critical care module 1

hypoxia

inadequate tissue perfusion; deficiency in the amount of )2 reaching the tissues

compliance

measure of the lung's distensibility (stretchability)- the change in lung volume per unit of pressure change

Vent settings: PEEP

(Positive End-Expiratory Pressure) is the adding of positive pressure into the airway during expiration increases oxygenation by preventing collapse and maximizing the # of alveoli available for gas exchange typical settings = 5-20 cmH2O

Vent settings: FiO2

(fraction of inspired oxygen)- settings > 0.21 (21% room air) - 1.00 (100% oxygen). set to whatever value is needed to maintain a PaO2 of 60-10 mmHg or an SpO2 of at least 90%

what are the diagnostic criteria for ARDS?

1) acute onset within 1 week of clinical insult 2) bilateral pulmonary opacities not explained by other conditions 3) altered PaO2/FiO2 ratio

What are the components of Virchow's triad?

1) venous stasis 2) hypercoagubility of blood 3) damage to the vessel walls

PaO2 normal values

80-100 mmHg

SaO2 normal values

92%-100%

handoff communication is essential in reducing errors. which action can the nurse take to reduce errors in communication? a) implement strategies to control noise during transfer report of a patient b) initiate a system of forms and checklists to convey information during rounds c) begin the practice of bedside shift report between nurses d) seek information on crew resource management training

A

the most important reason for the nurse to develop effective communication skills is to a) promote patient safety and reduce errors b) ensure that the hospital is meeting joint commission requirements c) develop skills in patient/family education d) collaborate with team members during interdisciplinary rounds

A

which intervention is important in meeting the needs of family members of critically ill patients? a) encourage family members to participate in small activities of patient care, such as range-of-motion exercises b) allow a minister to meet with the family only in the waiting room c) tell the family that "everything will be okay. the patient has the best team in the hospital." d) allow the family to visit the patient in large groups whenever they wish

A

as part of the nursing assessment, the nurse asks the family spokesperson, "since you have such a large family, can you tell me how well everyone gets along?" this question is part of which assessment? a) developmental assessment b) cultural assessment c) functional assessment d) structural assessment

C

the AACN publishes a variety of journals, including which of the following? a) critical care medicine b) dimensions of critical care nursing c) critical care nursing quarterly d) american journal of critical care

D

What patients are at risk for ARDS?

Patients after trauma who develop shock or required excessive fluids patients with pneumonia, sepsis, aspiration near drownings inhalation of toxic gases

Meds in Vent Patients: Dexmedetomidine (Precedex)

Side Effects: Bradycardia, Hypotension, nausea Implications: give only by continuous infusion, monitor heart rate, evaluate hepatic and renal function

Vent settings: Tidal volume

Vt - amount of air delivered with each preset breath in a volume-controlled mode is the Vt Starts at 4ml-8ml/kg for patients with ideal body weights pressures should remain below 30-40 cm H2O to prevent ventilator injury

Vent settings: Pressure Support

a mode of ventilation in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure ***used mostly to wean a patient off of the vent***

Patho of ARDS

acute injury and diffuse injury to lungs leading to resp. failure 1) lung injury (pneumonia, aspiration, smoke inhalation, sepsis) 2) acute phase (uncontrolled inflammation, release neutrophils to fight infection damaging alveolar-capillary membrane - less permeable = pulm. edema 3) proliferative phase (1-3 weeks after onset) - edema resolves; progressive hypoxemia 4) fibrotic phase (2-3 weeks after onset) - obliterate alveoli/bronchioles, worsening inflammation and edema, multi-organ death syndrome

AACN

american association of critical care nurses- uses the synergy model- matches the patient to the nurse based on the needs of the patient. supports a patient-by-patient mindset to set the plan of care

Meds in Vent Patients: Morphine

analgesic/opioid used for moderate -> severe pain Side effects: hypotension, resp. depression, N/V, decreased gastric motility, Urinary retention, constipation Implications: monitor BP, RR, HR; give fluids, push slowly Antidote = naloxone

what are the top stressors for patients in critical care?

anxiety, depression, fear, difficulty sleeping, lack of control, loneliness, pain, thoughts of death and dying, fear

Measures to prevent DVT

assess and identify patients at risk for DVT communicate risks with whole care team assess extremities medication therapies (anti coags) mobility regimen encourage fluids educate patient avoid massaging legs, elevating legs, etc.

Patients with increased risk of DVT

burns, over age 75, cancer, CHF, antithrombin deficit, HIT, immobile, lower extremity fracture, oral contraceptives, pregnancy/post partum, stoke, lupus

what is the purpose of critical care certifications?

certifications are tools that validate the nurses' knowledge, promotes professional excellence, and helps to facilitate a up to date and current knowledge base as practices enhance

what are the three elements of informed consent?

competence, voluntariness, disclosure of information

what are the indications for mechanical ventilation?

1) patients with acute respiratory failure who can't maintain adequate gas exchange evidenced by ABGs 2) patient demonstrates progressive physiological deterioration (rapid, shallow breathing; increase in the WOB evidenced by using accessory muscles 3) abnormal breathing and severe dyspnea 4) life-saving therapy to support the respiratory system

which intervention is most helpful in preventing sensory overload in critically ill patients? a) encourage family members to assist in the reorientation of the patient b) move the patient to a semiprivate room with another confused patient c) increase the amount of noise form equipment in the patient's room d) place the patient nearer to the nurses' station for observation

A

what does EPICS stand for in reference to the family bundle?

E- Evaluate (assess family background, stressors, coping skills, needs/desire to be involved) P- Plan (best needs of patient and how to meet them, plan family participation, facilitate meetings, and encourage touching the patient) I- Involve (have family participate, include in discussion of plan of care, invite suggestions, have family bring patient some belongings from home) S- Support (advocate for the family, provide resources, show concern, mediate between family and providers)

What are some of the complications of mechanical ventilation?

ETT out of position, unplanned extubation, injury/trauma, infection (VAP), resp. acidosis/alkalosis, O2 toxicity, aspiration

what are the competencies for acute and critical care nurses?

clinical judgment and clinical reasoning skills advocacy and moral agency in identifying and resolving ethical issues caring practices that are tailored to the uniqueness of the patient and their family collaboration with patients, family members, and healthcare team members systems thinking that promotes holistic nursing care response to diversity facilitator of learning for patients and family members, team members and the community clinical inquiry and innovation to promote the best patient outcome

hypoxemia

decrease in oxygenation of arterial blood (PaO2 < 60 mmHg)- < 60 mmHg = immediate intervention < 40 mmHg = life-threatening, leads to cell death

Meds in Vent Patients: Atracurium, Succinylcholine

neuromuscular blockades- therapeutic paralysis succinylcholine is used for short-term and is avoided in patients with hyperkalemia Side effects: hypotension, tachycardia, rash, hyperkalemia Implications: secure adequate airway, do train-of-four assessment to monitor paralysis

ordinary care v. extraordinary care

ordinary= usual and customary care for the patient and their condition extraordinary= made up of complex, invasive, and experimental treatments. ie: CPR, life support, dialysis, or emergency cardiac care

ABG Values

pH: 7.35-7.45 PaCO2: 35-45 HCO3: 22-26

Meds in Vent Patients: Benzodiazepines - midazolam, lorazepam

reduce anxiety and provide sedation Side effects: hypotension, resp. depression, hyperosmolar metabolic acidosis Implications: lower doses in older adults, monitor BP and RR/SpO2, monitor acid/base

Meds in Vent Patients: Propofol

reduce anxiety and provide sedation. Side effects: hypotension, resp. depression, CNS depression, fever, sepsis, hyperlipidemia Implications: in high doses pt. should be intubated and mechanically ventilated, avoid pushing too fast, monitor DP and hemodynamics

Vent Alarm: High Peak Pressure

set 10 cm H2O above average PIP - triggers when pressure increases in circuit (can be triggered by kinks in tubing, coughing, anxiety, etc.)

what are the 4 reasons for endotracheal intubation?

1) intubation to establish an airway 2) assist in secretion removal 3) protect the airway from aspiration in patients with a depressed cough 4) provide mechanical ventilation

the nurse is interested in pursuing critical care nursing practice as a career. after listening to an explanation of critical care nursing, which statement indicates understanding? a) critical care nurses coordinate care for critically ill patients in a variety of settings b) technological advances have had little effect on ethical dilemmas c) collaborative practice interferes with effective patient care d) critical care nursing is defined as care rendered in an intensive care unit

A

the nurse is participating on a committee to remodel the critical care unit and recommends which features to enhance care delivery and the patient-family experience? (select all that apply) a) space for the family within the patient room b) noise reduction features c) private patient rooms d) natural light

A, B, C, D

which stressors should the nurse anticipate the patient to have during the critical care experience? (select all that apply) a) feelings of dread b) difficulty sleeping c) difficult communication d) pain e) thoughts of death and dying

A, B, C, D, E

what actions can the nurse manager take to promote a healthy work environment? (select all that apply) a) give meaningful recognition to team members b) encourage respect for one another c) limit staffing to reduce noise d) acknowledge family contributions e) be effective in decision making

A, B, D, E

what actions can the nurse take to remain aware of current and emerging trends affecting practice and emerging trends affecting practice and patient care? (select all that apply) a) attend local professional meetings b) join a journal club c) work in many areas of nursing d) read professional journals e) become involved in a unit-based council

A, B, D, E

pleasant sensory stimuli in the critical care unit can be promoted by which interventions? (select all that apply) a) conversing with another nurse about another patient's condition b) providing a clock, calendar, and family pictures in the room c) discussing other patients' conditions within hearing range d) moving the patient's bed to facilitate looking out the window e) asking, "do you know what day it is?"

B, D

the charge nurse is making assignments for the critical care unit and assigns the experienced nurse to care for two complex patients. the novice nurse is assigned to care for the less complex patient. the charge nurse is basing assignments on which model of practice? a) institute for healthcare improvement b) universal care c) quality and safety education for nurses d) synergy model

D

How do you know the patient is ready to wean from the ventilator?

Assessment parameters: Underlying cause for mechanical ventilation is resolved Adequate oxygenation without a high FiO2 &/OR a high PEEP Hemodynamic stability - absence of hypotension, minimal vasopressors adequate respiratory muscle strength absence of factors that impair weaning (infection, anemia, fever, pain, abd. distention)

the nurse is interested in reducing health care-associated infections. which action should the nurse take to achieve this? a) assess the client for suicidal risk b) wash hands before and after patient care c) perform a time-out before procedures d) use two methods of client identifcation

B

The nurse is meeting with family members of a critically ill patient. which statement best addresses the psychological needs of the family members? a) there are coffee and cookies in the waiting room. why don't you take a short break? b) im adjusting the alarms on the monitor to reduce the noise level in the room c) the team has just made rounds on the patient. we are going to begin weaning the patient from the ventilator today since the patient's oxygen is improving d) it would help the patient if you can spend the night in the waiting room

C

The nurse manager is reviewing the WHO guidelines on noise in the critical care environment. how does the nurse manager interpret these guidelines? a) noise can be minimized by shutting off alarms b) noise can be eliminated with acoustic ceiling tiles c) noise levels often exceed recommended levels d) noise is something the nurse just has to deal with

C

which strategies should the nurse manager implement to improve collaboration in the critical care setting? (select all that apply) a) exclude family members from rounds b) institute morning briefings c) initiate interdisciplinary rounds d) create joint programs for continuing education

C, D

the critical care nurse has just listened to a lecture on standards of professional performance. the nurse then agrees to serve as a preceptor for undergraduate nursing students who are scheduled for observation in the critical care unit. which statement by the critical care nurse indicates an understanding of the standards of professional performance? a) professional standards include providing leadership in the practice setting. b) professional standards include using skilled communication to collaborate with others c) professional standards include using clinical inquiry in practice d) professional standards include contributing to the professional development of others

D

the nurse is on a committee related to family visitation in the critical care unit and discusses evidence to help in the planning. which statement reflects evidence? a) visitation shapes the critical care experience for the family but not the nurse b) allowing children to visit is stressful for the patient and the child c) restricted visitation prevents family exhaustion d) family presence during procedures promotes adaptation

D

what action can the nurse manager initiate to promote collaboration? a) implement weekly in-services presented by the intensivist b) invite team members to after-work social events c) mandate attendance at multiprofessional meetings d) institute multiprofessional bedside rounds one or two times per shift

D

Vent Alarm: Low PEEP/Low pressure

set 10 cm H2O below average PIP - triggers when pressure decreases (can be triggered by leaks in circuit)

Vent Alarm: Low/High exhaled VE/Vt

set 10% below/above average Vt/VE - ensures adequate alveolar ventilation assess/treat cause of increased or decreased RR

SBAR?

situation- what is going on right now background- what led up to this situation assessment- what do you think the problem is recommendation- what you think will correct the problem

SCCM

society of critical care medicine- collaborative care centered

work of breathing

the amount of effort required for the maintenance of a given level of ventilation

Vent settings: Respiratory Rate

the frequency of breaths (f) set to be delivered by ventilator many patients require full vent support at first as patient improves and begins to participate in breathing, the ventilator is changed for more spontaneous breathing

resistance

the opposition to the flow of gases in the airway

pressure-controlled ventilation

the vent is set to flow into the lungs until a preset inspiratory pressure has been reached. The Vt is variable and depends on lung compliance and airway and circuit resistance

volume-controlled ventilation

the ventilator is set to allow airflow into the lungs until a preset volume has been reached. Vt is delivered regardless of change in compliance or resistance of lungs

Ethical Issues in critical care include:

visiting hours, family presence during CPR, restraints, withhold/withdraw life support, informed consent, organ donation, refusal of blood products