NR 340 HESI Week 8 FINAL EXAM-160 Question Answers, NR 340 Week 3 Exam 1 Studyguide, NR 340 Week 1 Medication Exam, NR 340-Exam 2 Study Guide, NR 340 CRITICAL CARE FINAL Study Guide

Overview of CC Critical Care Nursing  Deals with human responses to critical illness or injury o Physiological o Psychological  Focus on both the patient’s and family’s responses  Critical Care Overview  Not always centered in an “ICU setting” o Inpatient o Outpatient o Home Care o eICU o Tele-stepdown o Post anesthesia o Flight nursing-transport  Professional Organizations o American Association of Critical-Care Nurses o Society of Critical Care Medicine Trends and Issues  Critical care patients more complex  Increasing costs for care  Facilities for long term ventilators  Reduces stays in hospitals: more risk for infection  Better for patient to be at home Focus on Quality and Safety  Errors and harm must be prevented o Communication is a big error o On record where to find items o Medication errors o Documentation errors o Handwashing o Falls  Nurses are challenged to reduce errors and promote a safe environment  Several initiatives o Joint Commission National Patient Safety Goals o Institute for Healthcare Improvement o Quality and Safety Education for Nurses (QSEN) National Patient Safety Goals  The Joint Commission National Patient Safety Goals  Examples relative to critical care nursing o Communication NR340 Exam 1 Chapters 1, 2, 3, 5, 7, 9, 14, pgs 228-324 Page 2 of 36 o Medication safety o Reduce infections o Reconcile medications o Telephone orders- SAY BACK o TALL letters for similar drug names Harms Targeted for Reduction  Adverse drug events  Infections o Catheter-associated urinary tract infections (CAUTI) o Central line–associated bloodstream infections (CLABSI) o Surgical site infections o Ventilator-associated pneumonia (VAP)  Injuries from falls and immobility  Obstetric adverse events  Pressure ulcers  Venous thromboembolism (VTE) Communication  Communication important for safe care  Standardized approaches o SBAR and SBAP  Situation  Background  Assessment  Recommendation (Plan)  Collaboration o Nurse/ doctor o Debreifing Other Trends and Issues  Reducing hospital readmission rates o Chronic illness (HF)  Increasing use of technology o Electronic medical records o Physician order entry  Ethical issues associated with prolonging life and futile treatment  Telemedicine and eICU  Aging population and workforce  Shortage of CC nurses The Critical Care Environment  Stressful  Noisy  Sleep Deprivation  Concerns of the Critically Ill Patient o Patients responses do vary  Loss of control (even breathing)  ↓ Communication (d/t vent)  ↓Mobility, ↓Comfort Psychosocial Support (HIGHEST CONCERN) NR340 Exam 1 Chapters 1, 2, 3, 5, 7, 9, 14, pgs 228-324 Page 3 of 36  Ensure safety  Reduce sleep deprivation  Reduce noxious sensory overload  Increase pleasant sensory input  Provide reorientation o Strategies  Mimic night/ day  Calendar/ clock  Tell them what you are doing  Talk to the patient  Allow for rest periods  Provide pleasant area Geriatric Concerns  Diminished ability to adapt to, or cope with, stressors of critical illness  At greater risk for negative outcomes  May not bounce back Ethical Issues  Critical care nurses confront in everyday practice o Informed consent and confidentiality o Withholding or withdrawal of treatment o Organ and tissue transplantation o Distribution of healthcare resources o Appropriate use of technology  Greater frequency in critical care Ethical Principles  Autonomy o Body o Ability to make decisions for self  Beneficence o To do good o To benefit the patient  Nonmalificence o To do no harm  Justice o People getting what they deserve/ need  Veracity o Be truthful  Fidelity o Be faithful  Confidentiality Nurse Involvement in Ethical Decision Making  Advocacy o Open communication of patient’s wishes and ethical concerns o True collaboration with healthcare team members  Dilemmas can result in moral distress  Formal mechanisms (The Joint Commission) o Bioethics committees NR340 Exam 1 Chapters 1, 2, 3, 5, 7, 9, 14, pgs 228-324 Page 4 of 36 o Ethics consultation  Opportunities for critical care nurses o Ethics forums and rounds o Peer review o Institutional review boards (research) Selected Issues  Informed Consent o Have to insure that patient is actually informed o No remaining questions about procedure/outcome  Advanced Directives  Organ and tissue donation o Call gift of hope – Nurses only responsibility  Life-sustaining treatment Forum to Resolve Issues  Bioethics Committees  Ethics Consultation Concerns of the Critically Ill  Pain o Physiology o Predisposing Factors  Disease process can cause pain  Changing dressing, movement, etc.  Ischemia o Assessment  Subjective  Pain is what the patient says it is  Objective  Vital signs  Non-verbal  Facial expressions  Moaning/Groaning  Grimiacing  Guarding  Body Movement  Pain Management (acute pain) o Nonpharmacologic  Heat, cold, massage, breathing, guided imagery, etc. o Prevention  Opioids  Fentanyl  Dilaudid  Morphine  Concern is respiratory depression  Antidote is narcan o Epidural o NSAIDS o PCA  Anxiety o Prolonged stated of apprehension in response to fear NR340 Exam 1 Chapters 1, 2, 3, 5, 7, 9, 14, pgs 228-324 Page 5 of 36  Either actual or perceived fear o Marked by  Apprehension  Agitation  Automatic arousal o Physiology  Activation of sympathetic nervous system  Flight or Fight o Predisposing Factors  Fear  Uncertainty  Loss of control o Assessment  Subjective  Objective  Increases BP  Increased RR  Fidgety  Agitation  Anxiety Management o Pharmacological treatment for anxiety  Sedatives  Benzodiazepines  Reversal agent – Romazicon (Flumazenil)  Lorazepam(Ativan) – Intermediate acting  Midazolam (Versed) – short acting  Propofol – Short acting  Continuous drip  Mechanical vent  Dexmedetomidine o Titrate to an end point (sedation scales or tools)  Level of sedation- calm, follow commands o Everyday turn off sedation – Sedation Vacation  Sedation may not be metabolized/excreted  Builds up in body  Delirium o Acutely changing mental status  Can’t make decisions  Hypoactive/ hyperactive o Multiple types  Hyperactive  Hypoactive o Multiple causes  Sleep deprivation  Pain  Fever o Goal—keep the patient safe o Medication—Haldol  Give antipsychotic meds o Nonpharmacologic Interventions NR340 Exam 1 Chapters 1, 2, 3, 5, 7, 9, 14, pgs 228-324 Page 6 of 36  Awaken them – establish normal sleep cycle  Breathing  Choice of sedation – certain sedatives contribute to delirium  Delirium screening Respiratory Alterations Nursing Goals  Maintain patent airway  Ensure adequate ventilation  Ensure adequate oxygenation Respiratory Anatomy o Upper  To bring air into the body  Filter, humidify, warm  Carnia is the beginning of the lower airway o Lower  Bronchi, bronchioles, alveoli Physiology of Breathing  Involuntary/ voluntary  Rest  Ventilation o Inspiration  Negative pressure o Expiration  Longer, passive  Gas Exchange o Alveoli- higher concentration PaO2to lower o Ventilation is CO2&O2 out of alveoli  Controlled by CNS  Regulation of Breathing o Chemoreceptors