Critical Care Nursing Management Quiz

Critical Care Nursing

• Critical Care Nursing Concepts:
  • Assess and teach patients and families about their needs
  • Evaluate the effectiveness of teaching
  • Teach colleagues
  • Possess excellent interpersonal skills
• Advance directives and End-of-life decisions
  • Resuscitation
  • Informed consent
  • Brain death:
    • Whole-brain death: the permanent, irreversible cessation of functioning of all brain areas
      • Complete loss of consciousness
      • Absent corneal, oculovestibular, oropharyngeal, ventilatory reflexes
• Organ donation:
  • Heart & lungs
  • Kidneys
  • Liver
  • Corneas
• The more compromised the client, the more severe or complex are their needs.
• Involves collaboration of all personnel who provide care.

Nurse-Educators

• Assess patients’ and families’ learning needs
• Plan and implement teaching strategies to meet those needs
• Evaluate effectiveness of teaching
• Educate peers and colleagues

Nurse-Managers

• Act as administrative representatives of the units
• Ensure effective and quality nursing care is provided in a timely and fiscally sound environment

Case-Managers

• Manage comprehensive care of an individual patient
• Encompasses the patient’s entire illness episode, crosses all care settings, and involves all personnel providing care
• Involved in discharge planning and making referrals
• Identify community and personal resources
• Arrange for equipment and supplies needed by the patient on discharge

Clinical Nurse Specialists

• Participate in education and direct patient care
• Consult with patients and family members
• Collaborate with other nurses and health care team members to deliver high-quality care

Care of Critically Ill Clients

• Provide direct one to one client care
• Responsible for making life and death decisions
• At high risk of injury or illness from possible exposure to infections
• Communication skills are of optimal importance

Critical Conditions

• Any persons with life-threatening conditions
• Patients with:
  • Acute Respiratory Failure
  • AMI
  • Cardiac Tamponade
  • Severe Shock
  • Heart Block
  • Acute Renal Failure
  • Poly Trauma, Multiple Organ Failure and Organ treatment such as drugs and mechanical support

Critically Ill Clients

• At high risk for actual or potential life-threatening health problems
• Require more intensive and careful nursing care

Multidisciplinary and Collaborative Approach to ICU Care

• Medical and Nursing Directors: co-responsibility for ICU management
• Team approach:
  • Nurses, doctors, respiratory therapists, pharmacists
• Use of standard, protocol, guidelines for a consistent approach to all issues
• Dedication to coordination and communication for all aspects of ICU management
• Emphasis on research, education, ethical issues, patient advocacy

Team Dynamics

• Multidisciplinary team to effectively attain specified objectives.
• Intra-arterial blood pressure measurement
• Evaluate the effectiveness of cardiovascular function such as cardiac output and index.

Indications for Hemodynamic Monitoring

• Deficits or loss of cardiac function:
  • Myocardial infarction
  • Congestive heart failure
  • Cardiomyopathy
• All types of shock:
  • Cardiogenic shock
  • Neurogenic shock
  • Anaphylactic shock
• Decreased urine output from:
  • Dehydration
  • Hemorrhage
  • G.I. bleed
  • Burns or surgery

Specialized Equipment Needed for Invasive Monitoring

• CVP, pulmonary arterial catheter
• Flush system:
  • Intravenous solution
  • Tubing stop cocks
  • Flush device providing continuous and manual flushing of the system
  • Pressure bag maintained at 300mmHg pressure
• Transducer to covert pressure into an electrical signal
• Amplifier or monitor to increase the electrical signal for display on an oscilloscope

Complications of Hemodynamic Monitoring

• Local destruction with distal ischemia
• External hemorrhage
• Massive ecchymosis
• Dissection
• Air embolism
• Blood loss
• Pain
• Arteriospasm
• Infection

Central Venous Pressure (CVP)

• Pressure in the vena cava or right atrium
• Used to assess right ventricular function and venous blood return to the right side of the heart

Mechanical Ventilation

• Assists or controls breathing
• Types:
  • Positive-pressure ventilation (PPV):
    • Pressure-controlled ventilation (PCV): ventilator delivers preset pressure to the lung at each breath.
    • Volume-controlled ventilation (VCV): ventilator delivers preset volume of air with each breath.

Hazards of Mechanical Ventilation

• Barotrauma: air escaping into the tissues of the lungs or chest wall.
• Volutrauma: injury to the alveoli.
• Ventilator-associated pneumonia (VAP): infection of the lungs.
• Atelectasis: collapse of the alveoli.
• Oxygen toxicity: damage to the lungs caused by high levels of oxygen.
• Pneumothorax: air in the space between the lungs and chest wall.

Ventilator Modes

• Assist-control ventilation (ACV): Provides breaths when the patient’s breathing is insufficient,
• Synchronized intermittent mandatory ventilation (SIMV): Allows patients to breathe at their own rate and volume spontaneously, while providing periodic mechanical breaths.
• Pressure support ventilation (PSV): Provides a continuous, assist-controlled ventilatory mode that helps to support spontaneous breathing.
• Continuous positive airway pressure (CPAP): Provides continuous flow of positive pressure to maintain lung inflation and increase oxygenation,
• Positive end-expiratory pressure (PEEP): Provides positive pressure to maintain lung inflation.

Considerations for Ventilator Use

• Monitor patient's respiratory status: to identify and adjust respiratory support as needed.
• Titrate ventilatory settings based on patient’s clinical condition.
• Monitor hemodynamic stability : for changes in blood pressure, heart rate, and urine output.

Nursing Care for Clients on Mechanical Ventilation

• Monitor for signs and symptoms of ventilator-associated pneumonia (VAP): such as fever, increased sputum production, and changes in respiratory rate and effort.
• Provide oral care: to prevent VAP.
• Turn and reposition the patient: to prevent atelectasis (collapse of the alveoli) or airway obstruction.
• Maintain adequate hydration : to improve lung function and decrease thick secretions.

Weaning the Patient from Mechanical Ventilation

• Gradual reduction of ventilator settings: to allow the patient to regain respiratory strength and assume more of the work of breathing.
• Assess the patient’s ability to breathe independently: to determine if the patient is ready for weaning.
• Monitor the patient’s response to weaning: to ensure that the patient is tolerating the decreased ventilatory support.
• Provide emotional support : to help the patient cope with the weaning process.

Nursing Management of Clients with Alterations in Metabolic GI, Liver Function

Acute GI Bleeding

• Nursing Interventions:
  • Assess for signs and symptoms of bleeding:
    • Melena
    • Hematemesis
    • Hematochezia
    • Abdominal pain.
• Support and monitor airway, breathing, and circulation (ABCs).
• Monitor vital signs for a decrease in blood pressure and increase in pulse.
• Monitor laboratory values for changes in blood clotting.
• Administer medications, such as proton pump inhibitors, H2 blockers, or antacids.
• Provide fluid resuscitation to replace blood volume.
• Prepare the patient for possible endoscopy or surgery to stop bleeding.

Intra-abdominal Hypertension and Compartment Syndrome

• Nursing Interventions:
  • Monitor for signs and symptoms of intra-abdominal hypertension (IAH) and compartment syndrome:
    • Abdominal distention.
    • Decreased urine output.
    • Increased respiratory rate.
    • Decreased bowel sounds.
    • Pain with palpation of the abdomen.
  • Monitor vital signs for decreases in blood pressure and increases in heart rate.
  • Monitor laboratory values for changes in blood clotting.
  • Monitor for signs of organ dysfunction:
    • Respiratory distress
    • Oliguria
    • Altered mental status
  • Administer antibiotics to prevent infection.
  • Patient may need treatment in a surgical ICU due to possible surgery for a condition such as decompression of the abdomen.
  • Provide emotional support to the patient and their family

Liver Failure

• Nursing Interventions:
  • Monitor for signs and symptoms of liver failure:
    • Jaundice
    • Ascites
    • Hepatic encephalopathy
    • Coagulopathy
  • Assess daily for changes in mental status, including signs of confusion or altered consciousness.
  • Monitor vital signs for changes, including fever, hypotension, tachycardia, and tachypnea.
  • Monitor laboratory values for liver function tests (LFTs) and blood clotting studies.
  • Assess intake and output to monitor volume status and for signs of fluid overload.
  • Administer medications, such as diuretics, lactulose, and vitamin K.
  • Provide supportive care, including nutritional therapy, and fluid and electrolyte management.

Acute Pancreatitis

• Nursing Interventions:
  • Monitor for signs and symptoms of acute pancreatitis:
    • Severe abdominal pain
    • Nausea and vomiting
    • Fever
    • Tachycardia
    • Hypotension
  • Monitor vital signs for changes in blood pressure, pulse, respiratory rate, and temperature.
  • Monitor laboratory values for changes in pancreatic enzymes (amylase and lipase).
  • Assess pain and provide pain management.
  • Provide IV fluid replacement: to help prevent dehydration.
  • Monitor for potential complications: such as fluid overload, respiratory distress, and infection.
  • Provide emotional support to the patient and their family,

Bariatric Surgery

• Nursing Interventions:
  • Provide nutritional counseling to the patient in order to support their weight loss,
  • Monitor for signs and symptoms of complications from the surgery such as bleeding, infection, or leaking (anastomotic leak).
  • Encourage ambulation to prevent DVT (deep vein thrombosis),
  • Provide psycho-social support to the patient and family.

Nursing Management of Clients with Alterations in Elimination

Diabetic Ketoacidosis (DKA)

• Nursing Interventions:
  • Monitor for signs and symptoms of DKA:
    • Hyperglycemia
    • Polyuria
    • Polydipsia
    • Kussmaul respirations
    • Acetone odor on breath
    • Abdominal pain
    • Nausea
    • Vomiting
  • Monitor vital signs for tachycardia, tachypnea, and hypotension.
  • Monitor laboratory values for blood glucose, electrolytes, and ketones.
  • Administer insulin to lower blood glucose.
  • Provide IV fluids, such as normal saline, to rehydrate your body.
  • Administer potassium to correct hypokalemia.
  • Provide emotional support to the patient.
  • Educate the patient about managing their diabetes and prevention of future DKA episodes.

Renal Failure

• Nursing Interventions:

  • Acute Renal Failure (ARF):

    • Causes of ARF:
      • Decreased blood flow to the kidneys (prerenal failure)
      • Damage to the kidneys (intrarenal failure)
      • Blockage of the urinary tract (postrenal failure)
    • Monitor for signs and symptoms of ARF:
      • Decreased urine output (oliguria or anuria)
      • Fluid retention (edema)
      • Elevated blood pressure
      • Electrolyte imbalances
      • Nausea and vomiting
      • Weakness and fatigue
      • Confusion and lethargy
    • Monitor vital signs for changes in blood pressure, heart rate, respiratory rate, and temperature.
    • Monitor laboratory values for electrolytes, BUN (blood urea nitrogen), creatinine, and urine output.
    • Provide supportive care, including diet restrictions, fluid management, and medication management.
    • Educate the patient about managing their renal failure.

  • Chronic Renal Failure (CRF) / End Stage Renal Disease (ESRD):

    • Monitor for signs and symptoms of CRF:
      • Fatigue
      • Nausea and vomiting.
      • Shortness of breath.
      • Swelling in the legs, ankles, and feet.
      • High blood pressure.
    • Monitor vital signs for changes in blood pressure, heart rate, and respiratory rate.
    • Monitor laboratory values for creatinine, BUN (blood urea nitrogen), electrolytes, and hemoglobin.
    • Provide supportive care, including diet restrictions, fluid management, dialysis, and medication management.
    • Educate the patient about managing their CRF and living with their disease

RIFLE Criteria for Diagnosis of ARF

• Risk: Increased creatinine by 1.5 times from baseline

• Injury: Increase in creatinine to two times baseline, or urine output less than 0.5 ml/kg/hr for six hours

• Failure: Increase in creatinine to three times baseline, or a urine output of less than 0.5 ml/kg/hr for 12 hours

• Loss: Complete loss of kidney function for more than four weeks

• End-Stage Renal Disease (ESRD): Complete loss of kidney function for more than three months

Management of Renal Failure

• Dialysis:
  • Hemodialysis: Removes waste products and excess fluid from the blood.
  • Peritoneal dialysis: Uses the lining of the abdominal cavity to filter the blood.
• Kidney Transplant: Replacement of a failing kidney with a healthy kidney from a donor.