ICU FINAL

Chapter 1 Overview

1. Healthy work environment:2. CC RN characteristics: clinical judgment/clinical reasoning skillsAdvocacy and moral agency, caring practices that are individualized, collaboration with patient, family and healthcare team, systems thinking promoting holistic nursing care, responsive to diversity, and facilitates learning.3. The critically ill patient

Chapter 2 Pt/family

1. Needs of family members: they have identified a predictable table set of needs of family memebers of critically ill patients: receiving information, reciving assurance, remaining near the patient, being comfortable, and having support availbale. Knowledge of intervetnions that are proven to be effective in reducing stress and promoting coping of family mmebers enables the critical care nurse to create a plan of care that will assist patients and their families.Molter:-receiving assurance -remianin near the paitent-reciving information-bieng comfortable-having support avaibleMaxwell: -to have questions honestly-know the prognosis-talk with the RN each day-how the pt is being treated-why things were done for the patient-to be called at home about changes-info about he pt everyday-to be assured that he best possible care was being given to the patient-lamens term-to feel there was hope2. EBP caring for the family:Decision making-make decisions based on a partnership btw the pt. family and the healthcare team-communicate the pts status and prognosis to family members-hold family meetings with the healthcare team withing 24 hrsto 48hrs after icu admission-train icu staff in communication, conflict management and facilitations skills.Family Coping-train icu staff in assessment of family needs, stress, and anxiety levels.-assigne consistent nursing and physician staff to each pt. if possible.-provide info to family memebrs in a variety of formats-provide family support using a team effortStaff StressCultural Support of FamilySpiritual and Religious SupportFamily VisitationFamily Environment of CareFamily Presence During Rounds Family Presence During ResuscitationPalliative Care

Chapter 3 Ethical/Legal

1. process of ethical principle making:Assess (contextual factors, physiological factors and personal factors)Consider options (patient wishes, burden versus benefit, ethical principles and potential outcomes)Develop plan with patient, surrogate, family and teamAct on planEvaluate plan (short term outcomes, long-term outcomes and apply to other cases)

2. ethical principles:Autonomy-right of self-determination concerning medical careBeneficence- Duty to prevent harm, remove harm, and promote the good of another personNon-maleficence- not to intentionally harmJustice- fair distribution of healthcare resourcesVeracity-truthfullnessFidelity- faithfulness to commitmentConfidentiality- respect for right to control information

Chapter 4 EOL

1. Nursing management at EOL:Assess patients 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 wil not be abandoned.Provide for any needed emotional support and spiritual care resources, such as grief counselors and spirirtual care providers.Facilitate physician communication with the familyProvide for visitation and presence of family and extended family.2. Principles of EOL:-present a clear and consistent message-allow ample time-agree on the plan of treatment-emphasize that the patient will not be abandoned.-facilitate continuity of care.

Chapter 5 Comfort and sedation

1. Vent management and sedation:

2. Non-pharmacological management of pain:Environmental manipulationGuided imageryMusic therapy3. Appropriate treatment of various patient population:4. Anxiety vs pain: PAINDisease, procedures, monitoring devices, nursing care, traumaMany factors influence pain perception Expectation Previous pain experiences Emotional & cognitive state ANXIETY Inability to communicate, noise, light, excess stimulationExamples ET tubes Monitor alarms Lack of mobility Unfamiliar surroundings Sleep deprivation

Chapter 6 Nutrition 1. Enteral vs. TPN:GUIDELINES FOR PARENTERAL NUTRITION-feeding delivered into blood stream (central line (TPN)-hypertonic, Peripheral line (PPN)-isotonic-used for patients who are unable to tolerate enteral feeding (GI obstruction, intractable vomiting, intractable diarrhea, NPO for an extended period of time (>1 week)-patients who are admitted very malnourished (start immediately, if unable to tolerate enteral feeding)-unable to meet nutritional demands with ENGUIDELINES for ENTERAL FEEDING-short-term enteral feeding (nasogastric, nasoduodenal route, nasojejunal)-long-term enteral feeding (gastrostomy tube, jejunostomy)-feeding schedule (intermittent: gastric, continuous: small bowel feedings)-Assess gastric residuals (how? How often? What is significant?Differences between gastric and small bowel locations)

2. Geriatric considerations:Elderly patients are at a higher risk for altered nutrition due to:Chornic diseases that affect the appetite or the ability to obtqain and prepare approporiate and adequate caloric intakedementia , chronic obstructive pulmonary disease, osteoarthritis, heart failure and impaired mobility.Decreased intake due to poorly fitting dentures or missing teeth.Decreased income levels, which may lead to food choices based on cost rather than nutritional value.Social isolationLack of transportationPotential drug-nutrient interactions are assessed in all elderly patients. A person who take multiple daily medications is at a higher risk for nutritional alteration due to medication side effects, which may alter appetite.3. Assessment/reassessment of nutritional status: -Patients medical history-malabsorption syndrome-labaratory values-input and output-daily weight-gag reflex-dysphagia-Adequate dentition-oral mucosa -hydration status

Chapter 7 Dysrhythmias

1. normal vs. abnormal rhythms and implications:Normal Sinus Rhythms60-100each complex has a P wave, QRS complex, and T waveSinus BradycardiaLess than 60Each complex has a P wave, QRS complex and T waveCAUSES: dig toxicity, calcium channel blockers, acute MI, and may be normal for athletes.Sinus TachycardiaGreater than 100Each complex had P wave, QRS complex, and T wave.CAUSES: Hyperthermia (fever), fear/anxiety, pain and hypoxia, shock states, congestive heart failure, and meds like bronchodilators, psychotropic.Premature Atrial Contractions

P wave may be buried in T wave.Heart rate varies, irregular.SIGNIFICANCE AND TREATMENT OF PACsMay be precursor to worsening dysrthmia Tx: Beta blocker, antiarrhythmic, cardiac glycoside: digoxin and to minimize aggravating factors.Atrial FibrillationAbnormally fast and chaotic heart rate; atria quiver rather than beat.Results in loss of atrial kick.High RISK of ThromboembolismCauses: ischemic heart disease, valvular heart disease, hyperthyroidism, lung disease, heart failure, and aging may cause atril fib.Treatment: anticoagulatns, possibly cardioversion with amiodarone.Atrial FlutterSaw toothCauses: lung disease, ischemic heart disease, hyperthyroidism, hypoxemia, hearth failure, and alcoholism. Treatment: antithrombic medication****most atrial dysrhythmias cause few symptoms, antidysrhythmics may be required, and teach measures to manage stress and avoid activities that exacerbate dysrhythmia.Ventricular Dysrhythmias Common causes: AMI or ischemiaElectrolyte imbalanceAcid base imbalanceHypoxiaNursing interventionsAssess VS for hypotension and shockAssess neuro status Assess airway, breathing and circulationCall a codeStart CPR prnPremature Ventricular ContractionsIncrease risk of V tach, wide bizarre beats, bigeminy, trigeminy, couplets and tiplets.Unifocal and multifocalQRS is greater than .12 seconds.Irregular rhythmHidden P waves.TREATMENT: start an amiodarone drip. Assess and treat cause: hypoxia, ischemia and electrolyte imbalance. Medical management. Dangerous if R falls on T; PVC falls into the vulnerable period of the T wave. Vtach or v. fib may result.Ventricular TachycardiaRapid, life threatening dysrhythmiaThree or more PVCs in a rowFast rate >100beatsInitiated by ventriclesWide QRS complexes >.10 seconds, usually regularMay or may not have pulse**treat pulseless same as ventricular fibrillaition*advanced cardiac life supportVentricular Fibrillationchaotic EKG patternPt becomes faintNo cardiac output; life-threateningV. fib= D. fibTreatment:Pulseless, apneic, no BP and no heart soundsConvert via defibrillationInitiate CPR; push fast and hardACLS protocolIf defib does not convert pt, resume CPR and provide airwayHigh quality CPR and defib are mainstay**nursing care for patients with atrial dysrhythmias-Most atrial dysrhythmias cause few symptoms -Antidysrhythmics may be required-Teach measures to manage stress and avoid activities that exacerbate dysrhythmias**nursing care of ventricular dysrhythmias-assess VS for hypotension and shock-assess neruo status ( nonresponsive, eyes roll back)-assess airway, breathing, and circulation-call a code-start CPR prn

Chapter 8 Hemodynamics

1. CVP/RAP: Normal central venous pressure: 2-6Pressure created by volume of blood in right heart, used to assess fluid balance and responsiveness CVP increases with renal impairment CVP elevated: CHF or overhydrationHow much overflow is hanging out on the Right Ventricle.CVP decreased: hypovolemia, hemorrhage, dehydrationComplications:Infection, pneumothorax or hemothorax, malpositioned catheters, and dysrhythmias.2. PAP pressures and interpretations:Provide direct CO measurementsMeausures CVP, PAP, PAOP, CI, Sv02Thermodilution: the amount of time it takes for the temp of the blood to return to normal is directly related to CODecreased COit takes longer for the temp to go back upIncreased COfaster return to baseline temp4-8 Liters/per hour3. Arterial line management:Arterial pressure monitoring is indicated for patients who are at risk for compromised tissue perfusion and volume status. Also for pts with hypotension or hypertension.Complications: the major complications of arterial pressure monitoring include thrombosis, embolism, blood loss, and infection. Embolism may occur as a result of small clot formation around the tip of the catheter or from air entering the system. Thrombosis (clot) may occur if a continuous flush solution is not properly maintained. Blood loss result form sudden dislodgement. However routine replacement is not recommended unless an infection is suspected.Clinical considerations:When the noninvasive value is higher thatn the invasive number, one must suspect equipment malfunction or technical error.Nursing implications:-document insertion date-change dressings according to institutional policy (assess for signs of infection and dater dressing changes) (document assessment of the extremity every two hours for perfusion, keep hand in neutral position, when removing make sure to apply pressure for at least five minutes and medications should never be administered through art line.)-maintain patency of the flush system ( flush the system after each use of a port, clear any blood from the tubing, ports, and/or stopcocks, maintain a pressure of 300mm Hg on the flush solution using a pressure bag, and ensure adequate amount of flush solution in the intravenous bag).-ensure tightened connections in the tubing and flush system-keep tuning free of kinks-minimize excess tubing and the number of stopcocks-limit disconnecting or opening the system-ensure that alarm limits are set on the monitor and alarms are turned on.

Chapter 9 vent management

1. Patient response to vent management:-suction as indicated by assessment+visible secretions+coughing+rhonch+high PIP on ventilator+ventilator alarm-convetional versus closed suction-procedures+hyperoxygenate throughout procedure+avoid normal saline instillation Several parameters are monitored during mechanical ventilation. Nurse should not rely on respiratory therapists to monitor these; nurse should be aware of values and implications for treatment. Exhaled tidal volume (EVT) Should not be more than 50 mL different from set VT Peak inspiratory pressure (PIP) Should be less than 40 mm Hg Total respiratory rate Count total rate, which accounts for set rate and patient effort

2. Reassessment during vent management:3. Interpreting ABGs:PaO2- partial pressure of oxygen dissolved in arterial blooda. Normal: 80 to 100 mmHgb. Hypoxemia: 7.45 = Alkalosis paCO2- partial pressure of CO2 in arterial blood. RESPIRATORY COMPONENT! Normal: 35 to 45 mmHg PaCO2 < 35 = Alkalosis PaCO2 > 45= Acidosis NaHCO3- concentration of sodium bicarbonate in the blood. METABOLIC COMPONENT! Normal: 22 to 26 mEq/L NaHCO3 < 22= Acidosis NaHCO3 > 26 = Alkalosis

4. Management of pts on vents:

Chapter 10 RRT and Code

1. nursing interventions related RRT:2. code management:3. triaging patients:4. abnormal lab values:

Chapter 11 Shock, Sepsis, and MODS

1. heat exhaustion:Clinical syndrome characterized by fatigue, nausea, vomiting, extreme thirst and anxiety.Other s/s: hypotension, tachycardia, elevated body temperature, dilated pupils, mild confusion, ashen color and profuse diaphoresisOccurs in individuals engaged in strenuous activity in hot, humid weather but it also occurs in sedentary individuals.Treatment:a. First place patient in cool area and remove constrictive clothingb. Monitor ABCs and cardiac dysrhythmias (due to electrolyte imbalances)c. Initiate oral fluid and electrolyte replacements EXCEPT if patient is nauseated. Initiate 0.9% NS via IV instead. An initial fluid bolus may be needed to correct hypotension. Correlate fluid replacement to clinical and lab findings.d. Do not use salt tablets because of potential gastric irritation and hypernatremiae. Place a moist sheet over the patient to decrease core temperature through evaporative heat lossConsider hospital admission for the elderly, the chronically ill, or those who do not improve within 3 to 4 hours2. lab findings shock/sepsis/MODS: Critical labsSerum chemistry BUN/Creat; CO2; blood glucose; Na+; K+; Cl-Hemogram (CBC) RBCs (4-5.5 million cells/microliter) WBCs (4,500-10,000 cells/mcl) H&H (14-17//12-15; 45%//40%) (1:3 hydration status) Platelets (150-450,000/mm3)Coagulation studies (PT, PTT or aPTT, INR)

LactateSerum lactate levelMarker for cellular hypoxia; indicator of adequacy of resuscitation Norm blood lactate is 0.5-1 mmol/L. Mild to moderate hyperlactatemia is 2-4 mmol/L. Lactic acidosis = > 5 mmol/L

3. treatment of shock/sepsis/MODs:MODs: Management- Control infection (ABX) Provide Adequate tissue oxygenation: Maintan 88%-92% arterial O2 saturation; Maintain hemoglobin above 7-9 g/dL Restore intravascular volume: aggressive fluid resuscitation, isotonic cystalloidsSupport organ functionSepsis management:Administer antibiotics, maintain adequate ventilation and oxygenation, maximize oxygen delivery, minize oxygen deman, replace fluid, administer vasoactive medication, 4. S/S shock vs. sepsis vs. MODs:MODs: Clinical Manifestations- -Tachypnea/hypoxemia-Petechiae/bleeding-Jaundice-abdominal distention-oliguriaanuria-tachycardia-hypotension-changes in LOC

Sepsis S/S:Hypotension, lactic acidosis, oliguria, acute change in mental status, patients receiving inotropic agents or vasopressors may not exhibit hypotension5. Reassessments:

Chapter 12 CV Alterations

1. arrhythmias:2. left vs. right sided heart failure:systolic HF results from impaired pumping of the ventricles. The left in ventricle cannot pump efficiently. The ineffective pumping action causes a decrease in cardiac output leading to poor perfusion. S/S dyspnea, cheyne-stoke, paroxysmal nocturnal dyspnea, cough, fatigue, diaphoresis, pulmonary crackles, tachycardia, tachypnea. Diastolic HF results from impaired filling or relaxation of the ventricles. S/S jugular venous distention, liver engorgement with ascites in severe cases, edema, loss of appetite, nausea, vomiting, elevated central venous or right atrial pressure3. Ablation/PCI/meds for CV alterations: Percutaneous Coronary Intervention (PCI): emergent PCI is being used in the management of MI w/improved outcomes over thrombolytic therapy. PCIs consist of PTCA (percutaneous transluminal coronary angioplasty) & stenting.Cardiac ablation- Cardiac ablation works by scarring or destroying tissue in your heart that triggers an abnormal heart rhythm. In some cases, ablation prevents abnormal electrical signals from traveling through your heart and, thus, stops the arrhythmia.4. Pharmacology: medications for HF ACE inhibitors-slow disease progression, improve exercise capacity, and decrease hospitalization and mortality.Angiotensin II receptor-reduce afterload and improve cardiac output. Can be used for patients with ACE inhibitors cough.Hydralazine- vasodialator effect; useful in patients intolerant to ACEDiuretics- manage fluid overloadAldosterone antagonist-manage HF associated with LV systolic dysfunction while receiving standard therapy, including diuretics.Digoxin-improve symptoms, exercise tolerance and quality of life no effect on ortality5. Patient education:6. Patient response to various therapies:

Chapter 13 Nervous system

1. S/S of ICP:a. Change in LOCb. Changes in VSc. Cushings triad widening pulse pressure, irregular respirations , bradycardia(late sign) medical emergency!d. Changes in pupil size: fixed unilateral dilated pupil indicates herniation of braine. Blurred vision, diplopiaf. Papilledemag. Contralateral hemiparesis or hemiplegiah. Continuous headache that is worse in the morningi. VomitingCVA: weakness or numbness of one side of the body, slurred speech or an inability to comprehend what is being said, visual disturbances such as transient loss of vision in one or both eyes, double vision, or a visual field deficit. Dizziness, incoordination, ataxia or vertigo. Sudden onset severe headache2. Monitoring ICP: Normal ICP: 0-15 mmHgVentriculostomy is the gold standard of ICP monitoring. A catheter is inserted into the lateral ventricle and coupled to an external transducerAllows for monitoring and drainage systemTransducer is level with foramen of Monro (reference point is the tragus of ear)Infection is a serious complication with ICP monitoringa. Prophylactic systemic antibiotics may be administered3. Interpretation of neuro findings:Map of 70-90CPP at least 70mmhg (60-100mmhg)ICP of 0-154. Nursing management various pathologies:For any patient with increased ICP it is important to ensure adequate oxygenation is being maintained to support brain function. ETT, tracheostomy or a mechanical ventilator may be necessary to ensure adequate oxygenationIf increased ICP is caused by a lesion, surgical removal is the best managementKeep CPP >70 mmHgPosition to maximize CPP:a. Neutral head positionb. Monitor best HOB elevation to increase CPP (30 degrees or greater)c. Careful side to side rotationd. Sedation administration- propofolChapter 14 ARF/ARDS

1. S/S of respiratory failure:a. Key clinical finding: lung insult (direct or indirect) followed by respiratory distress with dyspnea, tachypnea and hypoxemia that does not respond to O2 therapyb. Initial s/s: restlessness, disorientation, change in LOCc. Pulse and temperature may be increasedd. CXR usually normal in the initial stagee. Other s/s: hyperventilation with normal breath sounds, respiratory alkalosis, worsening chest rays after initial stage, increased PEEP on ventilation, eventual severe hypoxemia

2. Pharmacology: furosemide with albumin is advocated when the patients protein level is low. Corticosteroids administration should be considered in pts with severe ARDS.3. Treatment for various forms of ARF and ARDS:a. Treat the causeb. Oxygenation and ventilation: PEEP to restore functional residual capacity, open collapsed alveoli, and improve arterial oxygenationc. When using high levels of PEEP, the nurse must assess for potential adverse effects because PEEP increases intrathoracic pressure, potentially leading to decreased CO. May also result in barotrauma and pneumothorax. Treatment for pneumothorax are chest tubes.d. If patient is on PEEP: monitor patient every 2 to 4 hours and after every adjustment in the PEEP setting for changes in respiratory status (increased RR, worsening adventitious breath sounds, decreased or absent breath sounds, decreased SpO2 and increasing dyspnea.e. Possible non traditional modes on vent can be used: Pressure control ventilation, APRVf. Comfort and sedation: patients with ARDS routinely receive continuous sedation to promote comfort, sleep ,rest and alleviate anxiety. If they are undersedated, a major adverse effect is breathing dyssynchrony between patient and ventilator.g. Neuromuscular blockades are used for therapeutic paralysis and adequate oxygenationh. Prone positioning: alters V/Q ratio by shifting blood from the posterior bases of the lung to the anterior position. Also removes the weight of the heart and abdomen from the lungs, facilitates removal of secretions, improves oxygenation and enhances recruitment of airways. Proning is considered when PaO2/FiO2 ratio falls below 100.i. Continuous lateral rotation therapyChapter 15 AKI

1. pharmacology: diuretics, dopamine, N-acetylcysteine, fenoldopam2. prevention AKI: avoid nephrotoxins (use iso-osmorlar radioconstrast media, use antibiotics cautiously, monito drug levelsoptimize volume status before surgery or invasive procedure.Reduce incidence of nosocomial infectionsImplement tight glycemic control in the critically illAggressively investigate and treat sepsis.3. etiology AKI: ischemia, nephrotoxic agents (antibiotics and NSAIDS), contrast induced, rhabdomyolysis. Sepsis is the most common cause of AKI.

Chapter 16 Hema/Immune

1. patient education:2. coagulation profiles:lee-white clotting time 6-12 minutesAPTT