Critical Care Nursing Exam Preparation, Exams of Nursing

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what does AACN stand for - American Association of Critical Care Nurses

• largest nursing specialty organization in the world what does SCCM stand for - Society of Critical Care Medicine
• multiple professional society made of pharmacists, nurses, physicians, etc AACN mission - drive excellence in patient care through knowledge and influence AACN values - accountability, collaboration, leadership, and innovation Vision of AACN - create a health care system driven by the needs of patients and their families in which nurses make their optimal contributions synergy model - the needs of patients and their families influence and drive the competences of nurses how is the synergy model used in practice - nurse/patient interaction is reciprocal and constantly evolving by responding to the characteristic and actions of the others what is the critical care certification - CCRN : must renew every 3 years by completing a specific amount of education and proving you work in the critical care field ,pass the exam why is it important to get critical care certification - validates knowledge and promotes professional excellence and helps nurses maintain a current knowledge base

what does QSEN stand for - Quality and Safety Education for Nurses what are the 6 core competencies - patient centered care, teamwork and collaboration, evidence based practice, quality improvement, informatics, safety joint commission - identify national patient safety goals that should be implemented in hospitals and are updated annually what does IHI stand for - Institute of Healthcare Improvement bundles of care definition - evidenced based practices that are done in conjunction to help increase patient outcomes, research is ongoing to test their effectiveness, the bundles of care become the standard of nursing care in ICUs what does IHI do - national group that introduced bundles of care to help reduce harm examples of bundles of care - to prevent central line acquired blood infections or ventilator acquired pneumonia, there are everyday nurses practices used to prevent this what are barriers to effective communication - physical setting social setting language what are examples of barriers to effective communication - make sure to limit noise and allow for privacy, patient or nurse feels like they cannot speak up or raise concerns to their peers, medical jargon

standardized measures to prevent miscommunication at shift change - SBAR : Situation, Background, Assessment, Recommendation : concise and effective communication staying in communication with the family, updating the white boards in the room, keep the communication centered around the patient, include them patient centered communication - staying in communication with the family and the patient what does SBAR stand for - Situation, Background, Assessment, Recommendation what are things you may need to communicate during multi professional rounds - tell the physical about the patient's status, any needs that the patient has, any questions that you have about their care, any recommendations that you have since you are the one that is by the bedside sensory overload definition - something around us that overstimulates one or more of our senses contributing factors to sensory overload - beeping, alarming, loud tv, bright lights, consistent interruptions nursing interventions to reduce sensory overload - reducing volume of equipment, adjust the alarm thresh holds on the monitor, organize workflow to decrease interruptions, coming to alarms QUICKLY, speaking quietly, close door if allowed, shut off tvs patient stressors in ICU - anxiety, depression, inability to communicate, difficulty sleeping, relying on the nurse constantly, inability to get comfortable, and lack of control, physical restraint, thirst, loneliness ( physically and emotionally stressed )

elderly patients in the ICU - Elderly tend to do worse than younger patients in the ICU, higher risk for ICU delirium family assessment in ICU - determine who is who, what kind of support the patient will have family needs in the ICU - people cope differently and the nurse needs to support emotionally family conflict in the ICU - help with conflict that may arise, can bring out the worst in families examples of ways nurses care for the patient's family and help with coping - emotional support, be ready for all emotions, make sure you communicate main cause of emotional outbreak or inappropriate responses from family - having a loved one in the ICU causes very high stress, poor or lack of communication family visitation in the ICU - most widely researched issue in nursing, most critical care units have relaxed visiting hours, older nurses may see a big change because when they first started they did not allow visiting hours family presence during cardiopulmonary resuscitation - read the family, will if be helpful or more stressful, most families do no want to see a code but some families need to see the code to see that even when everything possible is done the member still will not survive autonomy - respect for the individual and the ability of individuals to make decisions about their own health and future beneficence - actions intended to benefit the patient or others nonmaleficence - actions intended not to harm or bring harm to the patient or others

justice - being fair, fair allocations or distribution of healthcare resources bioethics committees is made up of who? - made up of physicians, chaplains, nurses, social workers, and bioethicist what situations warrant ethics consults - if there is no family for the patient, made up of physicians, chaplains, nurses, social workers, and bioethicist, recommendations to the health care team in making decisions for the patient what must be present for a patient to consent - Patient must be competent, decision must be voluntary, disclosure of information what section talks about consent - Section 44-66- what is the order of decision makers in SC - spouse, children over 18 : one child does not get more say then another, parents, siblings, consult bioethics committee when would healthcare proxy/next of kin be used for decision making? - If the patient is ruled incompetent to make decisions on their own what clinical situations, medications, symptoms, and general diagnoses warrant the need for proxy/next of kin? - brain damage, respirator, coma, medications that affect your mental state advanced directive - witnessed written document or oral statement in which instructions are given by a person to express desires related to health care decisions living will - witnessed written documentation or oral statement that voluntarily is executed by the person and it expresses the person's instructions about life prolonging procedures

proxy - competent adult who has not been expressly designated to make health care decisions for the patient but is authorized by state to make decision or the person ( next of kin ) surrogate - competent adult who had been designated by a person to make their health care decisions ( health care power of attorney ) terminal condition - condition in which there is no reasonable medical probability of recovery, it can be expected to cause death without treatment unconsciousness condition that demonstrates persistant vegetative state - permanent, irreversible unconsciousness condition that demonstrates and absence of voluntary action and cognitive behavior, inability to communicate or interact purposely with the environment brain death - complete irreversible cessation of brain function, brain death = death DNR - no CPR or emergency cardiac care, can be tailored so they may want CPR but not intubation allow natural death - another term for DNR, no negative connotation what is withholding care - deciding against life supporting care ( no intubation, no dialysis ), family knows that the result is the patient dying what is withdrawing care - removing all life supporting equipment from the patient, ventilators, nutrient, life supporting medication, COMFORT IS KEY medical futility - interventions that simple cannot accomplish physiologic goals, no matter how many times you do the interventions it will not reach the goal

palliative care - complementary supplement to care, focus is relieving symptoms of chronic disease hospice care - generally reserved for patients with less than 6 months to live, used in place of aggressive life sustaining or restorative care how would you explain withholding to families - STEPS - has to be appropriate and the general consensus of the family and healthcare team, poor prognosis or terminal, prepare the patient and the family what is likely to occur to help alleviate anxiety and stress, terminal wean and extubation, nutrition is discontinued and all life saving measures are removed, nurses will medicate prior to extubation, remove endotracheal tube and monitor for symptoms symptoms to assess for during withdrawing care - dyspnea, tachypnea, anxiety, agitation, grunting, use of accessory muscles what medications are used during withdrawing care - Ativan, morphine, robins, atropine what types of therapies are stopped during withdrawing care - nutrition, endotracheal tube, all life saving measures how is withdrawal of care different from euthanasia - euthanasia is actively seeking to end a patient's life whereas withdrawal is letting the disease naturally progress on its own caring for the family during withdrawal of care - assess their needs and use your resources if you need to, chaplain or child life specialist nursing interventions to support care at end of life - assess patient's and family members' understanding of the condition and prognosis to address educational needs, educate family members about what will

happen when life support is withdrawn to decrease their fear of the unknown, assure family members that the patient will not suffer, assure family members that the patient will not be abandoned, provide any needed emotional support and spiritual care resources, such as grief counselors and spiritual care providers, facilitate physician communication with the family, provide for visitation and presence of family and extended family ( patient will not die alone ) signs and symptoms of pain - SNS activation = diaphoresis, hypertension, increased cardiac output, increased glucose production, nausea, flushing, sleep disturbances, tachycardia, dyspnea, urinary retention, constipation signs and symptoms of anxiety - SNS activation = diaphoresis, hypertension, increased cardiac output, increased glucose production, nausea, flushing, sleep disturbances, tachycardia, dyspnea, urinary retention, constipation What should you do prior to administration of pain or anxiety medication? - Assess pain first and the characteristics of pain, find out where the pain is occurring, need this information know what kind of medication give, medications will be based off of the score that you get from the scale What does a neuromuscular blockade do? - complete chemical paralysis, can be given IV push or continuous infusion, ZERO SEDATIVE OR ANALGESIC PROPERTIES What must be given beforehand? - before you give a neuromuscular blockade you must sedate the patient and provide pain control, make sure that the sedative medication lasts longer than the neuromuscular blockade what is train of four - how you monitor the state of chemical paralysis by using a peripheral nerve stimulator what specific number of twitches indicate - 4/4 twitches = incomplete NMB, 2/4 twitches : GOAL, 0/ twitches : complete NMB

BPS stands for - behavioral pain scale scoring with BPS - lowest score is a 3 and that equals NO PAIN, highest is a 12 when do you uses the BPS - can ONLY use it in intubated patients what are the 3 categories in BPS - facial expression, upper limbs, compliance with mechanical ventilation What does PEEP stand for? - Positive End Expiratory Pressure what does PEEP do - - helps with collapsed alveoli that are not allowing any gas exchange

• Addition of positive pressure into the airways during EXPIRATION what happens if there is too much PEEP - a pneumothorax can occur what happens during PEEP - There is a decrease in cardiac output ( HYPOTENSION ) because of decreased venous return which is caused by the extra pressure in the thoracic cavity SIMV stands for what? - Synchronized Intermittent Mandatory Ventilation indications of SIMV - patient can participate in WOB to recondition respiratory muscles, hyperventilation in VAC, ventilator weaning disadvantages of SIMV - poor choice for ventilator weaning, extra breaths are not supplemented when they may need to be

with SIMV what happens when the patient breaths - they get the volume that they can naturally pull in, patient HAS to be able to breathe on their own, if a patient initiates a breath near a mandatory breath, the vent synchronizes the breaths patient breaths for SIMV - allowed but not supported (variable) rate in SIMV - set pressure in SIMV - variable volume in SIMV - set for vent initiated breaths what does PS stand for - pressure support how does PS work - can be used in combination with other modes, comfortable for patient indications for pressure support - patient able to do all the WOB, weaning disadvantages for pressure support - patient has to trigger every breath, hypoventilation patient breaths in PS - PATIENT MAKES ALL THE EFFORT TO BREATH what does CPAP stand for - Continuous Positive Airway Pressure how does CPAP work - positive pressure applied throughout respiratory cycle to the spontaneously breathing patient

patient breathing CPAP - - patient HAS to be breathing on their own, all the CPAP is giving is PRESSURE indications of CPAP - used for weaning, patient can perform all the WOB but needs end expiratory pressure to stabilize alveoli and maintain oxygenation disadvantages of CPAP - patient can develop respiratory acidosis if they are not breathing enough times per minute, watch for hypoventilation what blood gas issues can be caused by CPAP - respiratory acidosis V/AC stands for - Volume Assist/Control indications of V/AC - ventilator is performing bulk of WOB, patient has normal inspiratory drive, but respiratory muscles are weak and unable to perform WOB disadvantages of V/AC - respiratory alkalosis can develop with hyperventilation, patient may rely on the ventilator and not attempt to initiate breaths volume in VAC - set rate in VAC - set pressure in VAC - variable patient breath in VAC - supported with full set volume

VAC works how? - ensures patient received adequate ventilation regardless of patient effort, if patient takes a spontaneous breath, the vent delivers a preset volume what blood gas issue occurs in VAC - respiratory alkalosis risks if ETT is placed improperly or if it becomes unsecured - lack of oxygen can cause tissue damage causes of high pressure alarms - patient is biting the tube, patient is coughing, kink in the tube, reduced lung compliance causes of low pressure alarms - patient self extubated, patient bit the tube in half causes of high volume alarms - taking in their own breaths and they are taking in too much air causes of low volume alarms - not enough air is going in, tube is disconnected or there is a leak in cuff or chest tube order of events when ventilator alarm goes off - what does ARDS stand for - acute respiratory distress syndrome what are the direct causes of ARDS - aspiration of gastric contents, fat embolism, inhalation of toxic gases, multi system trauma (chest or lung injury), near drowning, pneumonia what are the indirect causes of ARDS - burns, cardiopulmonary bypass, drug overdose, fractures, multiple transfusions : too much fluid, multi system trauma (without chest and lung injury), pancreatitis, sepsis

who is at extreme risk for ARDS - trauma patients what is the hallmark sign of ARDS - respiratory distress that does NOT respond to oxygen therapy ( usually in the 80s ) early signs of ARDS - ALKALOTIC presentation, hyperventilating, low CO2, restless, disoriented, confused, sleepy, drowsy, may be comatose, tachycardia late signs of ARDS - hypoxemia is getting worse, labored breathing, central cyanosis, crackles will present because of pulmonary edema, lungs will get harder to ventilate : ACIDOSIS STATE, metabolic acidosis : lactic acid build up what will a chest x ray show with ARDS - Bilateral infiltrates : ground glass appearance, will progress into a complete white out phases of ARDS - Acute Exudative/Inflammatory Phase: within 1 week of injury/insult, Proliferative Phase: 1-3 weeks of initial insult, Fibrotic Phase: 2-3 weeks after initial insult how do ARDS patients usually die - Most patients die from the organ failure not actual ARD diagnostic test for ARDS - Berlin Criteria Definition : acute onset within 1 week after clinical insult, bilateral pulmonary opacities not explained by other conditions, altered PaO2/FiO2 (P/F ratio) ( mild : 200 - 300 mmHg, moderate : 100 -200 mmHg, severe : <100 mmHg) medications for ARDS - no drugs have been deemed the "standard" medications for treatment : steroids and sedation/pain/neuromuscular blockades ABG changes with hypoventilation - respiratory acidosis

ABG changes with hyperventilation - respiratory alkalosis what are alveoli - Tiny air sacs at the end of the bronchioles what is the purpose of alveoli - the alveoli are where the lungs and the blood exchange oxygen and carbon dioxide during the process of breathing in and breathing out what happens when fluid fills the alveoli - pulmonary edema occur when they fill with fluid - interferes with gas exchange and causes respiratory failure what are the early signs of hypoexmia - neuro signs - confusion what are the common causes of pulmonary embolism - DVT most common, venous stasis, hyper coagulability of blood, damage to vessel walls what are the nursing interventions to prevent a pulmonary embolism - placed on heparin drip or lovenox, TED hose signs of a pulmonary embolism - Shortness of breath, hypoxemia, acute onset of chest pain, O2 drops, if the patient is vented the symptoms can be very vague, SpO2 drops and become tachycardia, dyspnea, crackles, fever, tachycardia, murmur, or gallop diagnostic testing for pulmonary embolism - CaT chest, pulmonary angiogram how do you calculate P/F ratio - PaO2/FiO what is prone position and why do you do it - laying them on their stomach, takes the weight of the heart and the belly off of the lungs

how many nurses are used to put a patient in prone - 5 to 6 nurses risks of patients that are going to be proned - - Airway can EASILY be pulled out

• pad them so they can have skin protection
• Turn side to side for position change, no injury on face so flip face and arms in swimmer position
• Prone for 16 hours, back for 8 hours what are contraindications for prone postion - Spine injuries and neck injuries and trachs Ventilator bundle of care - elevation of the head of the bed greater than 30 degrees, daily awakening, stress ulcer prophylaxis, VTE prophylaxis, regular oral care including chlorohexidine