-
What is the largest nursing specialty organization in the world
AACN
-
name some ways in which patient responses vary in the CC setting
- Age
- Prior illness/hospitalization
- Social support
- Coping
- Life/death beliefs
- Spirituality
- Culture
-
What are some things patient's recall about the CC experience
- Pain
- Thirst
- dysphagia
- anxiety
- difficult sleeping
- physical restraint
-
Name 4 things that contribute to relocation stress
- Fear of abandonment
- New routines
- New Staff
- New roomates
-
What are some post-CC sx
- fatigue/sleep-disturbance
- Pain/muscle weakness
- Poor concentration/impaired memory
- Poor appetite
- PTSD
-
Name 3 categories in Calgary Family Assessment
- Structural
- Developmental
- Functional
-
Category of Calgary Assessment that includes:
Who compromises familyDecision maker/spokespersonRace/ethnicity/culture
Structural
-
Category of Calgary Assessment that includes: stages, tasks, and attachments
developmental
-
Category of Calgary Assessment that includes: How family members interact with each other
functional
-
VALUE Mneumonic
- Value what family tells u
- Acknowledge family emotions
- Listen to family
- Understand patient as person
- Elicit questions from family
-
Name some ethical issues CC nurses face every day
- Informed consent/confidentiality
- Withholding/withdrawing treatment
- organ/tissue transplant
- Distribution of resources
- Appropriate use of technology
-
What professional organization includes the code of ethics for nurses and with interpretive statements
ANA
-
What are some ethical dilemma warning signs
- Emotionally charged
- Significant change in pt condition
- Confusion about facts
- Hesitancy about what's right
- Deviation from customary practice
- Need for secrecy about actions
-
5 steps of Ethical decision-making process
- Assess
- Consider options
- Develop plan
- Act on plan
- Evaluate plan
-
What 3 factors are assessed in the ethical decision-making process
- Contextual
- Physiological
- Personal
-
What should options be considered on in the ethical decision-making process
- Patient wishes
- Burden vs. Benefit
- Ethical principles
- Potential outcomes
-
7 ethical principles of nursing
- Authonomy
- Beneficence
- nonmaleficence
- Justice
- Veracity
- Fidelity
- Confidentiality
-
2 formal mechanisms of ethical dilemmas
- Bioethics committee
- Ethics consultation
-
Name 3 different opportunities nurses have to contribute to formal ethical decision making
- Ethics forums/rounds
- Peer review
- Institutional review boards
-
What is the duty of the nurse in a contractual relationship to care for assigned patients (required)
Duty to treat
-
What must the nurse to to ensure she does not abandon the patient
arrange with another nurse, including breaks and lunch
-
What can the nurse do if she finds herself in a situation that conflicts with her morals
She does not have to do it, but pt should be transferred to another nurse to avoid abandonment
-
Name 3 broad elements of Informed consent
- Competence
- Voluntariness
- Disclosure of info
-
What 6 things are included for disclosure of info during obtaining informed consent
- Dx
- Treatment
- Outcome
- Benefits/risks
- Alternative treatments
- Prognosis if no treatment
-
4 factors to consider when giving life-sustaining treatment
- Constitutional rights
- Quality of Life
- Impact of advanced technology
- Ordinary vs. extraordinary care
-
What type of care includes common, noninvasive, and tested treatment?
ordinary
-
Give some examples of ordinary care
- Nutrition
- Hydration
- Antibiotics
-
What type of care includes complex, invasive, experimental treatment
extraordinary
-
Give some examples of extraordinary care
- ACLS
- Dialysis
- Unproved therapies
-
What is needed in order to prevent initiation of a code
DNR
-
What is useful in guiding decision making PRIOR to a code
Advance directive
-
Not initiating life saving measures
Withholding
-
Weaning or removing life sustaining measures
Withdrawal
-
What is the Patient Self-determination Act
Patient's right to initiate advance directive and right to consent for or refuse treatment
-
What includes communication about preferences for treatments if pt is incapacitated
Advance directive
-
What includes desired treatment and what should be withheld
Living will
-
What determines who makes decisions for health care, health surrogacy or proxy
Durable power of attorney
-
Difference between health surrogate and proxy
Surrogate: you choose, Proxy: appointed
-
What percent of people die in acute care setting? CC unit?
-
What 4 things were discovered during SUPPORT study of 1995
- Lack of clear communication between pt & caregiver
- High freq of aggressive care
- Widespread pain/suffering
- Research on CC for dying pt is lacking/must be national priority
-
What is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in pt health condition
Medical Futility
-
What is the alleviation of distressing symptoms
palliation
-
Who should receive palliative care
everyone
-
Common sx at end of life
- Pain
- anxiety
- Thirst/hunger
- dyspnea
- n/d
- Confusion
- Agitation
- Sleep disturbances
-
5 nursing interventions for palliative care
- freq repositioning
- good hygiene
- skin care
- peaceful environment
- pain relief
-
3 elements of Palliative Care
- Early identification
- Pain management (5th VS)
- Pharm/Nonpharm
-
3 states where euthanasia is legal
-
What is the most common withdrawal intervention
ventilator
-
What is ventilator withdrawal also known as
terminal weaning
-
What does titration of pain and sedation meds help during terminal weaning
relieve tachypnea, dyspnea, and use of accessory muscles
-
When should life-sustaining treatment NOT be withdrawn from patients
PATIENT'S ON PARALYTIC AGENTS
-
Name 5 commonly withheld therapies
- Vasopressors
- Antibiotics
- Blood
- Nutrition
- Deactivation of implanted devices
-
What IV meds are used for anxiety during comfort of symptom management
Benzos
-
What IV med is giving for dyspnea and pain during comfort/sx management
Morphine
-
Whites verse black/hispanics in end-of-life options selections
- White: less aggressive
- Black/hispanic: more aggressive
-
Unpleasant sensory and emotional experiennce associated with actual or potential tissue damage
Pain
-
Prolonged state of apprehension in response to fear marked by apprehension, agitation, and autonomic arousal
Anxiety
-
What fibers does acute pain travel through to the SNS
A-delta
-
What fibers does chronic pain travel through?
C fibers
-
3 types of nociceptors
- Mechanical
- Chemical
- Thermal
-
What center is brain is anxiety linked to
reward/punishment center
-
Positive effects of pain/anxiety
- Increase performance
- Remove one from harm
- Fight/flight
-
Negative responses of pain/anxiety
- Raise catecholamines
- Interfere w/ healing
- Increase O2 consumption
- Increased Resp effort
-
What happens when catecholamines are raised in response to pain/anxiety
tachycardia/HTN
-
What happens with increased O2 consumption during response to pain/anxiety
End organ ischemia
-
Name 5 step assessment to pain using American Pain Society Guidelines
- Assess, treat promptly, document
- Engage pt in management of pain
- Provide preemptive treatment
- Reassess/treat to meet pt needs
- Institute quality improvement plan r/t practice/outcomes
-
5 characteristics of pain
- Precipitating cause
- Severity
- Location/raditation
- Duration
- Alleviating/aggravating factors
-
PQRST of Chest pain characteristics
- Provocation/position
- Quality
- Radiation
- Severity/associated sx
- Timing/triggers
-
What objective tool completely reflects pt pain level who cannot communicate
NONE
-
3 objective pain tools that can be used for pt who cannot communicate
- Behavioral Pain Scale
- CC Pain Observation
- Checklist of nonverbal pain indicators
-
What 3 scales is sedation adjustments based on
- Richmond Agitation-Sedation Scale (RASS)
- Ramsey Sedation (Ramsey)
- Sedation-Agitation (SAS)
-
What test assess brain activity
EEG
-
What is an acutely changing mental status
Delerium
-
What is the key word of Delirium
inattention
-
3 types of Delirium
- Hyperactive
- Hypoactive
- Mixed
-
Delirium where pt is agitated, combative, and disoriented
Hyperactive
-
Delirium that is quiet
Hypoactive
-
2 assessments used in Delirium
-
Drug of choice for Delirium
Haloperidol
-
Goal of pt with Delirium
Keep pt safe
-
ABCDE of preventing Delirium Bundle
- Awakening
- Breathing coordination
- Choice of sedation
- Delirium monitoring
- Early mobility/exercise
-
What reasons might a physician decide to use a Neuromuscular blockade (NMB)
- Emergency/difficult intubation
- Improve tolerance of mechanical ventilation
- Manage Elevated ICP
-
Interventions for pt on NMB
- Mechanical ventilation & airway management
- Eye lubrication
- DVT prophylaxis
- Reposition/ROM
- Oral care
- Urinary Cath
- Routine VS/assessments
-
4 benefits of opioid use in CC setting
- Rapid onset
- Ease of titration
- Lack of accumulation
- Low cost
-
Name 3 opioids commonly used in CC setting
- Fentanyl
- Morphine
- Hydromorphone
-
Which opioid has fastest onset
Fentanyl
-
Which opioid has longest duration
Morphine
-
2 concerns of opioid use in CC
- respiratory depression
- hypotension
-
How would opioids be administered in CC settings
- IV bolus
- IV infusions
- PCA
- Fentanyl patches
-
What Pharmacological pain management method facilitates mobility and pulmonary hygiene
Epidural
-
What meds can decrease the need of opioids
NSAIDs
-
What are the risks of NSAID use
GI bleed, renal (ibprofen) or liver (acetaminophen) insufficency
-
Name 3 sedatives used in CC to treat anxiety
- Benzo
- Propofol
- Dexmedetomidine (precedex)
-
Pts best suited for a PCA pump
- elective surgery
- Large surgical or traumatic wounds
- NL cog funtion
- NL motor skills
-
Where is food first broken down
mouth-saliva
-
What does stomach do with food
- Mix w/ gastric secretions
- Secrete intrinsic factor for Vit B12 absorption
- Secrete fluid high in Na & K
-
Where do pancreas and liver empty in the stomach
Duodenum
-
Where in the stomach is water-soluble vitamins absorbed
Jejunum
-
Where in the stomach is protein broken down and absorbed
Ileum
-
Where is fat-soluble vitamins absorbed
Ileum
-
What absorbs Na+ & K+
Colon
-
Where is Vit K formed
Colon
-
Where is water reabsorbed
Colon
-
Where is short-chain fatty acids absorbed
colon
-
What secretes digestive enzymes
Pancreas
-
What assists in emulsifying fats
Gallbladder
-
When does a patient who cannot meet needs orally require support
>3 days
-
Where does enteral nutrition deliver nutrients
GI tract
-
What is the preferred method of nutrition delivery and why
- Enteral
- Lower risk of infection/less expensive
-
What 2 things are used for long-term nutrition
PEG or jejunostomy
-
How many calorie per mL is standard for enteral feeds
1 calorie/mL
-
4 specialized formula examples
- Elemental
- High protein
- Fiber enriched
- Wound healing
-
3 types of short-term enteral feedings (routes)
- NG
- Nasoduodenal
- Nasojejunal
-
Feeding schedule for gastric? small bowel?
- Gastric: intermittent
- Small bowel: continuous
-
Signs of feeding intolerance (EN)
- N/V
- Absent bowel sounds
- Abd distention
- Cramping
-
Feeding delivered into blood stream called?
Parenteral
-
Type of feeding solutions that can go through a central line (TPN)
Hypertonic
-
Type of feeding solutions that can go through peripheral line (PPN)
Isotonic
-
When is Parenteral nutrition used
When unable to tolerate enteral
-
What conditions may require PN
- GI obstruction
- Intractable vomiting or diarrhea
- NPO >1 week
- Pt admitted malnourished
-
4 complications of Parenteral Nutrition
- Infection (sepsis)
- Electrolyte imbalance
- Fluid imbalances
- Hyperglycemia
-
When should u flush when administering meds via enteral route
before and after each med
-
What should be suspected for infection r/t PPN/TPN
Malnourishment
-
What type of malnutrition should be assessed in elderly
protein-energy
-
3 complications of PPN/TPN
- Refeeding syndrome
- DM/Glucose intolerance
- Liver function (parenteral)
-
Potential cause of diarrhea r/t nutrition feeds
Cdiff
-
When do half of all communication breakdowns occur
Handoff
-
4 barriers of effective handoff communication
- Physical setting
- Social setting
- Language
- Communication medium
-
Difference between situation and background from SBAR
- Situation: what's happening now
- Background: What led up to the situation now
-
Ventilator Bundle
- HOB elevated
- Titrate sedation/assess readiness to extubate
- Prophylaxis PUD
- Prophylaxis VTE
-
Which Legal case led to the Self-Determination Act
Nancy Cruzan
-
endogenous cytokines that suppress pain indication
endorphins
-
3 elements of behavioral pain scale used for mechanically ventilated patients
- Facial expression
- Upper limbs
- Compliance with Ventilation
-
Whats the target level of sedation
calm patient thats easily aroused
-
Which sedation scale is used for post-op patients emerging from general anesthesia
RAMSAY
-
Which sedation scale is used for pts on sedation over consecutive days of CC unit
RASS
-
What value on an EEG indicates fully conscious? Deep sedation? complete sedation?
- Fully conscious: >90
- Deep Sedation: 40-60
- Complete sedation: 0
-
What BIS score is associated with pt awareness and recollection
>60
-
What BIS value is goal in CC
<60
-
Most prevalent type of Delirium
Hypoactive
-
Using the CAM-ICU, what is considered positive delirium
- 1: Acute mental status change
- 2: Inattention
- 3: Disorganized thinking OR 4. Altered LOC
-
What can a long-acting NMB help with
- Improved chest wall compliance
- Reduce peak airway pressure
- Prevent pt from ventilator dyssynchrony
-
WHAT SHOULD YOU REMEMBER WHEN ADMINISTERING NMB!!??
- Does not possess sedative or analgesic properties
- MUST ALSO USE SEDATION
-
What is the Train of four test?
NMB test using peripheral nerve stimulator to assess number of twitches present
-
What does 4 twitches of thumb or face indicate? 0 twitches?
-
What is the TOF goal
2 out of 4 twitches
-
How often should propofol infusion set be changed
q 12 hrs
-
Pt criteria for use of propofol
intubated and mechanically ventilated
-
What should be monitored for with pt on precedex
Bradycardia
-
What should be avoided with fentanyl patches? When should they be changed?
-
Two side effects of aspirin
-
Name 2 NMB drugs
- Atracurium
- Succinylcholine
-
Major SE of Succinylcholine
HYPEKALEMIA
-
2 major SE of Haloperidol
-
What may be given prophylactically to prevent alcohol withdrawal
ethanol
-
What may be given to pt with hx of alcoholism to prevent Wernicke encephalopathy
Thiamine
-
How often should pt on restraints be assessed for sensation and perfusion
q hr
-
What meds have paradoxical effects in the elderly? SE?
Benzos, Agitation
-
What vitamin is critical for formation of RBC
Vitamin B12
-
When should nutritional screening be conducted when pt arrives at hospital
within 24 hours after admission
-
What waist circumference indicates abdominal obesity for women? Men?
-
Normal BMI?
Overweight?
Obese?
Extremely obese?
- 18.5-24.9
- 25-29.9
- 30-39.9
- >40
-
When should enteral feeding begin following pt who can't meet their demands orally
24-48 hrs
-
first step in formulating nutrition care plan
estimate protein and caloric requirements
-
What PN formula is given during the first week of critical illness
PN WITHOUT SOY-based lipid
-
When is elemental formula indicated
GI dysfuntions: SBS, Impaired digestion
-
When is calorie dense formula indicated
HF or liver disease
-
When is immune-modulating formula indicated
- Acute lung injury
- ARDS
- Sepsis
-
When are feeding tubes generally flushed? How many mL of water
- q 4 hrs: continuous
- b4 & after feeds/meds: intermittent
- 30 mL
-
How often is GRV checked? What should be of concern? When should feeding be held
-
What should you do when administering phenytoin via enteral route
stop infusion 1-2 hr before & after administration
-
What to do to prevent tube obstruction
- flush w/ 30 mL
- administer with elixir diluted w/ water
-
What to do if tube is obstructed
irrigate w/ warm water or pancreatic enzyme
-
What to do to prevent aspiration r/t nutrition tube feeds
- mark tube exit
- monitor GRV & place q 4 hrs
- HOB 30-45 degrees
-
What should you consider if GRV 200-250
promotility agent
-
What to do in case of dumping syndrome (abdominal distention and cramping)
slow rate and frequency of feeding bolus
-
What lab value indicates protein deficiency
albumin <3.5
-
If triglycerides are elevated what needs to be assessed and evaluated
- feeding route/formula
- propofol or lipids need adjustment
-
What lab value can indicate malnutrition and /or malabsorption
mg <1.9
-
What lab value can indicate malnutrition, sepsis, Inc calcium
Phos <1.0
-
What can glucose >200 indicate
Inability to tolerate glucose in PN and/or carb load in EN
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