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Care of the Patient With an Endotracheal Tube Immediately After Intubation

1. Check symmetry of chest expansion. 2. Auscultate breath sounds of anterior and lateral chest bilaterally. 3. Obtain order for chest x-ray to verify proper tube placement. 4. Check cuff pressure every 6-8 hours. 5. Monitor for signs and symptoms of aspiration. 6. Ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing. 7. Administer oxygen concentration as prescribed by the primary care provider. 8. Secure the tube to the patient's face with tape, and mark the proximal end for position maintenance. a. Cut proximal end of tube if it is longer than 7.5 cm (3 inches) to prevent kinking. b. Insert an oral airway or mouth device to prevent the patient from biting and obstructing the tube. 9. Use sterile suction technique and airway care to prevent iatrogenic contamination and infection. 10. Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion. 11. Provide oral hygiene and suction the oropharynx whenever necessary.

extubation (Removal of Endotracheal Tube)

1. Explain procedure. 2. Have self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation. 3. Suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff. 4. Give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube. 5. Have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through the tube as it is pulled out. Note: In some hospitals, this procedure can be performed by respiratory therapists; in others, by nurses. Check hospital policy.

Care of Patient Following Extubation

1. Give heated humidity and oxygen by facemask and maintain the patient in a sitting or high Fowler's position. 2. Monitor respiratory rate and quality of chest excursions. Note stridor, color change, and change in mental alertness or behavior. 3. Monitor the patient's oxygen level using a pulse oximeter. 4. Keep patient NPO (nothing by mouth), or give only ice chips for next few hours. 5. Provide mouth care. 6. Educate the patient about how to perform coughing and deep-breathing exercises.

QI

1. Intent is to improve current practice. For internal use only. 2. By definition, the data is confidential. 3. Action is within existing standards of care. 4. Institutional Review Board (IRB) approval is not necessary.

Quality improvement processes

1. defining the standards 2. determining measurement criteria 3. evaluating how well the criteria have been met 4. planning for change based upon the evaluation 5. following up the implementation of change

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? 30 to 35 mm Hg 10 to 15 mm Hg 15 to 20 mm Hg 0 to 5 mm Hg

15 to 20 mm Hg Explanation: Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. A measure of 10 to 15 mm Hg of water pressure would indicate that the cuff is underinflated. A measure of 30 to 35 mm Hg of water pressure would indicate that the cuff is overinflated. A measure of 0 to 5 mm Hg of water pressure would indicate that the cuff is underinflated.

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation? 25 minutes 10 minutes 20 minutes 15 minutes

20 minutes Explanation: The nurse records minute volume and obtains ABGs to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.

Medical management of septic shock includes all of the following except: A Administration of colloids. B Administration of Drotrecogin alfa. C Aggressive fluid resuscitation. D Aggressive nutritional supplementation.

A Administration of colloids is a management for hypovolemic shock. Option B: Administration of Drotrecogin alfa is done to avoid thrombosis, inflammation, and promote fibrinolysis. Option C: Fluid replacement therapy is done to correct tissue hypoperfusion. Option D: Aggressive nutritional supplement prevents malnutrition that impairs the patient's resistance to infection.

A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A Kinking of the ventilator tubing B A disconnected ventilator tube C An endotracheal cuff leak D A change in the oxygen concentration without resetting the oxygen level alarm

A Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.

A male client suffers adult respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A Kinking of the ventilator tubing B A disconnected ventilator tube C An ET cuff leak D A change in the oxygen concentration without resetting the oxygen level alarm

A Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the ET tube, and the client's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.

For a male client with an endotracheal (ET) tube, which nursing action is most essential? A Auscultating the lungs for bilateral breath sounds B Turning the client from side to side every 2 hours C Monitoring serial blood gas values every 4 hours D Providing frequent oral hygiene

A For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.

Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A - Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for Malfunction of the alarm button A cut or slice in the tubing from the ventilator A kink in the ventilator tubing Higher than normal endotracheal cuff pressure

A kink in the ventilator tubing Explanation: One reason an alarm on the ventilator, indicating increased peak airway pressure, could sound is from a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

Phases of Pathophysiologic Changes Injury or Exudative Phase

ARDS is a response to some kind of lung injury or insult. It is a massive inflammatory response in the body. • When a person starts developing ARDS, they become more and more refractory or resistant to oxygen therapy. So where as a normal person on a ventilator may be on 40% O2 and were able to maintain their O2 sats at 95% , Someone who is developing ARDS will require 50-70% O2 to keep their oxygen level up. It is a gradual increase over time. It is not going to be an in your face situation. It is important to assess your patient over time so that you can compare where they were yesterday and where they are today. Ideally, they should be getting better and requiring less oxygen to maintain O2 sats. • ARDS patients will become more tachypnic and more dysnpic • What is happening with this inflammatory response is that in alveolar level ( in blood/gas barriers) there is a build up of debris and inflammation at that place. When you and I take a breath in and the Oxygen goes in, it exchanges with the CO2 at the alveolar level. That is called gas exchange or respirations. With someone who has ARDS it shunts right past it and comes back out again there fore there is no oxygen exchange at the alveolar level due to the buildup of debris and inflammation. • The thoughts there are that if you expand the surface of the alveoli, you will give a better chance for the gas exchange to occur. We don't want to blow it out but if you can expand each alveoli and keep it expanded longer there is a better chance that some gas exchange will occur. Therefore, that is why patients who have developed ARDS will require PEEP. Positive end expiratory pressure artificially from the ventilator.

A client with obsessive compulsive disorder reports to the nurse that the routine of having the the nightlight on was not followed on the night shift. What would be the nurse's best course of action? Instruct the night nurse to follow the care plan more carefully in the future. Place a sign at the end of the client's bed stating that she needs a nightlight. Document the situation and make an incident report in accordance with hospital protocol. Ask the night nurse about the experience of caring for client the previous night.

Ask the night nurse about the experience of caring for client the previous night. Explanation: Asking the night nurse about the experience is the preferred approach to handling this situation; it creates a collaborative dialogue and is an effective strategy to gather information while creating a healthier working relationship. Instructing the night nurse to follow the care plan more carefully isn't the best course of action because the nurse may become defensive before considering all the facts. Placing a sign at the end of the client's bed might help ensure continuity of care during future assignment changes, but it's far better for the nurse to develop a cooperative relationship with the staff member. Making an incident report would be a presumptive overreaction. Gathering data and developing a positive relationship to solve the problem in a peer-oriented and collaborative manner is more appropriate than formally documenting the incident.

How to Determine the Real Root Cause?

Assign the task to a person (team if necessary) knowledgeable of the systems and processes involved Define the problem Collect and analyze facts and data Develop theories and possible causes - there may be multiple causes that are interrelated Systematically reduce the possible theories and possible causes using the facts Develop possible solutions Define and implement an action plan (e.g., improve communication, revise processes or procedures or work instructions, perform additional training, etc.) Monitor and assess results of the action plan for appropriateness and effectiveness Repeat analysis if problem persists- if it persists, did we get to the root cause?

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate? SIMV Assist-control Pressure support IMV

Assist-control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: A Lips B Mucous membranes C Nail beds D Earlobes

B Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A Pallor B Low arterial PaO2 C Elevated arterial PaO2 D Decreased respiratory rate

B The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg.

B The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient.

Complications of Mechanical Ventilation respiratory

Barotrauma (pneumothorax or cardiac tamponade) Hypo/Hyperventilation (Acid/base imbalance) Ventilator Associated Pneumonia (VAP) Airway infection that develops > 48hrs after intubation Prevention Position HOB 30-45 degrees, Check residuals if on tube feeds Proton Pump Inhibitor Brush teeth with 0.12% chlorhexidine Q12 hours. Oral care Q 4hrs Utilize ET tube with dorsal lumen for subglottic suctioning Do not routinely change ventilator circuit Sedation Vacation

Bench Marking

Benchmark refers to a measure of best practice performance. Benchmarking refers to the search for the best practices that yields the benchmark performance, with emphasis on how you can apply the process to achieve superior results. All process improvement efforts require a sound methodology and implementation, and benchmarking is no different. You need to: Identify benchmarking partners Select a benchmarking approach Gather information (research, surveys, benchmarking visits) Distill the learning Select ideas to implement Pilot Implement

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process? Vital capacity of 12 mL/kg PaO2 greater than 60 mm Hg with a FiO2 less than 40% Blood pressure increase of 20 mm Hg from baseline Heart rate less than 100 bpm

Blood pressure increase of 20 mm Hg from baseline Explanation: In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a heart rate increase of 20 beats/min, systolic BP increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume: 7 to -9 mL/kg, minute ventilation: 6 L/min, and rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria if met by the patient indicates that the patient is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A Cardiogenic pulmonary edema B Respiratory alkalosis C Increased pulmonary capillary permeability D Renal failure

C ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? A Continue to suction B Notify the physician immediately C Stop the procedure and reoxygenate the client DEnsure that the suction is limited to 15 seconds

C During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

What age group is the most susceptible to sepsis? A Infants. B Adolescents. C Elderly. D Young adults.

C Elderly patients are at most risk for developing sepsis because of decreased physiologic reserves and an aging immune system. Option A: Infants may have less physiologic reserves yet they have vaccines that strengthen their immune system than the elderly. Option B: Adolescents may not have fully mature reserves yet they have a stronger immune system than the elderly. Option D: Adolescents may not have fully mature reserves yet they have a stronger immune system than the elderly.

The main goal of treating septic shock is: A Preserving the myocardium. B Restoring adequate fluid status. C Identification and elimination of the cause of infection. D Identification and elimination of the cause of allergy.

C Prevention through identifying and eliminating the cause of infection could prevent the development of sepsis that could fall into septic shock. Option A: Preservation of the myocardium is the main goal of cardiogenic shock management. Option B: Restoration of fluid status is the goal in the treatment of hypovolemic shock. Option D: To prevent anaphylactic shock, identification and elimination of the cause of allergy are necessary.

Which phrase is used to describe the volume of air inspired and expired with a normal breath? A Total lung capacity B Forced vital capacity C Tidal volume DResidual volume

C Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

C - Rationale: Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.5. Expectations are clear. 6. Criticism is constructive and given in private.

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)? Cleaning the patient's mouth with chlorhexidine daily Maintaining the patient in a high Fowler's position Turning and repositioning the patient every 4 hours Ensuring that the patient remains sedated while intubated

Cleaning the patient's mouth with chlorhexidine daily Explanation: The five key elements of the VAP bundle include the following: elevation of the head of the bed (30 to 45 degrees: semi-Fowler's position), daily "sedation vacations," and assessment of readiness to extubate (see below); peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis (DVT) prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The patient should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first? Change the staffing schedule on nights to include a medication nurse. Consult the nursing supervisor. Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. Consult the nurses on the evening shift about their evaluation of the night nurses regarding these concerns.

Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. Explanation: To determine the cause of this problem, a quality improvement study should be conducted. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Consulting with the evening nurses may result in biased observations because the evening nurses are not conducting care under the same environment as the night nurses. Including a medication nurse is not the first step in understanding the problem and may be an unrealistic or expensive solution. The supervisor is not directly involved with the problem and should only be consulted if the problem cannot be solved by those involved.

The unlicensed assistive personnel (UAP) reports to the nurse that a client is "feeling short of breath." The client's blood pressure was 124/78 mm Hg 2 hours ago with a heart rate of 82 bpm; the unlicensed assistive personnel reports that blood pressure is now 84/44 mm Hg with a heart rate of 54 bpm, and the client stated, "I just do not feel good." What actions should the nurse take? Select all that apply. Confirm the client's vital signs and complete a quick assessment. Place the client in the semi-Fowler's position. Make a quick check on other assigned clients before spending the time required to take care of this client. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Call the health care provider (HCP) and report the situation using SBAR format. Stay with and reassure the client.

Confirm the client's vital signs and complete a quick assessment. Inform the charge nurse of the change in condition and initiate the hospital's rapid/emergency response team. Place the client in the semi-Fowler's position. Stay with and reassure the client. Call the health care provider (HCP) and report the situation using SBAR format.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications? Pulmonary emboli Immunosuppression Increased cardiac output Gastrointestinal hemorrhage

Gastrointestinal hemorrhage Explanation: Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? Synchronized intermittent mandatory ventilation (SIMV) Intermittent mandatory ventilation (IMV) Assist-control Pressure support

Intermittent mandatory ventilation (IMV) Explanation: Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

Collaborative Management for ARDS

Mechanical ventilation PEEP 10-15 cm to open alveoli. Lower tidal volumes Pressure support ventilation Prone positioning- BEST! Lateral rotation therapy Hemodynamic monitoring Inotropic/vasopressor medications Dopamine/dobutamine IV fluids TPN/lipids

Ventilator Associated PneumoniaPt compromised by multiple factors:

Normal airway defenses blocked by ETT or NGT, allowing direct access for pathogens. Poor nutritional status. Burn or surgical pts. Chronic diseases: CNS, cardiac, resp, renal. Immobility & age. Weakened immune systems. Steroids (COPD). Secretions &   risk of aspiration. Contaminated equipment or HCPs.

What is the priority action that a nurse should take after omitting an ordered medication? Notify the prescriber. Write an incident report. Notify the nursing supervisor. Document the omission and the reason for it.

Notify the prescriber. Explanation: A nurse who has omitted an ordered medication should prioritize the notification of the prescriber. She should then document the omission and the reason it occurred in the client's chart and, depending on facility policy, write an incident report. Depending on the facility's policy, the nursing supervisor may need to be notified, but this would be done after the prescriber has been notified.

Complications

Secondary infections: Catheter, nosocomial,sepsis Gastrointestinal: Paralytic ileus Pneumoperitoneum Stress ulceration and hemorrhage Renal: Acute renal failure Cardiac: Arrhythmias, decreased CO Hematologic: Anemia, DIC, Thrombocytopenia Respiratory complications: O2 Toxicity Pulmonary emboli, fibrosis Barotrauma/volu-pressure trauma Endotracheal tube complications

When Should Root Cause Analysis be Performed?

Significant or consequential events Repetitive human errors are occurring during a specific process Repetitive equipment failures associated with a specific process Performance is generally below desired standard

Six Sigma

Six Sigma is a measurement-based strategy for process improvement and problem reduction completed through the application of improvement projects. This is accomplished through the use of two Six Sigma models: DMAIC and DMADV. • DMAIC (define, measure, analyze, improve, control) is an improvement system for existing processes falling below specification and looking for incremental improvement. • DMADV (define, measure, analyze, design, verify) is an improvement system used to develop new processor products at Six Sigma quality levels.

Ventilator Associated PneumoniaCDC & IHI Prevention Guidelines

Try to avoid intubation. Try bipap mask first. Limit vent time, extubate ASAP. Intubate orally rather than nasally. OGT not NGT to ↓ risk of sinus infection. HOB  30-45 degrees at all times to ↓risk for gastric reflux & aspiration. Hand hygiene before & after suctioning. Gloves. Gown/ mask if soiling likely. Strict aseptic technique when suctioning. Daily ↓ in sedation to assess for extubation potential. Daily ABGs also. Before deflating the cuff, suction above it to clear secretions. Prophylactic anticoagulation for DVT & pulmonary emboli. Change the vent tubing only when visibly soiled or malfunctioning. Drain all tubing condensate away from the pt - why? Fill heated humidifiers with sterile water only. Disinfect all intubation equipment. Early broad spectrum antibiotic coverage. Frequent oral care with chlorohexadine swab. Brush teeth q 8. Use with simultaneous oral suctioning to remove secretions & bacteria. Verify tube placement & residuals prior to beginning TF. Check TF residuals q 4. Hold for 2 h if residuals > 200 cc.

Quality Improvement

the process of defining the degree excellence of nursing interventions, then taking steps to ensure that each patient receives the agreed upon level of excellence in care. It is the process of establishing desirable standards of nursing care, then planning and providing the type of care that will meet those standards

Clinical Manifestations of ARDS

Signs & symptoms are insidious Edema may not appear until fluid has 30%. decreased tidal volumes Diffuse crackles & rhonchi. PaO2/FIO2 ratio low... though O2 is being delivered. CXR shows "white out"...lung/s completely filled with fluid

Sepsis bundle

Aggressive fluids in hypotensive patients. o Crystalloids at 30ml/kg o Fluid Challenges o Achieve a target CVP (8-12 mmHg, MAP >65 mmHg, CVO2 >70%, and urine output >0.5ml/kg/hr) Vasopressors used if fluids to not ↑ or restore an effective BP or output. o Norepinephrine - 1st choice o If SEPTIC SHOCK is present do NOT give epi, phenylephrine or vasopressin as the initial vasopressor. Cultures then broad spectrum ABX o Cultures taken prior to ABX admin o ABX given within 3 hrs of admin of ER or 1 hr of impatient admission. Give supplemental O2 & mechanical vent PRBC's if Hgb >7g/dL → → target Hgb 7-9 g/dL in adults. Adequate IV sedation and analgesia - if possible do not use paralytics ( -curium, -curonim, -curarine) Insulin therapy → target serum glucose >180mg/dL DVT precautions Possible steroid therapy of pt is not responding to vasopressors and fluid resuscitation Discuss advanced POC with family

Septic shock risk factors

Increased use of invasive procedures and indwelling medical devices The increased number of antibiotic-resistant microorganisms The increasingly older population (decreased physiologic reserves and an aging immune system) Surgical and other invasive procedures Malnutrition or immunosuppression Chronic illness such as diabetes, hepatitis, chronic renal failure, and immunodeficiency disorders Extremes of age (<1 y and >65 y)

QI cycle

1 select the opportunity for improvement 2 select the team 3 study the current situation 4 analyze the cause 5 develop a theory for improvement 6 implement the improvement 7 study the results 8 standardize the improvement 9 establish future plans

PDSA Model

Another commonly used QI model is the PDSA cycle: 1. PLAN: Plan a change or test of how something works. 2. DO: Carry out the plan. 3. STUDY: Look at the results. What did you find out? 4. ACT: Decide what actions should be taken to improve. Repeat as needed until the desired goal is achieved

Indications for Intubation and Ventilation

Apnea Acute or impending ventilatory failure (Trauma, RR >35) Refractory hypoxemia (PaO2 <50 mmhg with FIO2 > 60%) Respiratory muscle fatigue Support when anesthesia or sedation is required Acute respiratory failure or the inability to maintain an acceptable CO2 (Respiratory Acidosis pH <7.25)

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff? Pressure necrosis Aspiration pneumonia Tracheal bleeding Tracheal ischemia

Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

complications

Cardio Decreased cardiac output (preload or venous return to the heart) Neuro Decreased cerebral venous return = ↑ ICP GI Air leakage could result in gastric distention NG/OG tube GU Decreased urine output

Continuous Positive Airway Pressure (CPAP)

Constant positive pressure is applied throughout respiratory cycle. Patient initiates all breaths (no set rate or tidal volume)

The continuous improvement cycle

Identify oppurtunities in the process workflow Plan- how can the current process be improved Execute- implement changed Review- how changes working for the team?

Ventilator Associated PneumoniaClinical Manifestations

Gram negative sputum culture. Fever  WBCs Copious thick tan or green sputum. Bilateral rhonchi and crackles. CXR that is "whited out" Dyspnea, SOB, low O2 sats.

Collaborative Practice Interventions to Prevent Ventilator-Associated Pneumonia

Current best practices can include the implementation of specific evidence-based bundle interventions that, when used together (i.e., as a "bundle"), improve patient outcomes. This chart outlines specific parameters for the ventilator-bundled collaborative interventions that have been found to reduce ventilator-associated pneumonia (VAP). What are the five key elements of the central venous line bundle? • Elevation of the head of the bed (30-45 degrees) • Daily "sedation vacations" and assessment of readiness to extubate (see below) • Peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]) • Deep venous thrombosis (DVT) prophylaxis (see below) • Daily oral care with chlorhexidine (0.12% oral rinses) What is meant by daily "sedation vacations," and how does this tie into assessing readiness to extubate? • Protocols should be developed so that sedative doses are purposely decreased at a time of the day when it is possible to assess the patient's neurologic readiness for extubation. • Vigilance must be employed during the time that sedative doses are lower to ensure that the patient does not selfextubate.

A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? A Leg movement B Finger movement C Lip movement D Fighting the ventilator

D Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

DMAIC performance improvement methodology

Define the problem Measure the current state Analyze the root causes Design and implement the solution measure the impact and establish the control plan

Diffusion Limitation in ARDS

Exchange of CO2 and O2 cannot occur due to the thickened alveolar-capillary membrane. Exchange of O2 is not occurring • Patients will require o More oxygen o PEEP o More pressure support

Quality Assurance (QA) focuses on which of the following? Analyzation of operational processes Individual incidents or errors and minimal expectations Improvement in financial processes Processes used to provide care

Individual incidents or errors and minimal expectations Explanation: QA focuses on individual incidents or error and minimal expectations. CQI focuses on the processes used to provide care, with the aim of improving quality by assessing and improving those interrelated processes that most affect patient care outcomes and patient satisfaction. CQI involves analyzing, understanding, and improving clinical, financial, and operational processes.

Common Errors of Root Cause

Looking for a single cause- often 2 or 3 which contribute and may be interacting Ending analysis at a symptomatic cause Assigning as the cause of the problem the "why" event that preceded the real cause

A hospice program director is examining client care activities with the intention of improving quality. After determining that many clients do not have advance directives at the time of their admission, the director and a team of professionals develop a plan to address the issue. What is this approach, which includes objectives, goals, and a timeline, known as? Risk-management program Client care initiative Palliative care project Performance improvement project

Performance improvement project Explanation: The purpose of a performance improvement project is to design, measure, assess, and improve organizational performance using established objectives, goals, and a timeline. A risk-management program is a planned program of loss prevention and liability control. Although this initiative involves client care, the scope of the issue extends beyond direct care providers. Although advance directives are important in the context of palliative care, ensuring that all clients have them relates more closely to organizational performance.

Why Determine Root Cause?

Prevent problems from recurring Reduce possible injury Reduce rework and waste Increase competitiveness Promote happy customers and stockholders Ultimately, reduce cost and save money

Diagnostic Findings in ARDS

Refractory hypoxemia. Bilateral alveolar & interstitial infiltrates. Normal PCWP pressure - normal cardiac function. Pre-disposing condition for ARDS in last 48 hrs. Pleural effusions may form. Metabolic acidosis. Profound respiratory distress.

Most Times Root Cause Turns Out to be Much More

Such as: Process or program failure System or organization failure Poorly written work instructions Lack of training

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Tracheal cuff pressure set at 30 mm Hg Symmetry of the client's chest expansion Cool air humidified through the tube A scheduled time for deflation of the tracheal cuff

Symmetry of the client's chest expansion Explanation: Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

Useful Tools For Determining Root Cause are:

The "5 Whys" Brainstorming Flow Charts / Process Mapping Cause and Effect Diagram Benchmarking (after Root Cause is found)

Methods of QI the FADE MODEL

There are 4 broad steps to the FADE QI model: → FOCUS: Define and verify the process to be improved → ANALYZE: Collect and analyze data to establish baselines, identify root causes and point toward possible solutions o The key to the analysis step of the FADE model is: • **identify the site of the defect before you make a change!** → DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring → EXECUTE: Implement the action plans, on a pilot basis as indicated, and → EVALUATE: Install an ongoing measuring/monitoring (process control) system to ensure success.

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first? Notify the respiratory therapist. Troubleshoot to identify the malfunction. Manually ventilate the patient. Reposition the endotracheal (ET) tube.

Troubleshoot to identify the malfunction. Explanation: The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

Positive End Expiratory Pressure (PEEP)

Used to prevent closure of alveoli Improves Pa02 while decreasing FIO2 demand

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? Pressure cycled Time cycled Negative pressure Volume cycled

Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

It is important for nurses to communicate with clients about their health care because: the media provides misleading information. clients are more demanding that their rights be respected. health care services are often specialized and fragmented. consumers of health care cannot keep up with rapid advances in science.

health care services are often specialized and fragmented. Explanation: Managing clients' health involves many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring. One of the significant roles of the nurse is to ensure clear communication with the client and among the health care team. Due to expanded media coverage of health care issues, clients may be more aware of health care issues, but may not be able to determine if the information is accurate or pertains to them. Because of increasing numbers of media sources, both digital and print, it is difficult for consumers to keep up with all of the advances in the science of health care. Clients are more aware of their rights because of media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well, and communication should not be impacted by a client's knowledge or demand for those rights.

Nursing interventions for low pressure alarms

o Disconnection between the ventilator and the patient. Disconnect in the circuit. (to advocate for the patient you need to assume the patient is not getting the oxygen so you need to troubleshoot it that way) o Do not silence the alarm without assessing for a problem.

Normal Arterial Blood Gas Values

pH 7.35-7.45 PaCO2 35-45 mm Hg PaO2 80-95 mm Hg HCO3 22-26 mEq/L O2 Saturation 95-99%

Late stages of ARDS

• After someone gets of the ventilator and they have recoverd from ARDS, tey may never have full lung function again. It just depends on if they were allowed to the final stage of ARDS. • The last stage, and this is going to be a long process (couple of weeks at least). • We also want to make sure we give oral care because our patients are on the ventilator. We don't want them to develop VAP on top of ARDS. For sure they will die. o According to the literature, we do oral care with chlorhexadine every 2-4 hours.

o DISADVANTAGES OF ET TUBE

• Discomfort • Thicker secretions • Swallowing reflexes are depressed • Risk of aspiration • Ulcers on larynx or trachea may develop • Inability to communicate needs

Sepsis Interventions

• Implementing programs to prevent central line infection (CLABSI) • Ensuring early removal of invasive devices that are no longer necessary • Implementing prevention programs to prevent VAP • Early debriding of wounds to remove necrotic tissue • Carrying out standard precautions and adhering to infection prevention/control practices, including the use of meticulous aseptic technique; and properly cleaning equipment and the patient environment.

ARDS

• You will see on chest X-Ray that a patient who had developed ARDS a fluffy white appearance. Looks like little snow drifts in their lungs. • PREVENTION IS KEY --- THIS IS WHY WE WANT TO GET THE PATEINTS OFF THE VENT AS SOON AS POSSIBLE. BUT IF THEY BEGIN TO DEVELOP ARDS, THAT IS NOT THE TIME TO TAKE THEM OFF THE VENTILATOR. GET THE PATIENTS OFF THE VENTILATOR AS SOON AS POSSIBLE

Care of the Patient Being Weaned From Mechanical Ventilation

• Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status. Reestablishing independent spontaneous ventilation can be physically exhausting. It is crucial that the patient have enough energy reserves to succeed. • Assess the patient's and family's understanding of the weaning process, and address any concerns about the process. Explain that the patient may feel short of breath initially and provide encouragement as needed. Reassure the patient that he or she will be attended closely and that if the weaning attempt is not successful, it can be tried again later. • Implement the weaning method as prescribed (e.g., continuous positive airway pressure [CPAP], T-piece). • Monitor vital signs, pulse oximetry, electrocardiogram, and respiratory pattern constantly for the first 20-30 minutes and every 5 minutes after that until weaning is complete. Monitoring the patient closely provides ongoing indications of success or failure. • Maintain a patent airway; monitor arterial blood gas levels and pulmonary function tests. Suction the airway as needed. • In collaboration with the primary provider, terminate the weaning process if adverse reactions occur. These include a heart rate increase of 20 bpm, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to <90%, respiratory rate <8 or >20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, paradoxical chest movement. • If the weaning process continues, measure tidal volume and minute ventilation every 20-30 minutes; compare with the patient's desired values, which have been determined in collaboration with the primary provider. • Assess for psychological dependence if the physiologic parameters indicate that weaning is feasible and the patient still resists. Possible causes of psychological dependence include fear of dying and depression from chronic illness. It is important to address this issue before the next weaning attempt.

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is "If this upsets you, it may be better to not visit." "He is going to get better" "I know what you are going through." "Tell me what you are feeling."

"Tell me what you are feeling." Explanation: The best option is to have the spouse verbalize feelings. The other statements are not therapeutic. The first option does not allow the family to participate in the care of the client; it also does not allow the client to benefit from family visitation. The nurse does nto know the third option is true. Clients can get worse and die. The fourth option minimizes what the client is experiencing. Each person's experience and perception is unique.

Predisposing Conditions for ARDS direct

GI aspiration Pneumonia Chest trauma Embolism O2 toxicity Inhalation of irritant Near drowning

A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility. d. provide hope and encouragement to the family because the patient's disease process has started to resolve.

A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process.

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? A Stridor B Occasional pink-tinged sputum C A few basilar lung crackles on the right D Respiratory rate 24 breaths/min

A The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.

Patients receiving fluid replacement therapy should be frequently monitored for: A Adequate urinary output. B Changes in mental status. C Vital sign stability. D All of the above.

D The nurse must monitor for adequate urinary output, changes in mental status, and vital sign stability because these factors are directly influenced by fluid replacement therapy. Option A: Urinary output should be monitored because an effective fluid replacement therapy is manifested by adequate urine output. Option B: Fluid replacement therapy affects the mental status of the patient directly. Option C: Vital sign stability could be achieved through an effective fluid replacement therapy.

Physiologic responses to all types of shock include the following except: A Activation of the inflammatory system. B Activation of the coagulation system. C Hypoperfusion of tissues. D Vasoconstriction.

D Vasodilation and not vasoconstriction occurs because of the body's immune response. Option A: Activation of the inflammatory system occurs as a response to the invasion of microorganisms. Option B: Activation of the coagulation system occurs because proinflammatory and anti-inflammatory cytokines are released during the inflammatory response. Option C: Hypoperfusion occurs because of vasodilation.

SIRS medical management

FLUID REPLACEMENT THERAPY - To correct tissue HYPOperfusion r/t incompetent vasculature and inflammatory response o To check for effectiveness - Monitor: BP, CVP, serum lactate and urine output PHARMACOLOGICS - Broad spectrum ABX If fluids do not improve tissue perfusion - use vasopressors - specifically norepinephrine & dopamine Inotropic agents to support myocardium PRBC's to support O2 delivery and transport to tissues DVT prophylaxis PPI's and H2 blocking agents for stress ulcer prophylaxis NUTRITION THERAPY Start within 24-48 hours in ICU admission o Why? Pt is in a HYPERMETABOLIC state r/t the septic shock Elevated body temperature (hyperthermia) is common with sepsis and raises the patient's metabolic rate and oxygen consumption. Fever is one of the body's natural mechanisms for fighting infections. Therefore, elevated temperatures may not be treated unless they reach dangerous levels (more than 40°C [104°F]) or unless the patient is uncomfortable.

Often the Stated Root Cause is the Quick, but Incorrect Answer

For example, a normal response is: Equipment Failure Human Error Initial response is usually the symptom, not the root cause of the problem. This is why Root Cause Analysis is a very useful and productive tool.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Risk for trauma related to endotracheal intubation and cuff pressure Impaired physical mobility related to being on a ventilator Risk for infection related to endotracheal intubation and suctioning Impaired gas exchange related to ventilator setting adjustments

Impaired gas exchange related to ventilator setting adjustments Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage her client care assignment? Refuse to accept the new admission. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. Call the obstetrician and ask him to postpone the cesarean birth. Ask the administrative assistant to complete the new client's paperwork.

Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. Explanation: A nurse in the labor and delivery unit can't safely care for three clients. Therefore, the nurse should notify the charge nurse that an additional staff member is needed to safely meet the needs of the increasing client census. Postponing the cesarean birth isn't the best option. Although asking the administrative assistant to assist with paperwork is appropriate, obtaining an additional nurse is a higher priority. The nurse can't refuse to admit a client in labor.

Ventilator Alarms

Low Pressure Alarms Leak or patient disconnected from ventilator High Pressure Alarms Patient asynchronous with vent (aka bucking) Biting ET tube, tubing kinked Coughing, gagging, attempting to talk Pneumothorax/hemothorax

SIRS

Presents like sepsis clinically and is part of the initial continuum of sepsis. → The physiologic presentation of SIRS is similar to sepsis, except there is no identifiable source of infection. MEDICAL MANAGEMENT • Identification and elimination of the cause of infection • Identify and treat patients in early sepsis within 6 hours to optimize patient outcome • Antibiotics should be initiated within the first hour of treatment of a patient with sepsis • Rapid and effective restoration of tissue perfusion • Evaluation and treatment of the patient's immune response • Treatment of dysregulation of the coagulation system that occurs with severe sepsis

Settings within Pressure and Volume modes

Rate (f) - number of breaths delivered per minute (Determined by Physician and RT) Tidal Volume - The amount of gas delivered with each breath (6-10 mL/Kg) Fraction of Inspired Oxygen (fiO2) - concentration of oxygen (21%-100%) Positive End Expiratory Pressure (PEEP) - pressure in the lungs that exists after expiration. (Usually 5cm H20)

Root Cause Analysis

Root Cause Analysis is an in-depth process or technique for identifying the most basic factor(s) underlying a variation in performance (problem). Focus is on systems and processes Focus is not on individuals

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube? Routine cuff deflation is recommended Cuff is deflated prior to tube removal Humidified oxygen should always be introduced through the tube Cuff pressures should be checked every 6 to 8 hours

Routine cuff deflation is recommended Explanation: Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

Predisposing Conditions for ARDS indirect

Sepsis Massive trauma Pancreatitis Anaphylaxis CABG DIC Multiple Blood transfusions Severe head injury Shock

Example of Five Whys for Root Cause Analysis

Why? Nails on garage floor Why? Box of nails on shelf split open Why? Box got wet Why? Rain thru hole in garage roof Why? Roof shingles are missing

A large university hospital has commissioned a multidisciplinary group to review patient records following discharge in order to evaluate patient outcomes and the character and quality of nursing care that patients receive. This evaluative program is: a nursing audit. a structure evaluation. an outcome evaluation. a process evaluation.

a nursing audit. Explanation: A nursing audit is a method of evaluating nursing care that involves reviewing patient records to assess the outcomes of nursing care or the process by which these outcomes were achieved. Outcome evaluation focuses on health status changes in the patient while structure evaluation addresses the environment in which care is provided. A process evaluation addresses performance expectations during the various stages of the nursing process.

An infant was taken from the ward by its parents without the knowledge of the nurses on the ward. The charge nurse conducts a performance improvement process to determine which of the following statements? requesting that a documented expert in the field perform a review. randomly observing client care without advance warning. conducting root cause analysis. evaluating a single incident that resulted in an unanticipated outcome.

conducting root cause analysis. Explanation: Root cause analysis is used to gather information about factors that contribute to a problem (root causes) so that the nurse can identify ways to correct the problem. Random observation doesn't necessarily produce data to explain a specific sentinel event. Evaluation of a single incident rarely identifies underlying causes and contributing factors to sentinel events. An expert consultation doesn't necessarily reveal site-specific underlying causes and contributing factors in an individual health care facility.

Nurses on a pediatric unit have developed a program to decrease the infection rate on the unit. What is an expected outcome of this quality improvement program? evaluation of the system and client outcomes preparation for accreditation of the organization evaluation of staff members' performances improvement in efficiency of care

evaluation of the system and client outcomes Explanation: The goal of a quality improvement (QI) program is to ensure that the best care is delivered to clients and families. This can be achieved by attention to client outcomes. Staff performance evaluations should be completed according to institutional policy and focus on staff, not client outcomes. Improved care efficiency may be an aspect of quality client care, but it is not the primary outcome. Accreditation agencies have strict parameters to which an institution must adhere to ensure accreditation. QI is one method to demonstrate adherence to the parameters. The goal of QI is to ensure that the best care is delivered to clients and families, not to ensure accreditation.

The nurse is serving on the Quality Improvement Committee for the maternity unit. Quality improvement projects for this unit impacting safety and quality of care include which projects? Select all that apply. sibling and family visitation policies use of recycling bins on the unit infant identification system postpartum discharge instructions rooming in guidelines

infant identification system sibling and family visitation policies postpartum discharge instructions rooming in guidelines Explanation: The use of recycling bins on the unit does not impact safety or contribute to the quality of care. The infant identification system is a safety practice. Nursing influences the type of system used and how monitoring and identification occur, which improves the quality of care. The sibling and family visitation policy can be an excellent project. Sibling policies regarding visitation can influence safety (safety of mother and infant by keeping children with colds/flus, infections away from the obstetrics unit). Nursing influences development of the policy utilized and implemented on a daily basis. Postpartum instructions represent an area where the skill level, quality, and quantity of instruction represent nursing contributions to care. The ability for a family to remain together during a hospital stay is important to families. The quality of the obstetrical experience can be enhanced or determined to be negative by this particular policy, one that is often looked at by these committees.

Sick and preterm neonates who experience continuity of nursing care directly benefit from: higher levels of professional satisfaction among nurses. higher levels of parent satisfaction with nursing care. nursing recognition of subtle changes in high-risk neonates' conditions. decreased hospital liability for professional malpractice.

nursing recognition of subtle changes in high-risk neonates' conditions. Explanation: Continuity of care allows the nurse to observe subtle changes in a neonate's condition. Although nurses and parents experience higher levels of satisfaction and professional liability may decline, these results aren't direct benefits to the neonate.

Nursing interventions for vent alarms- high pressure

o Biting on the tube: More sedation, emotional support, bite block o Kink in the tube: Unkink the tube o Coughing o Bucking the vent: More sedation, change the mode o Secretions that are occluding the tube: suction the tube o A patient may be on the wrong mode and we can change the mode. Nurses can give more and more sedation until the patient is so snowed that they cannot breathe on their own. Therefore we have just created more problems. It is important to evaluate the whole situation and not just go for the one simple answer.