Nursing 4 Lecture 1

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Nursing 4 Lecture 1
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Nursing 4 Lecture 1
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  1. Definition of a Critically Ill Patient:
    - Critically ill patients are defined as those patients who are at hight risk for acual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and comples, thereby requiring intense and vigilant nursing.
  2. Definition of Critical Care Nursing:
    • - Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.
    • - A critical care nursing needs there associates
  3. What do Critical Care Nurses do?
    - Critical care nurses practice in settings where patients require complex assessment, high-intensity therapies and interventions, and continuous nursing vigilance. Critical care nurses rely upon specialized body of knowledge, skills and experience to provide care to patients and families and create enviroments that are healing, humane and caring. Foremost, the critical care nurse is a PATIENT ADVOCATE.
  4. What are the responsibilities of a patient advocate?
    • - Respect and support the right of the patient of the patients designated surrogate to autonomous informed decision making
    • - Intervene when the best interest of the patient is in question
    • - Help the patient obtain necessary care
    • - Respect the values, beliefs, and rights of the patient
    • - Provide education and support to help the patient of the patients designated surrogate make decisions
    • - Represent the patient in accordance with the patients choices
    • - Support the decisions of the patient of designated surrogate, or transfer care to an equally qualified critical care nurse
    • - Interceded for patients who cannot speak for themselves in situations that require immediate action
    • - Monitor safegaurd the quality of care the patient receives
    • - Act as a liasion between the patient, the patients family and other healthcare professionals
  5. Trends and Ethical Issues
    • - Criticall ill patients are more complex
    • - Aging population= more MSOF (multi system organ failure
    • - Termination of life support
    • - Transplantation
    • - Quality of life issues
    • - Point of care service- can do more right at the patients bed side
    • - Critical pathways- everyone has the same procedures and outcomes with the procedures *ensures that things are getting done
  6. Interventions for patients:
    • - Intense surveillance
    • - Control Pain
    • - Promote physical comfort
    • - Use sensory aids (to draw away whats going on aroudn them)
    • - Promote sleep
    • - Explain procedures
    • - Encourage family visits
    • - Instill hope (NOT FALSE)
    • - Affirm the healing process- slow process, healing takes time
    • - Spiritual support
    • - Privacy and dignity
    • - Temperature and sound
    • - Time (HARD TO TELL TIME IN THE ICU!**)
  7. Patient Stressors
    • Physical
    • - Hemodynamic instability
    • - Alteration in metabolism
    • - pain
    • - Alteration in circadian rhythm

    • Psychological
    • - Irritability
    • - Restlessness
    • - Anger
    • - Fear and anxiety
    • - Hopelessness
    • - Spiritual distress

    • Enviromental
    • - Sensory overload
    • - Sensory deprivation
    • - ICU syndrome
  8. Elderly Considerations
    Ageism: discriminating against someone because of age

    Adverse drug reaction: body doesn't metabolize/excrete drugs as well causing more adverse effects

    Functional decline: happens once in hospital

    Sleep pattern disturbance: older people are much lighter sleepers in the hospital
  9. Pediatric Considerations
    THE EXPERIENCE IS INTENSIFIED!

    • - Child in pain
    • - Undergoing painful procedures
    • - Perceived incomprehensible loss
    • - Reduce stress by inclusion of family
  10. How Children Perceive Dying
    Infant/Toddler: death as a loss of caregiver

    Early childhood(preschool): death is reversible and temporary

    Middle childhood: death is sad and irreversible but not inevitable

    Adolescence: death as inevitable and irreversible but often a distant event
  11. Effects on Families
    • Family Assessment
    • - structure, function and communication

    • Identifying stressors and needs
    • - receiving assurance
    • - remaining near the patient
    • - receiving information
    • - being comfortable
    • - having support available
  12. Effects on the Nurse
    • Phsyical
    • - shift rotation
    • - physical labor
    • - long hours
    • - missed breaks and meals
    • - exhaustion

    • Psychological
    • - must think and act quickly
    • - accuracy
    • - crisis atmosphere
    • - death
    • - ethical dilemmas
    • - constant learning
    • - conflict

    • Enviromental
    • - light
    • - noise
    • - smells
    • - crowded space
    • - hazards
  13. Burnout
    - AKA "compassion fatigue"

    • Stages:
    • - emotional and physical exhaustion
    • - negativism and cynicism
    • - self isolation
    • - terminal burnout

    * be on the lookout for this
  14. Nutritional Support
    • - All critically ill patients are assumed to be at nutritional risk
    • - Nutritional support is an important part of overall care plan
    • - Goal is nutritional support consistent with metabolic needs and disease process while avoiding complications
    • - Any patient who cannot meet needs orally for 3 days requires enteral nutrition
  15. Enteral Nutrition
    Refers to the delivery of nutrients into the GI tract, which is the preferred route of nutrient administration, unless contraindicated
  16. Large Bore Nasogastric Tubes
    - Can be used for medication administration, decompression of the gut, gastric suction, or drainage.
  17. Small Bore Nasogastric Tube
    • - Flexible
    • - 5 to 12 french
    • - Often inserted in place of large bore tubes to initate feedings
    • - Better tolerated because of its size and flexibility
    • - Reduces the risk of nasal tissue necrosis
  18. Nasogastric (NG tube) Route
    • - Any feeding tube inserted nasally and advanced to the GI tract
    • - Used in short term situations, usually for no more than 6 weeks BUT may not be beneficial in patients at high risk for aspiration
  19. Nasoduodenal (NDT) Route
    - Smaller bore tube, used for short term, usually less than 4 weeks, safer for patients at risk for aspiration if the tip is placed below the pyloric sphincter of the stomach and into the duodenum
  20. Nasojejunal
    • - Small bore
    • - Used in short term situations, usually for no more than 6 weeks BUT may not be beneficial in patients at high risk for aspiration
  21. Gastrostomy Tube
    • - Stoma created from the abdominal wall into the stomach
    • - Very secure
    • - Long term

    • Percutaneous endoscopic gastrostomy (PEG) tube:
    • - Often inserted because placement does not require general anesthesia, and allows for feeding to begin soon after placement
  22. Jejunostomy Tube
    • - Long term
    • - Chosen for patients at high risk for aspiration pneumonia
    • - Must be placed during a laparatomy
  23. Feeding Schedule
    • Intermittent: Gastric-
    • - Right into stomach, mimics the way you eat
    • - Administered by bolus feeding
    • - Intermittent feeding of specified amount of enternal product at set intervals 24hrs/day;Q4hrs

    Continuous: Small bowel feedings
  24. Assess Gastric Residuals
    • - Checked every 4 hours
    • - Stop tube feeding if the residual is greater than 200mL in 2 consecutive assessments OR if it is greater than 250mL

    • Checking Gastric pH:
    • - Gastric fluid ranges for 0-4
    • - If the tube is in the intestinces the pH will be 7.0-8.0
    • - If the tube is in the lungs the pH will be greater than 6
    • - pH can also be high int he stomach if the patient takes certain drugs (H2 blockers: zantac, pepcid)
  25. Parenteral Nutrition
    • Feeding delivered into bloodstream
    • - Central line (TPN) = HYPERTONIC
    • - Peripheral line (PPN)= ISOTONIC

    • TPN:
    • - When patient requires intensive nutritional support for an extended time administered with an infusion pump
    • - No TPN into peripheral because veins would get wrecked

    • PPN:
    • - Usually given through cannula or catheter in left distal vein through PIIC line

    • Monitor for complications
    • - Refeeding syndrome: LIFE THREATENING; metabolic complication that occurs when nutrtion is restarted for a patient in "starvation state"; electrolyte shift can cause cardiac, respiratory, and neurologic problems (primarily caused by hypophosphatemia)- observe for: shallow respirations, weakness, confusion, seizures, and increased bleeding tendency
    • - Tube misplacement or dislodgement= can cause aspiration and possible death; **immediatley remove any tube you think is dislodged; observe for increased temp and increased pulse
    • - Hyperkalemia and hyponatremia= two of the most common electrolyte imbalances
    • - Infection
    • - Fluid imbalances
    • - Hyperglycemia
  26. Cardiac Output
    - Amount of blood ejected from the left ventricle each minute

    • CO= HR X STROKE VOLUME
    • -----> Norm: 4-8 L/min
  27. Ejection Fraction
    - Fraction of blook ejected with each beat

    -------> Norm: 60%-70%
  28. Stroke Volume
    - The amount of blood ejected from the left ventricle each contraction

    - It is affected by preload, afterload, and contractility
  29. Preload
    • - Refers to the degree of myocardial fiber stretch at the end of diastole and just before contraction
    • - Volume of blood in ventricle prior to contraction

    • Frank-Starling Law
    • - Increased stretch=increased volume
    • - Stretch is within physiologic limits

    EXAMPLE=BALLOON
  30. Afterload
    - Pressure or resistance against flow

    - Related to lumen size and viscosity

    • Systemic vascular resistance
    • - Force overcome by the left ventricle upon contraction

    • Pulmonary vascular resistance
    • - Force overcome by the right ventricle upson contraction

    EXAMPLE- OPENING DOOR AGAINST WIND
  31. Hemodynamic Monitoring
    Invasive system used in critical care areas to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion.

    • - Need to sign an consent form
    • - Invasive monitoring
    • - Used for detailed information
    • - Used for critical care patients to provide quantitative information about vascular capacity, blood volume, pump effectiveness, and tissue perfusion
    • - Patency maintained with infusion of NS at about 3 to 4 mL/hr to prevent the back up of blood an occlusion of the cath

    • Components:
    • - Catheter with an infusion system: receives the pressure waves (mechanical energy) from the heart or great vessels
    • - Transducer: converts the mechanical energy into electrical energy which is displayed as waveforms of numbers on the monitor
    • - Monitor
  32. Evidence of Hemodynamic Stability: Intervention Outcomes
    • - Systolic BP above 100mm Hg
    • - UOP (urine output) greater than 30 mL/hr
    • - Spontaneous respirations with normal rate and rhythm
    • - Intracranial pressure no greater than 15mm Hg **Supine adult Normal: 7-15mm Hg; Vertical position -10mm Hg
  33. Types of Catheters
    • Pulmonary Artery Catheter aka pulmonary arter occlusive pressure (PAOP)
    • - Measure right atrial and indirect left atrial pressures AKA pulmonary artery wedge pressure (PAWP)
    • - Multi lumen
    • - Obtain and record reading every 1 to 4 hours
    • - Trend helps guid therapy
    • - Transducer needs to be a the phlebostatic axis
    • - Patient supine with head up to 45 degrees
    • - Patient must be in supine or transdelenburg for the HCP fo input the catheter

    • PAWP:
    • - 4 to 12 mm Hg
    • - Increased with left ventricular failure, hypervolemia, mitral regurgitation, and intracardia shunt
    • - Decreased with hypovolemia or afterload reduction

    • Right Atrium Pressure:
    • - 1 to 8mm Hg
    • - Increased: right ventricular failure
    • - Decreased: Hypovolemia

    • Pulmonary Artery Pressure:
    • - 15 to 26mm Hg systolic
    • - 5 to 15mm Hg diastolic
  34. What is the location of the Phlebostatic Axis?
    Fourth intercostal space, mid-point A-P chest wall
  35. Arterial Therapy
    Catheters are placed into arteries to obtain repeated arterial blook samples to monitor various hemodynamic pressures continuously and to infuse chemotherapy agents

    • - Pulmonary artery pressure measures the function of the left ventricle
    • - Catheters in radial, brachial, or femoral arteries are used to obtain blook samples or arterial pressure monitoring
    • - External catherters can be used for 3 to 7 days
    • - Femoral catheter: WEAR ANTIEMBOLIC STOCKINGS!
    • - Observe insertion site and involved extremity closely; Assess warmth, sensation, capillary refill, and pulse; When carotid artery involved= PERFORM NEURO ASSESSMENT

    • Complications:
    • - Pulmonary infarction or pulmonary rupture if remains in wedge position
    • - Air embolism
    • - Ventricular dysrhythmia during insertion or if catheter slips into right ventricle and irritates the myocardium
    • - Thrombus/embolus formation
    • - Infection
    • - Bleeding
  36. Allens Test
    When the patients hand is held above the head the fist clenched, both radial and ulnar arteries are compressed

    • - The hand is lowered
    • - Open the hand
    • - Pressure is then released over the ulnar artery
    • - Color should return to the hand within 6 seconds, indicating a patent ulnar artery and an intact superficial palmar arch
  37. Nurse must be on the look-out for:
    • - Cardiac perforation
    • - Cardiac Tamponade: mechanical compression of the heart resulting from large amounts of fluid collecting in the pericardial space and limiting the heart's normal range of motion
    • - Induction of ventricular arrhythmias
    • - Local bleeding
    • - Pheumothorax
    • - Thrombophlebitis: inflammation of a vein that occurs when a blood clot forms
    • - Air embolism
    • - Infection

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