii) Inotropy iii) Dromotropy d) Baroreceptor activity during Hypertension i) Increase BP (hypertension) = Increase parasympathetic activity and inhibit sympathetic= Decrease BP and HR e) Baroreceptor activity during hypotension i) Decrease BP (hypotension) = decrease parasympathetic activity and enhances sympathetic= increase BP and HR Baroreceptors- think PARASYMPATHETIC 4) Stroke volume a) Determined by i) Preload ii) Afterload iii) Contractility 5) Preload and afterload a) Preload i) Degree of stretch of ventricular cardiac fibers at end of diastole ii) Filling of volume of ventricles is at its highest iii) Volume of blood at end of diastole= preload Increased Preload Decreased Preload Increased by increasing the return of circulating blood volume to the ventricles Decreased by reduction in volume of blood returning to the ventricles • Blood products • Diuresis • Crystalloids • Venodilating agents • Colloids • Excessive blood/volume loss (dehydration) b) Afterload i) Resistance to ejection of blood from the ventricle ii) Resistance to left ventricular ejection: Systemic vascular resistance (SVR) 4 iii) Resistance to right ventricular ejection: pulmonary vascular resistance (PVR) iv) Inverse relationship between afterload and stroke volume…afterload ^= SV decrease Increased Afterload Decreased Afterload Afterload is increased due to arterial vasoconstriction Afterload is decreased due to arterial vasodilation Leads to decreased stroke volume Leads to increased stroke volume • Increased resistance to ejection • Decreased resistance to ejection 6) Contractility a) The force generated by the contracting myocardium b) Increased contractility results in increased stroke volume Enhanced Contractility Reduced Contractility Circulating catecholamine's Hypoxia Increased sympathetic activity Acidosis Medications Digoxin Dopamine Dobutamine Medications Beta blockers MEDICATIONS TO INCREASE CONTRACTILITY: DIGOXIN, DOPAMINE, DOBUTAMINE 7) Types of monitoring devices a) Central Venous Pressure (CVP) monitoring- VENA CAVA OR RIGHT ATRIUM i) Measurement of the pressure in the vena cava or right atrium and right ventricle (preload) ii) Vena cava, right atrium and right ventricle pressures are all equal at the end of diastole; thus, CVP also reflects right ventricle pressure= Measures right ventricular PRELOAD iii) Normal CVP= 2-6 mm Hg iv) Catheter is positioned in the right atrium or vena cava and connecting it to a pressure monitoring system v) Most valuable when monitored over time and correlated with patient’s clinical status vi) CVP >6 mm Hg- elevated right ventricular preload (1) Hypervolemia- excessive fluid circulating in the body-most common problem causing elevated CVP (2) Right heart failure vii) CVP <2 mm Hg- reduced right ventricular preload (1) Hypovolemia- from dehydration, blood loss, vomiting/diarrhea, overdiureses viii) Preferred site is subclavian vein, femoral is avoided. Local anesthetic is used, physician threads single or double lumen cath into vein into vena cava or within right atrium ix) Position is confirmed by xray** b) Phlebostatic Axis: left atrium i) Reference point for the atrium when the patient is positioned supine ii) It is the intersection of two lines on the chest wall (1) The midaxillary line drawn btw the anterior and posterior surfaces of the chest (2) The line drawn through the 4 th intercostal space c) Pulmonary Artery Pressure (PAP) Monitoring i) Used in critical care to assess (1) Left ventricular function 5 (2) Diagnose the etiology of shock (3) Evaluate response to medical interventions ii) Balloon tipped, flow-directed catheters with multiple lumens (1) Distal lumen: opens into pulmonary artery (2) Proximal lumen: port that opens into right atrium-used to administer IV meds and fluids or to measure right atrial pressures iii) Preferably entered into the subclavian vein-into vena cava, into right atrium, balloon is inflated in right atrium, catheter is carried through tricuspid into right ventricle, through pulmonic valve, into branch of pulmonary artery, then balloon is deflated and secured with sutures (1) Fluoroscopy may be used to visualize (2) Can be performed in cath lab, icu bed side, or OR. (3) Bedside monitor observed for arrythmias during insertion iv) May include specialty functions: cardiac pacing, oximetry, cardiac output measurements v) Enables measurement of: (1) Right atrial pressure= 0-8 mm Hg (2) Pulmonary artery systolic pressure= 15-25 mm Hg (3) Pulmonary artery diastolic pressure= 8-15 mm Hg (4) Pulmonary artery wedge pressure (Measures left ventricular PRELOAD)= 4-12 mm Hg- achieved by infliatin g (a) Pulmonary artery wedge pressure and pulmonary artery diastolic are used to evaluate left ventricular filling pressures d) Pulmonary artery Pressure Device e) Intra-arterial blood pressure monitoring i) Obtains direct and continuous BP measurements for patients with Severe HTN or severe hypotension ii) Also useful is ABGs and blood samples may be drawn frequently iii) Radial artery is most common site of placement iv) Allen’s test (1) Way to assess collateral circulation to the involved extremity (2) The hand is elevated and the pt is asked to make a fist for 30 seconds (3) The nurses compresses the radial and ulnar arteries simultaneously (4) After the patient opens their hand the nurse releases the pressure on the ulnar artery (5) If blood flow is restored within 6 seconds, the hand is adequate for placement of radial artery catheter v) Nursing Interventions (1) Monitor for (a) local obstruction/distal ischemia (b) Hemorrhage (c) Ecchymosis (d) Dissection (e) Air embolism (f) Pain (g) Arteriospasm (h) Infection Cardiac Dysrhythmia Management and Pacemakers