Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Respiratory Case Study

No description
by

Joanna Alicea

on 3 March 2014

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Respiratory Case Study

Respiratory Case
Study

Joanna Alicea, Abiba Arouna, Bethany Chhim
Jake Miller & Nick Noel Peret

What two priority actions should you take? Provide your rationale.

Look at cardiac monitor & implement cardiac protocols if necessary (code) to detect arrhythmia and correct it.
Vital signs to detect current patient status.


Contact the pharmacist
Contact the doctor
If necessary, contact the charge nurse
Go up the chain of command

You realize that it is illegal to take medication dispensed by a pharmacist for one patient and use it for another patient. What should you do?


Given that KCL and CaCL are compatible, would you mix them in the same bag of D5W? State your rationale.


The physician prescribes the following: Draw STAT Mg level; if below 1.4 mg/dl, give MgSO4 3Grams in 100 ml D5W over 4 hours, administer KCL 40 mEq in 100 ml D5W IVPB over 1 hour; and give CaCl2 grams in 100 ml D5W IVPB over 3 hrs. The laboratory is called to draw a STAT Mg. level. 

It is time to administer 40 mg of furosemide IVP.
-Why is this medication indicated?
-What are the nursing considerations for giving this drug IVP?
- What effect if any will furosemide have on the clinical presentation of G.S.?


The nurse from the previous shift charted the following statement, “Crackles and rhonchi clear with vigorous coughing.” Based on your knowledge of pathophysiology, determine the accuracy of this statement.


Identify the following adventitious lung sounds:

Stridor – high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over the chest wall.
Pleural friction rub – a very superficial sound that is coarse and low pitched; has a grating quality as if two pieces of leather are being rubbed together.

Rhonchi – low-pitched wheezing or snoring sound associated with partial airway obstruction.
Wheeze (sonorous) low-pitched, monophonic single note, musical snoring, moaning sound heard throughout the resp. cycle.
Wheeze (sibilant) – high-pitched, musical squeaking sounds, polyphonic and heard predominantly in expiration.

The nurse completes his/her assessment of G.S. The nurse notes dyspnea, crackles throughout all lung fields posteriorly and in both lower lobes anteriorly, and rhonchi over the large airways.

What is the significance of these assessment findings in G.S.’s case?

Provide an example of your transfer report note. - Handout

What additional information should you require during this report?
Resp: lung sounds, depth pattern,
GI: feeding type, rate
GU: foley output,
pain level


G.S. has been in the ICU for 6 weeks, and her ARDS is nearly resolved. She is transferred out of the ICU and is admitted to your unit You receive the following report:
Neuro: AAO to person and place, she can move both arms and wiggle her toes on both feet:
CV heart tones are clear, VS are 138/90, 88, 26, 99.2°F, bilateral radial pulse 3+, foot pulses by Doppler only,
Skin: incisions and dressings are dry and intact;
GI: duodenal feeding tube in place;
GU (genitourinary): Foley catheter to gravity drain.

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The physician has decided that he would like to wean the patient from the ventilator. What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

The nurse hears the alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off?


What are the characteristics of a mechanical ventilator that is pressure-cycled?

The ICU has been working on improving quality and safety outcomes each quarter. One nurse sensitive indicator that they have been tracking is the incidence of VAP. The nurse know that in the care of a patient on a mechanical ventilator, what action by the nurse will contribute to the prevention of ventilator assisted pneumonia?

Check tube placement
Absence of appropriate pressure would allow her to make sounds.
Assess for an air leak around the cuff/inadequate cuff pressure.


While the nurse is caring for this patient on a mechanical ventilator, the nurse hears G.S. making sounds that sound like she is talking. What does the nurse need to check?


The nurse hears in report that the patient has been agitated and pulling on the ET. Restraints have been recently ordered and placed on the patient, but she continues to move her head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?

What are the nursing considerations related to emergent transfusion of this patient?


What were the legal implications of consent when the patient was brought in to the hospital requiring immediate OR care?


Acute onset of
- dyspnea
- tachypnea
- crackles/wheezes on auscultation
- bilateral lung infiltrates on CXR
- restlessness/agitation
- continually decreasing PaO2

Clinical presentation


Describe her clinical presentation and diagnostic evidence of ARDS?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

http://www.youtube.com/watch?v=MzTcy6M3poM
http://www.easyauscultation.com/lung-sounds-reference-guide.aspx
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html
http://www.nlm.nih.gov/medlineplus/respiratoryfailure.html
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/
http://www.nlm.nih.gov/medlineplus/ency/article/000187.htm
http://www.meddean.luc.edu/lumen/MedEd/medicine/skills/ekg/les2prnt.htm
Nursing Central, (2014).





Websites

Anderson, M., Arnold, E., Bishop, S., Boyd, M., Britt, R., Cassem, M…Yoho, M. (2011). HESI Comprehensive Review for the NCLEX-RN examination (4th edition). St. Louis:Elsevier.
Anne, Y., Brenda, H., Laura, E.(2010). ICU Nurses’ Experiences in Providing Terminal Care. Critical Care Nurse Quarterly, 33(3), 273-281
ATI Nursing Education. (2010). RN Adult Medical Surgical Nursing Edition 8.0 . ATI Nursing Education.

References

What’s the difference between hospice and palliative care?
All hospice care (care at the end of life) is palliative care, but not all palliative care (care to make the patient comfortable), is hospice

Questions

Vacation,
Grieving with the family
limit OT, realize the nurses in role in end of life care.
Find activities to do outside of work,
crying relieves stress,
group counseling, therapy.
Talking with others co-workers
Designing and helping to implement policies and procedures, education reform


How can nurses avoid suffering from moral distress and burnout?

Ineffective coping strategy:

- crusty nurse attitude.

coping

Abandonment and powerless


Conflict with meds administration



internal conflict


Lack of involvement in the plan of care
Differences between the medical and nursing practice models
Unrealistic expectation of the family
Lack of education

barrier to optimal care


According to Laura Epsinosa, Three factors contribute to the moral distress
1 barrier to optimal care
2 internal conflict
3 coping

Define Moral distress and explain its association with patient care in critical care settings?

Taking it as a valuable experience,
nursing education reform, guidelines for providing terminal care
More training on how to communication with families.
Experiences can make nurses realize that not everyone can be saved.
Death is a part of life.

How can nurses use the experience of caring for a dying patient for personal and professional growth?

Give them time off,
Provide a place of privacy for grieving
grieving process with the family, counseling, grief counseling,
Help facilitate steps necessary for the family to carry out the desired arrangements
nurse must go through the grieving process as well.



What steps can be taken for the nurses of dying patients?

G.S.’s arrhythmias respond to your treatment. Unfortunately, 1 week later, she puts the call light on and complains of difficulty breathing. As you enter the room you find the following: G.S. has no pulse and is not breathing.

Case study

Family-grief counseling,
offering clergy,
staff counseling,
pain control, comfort measures,
encourage the family to communication with patient.



Give examples of end-of-life care requiring the intervention of skilled critical care nurses for G.S. at this point in her care.




Determine the patients ability to receive support.
Increase consistent communication between doc and family,
advocate for the pt.
Be there/ present and support the family (listen).

What is the nurse’s role in supporting that patient’s needs in this situation?

Involve social work to evaluate the seriousness of the situation,
discuss options: need to identify the chances of her surviving in either setting.
Family meeting, explaining the necessity of the transfer, risks of staying in the ICU.
May calm the family, determine family needs.



Nursing action


Even if death is imminent, a transfer from the ICU could be disruptive to the patient, family and staff members. What nursing action(s) can or will you take to respond to this situation?


Question

Patient
Advance directives
Assess mental status first; may need psych eval.
Ethics committee if needed



Who is responsible for the decision-making in this case?


Coronary Care Unit (Cardiac); Cardiac Intensive Care Unit.
Need to discuss advance directives and health care proxy
(remember there is an article that goes with this)


Discuss what type of ICU care is appropriate for G.S. and her family?


Based on the recent turn of events the team of physicians recommend that a family meeting should be conducted to determine G.S.’s wishes should her condition worsen and her heart and lungs stop functioning.

Case study

CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Correcting the underlying cause, correct electrolyte levels, administer meds, continue cardiac monitoring.



What treatment is indicated for G.S.’s arrhythmias?


You notice that G.S. looks frightened and is lying stiff as a board.

How would you respond to this situation?
Support the patient. Explain to the patient what is happening to ease the anxiety.
Non-pharmacological relaxation techniques.
Social worker.


Case study

If the heart rate during a ventricular tachycardia episode is very fast or lasts longer than a few seconds. There may be symptoms such as:
Chest discomfort (angina)
Fainting (syncope)
Light-headedness or dizziness
Sensation of feeling the heart beat (palpitations)
Shortness of breath


What factors have contributed to these clinical findings?


CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Call a code.


What is your next priority action?


Single irritable focus in Ventricles
Ventricular rate 150-250 bpm
Wide QRS complexes
No P wave
RR intervals approximately equal
A run of three or more VPB's in a row @ rate greater than 100/min
AV dissociation may be present
Atrial capture beats may be present
Ventricular fusion beats may be present
Retrograde concealed conduction
VPB's with the same shape QRS


Ventricular Tachycardia


G.S.’s pulse is irregular. Her BP is 92/70 and her respirations are 28. She admits to being “a little lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a “quick look”. You are able to distinguish normal P-QRS-T complexes but you also note approximately 22 very wide complexes per minute. The wide complexes come early and are not preceded by a P wave.

What is your impression of these findings?

Case Study

While you administer the furosemide and hang the intravenous medication, G.S. tells you, “ This is so strange, a couple of times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.”


Case Study

You open G.S.’s medication drawer to draw the furosemide into the syringe. You find one 20 mg. ampule. The pharmacist tells you that it will be at least another hour before he can send the drug to you.


Case study

hyperkalemia s/s, hypercalcemia s/s disrythmias, slow irregular heartbeat, fluid overload, hyperglycemia.

What clinical implications may be anticipated based on these current laboratory findings?

Chem 7

What additional bloodwork should be ordered?

BP, allergies, current lab values, baseline/trend values, Bp and pulse noting irregularities, PT output must be recorded.
Should be on telemetry under constant cardiac monitoring.


What additional nursing action is necessary?

monitor vitals, allergies, lab values, frequent monitoring, I/O ratio WNL

Discuss safe administration of IV KCL and CaCL.

Low Potassium, low sodium, low calcium, low chloride, high glucose. Most concerning is the potassium because it may cause arrhythmias.
Monitor renal function as the BUN and creatinine increases.


Keeping in mind that you are about to administer furosemide, which laboratory values concern you and why?


values concern you and why? Low Potassium, low sodium, low chloride, high

glucose most concerning is the potassium because it may cause arrhythmias. By

RESPIRATORY ACIDOSIS WITH COMPENSATION

Na: 135-145 mEq/L
K: 3.6-5.1 mEq/L
Cl: 98-110
Ca:
BUN: 6-24mg/dl
Creatinine: 0.64-1.27
Glucose: 67-99 mg/dl
HCO3 :
ABGs
pH: 7.35–7.45
Paco2 : 35–45 mmHg
Pao2 : 80–95 mmHg
HCO3 : 22-26
BE :
Sao2 : 95–99%

Normal Lab Values

Na - 129 mmol/L
K - 2.8mmol/L,
Cl - 92 mmol/L
Ca - 7.1 mg/dl
BUN - 37 mg/dl
Creatinine - 2 mg/dl
Glucose - 128 mg/dl
HCO3 26 mmol/ L
ABGs on 6L O2 /NC:
pH - 7.38
Paco2 - 49 mmHg
Pao2 - 82 mmHg
HCO3 - 36 mmol/L
BE - 2.2
Sao2 - 91%

The 0500 laboratory values are as follows:

5 Rights + allergy
Assess intake and output, lung sounds, BP and pulse, BUN and creatinine levels, electrolytes.
Administer slowly for 2 minutes. 4mg/min recommended IV rate.





Nursing Considerations

Dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis.
Hypotension, ↑ BUN, excessive urination, constipation, diarrhea, dry mouth, tinnitus, hearing loss.
ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, APLASTIC ANEMIA, AGRANULOCYTOSIS.

Possible Adverse Reactions

-loop diuretic
-Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
-Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
-Diuresis and subsequent mobilization of excess fluids (edema, pleural effusions).
-IV dose for adults: 0.1 mg/kg/hr max 0.4 mg/kg/hr

What is furosemide (Lasix)?

Crackles (fine) – discontinuous, high-pitched sound, short popping sounds during inspiration that are not cleared by coughing.
Crackles (coarse) – Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease by coughing but will reappear shortly.

Adventitious Lung Sounds

Monitor the client for signs of respiratory distress, or airway obstruction, such as ineffective cough, dyspnea or stridor.
Heliox- Heliox generates less airway resistance than air and thereby requires less mechanical energy to ventilate the lungs.

Extubation

Hemodynamic, cerebral, and metabolic stability.
Temp <38 C
Ability to maintain patent airway and initiate inspiratory effort
Evidence of partial or full resolution of underlying disease process that prompted intubation.
Physician determination of readiness.

Weaning criteria

Volume (low pressure)
Pressure (high pressure)
Apnea

Ventilator Alarms

Volume-cycled- inspiratory flow halts once the target volume is delivered.
Pressure-cycled- inspiratory flow ceases once a peak inspiratory pressure is reached.
Flow-cycled- inhalation is programmed to cease when it senses a drop in the peak flow rate, and expiratory phase begins.
Time-cycled- a timed inhalation limit is set and exhalation will begin when that limit is reached


Types of Cycling

Airway management
NPPV
Timely ET tube removal/ 1 time placement
CASS tube
Gastric reflux prevention
-Patient positioning
Equiptment maintenance
-ventilator circuit (tubing, exhalation valve/humidifier
Cross-contamination
-standard/contact precautions

VAP Prevention

The patient may also need a sitter or to be put on constant observation.
Family member
Patient teaching
Moderate sedation.

ET tube placement

Define Emergency situation
-If immediate treatment is required in order to prevent death or other serious harm to a patient, that treatment may be provided without informed consent.

Implication of Consent

Rule out basis
Consists of
Acute onset
Bilateral infiltrates
PCWP <18 mmhg w/o L atrial HTN
PaO2/FiO2 ratio <200

ARDS Diagnostic Criteria

Dyspnea, hypoxemia, and tachypnea are assessment findings considered early sign of ARDS.

8. What additional assessment findings may be found in ARDS?
Additional assessment findings include:
· Pulmonary HTN
· Multiple organ system failure
· Hypotension
· Cyanosis of skin, lips, nail beds
· Delayed capillary refill
· Confusion/disorientation
· Adventitious lung sounds

9. What factors contributed to this diagnosis?
The factors that contributed to this diagnosis are trauma the patient suffered from the car accident and also the amount of transfusions received during emergency resuscitation.



7. What assessment finding is considered an early sign of ARDS?

Acute respiratory distress syndrome is characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event, such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. Increased capillary permeability is distinctive. Damage of the capillary endothelium and alveolar epithelium in correlation to impaired fluid removal from the alveolar space results in accumulation of protein-rich fluid inside the alveoli, thereby producing diffuse alveolar damage, with release of pro-inflammatory cytokines. Neutrophils are recruited to the lungs by cytokines, become activated and release toxic mediators. Extensive free radical production overwhelms endogenous anti-oxidants and causes oxidative cell damage. If the fluids, proteins, and blood cells accumulate too rapidly for the lymphatic system to remove, the consequences is noncardiogenic pulmonary edema (http://emedicine.medscape.com/article/165139-clinical).
In addition, the lungs experience an increase in hyaline membrane formation, development of fibroblasts, and an increased number of alveolar type II cells, as well as the inactivation of pulmonary surfactant. Interstitial fibrosis may also develop. together, these factors worsen gas exchange. decrease lung compliance, and produce areas of atelectasis (York & Kane, 2012).


6. Pathophysiology of ARDS?

Delegatable tasks include:
· Specimen/sputum collection
· Bed bath, mouth care
· I&O
· ROM


5. While you are caring for G.S. on a ventilator, you may delegate what actions to an experienced nursing assistant?

1. Assess for bilateral breath sounds and symmetrical chest movement.
2. Auscultation over the stomach to rule out esophageal intubation.
3. Marking the tube 1 cm from where it touches the incisor tooth or nares
4. Ordering chest radiography to verify that the tube placement is correct.


4. You are the preceptor for an RN who is undergoing orientation to the ICU. The RN is providing care for G.S. who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you perform immediately?

The nurse should first verify if there is an DNI (Do Not Intubate) order in place to verify if intubation is appropriate.
· Preparing the patient
The nurse should tell the patient what is about to happen, then pre-oxygenate. Intubation should be preceded by ventilation with a high concentration of oxygen, ideally at least 85%, for a minimum of 15 seconds. The aim is to maximize the patient’s PaO2 as the patient will be unable to maintain any respiratory effort (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).
The nurse should gather the necessary equipment for intubation. The following essentials must be present prior to the procedure, using the mnemonic SALT:
-Suction: crucial to clear the airway and allow visualization of the vocal chords
-Airway: the oral airway can make it easier to mask ventilate a patient and oxygen must always be available
-Laryngoscope: for inserting the tube
-Tube: an ET tube for intubation.
The bed head should be lowered and the patient’s position flat, with their face at the level of the xiphoid cartilage of the standing person performing the procedure. A small pad/pillow should be placed under the occiput. Extend the head at the atlanto-occipital joint, which aligns the oral, pharyngeal, and laryngeal axis so that the passage from the lips to the glottic opening is a straight line (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article)
· The process of intubation
As the procedure continues, the nurse will administer the patient a combination of medications. The nurse will monitor and describe the vital signs status of the patient regularly and be prepared to pass the ET tube and other equipment to the person intubating.
Once the tube is inserted, the cuff should be inflated and checked for pressure with a manometer. The patient’s chest should be observed for equal expansion and auscultation performed at the mid-axillary line. The tube should be secured, the patient attached to an appropriate ventilator and a check X-ray ordered. A high concentration of oxygen should continue and arterial blood gases should be taken. Appropriate humidification is required (http://www.nursingtimes.net/nursing-practice/clinical-zones/critical-care/endotracheal-intubation/199630.article).

3. What should the nurse do to prepare for intubation of this patient?


2. As the nurse responsible for the care of this patient, what would you anticipate a physician to order to respond to the acute respiratory needs of this patient?

Diagnosis is reached by ruling out other diseases and disorders through specific diagnostic procedures:
· Imaging
o CXR - to reveal which parts of the lungs have fluids and enlargement of heart.
o CT scan – can provide detailed information about structures within heart and lungs.
· Lab Tests
o CBC/Chem 7 – assess for other abnormalities and bodily functions.
§ Hematologic - Von Willebrand factor (VWF) may be elevated in patients at risk for ARDS and may be a marker of endothelial injury.
§ Renal - Acute tubular necrosis (ATN) often ensues in the course of ARDS, probably from ischemia to the kidneys. Renal function should be closely monitored.
§ Hepatic - Liver function abnormalities may be noted in either a pattern of hepatocellular injury or cholestasis.
o ABGs - often initially show a respiratory alkalosis. However, in ARDS occurring in the context of sepsis, a metabolic acidosis with or without respiratory compensation may be present. As the condition progresses and the work of breathing increases, the partial pressure of carbon dioxide (PCO2) begins to rise and respiratory alkalosis gives way to respiratory acidosis.
o Sputum Cx – r/o infection
o BNP – An BNP level of less than 100 pg/mL in a patient with bilateral infiltrates and hypoxemia favors the diagnosis of ARDS/acute lung injury rather than cardiogenic pulmonary edema.
· Cardio
o EKG
o ECG - provides information about left ventricular ejection fraction, wall motion, and valvular abnormalities.
· Bronchoscopy - Bronchoscopy may be considered to evaluate the possibility of infection, alveolar hemorrhage, or acute eosinophilic pneumonia in patients acutely ill with bilateral pulmonary infiltrates.
· Hemodynamic monitoring - hemodynamic monitoring with a pulmonary artery (Swan-Ganz) catheter may be helpful in selected cases for distinguishing cardiogenic from noncardiogenic pulmonary edema.
(http://emedicine.medscape.com/article/165139-clinical)

1. What diagnostic procedures should be done to determine the cause of this acute
respiratory compromise?

End-tidal carbon dioxide detection is the most accurate technology to evaluate endotracheal tube position.
Capnograph

Reconfirmation of endotracheal tube position should be undertaken immediately at any time there is concern regarding proper location of the endotracheal tube.


ET tube placement

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097557/

setting does not allow for pretransfusion/compatibility testing.
-In extreme emergencies, when there is no time to obtain and test a sample, group ‘O’ Rh-negative packed red cells can be released.
-clinician must sign a release authorizing and accepting responsibility for the use of incompletely tested products as a life-saving measure.



Emergent Transfusion

Joanna Alicea, Abiba Arouna, Bethany Chhim, Jake Miller, & Nick Peret

Respiratory Disorder

Acute Respiratory Distress Syndrome

Student Led Case Study

· Fluid management - diurectics, strict I&O
· Noninvasive ventilation – non-rebreather mask (already in placed)
· Mechanical ventilation - to maintain oxygenation while avoiding
oxygen toxicity and the complications of mechanical ventilation. Generally, involves
maintaining oxygen saturation in the range of 85-90%, with the aim of reducing the fraction of
inspired oxygen (FIO2) to less than 65% within the first 24-48 hours. Achieving this aim almost
always necessitates the use of moderate-to-high levels of positive end-expiratory pressure (PEEP).
· Nutritional support – NPO, Enteral nutrition via a feeding tube.
· Activity restriction – Bed rest. Frequent position changes, passive and, if possible, active range of
motion activities of all muscle groups. Elevation of the head of the bed to a 45° angle is recommended to
diminish the development of VAP. Prone positioning.
(http://emedicine.medscape.com/article/165139-clinical)



Describe her clinical presentation and
diagnostic evidence of ARDS.
Acute onset of:
- dyspnea
- tachypnea
- crackles/wheezes on auscultation
- bilateral lung infiltrates on CXR
- restlessness/agitation
- continually decreasing PaO2

ARDS Diagnostic Criteria
-Rule out basis
-Consists of
Acute onset
Bilateral infiltrates
PCWP <18 mmhg w/o L atrial HTN
PaO2/FiO2 ratio <200

What were the legal
implications of consent when the patient was brought in to the hospital requiring immediate OR care?

Define Emergency situation
-If immediate treatment is required in
order to prevent death or other serious
harm to a patient, that treatment may be provided without informed consent.

What are the nursing considerations
related to emergent transfusion of this patient?

setting does not allow for pretransfusion/compatibility testing.
-In extreme emergencies, when there is no time to obtain and test a sample, group ‘O’ Rh-negative packed red cells can be released.
-clinician must sign a release authorizing and accepting responsibility for the use of incompletely tested products as a life-saving measure.



Case Study

You open G.S.’s medication drawer to draw the furosemide into the syringe. You find one 20 mg ampule. The pharmacist tells you that it will be at least another hour before he can send the drug to you.
You realize that it is illegal to take medication dispensed by a pharmacist for one patient and use it for another patient. What should you do?

DO NOT USE THE MED; violates 5 rights of med admin. (RIGHT PATIENT)
Contact the pharmacist for stat refill (if not already done)
Emergency med kit per facility protocol
Contact the doctor
If necessary, contact the charge nurse/supervisor
Go up the chain of command if further interventions needed
Make sure meds are ordered in a timely fashion in the future for patient safety & quality care.

Case Study

While you administer the furosemide and hang the intravenous medication, G.S. tells you, “This is so strange, a couple of times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there’s a bird flopping around in there.”

What two priority actions should you take? Provide your rationale.

Look at cardiac monitor & implement cardiac protocols if necessary (code) to detect arrhythmia and correct it.
Vital signs to detect current patient status and recent lab values.

Case Study
G.S.’s pulse is irregular. Her BP is 92/70 and her respirations are 28. She admits to being “a little lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a “quick look”. You are able to distinguish normal P-QRS-T complexes but you also note approximately 22 very wide complexes per minute. The wide complexes come early and are not preceded by a P wave.

What is your impression of these findings?

What is your next priority action?
CPR
Electrical defibrillation or cardioversion (electric shock)
Anti-arrhythmic medications (such as lidocaine, procainamide, sotalol, or amiodarone) given through a vein
Call a code.

What factors have contributed to these clinical findings?
Case Study
You notice that G.S. looks frightened and is lying stiff as a board.

How would you respond to this situation?
Support the patient.
Explain to the patient what is happening to ease the anxiety.
Non-pharmacological relaxation techniques.
Social worker.
Recheck EKG and VS to prevent possible V-tach

What treatment is indicated for G.S.’s arrhythmias?
Based on the recent turn of events the team of physicians recommend that a family meeting should be conducted to determine G.S.’s wishes should her condition worsen and her heart and lungs stop functioning.

Case Study
Discuss what type of ICU care is appropriate for G.S. and her family?
Coronary Care Unit (Cardiac); Cardiac Intensive Care Unit.
Need to discuss advance directives and health care proxy


Who is responsible for the decision-making in this case?
Patient
Advance directives
Assess mental status first; may need psych evaluation.
Ethics committee if dispute arises.

http://www.nlm.nih.gov/medlineplus/ency/article/000187.htm
http://www.meddean.luc.edu/lumen/MedEd/medicine/skills/ekg/les2prnt.htm
Nursing Central, (2014).
http://www.andrews.edu/~schriste/Course_Notes/Rhythms_and_Criteria/rhythms_and_criteria.html


References
What do you think this means?
G.S. has been in the ICU for 6 weeks, and her ARDS is nearly resolved. She is transferred out of the ICU and is admitted to your unit You receive the following report:
Neuro: AAO to person and place, she can move both arms and wiggle her toes on both feet:
CV heart tones are clear, VS are 138/90, 88, 26, 99.2°F, bilateral radial pulse 3+, foot pulses by Doppler only,
Skin: incisions and dressings are dry and intact;
GI: duodenal feeding tube in place;
GU (genitourinary): Foley catheter to gravity drain.
Diagnosis is reached by ruling out other diseases and disorders through specific diagnostic procedures:

Imaging
CXR
CT Scan
Lab Tests
CBC
Chem 7
*ABGs*
BNP
Sputum Cx
Cardio
EKG
· Fluid management
· *Mechanical ventilation and intubation*
· Nutritional support
· Activity restriction
Medications
As the nurse responsible for care of this pt, what orders would be anticipated from a physician?
Diagnostic tests involved?

Inform the patient of procedure
Gather supplies.
The following essentials must be present prior to the procedure, using the mnemonic SALT:
-Suction
-Airway
-Laryngoscope
-Tube
HOB flat
Preoxygenate
Administer medications if necessary

You are the preceptor for an RN who is undergoing orientation to the ICU. The RN is providing care for G.S. who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you perform immediately?
Characterized by the development of acute dyspnea and hypoxemia within hours to days of an inciting event.
Increased capillary permeability lead to damaged capillary endothelium and alveolar epithelium related to impaired fluid removal from alveolar space leading to alveolar damage and accummulation of protein rich fluid.
Diffuse alveolar damage with release of pro-inflammatory cytokines.
Neutrophils are recruited to the lungs by cytokines, become activated and release toxic mediators.
In addition, the lungs experience an increase in hyaline membrane formation, development of fibroblasts, and an increased number of alveolar type II cells, as well as the inactivation of pulmonary surfactant. Interstitial fibrosis may also develop. together, these factors worsen gas exchange. decrease lung compliance, and produce areas of atelectasis.
Pathophysiology of ARDS
Dyspnea
Hypoxemia
Tachypnea
CXR w/diffuse bilateral infiltrates



Wht are considered the early signs of ARDS?
What additional information should you require during this report?

-Resp: lung sounds, depth pattern,
-GI: feeding type, rate
-GU: foley output,
-pain level
- medications
Provide an example of your transfer report note.
- Handout

The nurse completes his/her assessment of G.S. The nurse notes dyspnea, crackles throughout all lung fields posteriorly and in both lower lobes anteriorly, and rhonchi over the large airways.

What is the significance of these assessment findings in G.S.’s case?


Adventitious Lung Sounds

Crackles (fine)
– discontinuous, high-pitched sound, short popping sounds during inspiration that are not cleared by coughing.
Crackles (coarse)
– Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease by coughing but will reappear shortly.
Rhonchi
– low-pitched wheezing or snoring sound associated with partial airway obstruction.
Wheeze (sonorous)
low-pitched, monophonic single note, musical snoring, moaning sound heard throughout the resp. cycle.
Wheeze (sibilant)
– high-pitched, musical squeaking sounds, polyphonic and heard predominantly in expiration.

Stridor
– high-pitched, monophonic, inspiratory, crowing sound, louder in neck than over the chest wall.
Pleural friction rub
– a very superficial sound that is coarse and low pitched; has a grating quality as if two pieces of leather are being rubbed together.
Identify the following adventitious lung sounds:

http://www.easyauscultation.com/lung-sounds-reference-guide.aspx


The nurse hears in report that the patient has
been agitated and pulling on the ET. Restraints have been recently ordered and placed on the patient, but she continues to move her head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?

The nurse from the previous shift charted the following statement, “Crackles and rhonchi clear with vigorous coughing.”

Based on your knowledge of pathophysiology, determine the accuracy of this statement.
End-tidal carbon dioxide detection is the most accurate technology to evaluate endotracheal tube position.
Capnograph
Reconfirmation of endotracheal tube position should be undertaken immediately at any time there is concern regarding proper location of the endotracheal tube.
Mark tube where it touches teeth
Ausculation


It is time to administer 40 mg of furosemide IVP.
-
Why is this medication indicated?
-What are the nursing considerations for giving this drug IVP?
- What effect if any will furosemide have on the clinical presentation of G.S.?

What is furosemide (Lasix)?
-loop diuretic
-Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule.
-Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium.
-Diuresis and subsequent mobilization of excess fluids (edema, pleural effusions).
-IV dose for adults: 0.1 mg/kg/hr max 0.4 mg/kg/hr
Possible Adverse Reactions

-Dehydration, hypocalcemia, hypochloremia, hypokalemia, hypomagnesemia, hyponatremia, hypovolemia, metabolic alkalosis.
-Hypotension, ↑ BUN, excessive urination, constipation, diarrhea, dry mouth, tinnitus, hearing loss.
-ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, APLASTIC ANEMIA, AGRANULOCYTOSIS.

Nursing Considerations

-5 Rights + allergy
-Assess intake and output, lung sounds, BP and pulse, BUN and creatinine levels, electrolytes.
-Administer slowly.
-4mg/min recommended IV rate.
The 0500 laboratory values are as follows:

Na - 129 mmol/L
K - 2.8mmol/L,
Cl - 92 mmol/L
Ca - 7.1 mg/dl
BUN - 37 mg/dl
Creatinine - 2 mg/dl
Glucose - 128 mg/dl
HCO3 26 mmol/ L
The patient may also need a
sitter or to be put on constant
observation.
Family member
Patient teaching
Moderate sedation if
needed


While the nurse is caring for this
patient on a mechanical ventilator, the
nurse hears G.S. making sounds that
sound like she is talking. What does the
nurse need to check?

Check tube placement
Absence of appropriate pressure
would allow her to make sounds.
Assess for an air leak around the cuff/inadequate cuff pressure.

ABGs on 6L O2 /NC:
pH - 7.38
Paco2 - 49 mmHg
Pao2 - 82 mmHg
HCO3 - 36 mmol/L
BE - 2.2
Sao2 - 91%

Normal Lab Values

Na: 135-145 mEq/L
K: 3.6-5.1 mEq/L
Cl: 98-110
Ca: 8.2-10.2 mg/dL
BUN: 6-24mg/dl
Creatinine: 0.64-1.27
Glucose: 67-99 mg/dl
HCO3 :
The nurse knows that in the care
of a patient on a mechanical ventilator, what action by the nurse will contribute to the prevention of VAP?

ABGs
pH: 7.35–7.45
Paco2 : 35–45 mmHg
Pao2 : 80–95 mmHg
HCO3 : 22-26
BE : -2 - +3
Sao2 : 95–99%

Airway management
NPPV
Timely ET tube removal/ 1 time placement
CASS tube
Gastric reflux prevention
Patient positioning
Equiptment maintenance
ventilator circuit (tubing, exhalation valve/humidifier
Cross-contamination
standard/contact precautions

RESPIRATORY ACIDOSIS WITH COMPENSATION
What values concern you and why?
Low Potassium, low sodium, low chloride, high glucose most concerning is the potassium because it may cause arrhythmias.

Keeping in mind that you are about to administer furosemide, which laboratory values concern you and why?

-Low Potassium, low sodium, low calcium, low chloride, high glucose. Most concerning is the potassium because it may cause arrhythmias.
-Monitor renal function as the BUN and creatinine increases.

The physician prescribes the following: Draw STAT Mg level; if below 1.4 mg/dl, give MgSO4 3Grams in 100 ml D5W over 4 hours, administer KCL 40 mEq in 100 ml D5W IVPB over 1 hour; and give CaCl2 grams in 100 ml D5W IVPB over 3 hrs. The laboratory is called to draw a STAT Mg. level. 

Given that KCL and CaCL are compatible, would you mix them in the same bag of D5W? State your rationale.
Discuss safe administration of IV KCL and CaCL.

-assess kidney function
-monitor vitals, allergies, lab values, frequent monitoring, I/O ratio.

What additional nursing action is necessary?

-BP, allergies, current lab values, baseline/trend values, Bp and pulse noting irregularities, PT output must be recorded.
-Should be on telemetry under constant cardiac monitoring.
What additional bloodwork should be ordered?

-Chem 7

What are the characteristics of a mechanical ventilator that is pressure-cycled?

What clinical implications may be anticipated based on these current laboratory findings?

-hyperkalemia s/s, hypercalcemia s/s disrythmias, slow irregular heartbeat, fluid overload, hyperglycemia.

Volume-cycled- inspiratory flow halts
once the target volume is delivered.
Pressure-cycled- inspiratory flow ceases once a peak inspiratory pressure is reached.
Flow-cycled- inhalation is programmed to cease when it senses a drop in the peak flow rate, and expiratory phase begins.
Time-cycled- a timed inhalation limit is set and exhalation will begin when that limit is reached


The nurse hears the alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off?

Volume (low pressure)
Pressure (high pressure)
Apnea
Tubing disconnect
PT needs suctioning
What signs and symptoms of improvement should the nurse watch for, that would indicate that the patient is ready to be weaned from the ventilator?

Hemodynamic, cerebral, and metabolic stability.
Temp <38 C
Ability to maintain patent airway and initiate inspiratory effort
Evidence of partial or full resolution of underlying disease process that prompted intubation.
Physician determination of readiness.

Monitor the client for signs of respiratory distress, or airway obstruction, such as ineffective cough, dyspnea or stridor.
Heliox- Heliox generates less airway resistance than air and thereby requires less mechanical energy to ventilate the lungs.

The nurse taking care of G.S.
knows that she must assess what respiratory parameters after extubation?
Bronchoscopy
Hemodynamic Monitoring
The patient is now receiving oxygen by nonrebreather mask. The CXR shows evidence of scattered infiltrates throughout the lung fields as well as diffuse atelectasis. GS's PAO2 continues to decrease and is now at 60 mmHg.
What should the nurse do to prepare for intubation?
1. Marking the tube 1 cm from where it touches the incisor tooth or nares.
2. Assess for bilateral breath sounds and symmetrical chest movement.
3. Auscultation over the stomach to rule out esophageal intubation.
4. Ordering chest radiography to verify that the tube placement is correct.
Specimen/sputum collection--if pt not on vent
Bed bath, mouth care
I&O
ROM
VS, pulse ox

What additional assessment findings may be found in ARDS?

Pulmonary HTN
Multiple organ system failure
Hypotension
Cyanosis of skin, lips, nail beds
Delayed capillary refill
Confusion/disorientation
Adventitious lung sounds
Prolonged hypoxemia
despite 02 delivery


Trauma the patient suffered from the car accident .
The amount of transfusions received during emergency resuscitation.
What factors contributed to this diagnosis?
While caring for GS, what tasks may be delegated to an experienced nursing assistant?
Patient
-heart flip-flop sensations
pulse irregular
-b/p 92/70
-RR 28
-"a little lightheaded"
-denies pain
-denies nausea
EKG
-22 very wide complexes/minute
-early complexes
-not preceded by P wave

-A premature ectopic impulse originating in the ventricles
-Usually caused by increased automaticity and electrical irritability in the ventricular conduction system or muscle tissue
-Can lead to more serious arrhythmias (V tach: 3 PVCS in a row with a fast rhythm,150-250 HR) and decreased cardiac output
-Characterized by an early, abnormal QRS complex
-No P wave; P wave can be within underlying rhythm
-Some causes are Hypoxia, acidosis, electrolyte imbalance, anxiety which are related to G.S.
-Typically dx after patient describes "skipping, racing, flipping, flopping sensations"
-Those sensations are due to a pause after the premature
contraction and then a powerful contraction after the pause.
Signs and symptoms include:

Abnormal EKG

Irregular heart beat
• Shortness of breath

Dizziness
• Feeling your heart beat (palpitations)
• Feeling of occasional, forceful beats
• Increased awareness of your heart beat

Premature Ventricular Contractions
-Correct underlying problem
-Could require no treatment
-If frequent or poorly tolerated, IV lidocaine or procainamide may be used
-In non-acute setting, oral antiarrhythmics may be given

-heart flip-flop sensations
-pulse irregular
-b/p 92/70
-RR 28
-"a little lightheaded"
-denies pain
-denies nausea
-electrolyte imbalances; WHAT ELECTROLYTE IS MOST IMPORTANT?
-respiratory acidosis
-hypoxic

EKG
-22 very wide complexes/minute
-early complexes
-not preceded by P wave

Ventricular Tachycardia Treatments
-correcting the underlying causes
-correct electrolyte levels; oxygen
-continue current meds
-continue cardiac monitoring and VS
-support the patient and family
-prevent further complications
Even if death is imminent, a transfer from the ICU could be disruptive to the patient, family and staff members. What nursing action(s) can or will you take to respond to this situation?

Involve social work to evaluate the seriousness of the situation,
discuss options: need to identify the chances of her surviving in either setting.
Family meeting, explaining the necessity of the transfer, risks of staying in the ICU.
May calm the family, determine family needs.


NURSING ACTIONS

-Involve social work to evaluate the seriousness of the situation,
-discuss options: need to identify the chances of her surviving in either setting.
-Family meeting, explaining the necessity of the transfer, risks of staying in the ICU.
May calm the family, determine family needs.

What is the nurse’s role in supporting that patient’s needs in this situation?
-Determine the patients ability to receive support.
-Increase consistent communication between doc and family,
-Advocate for the pt.
-Be there/ present and support the family (listen).

Give examples of end-of-life care requiring the intervention of skilled critical care nurses for G.S. at this point in her care.
-pain control, comfort measures,
-encourage the family to communicate with patient.
-Grief counseling referral,
-offering clergy,
-Psychosocial support
-Active istening
-Just being present for the patient and family
G.S.’s arrhythmias respond to your treatment. Unfortunately, 1 week later, she puts the call light on and complains of difficulty breathing. As you enter the room you find the following: G.S. has no pulse and is not breathing.
What steps can be taken for the nurses of dying patients?
-Give them time off,
-Provide a place of privacy for grieving
-grieving process with the family, -counseling, grief counseling,
-Help facilitate steps necessary for the family to carry out the desired arrangements
-nurse must go through the grieving process as well.

How can nurses use the experience of caring for a dying patient for personal and professional growth?
-Taking it as a valuable experience,
nursing education reform, guidelines for providing terminal care
-More training on how to communication with families.
-Experiences can make nurses realize that not everyone can be saved.
-Death is a part of life.
Define Moral distress and explain its association with patient care in critical care settings?
-According to Laura Espinosa, Three factors contribute to the moral distress
1. barrier to optimal care
2. internal conflict
3. coping
Barriers to optimal care
-Lack of involvement in the plan of care
-Differences between the medical and nursing practice models
-Unrealistic expectation of the family
-Lack of education

Internal conflict
-Abandonment and powerless

-Conflict with meds administration

Coping
-Ineffective coping strategy:

- crusty nurse attitude.

How can nurses avoid suffering from moral distress and burnout?
-Vacation,
-Grieving with the family
limit OT, realize the nurses in role in end of life care.
-Find activities to do outside of work,
crying relieves stress
-Group counseling, therapy.
-Talking with others co-workers
-Designing and helping to implement policies and procedures, education reform.
-What’s the difference between hospice and palliative care?
-
All hospice care (care at the end of life) is palliative care, but not all palliative care (care to make the patient comfortable), is hospice
GS 36 yo F
Employed as a secretary
Involved in head on MVA
Injuries include:
bilateral flail chest
torn innominate artery
Right hemo/pneumothorax
Ruptured spleen
multiple small liver lacerations
bilateral compound leg fx
probable cardiac contusion
Received 36 units PRC, 20 units platelets, 20 units cryoprecipitate, 12 units FFP, and 18L of LR in OR.
GS is admitted to ICU post-op. Upon assessment she is complaining of difficulty breathing and RR is 32/min. She is becoming restless, lung sounds notable for diffuse crackles and wheezes, bilaterally throughout lung fields with worsening at the bases. She has an occasional productive cough, pulse ox 85%.
Helpful Links
http://www.easyauscultation.com/lung-sounds-reference-guide.aspx
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html
http://www.nlm.nih.gov/medlineplus/respiratoryfailure.html
Beckstrand, R., Callister, L.C. & Kirchhoff, K.T. (2006). Providing a “good death”, Critical care nurses’ suggestions for improving end-of-life care. American Journal of Critical Care, 15(1), 38-45.
Dirkes, S., Dickinson, S. & Havey, R. (2012). Prone positioning is it safe and effective? Critical Care Nurse Quarterly, 35(1), 66-75.
Engstrom, A. & Soderberg, S. (2005). Close relatives in intensive care from the perspective of critical care nurses. Journal of Critical Nursing, 16, 1651-1659.
Espinosa, L., Young, A., Symes, L. Haile, B. & Walsh, T. (2010). ICU nurses’ experiences in providing terminal care. Critical Care Nurse Quarterly, 33(3), 273-281.
Fenstermacher, D. & Hong, D. (2004). Mechanical ventilation; What have we learned? Critical Care Nurse Quarterly, 27(3), 258-294.
Jacobowski, N.L., Girard, T.D., Mulder, J.A. & Ely, E.W. (2010). Communication in critical care: Family rounds in the intensive care unit. American Journal of Critical Care, 19(5), 421-430.
Markou, Myriantbefs, P.M. & Bartopoulos, G.J. (2004). Respiratory failure: An overview. Critical Care Nurse Quarterly, 27(4), 353-379.
Putensen, C., Theuerkauf, N., Zinserling, J., Wrigg, H. & Pelosi, P. (2009). Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Annals of Internal Medicine, 151(8), 566-577.
Siela, D. (2008). Chest radiograph evaluation and interpretation, AACN Advanced Critical Care, 19(4), 444-473.
York, N.L. & Kane, C. (2012). Trends in caring for adult respiratory distress syndrome. Dimensions in Critical Care Nursing, 31(1), 153-158.

Oral care
*ABGs WNL*
LOC, HR, BP Pulse OX
-Tingling, Calcium taste, heat wave feeling
- Ca irritates veins, use central line
- Ca level q2-6hr
- K level q30-60 min via ABG line
Full transcript