Critical Care Nursing: Optimizing Patient Outcomes through Evidence-Based Practices, Exams of Nursing

Download Critical Care Nursing: Optimizing Patient Outcomes through Evidence-Based Practices and more Exams Nursing in PDF only on Docsity! Critical Care Test 1 Two main professional organizations mentioned that support critical care practice. - American Association of Critical-Care nurses (AACN) and Society of Critical Care Medicine (SCCM) Which organization best supports critical care nurses out of the two mentioned? - The AACN's mission is to assist acute and critical care nurses to attain knowledge and influence to deliver excellent care using the "synergy model". The SSCM is targeted more toward the entire health care team in critical care, so AACN would serve nurses more. What is the mission of AACN? - assisting acute and critical care nurses to attain knowledge and influence to deliver excellent care What is the Vision of AACN? - a. creating a health care system driven by the needs of patients and families in which critical care nurses make their optimal contributions (described as synergy) What is the Values of AACN? - Accountability, advocacy, integrity, collaboration, leadership, stewardship, lifelong learning, quality, innovation, and commitment Explain the Synergy Model and how it is used in practice? - Patient needs (medically, emotionally, culturally, etc.) drive the nurse competencies required for patient care - when competencies stem from patient needs, and the characteristics of the nurse and patient match, synergy occurs and enables optimal outcomes - Many organizations use this model as a basis for developing frameworks for nursing practice, this is also used to implement appropriate staffing by ensuring the best nurse is matched with the patient that matches that nurse's competencies What types of certifications are available for ICU nurses? - CCRN (nurses who provide care for critically ill adult, peds, or neonatal populations) and PCCN (nurses who provide acute care in progressive care, telemetry, and similar units) 1 | P a g e Why are critical care certifications important? - They validate knowledge of critical care nursing, promotes professional excellence, and helps nurses to maintain a current base of knowledge What 3 specific projects/organizations are in place to assist nurses in providing safe care? - i. Quality and safety Education for Nurses (QSEN) project ii. Joint Commissions National Patient Safety Goals iii. Institute for Healthcare Improvement (IHI) Quality and Saftey Education for Nurses (QSEN) - defines 6 core competencies that provide a foundation for safe nursing care - patient- centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety Joint Commission- National Patient Safety Goals - goals updated annually to ensure facilities implement actions and protocols to address safety - ex. improve accuracy of patient identification, improve communication among HC providers (report critical values/test results), improve medication safety (labeling meds, contraindications, harmful side effects), use alarms safely, reduce risk of healthcare-associated infections (hand hygiene, aseptic techniques), identify safety risks (self-harm patients, fall risks), and prevent complications associated with surgery and procedures Institute for Healthcare Improvement (IHI) - produced an action plan for reducing healthcare-associated infections and preventing infections with multidrug-resistant organisms - action plan includes bundles of care to reduce harms Explain what a Bundle of Care is? - Care bundles are a set of 3-5 EBP (interventions) that when used together cause significant improvement in patient outcomes 2 | P a g e Age 65 and older and 33% die within 6 months after discharge from a critical care unit - Older patients have a decreased ability to adapt and cope with major physical and psychosocial stressors of critical illness What types of situations do you think could contribute to family conflict being present? - a. The patient's family role, families coping strategies, socioeconomic issues, and if the family members are feeling angry, guilty, or have unaddressed concerns regarding the patients condition and care. b. Illness within the family may uncover underlying conflicts among family members, especially if they are estranger or have other unresolved issues. How can nurses best support the family members of patients and assist them in coping? - i. Decision Making- involve family members in decision making, communicate the patient's status and explain all options for future care, hold meetings with health care team and family within 48 hours of admission to ICU ii. Family Coping- assign consistent nurses and physician staff, provide information to family members in various formats, provide family support through support groups, consult, etc. iii. Staff Stress- keep all healthcare members informed of treatment goals IV. Cultural Support of Family- culturally competent care Spiritual and Religious support of appropriate Family Environment of V. Care- allow family to be present during rounds, regular visitations, and allow family to be present during CPR VI. Palliative Care What is the main cause of emotional outbreak or inappropriate responses from family members? - Lack of communication 5 | P a g e - Always be truthful, prompt, and communication in a jargon the family can understand - Facilitate open communication with family members to keep them involved in the patient's care What does research say about family visitation in the ICU? - Family presence has a positive impact on the patient's condition What are the benefits to allowing family presence during cardiopulmonary resuscitation (codes)? - i. Increases family knowledge of the patient's condition ii. Able to witness "everything possible" being done as well as the extreme stress CPR has on the body iii. Decreases anxiety and fear about what is happening IV. Gain a sense of closure and grieving, should death occur Autonmy - respect for the individuals and the ability of individuals to make decisions with regard to their own health and future (the basis for the practice of informed consent) Benefience - Actions intended to benefit the patient and others Nonmaleficence - Actions intended not to harm or bring harm to others Justice - Being fair or just to the wider community in terms of consequences of an action. In healthcare, it is described as the fair allocation or distribution of health care resources. 6 | P a g e What are bioethics committees? - i. a multiprofessional committee that can serve as an education and policy-making body and provide ethics consultation on case-by-case basis ii. purpose: improve the process and outcomes of patient care by helping to identify, analyze, and resolve ethical problems - should be used when the issues cannot be resolved among the health care team, patient, and family What types of situations may warrant an Ethics consult? - i. Disagreement or conflict exists on whether to pursue aggressive life-sustaining treatment in a seriously ill patient (like CPR) or emphasize comfort and palliative care ii. Family demands to provide life-sustaining treatment which physician and nurses consider futile iii. Competing family members are present and want to make critical decisions on behalf of the patient IV. A seriously ill patient is incapacitated and does not have a surrogate decision maker or advance directive Identify what must be present in order for a patient to provide consent for themselves? - Competence, voluntariness, and disclosure of information What basic information must be present for decision making? - i. A diagnosis of the patient's specific health problem and condition ii. The nature, duration, and purpose of the proposed treatment or procedures iii. probable outcome of any medical or nursing intervention IV. benefits of medical or nursing intervention V. potential risks that are generally considered common or hazardous 7 | P a g e Allow Natural Death - An alternate with less negative connotations, but essentially meaning DNR Withholding or Withdrawing Life Support - Not initiating hemodialysis (withholding) to terminal weaning from mechanical ventilation (withdrawing). - an ethical decision-making approach is used to decide on the best action to take, - if conflict arises, ethics consult, ethics committee, and risk managers can provide assistance. an advance directive is key to avoiding treatment given or not given against one's wishes Medical Futility - Situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient's health condition, or a lack of attainable goals of care Palliative vs. Hospice Care - a. Palliative care is the provision of care interventions that are designed to relive symptoms of illness or injury that negatively affect the quality of life of the patient or family. This is in supplement to care and can be used during any point of illness, not just at end of life. b. Hospice care is generally reserved for those with a prognosis of less than 6 months to live and usually in place of aggressive life-sustaining or restorative care What distressing symptoms does palliative care address? - Pain, anxiety, hunger, thirst, dyspnea, diarrhea, nausea, confusion. Agitation, and sleep disturbance in patters How would you educate families on what withdraw/withhold of care looks like (think: symptoms, order of events, what nurses are assessing)? - i. The nurse will medicate to alleviate symptoms associated with the withdrawal of each therapy 10 | P a g e ex. for ventilator withdrawal, the patient will experience symptoms similar to respiratory distress and the nurse will medically sedate the patient to alleviate distress symptoms iii. Therapies that are commonly held/stopped during withdrawal of care: mechanical assistance, vasopressors, antibiotics, blood and blood products, dialysis, and nutritional support How is withdraw of care different from euthanasia? - It is different in you're withdrawing the care that is keeping them alive, but are not doing anything to kill them or speed the process along (such as euthanasia and assisted suicide) In what manner should we communicate with families? - i. needs are as variable as family situations, use non-judgmental assessment to become aware of patient's and family's personal feelings and values about the situation - keep in mind that the family can consist of different persons and different feelings ii. coordinate the communication process between patient, family and healthcare team to ease anxiety and ensure the most peaceful death possible What types of things should we allow/provide for family members? - Adequate staffing for family, helpful organizational behaviors include bereavement programs for families and assistance or guidance in making funeral arrangements. Use cultural sensitivity, maintain patients dignity**, allow unrestricted family presence, provide items of comfort (tissues, refreshments, and chairs), maintain a respectful presence. Nursing Interventions to Support Care at the End of Life - i. Assess patient's and family members' understanding of condition and prognosis to address educational needs. ii. Educate family members about what will happen when life support is withdrawn to decrease their fear of the unknown iii. Assure family members that the patient will not suffer iv. Assure family members that the patient won't be abandoned 11 | P a g e v. Provide for any needed emotional support and spiritual care resources (grief counselors and spiritual care providers) vi. Facilitate physician communication with family vii. Provide visitation and presence of family and extended family s/sx of pain - tachycardia, diaphoresis, restlessness, agitation, which can lead to anxiousness, fearful, apprehension. (most of the time activated by SNS) s/sx of anxiety - Apprehension, agitation, fearful, hyperventilation, sweating, tachycardia, trembling, feeling weak/tired, social withdrawal What should you do prior to administration of pain or anxiety medication? - - depending on anxiety medication (the respiration rate) - Assess the level of anxiety as well, what is causing it (pain and anxiety can cause each other, and it can become cyclic) What does a neuromuscular blockade do? What must be given beforehand? - Blocks all muscular function, but not a sedative or analgesic i. MUST GIVE A SEDATIVE beforehand!! Train of Four - what it is, what specific number of twitches indicate? - An electrode machine that is used before and during NMB to ensure the proper amount of paralysis is given Delivers 4 impulses and must assess the number of twitches on the thumb and pinky you see i. Always get a baseline number (energy & twitches) 12 | P a g e Hyperventilation ABG changes - Respiratory alkalosis (blowing off too much CO2) -EX= anxiety attack, anaphylactic shock, one-sided collapsed lung Alveoli - Air Filled Sacs in which gas exchange occurs in them What happens when fluid fills alveoli? - Diffusion of CO2 and O2 cannot occur (membranes become leaky and alveoli start to collapse) Early Signs of Hypoxemia - Neuro symptoms (#1 restlessness!!!, anxiety, decreased LOC) pulmonary embolism (PE) - When a DVT forms or a embolism travels and becomes lodged in the pulmonary vasculature Common Causes of PE - - Lack of perfusion (V/Q mismatch) *Lack of gas exchange which causes IM to be released * inflammatory mediators * Virchow's Triad (venous stasis= #1 cause) PE Prevention - Heparin or lovenox, SCDs, and mobilize them Common S/sx of PE - tachypnea, SOB, impending doom, extreme episode of anxiety, acute change in HR (super tachycardic) 15 | P a g e Diagnostics for PE - CTA chest with contrast (looks at lung vasculature and blood flow) and pulmonary angiogram PaO2/FiO2 ratio - take the PaO2 and divide it by the FiO2 (in decimal form) - Less than or equal to 300 is indicative of ARDS - 500 or greater = normal 2 Main Priorities for patients who are going to be Proned - #1 Maintaining a patent airway/protection & #2 pressure injury IHI's Ventilator Bundle of Care - 1) HOB 30-45 degrees (based on pt tolerance) 2) Sedation vacations to assess readiness to wean (pausing sedation and seeing how well pt can breathe on their own and monitor ABGs) - you can do your best neuro assessment 3) DVT prophylaxis (heparin, lovenox, SCD, repositioning) 4) PUD prophylaxis (Pepcid to prevent ulcers) 5) Daily oral care (minimum q4h) with CHG/Peroxide (around the tube, on their mouth and teeth) PEEP (positive end expiratory pressure) - Keep the alveoli open and maximizing the number of alveoli open for gas exchange - SE: an increase in intrathoracic pressure leading to decreased CO, trauma to surrounding tissues, increased intracranial pressure, hypotension Suctioning Procedure - 16 | P a g e Most of the time you want to pre oxygenate your patient, then you tell them you're about to inline suction and insert the line down the ET and then once you meet resistance, pull up about an inch and then start suctioning all the way up. This should be for no longer than 15 seconds and then allow your patient to rest. Suctioning Indications - ****Nurse is only to suction pt when they need it!!! (not on a schedule)**** - If pt is coughing, hear secretions, crackles in BS then you suction, but if pt is fine then DO NOT SUCTION SIMV (synchronized intermittent mandatory ventilation) - A weaning mode that is a good setting for pts to exercise their lungs - Benefits: 1. Patient is able to condition their lung muscles by attempting to breath 2. Could possibly help patients wean off the ventilator - Risks: Extra breaths not supplemented when they may need to be - ABG changes: Respiratory acidosis because all the CO2 may not be fully blown off due to the ventilator not supporting the patient's breaths PS (Pressure Support) - Best mode to put a patient on to stimulate spontaneous breathing (with a set pressure given on inspiration to give support when the vent recognizes that the patient is inspiriting) - Benefits: 1. Weaning Mode- stimulates normal breathing 2. Comfortable for pt - Risks: Patient has to trigger every breath won't be able to use this mode if the patient cannot breathe enough times - ABG Changes: Respiratory acidosis can occur due to the lack of breaths the patient may take 17 | P a g e