NRNP6566 Advanced Care of Adults in Acute Settings I Week 8 Knowledge Check | Questions and Verified Answers | Latest Update

NRNP 6566 / NRNP6566 Advanced Care of Adults in Acute Settings I Week 8 Knowledge Check | Questions and Verified Answers What type of ICU sedation would be appropriate for a 32 year old male patient who is intubated with bilateral chest tube following a motor vehicle crash. Correct Answer: The Society of Critical Care Medicine publishes a guideline on sedation. It is: Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018). Light sedation is suggested for intubated ICU patients. Non-benzodiazepine sedatives (either propofol or dexmedetomidine) are preferable to benzodiazepine sedatives (either midazolam or lorazepam) in critically ill, mechanically ventilated adults. Describe the levels of sedation (minimal, moderate, deep, general anesthesia, and dissociation) and its affect on consciousness, airway, ventilation, and reflexes. Correct Answer: Sedation decreases a patient’s awareness to the environment and their responses to external stimulation. Sedation occurs a long a continuum which includes minimal, moderate, deep, general anesthesia, and dissociation. Minimal sedation is a drug induced relief of anxiety or apprehension with minimal to no affection on sensorium. Most often this is achieved with an anti- anxiety medication. Moderate sedation causes a depression of consciousness but the patient can still respond to external stimuli. Airway, spontaneous ventilation, and cardiovascular function are maintained. Deep sedation causes a depression of consciousness in which the patient cannot be aroused but responds purposefully to repeated or painful stimuli. Cardiovascular function is maintained but airway and spontaneous ventilation may be compromised. General anesthesia is a state of unconsciousness where the patient is unable to respond to any stimuli. Close monitoring of all airway, ventilation, and cardiovascular function is essential. Dissociation is considered to be a type of moderate sedation that occurs when using medications in the phencyclidine group (such as ketamine). They cause a dissociation of the limbic system preventing higher centers from receiving sensory stimuli. Like moderate sedation, airway reflexes, spontaneous ventilation, and cardiovascular function are all maintained. The APRN has determined that a 21 year old motor vehicle crash victim needs a rapid sequence intubation. The patient weighs 77 kg. What medications are indicated to successfully achieve the rapid sequence intubation? Correct Answer: Rapid sequence intubation requires the use of induction agent to cause unresponsiveness and a neuromuscular blocking agent to cause muscular relaxation. It is the fast and most effective means of controlling the emergency airway. There are no contraindications to using Etomidate and Succinylcholine Etomidate 23 mg IV and Succinylcholine 115 mg IV Here are details about the different medications and their uses. INDUCTION AGENTS Etomidate 0.3mg/kg IV onset: 10-15 seconds Use: good option for most situations including hemodynamically unstable patient. Avoid in sepsis or seizures Can cause adrenal suppression, myoclonus, pain on injection Ketamine Dose: 1.5 mg/kg IV (4mg/kg IM) Onset: 60-90 sec Duration: 10-20 min Use: good option for any RSI,especially if hemodynamically unstable. May be used in TBI (no increase in ICP) and reactive airway disease (causes bronchodilation) Can cause an increase in secretions, caution in hypertension and tachycardia, may cause laryngospasm and increased intra-ocular pressure. Thiopentone Dose: 3-5 mg/kg IV TBW Onset: 30-45 sec Duration: 5-10 min Use: good option in hemodynamically stable patients, also for status epilepticus Causes histamine release, myocardial depression, vasodilation, hypotension Propofol Propofol 1.5-2.5 mg/kg x TBW as the general guide Onset: 15-45 seconds Duration: 5 – 10 minutes Use: should be used in hemodynamically stable patients, appropriate for patients with reactive airways disease or status epilepticus Can cause hypotension, myocardial depression, reduced cerebral perfusion muscular rigidity in high induction doses, bradycardia, tissue saturation at high doses PARALYTIC AGENTS Suxamethonium (aka succinylcholine) Dose: 1.5 mg/kg IV (2 mg/kg IV if myasthenia gravis) and 4 mg/kg IM (in extremities) Onset: 45-60 seconds Duration: 6-10 minutes Use: widely used unless contra-indicated; ideal if need to extubate rapidly following an elective procedure or to assess neurology in an intubated patient Drawbacks: numerous contra-indications (hyperkalemia, malignant hyperthermia, 5d after burns/ crush injury/ neuromuscular disorder), bradycardia (esp after repeat doses), hyperkalemia, fasciculations, elevated intra-ocular pressure, will not wear off fast enough to prevent harm in CICV situations Rocuronium Dose: 1.2 mg/kg IV IBW Onset: 60 seconds Use: can be used for any RSI unless contra-indication or require rapid recovery for extubation after elective procedure or neurological assessment; ensures persistent ideal conditions in CICV situation (i.e. immobile patient for cricothyroidotomy) – can be reversed by sugammadex Drawbacks: allergy (Rare) A 66 year old women in the ICU is diagnosed with delirium. What would be the best approach to treating her delirium? Correct Answer: Delirium is common in critically ill adults. Delirium is a clinical diagnosis which can be detected with some screening tools such as the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist. Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (2018) by the Society of Critical Care Medicine recommends a muticomponent, nonpharmacologic intervention focused on reducing modifiable risk factors. These interventions include reorientation, cognitive stimulation, use of clocks, improved sleep, reduced sedation, early rehabilitation and mobilization, use of hearing aids and eye glasses. Haloperidol is not routinely recommended and studies have not shown that it shortens the duration of the delirium. However, short term use of haloperidol or an atypical antipsychotic may be warranted for those patients who experience significant distress, agitation, or physical risk to themselves or others. The NP is beginning to repair a laceration on a 22 year old female. The patient mentions that she is allergic to lidocaine. What medication would be an appropriate alternative for this patient? Correct Answer: Local anesthetics include two classes of medications that include esters and amides. Lidocaine and bupivacaine are amide anesthetics. In this patient, an ester anesthetics should be utilized. Procaine is an example of an ester local anesthetic. A 54 year old 112 kg women is admitted for incision and drainage of a left renal abscess. She needs TID wet to dry dressing changes that are very painful. She rates the pain during the dressing change as a 10 and describes in as sharp, pulling, and burning. Prior to the last dressing change she received 2 mg of morphine IV which was totally ineffective in relieving any pain of the dressing change. How would you manage the medication dosing prior to the next dressing change? Correct Answer: Recommended IV morphine dosing is 0.05 to 0.1 mg/ kg. Based on her weight, the recommend-ed dose would be 6-12 mg IV every 1-2 hours. Since 2 mg was ineffective, it would be reasonable to increase the next dose to 6 mg IV 20 minutes prior to the dressing change. Assess her response to this dose increase and determine if it is appropriate or another increase (add 2 mg) is needed to achieve pain relief during the dress-ing change. A 36 year old man complains of sciatic type nerve pain in his left posterior leg. What medication would be best to manage his pain? Correct Answer: Nerve pain is usually poorly treated with opioids. Anti-inflammatories, anti- convulsants (such as gabapentin, carbamazepine, and pregabalin), and anti- depressants are more effective in treating never pain such as sciatica, peripheral neuropathy, or other nerve related pain secondary to cancer or HIV. A 44 year old man was given fentanyl to achieve moderate sedation for a colonoscopy. During the procedure, the patients oxygen saturation begins to decline and while assessing the patient the NP notices chest wall rigidity. What is the cause of the rigidity and how would you treat it? Correct Answer: Intravenous administration of narcotics, especially fentanyl, can cause chest wall rigidity which is an uncommon but life threatening complication. The patient is unable to be ventilated because of the tightness in the chest wall. To treat this, succinylcholine should be administered and the patient ventilated with a bag-valve-mask device until his respiratory drive returns. A dose of naloxone should also be administered to combat the effects of the narcotics. Additional doses can be administered if needed. A 66 year old man is admired to the ICU with respiratory distress and bilateral pneumonia. He has a history of a CVA 2 years ago with right hemiplegia and aphasia. Current vitals signs are T 98.8 HR 115 BP 170/99. RR 32. Oxygen saturation is 90% on a nonrebreather mask. The patient weighs 70 kg. The NP decides to perform a rapid sequence intubation. What medications and doses would be appropriate for this patient? Correct Answer: Rocuronium 70 mg IV and etomidate 20 mg IV Succinylcholine is contraindicated in this patient due to his history of CVA and immobility. Rocuronium is more appropriate drug for this patient. A 77 year old man fell and suffered a laceration across his upper right lip. The APRN decides to utilize a block for pain control which suturing the laceration. What type of block and what medication would be appropriate for this patient? Correct Answer: An infra-orbital nerve block provides good coverage for the upper lip on the affected side. (Refer to your procedure manual for block coverage and placement of the block). The skin and mucous membrane should be cleansed and a sterile field prepared. Topical 2% viscous lidocaine should be used prior to performing the nerve bock for both intraorlal and superficial procedures. The addition of epinephrine to buffered lidocaine causes vasoconstriction and should be used with caution on facial tissue as it might compromise tissue viability. The total dose of lidocaine without epinephrine should not exceed 4 mg/kg (0.4 ml /kg) and with epinephrine should not exceed 7 mg/kg (0.7 ml/kg). A small needle 25 or 27 gauge is used with 2-3 ml of buffered lidocaine 1%. Typically a small suture is utilized (6-0 non absorbable nylon). Consider utilizing a color suture that does not match a patients facial hair. Show Less