Respiratory Failure & Advanced Airways PDF

Respiratory Failure & Advanced Airways Airway overview Endotracheal intubation Tracheostomy tubes Respiratory Failure & Advanced Airways Airway overview Endotracheal intubation Tracheostomy tubes Normal Resp. Alteration Resp F...

Respiratory Failure & Advanced Airways Airway overview Endotracheal intubation Tracheostomy tubes Respiratory Failure & Advanced Airways Airway overview Endotracheal intubation Tracheostomy tubes Normal Resp. Alteration Resp Failure -Acute. system - status - - asthma > asthmations sat - albuterol infl oxygen + broncho constriction - +. - pink/appropriate mucus & inflammation -steroids - - Oz -rate - epi relaxes muscle Mg - expansion - - - pop alvedi openy - BCL sounds - coppe NIPPV (bipap) , HENC ment to - CO2 slep - do not really - ABG intubate - CXR - PNA- - PFTs Hgb 4 - > - O -  1. Differentiate between oxygenation and ventilation while determining impact on body systems and homeostasis (CO: EBO 1, 2, 3) 2. Discuss the analysis of respiratory diagnostic studies and appropriate nursing interventions in the care of the client with complex alterations in oxygenation (CO: EBO 1, 2, 3; VBO 1) 3. Compare the various oxygen modalities and therapies utilized in Unit II clients experiencing alterations in oxygenation (CO: EBO 1, 3) Objectives 4. Prioritize best practice nursing interventions with focus on safety, prevention, and management of clients with complex alterations in oxygenation (CO: EBO 1, 2, 3, 5; VBO 1) 5. Discuss effective collaborative communication strategies with client, family, and interdisciplinary team to ensure positive client outcomes (CO: EBO 4; VBO 1,2) 2   It is a failure of….  Oxygenation not crossing to alveali  Ventilation Acute  Both of the above Respiratory  Altered gas exchange (room air) Failure (ARF)  PaO2 < 60 mm Hg → hypoxemia  PaCO2 > 50 mm Hg → hypercapnia  pH ≤ 7.30 → acidemia  Sa02 < 90% 190 = keep dive in padz for COPD pt - can be problem oxygenation 3   Hypoventilation  Intrapulmonary shunting Failure of  Ventilation-perfusion mismatch Oxygenation  Diffusion defects  Decreased barometric pressure (high altitude) lead  Non-pulmonary hypoxemia - tissue hypoxia  Low cardiac output (CO)  Low hemaglobin - if bad heart , not getting hemoglobin not reliable in anemic pt SpOz is 4   Some conditions prevent tissues from using oxygen despite availability:  CV related: shock, altered perfusion Tissue  Pulmonary related: Carbon monoxide poisoning Hypoxia  Tissue hypoxia results in anaerobic metabolism and lactic acidosis 5  Results in Hypercapnia  Related to:  Increased C02 production  Decreased alveolar ventilation Failure of  Airway and alveoli abnormalities Ventilation  CNS dysfunction  Chest wall abnormalities  Neuromuscular conditions 6  Ms. Emmi Physema is a 62 y/o presenting to the ER with increasing SOB, new onset confusion, and restlessness. She resides at a local assisted living facility. Medical History: COPD and hypertension Medications: Budesonide / Formoterol and amlodipine steroid bronchodilalar CCB Assessment Data: Case Study: Subjective: “I need to get up and go make breakfast…let me up….I feel like I can’t catch my breath…” Objective: Disoriented (only knows name/DOB), auscultated bilateral wheezes with rales in right middle and lower lobes, S1 S2 noted, peripheral pulses 2+/ 2+, 1+ edema ankles, capillary refill bi-pap (1st) 10 ↳ wash out CO2 Acute Respiratory Failure Concerns and Actions Possible corticosteroids 11  Ms. Physema is placed on BiPaP with 45% oxygenation and appropriate inspiratory and expiratory pressure settings to ease breathing. Critical Thinking What are reasons Noninvasive Positive Challenge…. Pressure Ventilation (NIPPV) would be contraindicated?? - CNS d - N/V (aspiration into lungs) manage patent airway to - unable drug overdose : no respiratory drive - reversal intubate -give - (ARDS) refactory hypoxemia - ↳> intubation straight into 12  Ms. Physema is continuously monitored in the ER while awaiting a bed in the ICU. Her vitals are as follows: T 99 (oral) HR 135 (sinus tachy), RR 34 with increased use of accessory muscles, BP 165/105 (125 MAP), pulse oximetry 86% despite increasing oxygen to 80% via BiPaP. - CO2 faster Case Study to fix us HCO3 ABG: -Slow + steady Progresses…. normal & ↑ - pH 7.42 PaC02 58 Pa02 60 HC03 30 acid alkaline = Fully compensated Respiratory Acidosis The decision is made to insert an endotracheal tube (intubation) and place her on a ventilator. 13  Oropharyngeal airway - no oropharynged airway in conscious pt Airway Adjuncts Nasopharyngeal airway 14   Hypoxemia  PaO2 ≤ 55 mm Hg on FiO2 > 0.5 (50% oxygen)  Pulse oximetry 0.5 Indications  Hypercapnia for  PCO2 ≥ 50 mm Hg with pH ≤ 7.32 Intubated  Progressive deterioration Ventilation  Tachypnea, bradypnea, or apnea Crashcart (  Decreasing Tidal Volume (VT ) intout breathing art.  Increase in work of breathing (WOB)  Inability to maintain airway  Neurological dysfunction 15  - Head/neck trauma = tracheostomy  Insertion of an endotracheal tube (ETT)  Orotracheal route preferred to reduce infections  Nasal if oral trauma or oral surgery Endotracheal  Used to: Intubation  Maintain an airway  Remove secretions  Prevent aspiration  Provide mechanical ventilation - below where bronchi split - bronchial hygiene 16  Intubation Equipment Equipment used for endotracheal intubation: A. stylet (disposable); B. endotracheal tube with 10-mL syringe for cuff inflation; C. laryngoscope handle with attached curved blade (left) and straight blade (right); D. water-soluble lubricant; E. colorimetric CO2 detector to check tube placement; F. tape or G. commercial device to secure tube; H. Yankauer disposable pharyngeal suction device; I. Magill forceps (optional). Additional equipment, not shown, includes suction source and stethoscope. 17   Explain procedure to  Sniffing position (next client slide) pt - head back Endotracheal  Remove dentures  Suction oropharynx Intubation  Ensure patent IV  Pre-medicate—RSI (by RT or  Hyperoxygenate client sedation 1 st (plus pain med) then paralytic if provider) with 100% NRB prescribed pain meds paralyti  Continuous SpO2 sedate - > - ->  Intubate within 30 sec  Gather supplies  Inflate balloon RSI:  Endotracheal tube  Stylet  Ventilate w/100% 02 Rapid  Lubricant for tube via BVM (w/ambu) Sequence ↓  BVM, Ambu, C02 st  Verify placement detector available (capnography then Intubation CXR)  Laryngoscope and blade  Connect to ventilator available - to see air way "lungs bilaterally heard , negative over abdomen" 18  "C + E" Airway and Breathing Rescue breathing with bag-mask device. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.) 19  015L Airway and Breathing Advanced Airway- endotracheal Bag-valve-mask should tube have a reservoir and be connected to 02 with regulator dialed to 15L Ventilation with a bag-valve device connected to endotracheal tube. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.) 20 Airway and Breathing Capnography aka ETC02 End-tidal carbon dioxide detector connected to an endotracheal tube. Exhaled carbon dioxide reacts with the device to create a color change indicating correct endotracheal tube placement. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.) 21  out out out Waveform in in in Capnography - breathing out CO2 - flat = lost ET placement lost pulse t endotrachea tube carotid pulse * or * check Normal waveform indicating adequate ventilation pattern (ETCO2 35 to 40 mm Hg). B. Abnormal waveform indicating airway obstruction or obstruction in breathing circuit (ETCO2 decreasing). Check the endotracheal tube for placement and then check for carotid pulse. Major determinate of C02 delivery to the lungs is cardiac output (CO), if ETC02 drops, client is no longer perfusing with adequate CO 22   Visible bilateral chest rise  Auscultate bilateral breath sounds  Auscultate epigastric area Immediately  ETCO2 detector after  Secure tube Intubation:  CXR (confirmatory)—2 to 6 cm above carina  Record position of ETT in cm at the teeth/ lip Verify 22 o cm the lip Placement  Follow up ABG in 30-60 minutes post intubation 23   How do you tell if the ET tube is in the right mainstem bronchus? lobe Lung only be in right left + sounds will none on Critical - and equal chest expansion Thinking - a chance to go into Challenge  What do you do if you suspect the ET tube is in the esophagus? -Remove toke ventillate /100 % then , manually Oxygen to interbate seconds attempt again w/in 30 24   Indications Tracheostomy:  Long-term mechanical ventilation and/or recovery Surgically  Frequent suctioning created stoma  Protecting the airway  Bypass an airway obstruction  Reduce work of breathing BS Chapter  Sometimes in morbid obesity w/ OSA 19…starting  Placed in OR or bedside in the ICU p. 557  Cuffed tube for mechanical ventilation to prevent air leak cuff for ventilation - from prevents air  Keep obturator at bedside - leaking  Replacement trach tube at the bedside - same size O bedside - hold retention suture stay opened for Crew airway - opened 25 Parts of Tracheostomy Tube   Post-procedure care  Obturator removed, kept  Cuff (balloon) is inflated if using vent  Auscultate for air entry  Connect client to ventilator w/cuff inflated Tracheostomy  Deflate cuff when on trach collar Nursing  Tracheostomy sutured in place and Management secured with velcro strap/ ties days for ↳ sutures  Mouthcare 92h encourage , to swallow if awake  Skin care around neck  Trach care  Replace trach ties - one side first , to other when get side then place 27   Explain procedure, position semi-fowler  Cleansing inner cannula  Gather equipment, position client, don NCLEX PPE, set up equipment Readiness:  Don sterile gloves  Unlock and remove inner cannula; place Trach Care in sterile saline, cleanse with trach brush, rinse in sterile NS, reinsert, lock (Review on in place your own—  If disposable, replace notes on  Cleanse stoma slide)  Change ties (if needed 24 hours after placement of trach)  Remove old ties after new ones applied - Sterile (3 mos. months clear 28 - 3 procedure =   Suction only as indicated by assessment  Visible secretions  Coughing Advanced  Rhonchi  High pressure alarm on ventilator Airway  Decreasing O2 sats Suctioning:  Open versus inline (closed) suction (next slide)  Procedures  Hyperoxygenate with 100% 02 Endotracheal  Explain procedure to client! or  Only suction while withdrawing catheter and no longer than 10 seconds only - when needed tracheostomy  Allow for rest in between suctioning  Avoid normal saline instillation - put never salive down  Monitor SpO2 and heart rate before, during, and after suctioning - doesn't drop 29 Closed Suctioning Ex. Ballard suction Closed tracheal suction device. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2011-2016. All rights reserved.) 30  pressureport Courtesy of AACN 31   Respiratory rate 21 % RA =  FiO2 "Oxygen"  Tidal Volume (VT) Cusually low)  Peak inspiratory pressure (PIP) Chormuchprese that ( air  Positive end-expiratory pressure (PEEP) Ventilator  5-20 cm H2O exhalation - end Settings - minimum  Decreases CO and venous return to of 5 c H2G heart - good make sure BP , tank after - intubation sedation + ↓ CO  Pressure support  Mode of ventilation  Alarm settings 32  collapsed reali Effect of Positive End- Expiratory Pressure (PEEP) on alveoli.... Alveoli with peep on right Effect of application of positive end-expiratory pressure (PEEP) on the alveoli. (Modified from Pierce LNB. Management of the Mechanically Ventilated client. Philadelphia: Saunders; 2007.) 33   Describes how breaths are delivered Modes of  Method by which the client and the ventilator Mechanical interact to perform the respiratory cycle Ventilation  Full or partial support  Client triggered or ventilator triggered breaths  Spontaneous or mandatory breaths 34 Classified by - the volume is constant method of ending the  The VT delivered by the ventilator is constant inspiratory  Regardless of compliance and resistance phase  Air will flow into lungs until preset volume reached  Must monitor PIP (do not want above 40cm H20)  Risk of hyperventilation, respiratory alkalosis, Volume- ventilator induced lung injury (VILI) Cycled Ventilation 35 Classified by -set to preset pressure method of - concerned for stiff lungs ending the  Ventilator set to allow airflow until preset pressure is reached inspiratory  VT is variable—must watch exhaled tidal phase volume!  PIP can be better controlled  Risk of hypoventilation, atelectasis, respiratory Pressure- acidosis sog - Cycled - when reaches pressure = exhales Ventilation - if doesn't reach pressure = hypoventilation 36  ↓ work of breathing  Client’s spontaneous inspiratory effort is assisted by preset amount of positive pressure during inspiration Pressure  Decreases work of breathing with spontaneous Support (PS) breaths  Also useful in weaning, when vent rate is turned off 37 CPAP:  Administered throughout respiratory cycle to client who is spontaneously breathing  Similar to PEEP Continuous  Via ventilator or nasal or face mask Positive (NIPPV)  Option for clients with sleep apnea Airway (OSA) Pressure  May facilitate weaning  Can also be used to prevent reintubation (NIPPV) 38  Which client would not be a candidate for NIPPV (BiPaP)? A. COPD with acute pneumonia = helps alveavi + secretion Quick Quiz! B. Heart failure exacerbation in need of ↑ pressure in diuretics alveoli alveali HF = fluid in fluid out -blowing + giving diuretics C. Drug overdose with shallow respirations ↳ need intubation D. Asthma exacerbation in need of bronchodilators and steroids ↳ If tolerate helps gas exchange stay + , open 39  ETT Out of Position  Right mainstem bronchus  Dislodged Unplanned Extubation Complications  Nurse must protect airway to prevent unplanned of extubation Mechanical  Securing the tube is important, Keep ambu at bedside Ventilation Laryngeal/Tracheal Injury - calm  Prevent excessive head movement  Routine monitoring of ETT cuff pressure Damage to Oral and Nasal Mucosa  Skin breakdown from tape and commercial devices if needed - mouthcome g2H , retape  Reposition tube in mouth per policy 40  Never turn alarms off; silence only. Manually ventilate with ambu bag if uncertain of problem and call respiratory therapy Types of Alarms and  High pressure alarms → potential - Secretions : blocking movement of rent air-a lot of pressure needed biting tube coughing breathing against - causes on , , - kinks in tube bronchospasm prewmothorax - pulmonary edema , , B/S table 19-5  Low pressure limit → - disconnection tubing from went or from ETT - cuff leak (should not hear air ATI - unplanned extubation Chapter 19  Apnea (only be seen in the weaning) - sedation is off 41 Ms. Physema is moved to the intensive care unit where she is placed on a cardiac monitor, ventilator, and attached to the monitoring devices. Case The nurses will work together to get her settled and comfortable. Pharmacology will be covered next Study week. Care for the client in the ICU involves a Continues holistic approach with interdisciplinary input to make certain that the client receives evidence- based care with a focus on ICU liberation, aka discharge out of the unit to a lower level of care as soon as possible.  Collaboration  Create a collaborative culture of safety  Part of a Healthy Work Environment  Interdisciplinary daily rounds at the bedside  ICU Liberation → A – F Bundle  Care of the client in the ICU is protocolized Courtesy of the SCCM http://www.iculiberation.org/Bundles/Pages/default.aspx   Normal protective mechanisms bypassed—aspiration risk  Ventilator-associated pneumonia (VAP)  Oral flora Infection - if doing well-call HCP Prevention:  VAP Bundle /VAI Bundle - calm = talk to them  HOB 30º to 45º Ventilator off sedation  Sedation vacation (B) turning everyday If + breathe see can Associated  Stress ulcer prophylaxis to irritation on ow n = Gl bleed - secrete cortisol = prove CH2 blocker)  DVT prophylaxis - famotide IV Pneumonia - PPI if needed higher - SCD's anticoag : Heparin 50000 , BID  Oral care and oral suction (q , 2 hr) - clean mouth , swab , suction 44  have tidal -make sure we right volume /out  Under ventilating - good volume in - PEEP  Cuff leaks, low volume setting, lung secretions, Alveolar hypo- mucous plugs ventilation  Results: atelectasis, hypoventilation, respiratory acidosis  Treatment: Appropriate Vt setting, increase in PEEP, turn q 2 hours, suction as needed - pulm. (skin  Over ventilating - good settings Alveolar hyper-  Results: respiratory alkalosis - no pain/anxiety ventilation  Treatment: appropriate settings  If client hyperventilating: sedation, pain medication, anti-anxiety medications 45   Due to lung inflation pressures increasing  Examples  Pneumothorax  Tension pneumothorax  Detect  High pressure alarm Barotrauma  Decreased breath sounds  Tracheal shift TensionPneumo  Subcutaneous crepitus temphysema  Hypoxemia  Treat tension pneumothorax emergently  Needle decompression emergency : - CT in  Chest tube if : notimmediate distress 46   Overdistension of alveoli causes tissue Volutrauma changes  Damages the lung similar to early ARDS  Monitor inspiratory pressures ventillation long time -  Respiratory acidosis Acid-Base  Respiratory alkalosis Disturbances 47   Hypotension Cardiovascular  Decreased cardiac output (CO) > - PPV causes ↓ Co + System  Decreased venous return to heart venous return stimulate - renin > - angiotens 1 in + 2 lungs  Decreased CO decreases renal blood flow in ACE cough - angio tensin aldosterm Sodium & Water renin  Causes compensatory RAAS activation ↳ fluid Imbalance retaining  Possible decrease in atrial natriuretic peptide→ sodium retention  Stress response: ADH and cortisol→ more sodium and water retention RAAS = water retention 48   Complications NGT to suction  Stress ulcers - maybe - small bore Feeding to be  GI bleeding  risk for aspiration (from stomach) & HOB  Weakened swallowing  Dysphagia > - extubation speech therapy - GI System  Interventions  SUP (H2 or PPI)  NGT or OGT  Provide nutritional  Keep HOB 30-45º  Oral care q2hr and prn  Speech Therapy consult post extubation 49  feed gut -  Hypermetabolic  Early enteral nutrition via gastric tube once intubated Nutritional  Preserves structure and function of gut mucosa, Therapy microvilli  Prevents translocation of gut bacteria  Monitor albumin, prealbumin, total protein, electrolytes, CBC - most sensitive - RBC -+ Mgia /buliso 2-3 says possible if Feed sepsis no - 50   Passive ROM  Active ROM Musculoskeletal  Consult PT/ OT System  Is “E” on the ICU liberation bundle: Early mobility and exercise 51   Impaired blood flow to and from the brain Neurological  Detrimental in elevated ICP System  Treatment: use lowest possible PEEP, tidal volume (Vt), keep head midline vacation - daily sedation  Stress & Anxiety Psychosocial  Delirium Complications  Noise  Altered sleep-wake patterns  Dependence 52   Cannot vocalize needs  Major stressors  Fear  Frustration Communication  Isolation  Anger with ET Tube  Helplessness  Anxiety  Sleeplessness  Delirium  Restraints 53   Create a healing environment  Focus plan of care on client and family  Reduce noise  Reduce light  Provide reassurance Non-pharm  Sleep-wake cycles Interventions  Orientation measures (time, place)  Complementary and alternative measures  Therapeutic touch  Guided imagery/relaxation  Spirituality/prayer 54  awakened them " "I have , maybe ready  Individualized  Collaborative effort  Inform client of expectations Weaning  The “B” of Bundle Clients from Ventilator:  The “F” of Bundle  Involve family, loved Liberating ones 55   Resolution of respiratory failure cause  Hemodynamic stability; adequate CO Readiness to  Adequate respiratory strength Wean  Oxygen: SpO2 ≥90% PEEP ≤5 FiO2 ≤50%  Mental readiness and neuro intact  Respiratory suppressing meds are minimal vacation when stable sedation - only - vasopressors , tachy , ↓ BP = not ready - off sedation + follow commands 56   Ventilator settings  Provide pressure support or CPAP Weaning  No vent respiratory rate Methods  T-piece trials - if = can ready do this 57  Respiratory  Rate > 30 or < 8 bpm  Low spontaneous tidal volume  Increased WOB Stop the  Abnormal breathing pattern Weaning  Low oxygen saturation < 90% Process Cardiovascular  HR or BP changes > 20% from baseline  Dysrhythmias (e.g., PVCs)  ST-segment elevation  Diaphoresis Neurologic  Decreased LOC - Co24/2 gas exchange  Anxiety/ agitation/ restlessness  Subjective discomfort 58   Determine need for secretion management 100 % 1-2 min  Hyperoxygenate, suction prior to extubation - RT will deflate cuff  Assess Suction cough - -...  Hoarseness—expected Extubation  Stridor—airway obstruction  Change in vital signs  Low oxygen saturation ] -not normal  NIPPV may be needed - bridge 1-2 hours  Monitor closely first hour post extubation 59 Welcome to NURS 4130 Complex Illness and Disease Management NCSBN Clinical Judgment Measurement Model Six Cognitive processes, embracing the nursing process, drive nursing clinical judgment and decision-making ability Assessment Analysis Planning Implementation Evaluation Form & Recognize Analyze Generate Evaluate Prioritize Take Actions Cues Cues Solutions Outcomes Hypotheses Critical Thinking & Prioritization Acute before chronic Expected vs. unexpected Urgent vs nonurgent Unstable vs stable Life over limb How do I prioritize?? Maslow’s Hierarchy, nursing process, ABC, Safety and risk reduction, least restrictive and least invasive first (“freebies”), survivability Stay with your client! Trust your knowledge! Prevent client harm! Evaluate Response! Rapid Response Teams: Student Learning Objectives Discuss possible client indicators that would require the notification of the rapid response team. 1. Examine the collection of data to include analysis of complex health care needs, health patterns, and the plan of care to determine clients in need of RRT notification (CO: EBO 1) 2. Discuss barriers to RRT activation and devise methods to overcome them in nursing practice (CO: EBO 4) 3. Demonstrate understanding of safe nursing practice as it relates to complex client needs requiring notification of RRT (CO: VBO 1; Essentials) 4. Utilize the SBAR format as an interprofessional communication tool in complex care situations (CO: EBO 1, 4; VBO 1) 5. Recall BLS guidelines and how to apply to notification of rapid response teams or advanced resuscitation teams (CO: EBO 4, VBO 1) Sequence of Events: BLS→ CAB Advance directives, living wills, DNR? Assess responsiveness Call for help/ AED/ Defibrillator Check for breathing & pulse Circulation: chest compressions proper hand position! Early defibrillation if indicated (use AED) Progresses to Advanced Cardiac Life support (ACLS)—will cover later in Unit III 5  Rapid Response Team Concept 1) Identification of clinical deterioration that triggers early notification of team: ISBAR Report to provider about a critical situation ICU nurse, respiratory therapist, nursing supervisor, hospitalist, pharmacists for example Identify: What is your name and position? I Where are you calling from? Situation: What is the situation you are calling about? Identify the client, age S Briefly state the problem, what is it, when it happened or started, Rapid intervention of personnel and equipment brought to the and how severe. 2) client Background: Pertinent background information related to the situation Diagnosis and date of admission B Code status Relevant medical history related to the situation Recent interventions done for the client primary RN never leaves the client’s bedside! Other clinical information if pertinent: medications, allergies, IV fluids, lab Assessment: What is the nurse’s assessment of the situation? Most recent vital signs A Level of consciousness/ behavior 3) Evaluation: data collection and analysis improves outcomes, Provide other relevant or focused assessment data What you think the problem is prevents complications, and promotes interdisciplinary Recommendation: What are nursing recommendation or what do you suggest? Recommendation that client be seen now, this is urgent need Transfer to higher level of care/ intensive care unit R Request order for: CXR, ABG, CBC, BMP, others? Consult for respiratory therapy, physical therapy, others? response. When would provider like to be notified if there is no improvement? Repeat and verify orders: If orders provided, read back & verify them with provider Modified from: Institute for Healthcare Improvement ∙ ihi.org | This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition  Why Call RRT? Any time concerned about changes in a client’s condition, including: HR, BP Modified RR, oxygen saturation Early Warning Score Temperature changes Acute mental status change Decreased urinary output Laboratory values Align with National Patient Safety Goals (Improve staff communication, using medications safely) Timely documentation of vital signs and assessments is imperative for early warning systems (EWS) to be effective!! Do not delay charting!! Which vital sign is an early indicator of clinical deterioration? Cacid-base imbo) Respiratory early; sign of compensation - Rate  Highly Protocolized ICU nurse is usually the first to respond and team leader Protocols are in place with standing orders for emergent care Supplemental 02, Noninvasive positive pressure ventilation (BiPAP) Stat CXR, EKG Medications: Diuretics, antidysrhythmic Laboratory orders: CBC, BMP with Mg, cardiac enzymes, coagulation Panel Emergent transfers to ICU If neurological event, neurosurgical ICU RN→ NIHSS scale (for possible stroke), expedite stat head CT, transfer to ICU Local ICUs have a “rounding nurse” model Delay in Activation of RRT According to current research, three reasons for delay fall into three main areas: _____________________________ Failure to monitor _____________________________ Failure to recognize ↑ RRT calls = ↓ cardiac arrests _____________________________ Failure to escalate - SBAR exam Call BEFORE cardiac/respiratory arrest What do you think are barriers to activation? Concerned CUS Failure to education, - - uncomfortable - safety issue w/ this pt Effectiveness is only as good as the utilization!! Endocrine Emergencies: Student Learning Outcomes 1.Use the nursing process and the Clinical Judgment Measurement Model to develop nursing actions for clients experiencing endocrine emergencies (CO: EBO 1-4) 2.Discuss barriers to client adherence to therapy which then potentiates endocrine emergencies Develop several nursing actions to intervene for positive client outcomes (CO: VBO 1) Identify client education needs as it relates to pharmacological therapy and endocrine disorders/ emergencies (CO: EBO 3, 5)  - pit Endocrine Hormones—the Wheel - post. pit : ADH + oxy · A Review….  Case Study #1 Thyroid storm vs Myxedema Coma - - HAP history med. - hyperthyroidism An adult assigned female at birth client presents to the ED with reported insomnia, heart fluttering, weight loss, and intolerance to heat. Nurse’s assessment includes: Subjective: Nausea x 1 week, diarrhea x 2 days. Along with reported data, family states client also has been exhibiting increasing irritability and restlessness. Objective: Restless, mild diaphoresis, Eyes appear dry with irritated redness, and slightly protruding (exophthalmos). Lungs clear bilateral upper anterior lobes with bibasilar crackles. S1 and S2 are appreciated with audible S3, peripheral pulses bounding 3+, sinus tachycardia noted on cardiac monitor. A visibly enlarged bulging on the front of neck (goiter), auscultation of the thyroid gland reveals a bruit (turbulent blood flow). VS: T 105.5 HR 145 RR 32 BP 164/92 Sp02 92% (RA) Ht: 5’ 9” Wt: 130 lbs. (150 lbs. 3 months ago) goiter airway : fluid overload Lungs - in What important questions does the nurse need to ask at this point? Circle areas of concern What laboratory data should be obtained? Why? T3 Ta TSH , , S3 overload : lubb-dubb dubb Highlight text (+/-) point for correct item, lose point for wrong—default to zero.. 92 T V Cryperthy). + = - bruit : turb blood flow ,  Assessment Cues Select the 4 findings that require immediate attention. Signs and symptoms Requires Immediate Attention YES NO Օ · Օ Weight loss Client temperature ⑪ Օ Օ Օ # Օ Diarrhea D Օ Օ Restlessness Palpitations and S3 Օ- Օ Bibasilar crackles and tachypnea Օ~ Օ NGN item Matrix Multiple Response N= the sum of all correct responses (0/1)  Analyze Cues Which client labs would support a diagnosis of hyperthyroidism? Select all #org that apply DISH & TOTE , O A. Elevated T4 B. Decreased T3 C. Elevated TSH g D. Elevated T3 E. Decreased TSH Multiple Response select all that apply is +/- = points for correct, lose point for wrong, default to zero  Recognize and Analyze Cues: Client Findings Thyroid Storm Myxedema Coma (thyrotoxicosis, extreme (decompensated hyperthyroidism) hypothyroidism) Tachycardia □A □ Fatigue □D □* Hyperthermia □X □ gzf VS Constipation □ □① Seizures □* rit hyperthernia □ Facial edema □ □ ↓ deposits in Face/tongue Hypothermia □ □* Hypoventilation □ □Y □X-hypoxygenation brady > - CP Chest pain □* , https://emcrit.org/ibcc/tstorm/ Hypotension □ □* https://emcrit.org/ibcc/myxedema/ Matrix Multiple Response is +/- = points for correct, lose point for wrong, default to zero Prioritize Hypothesis: Planning After the nurse’s initial assessment of a client diagnosed with acute thyrotoxicosis, the client is at highest risk for developing ______#1______ as evidenced by the client’s _____#2______. seizures hyper thermia seizure precaution Options for #1: Options for #2: - padded - Siderails a. airway obstruction g a. hyperthermia - Oz - suction b. fear and anxiety b. decreased reflexes c. seizures g c. insomnia d. constipation d. edema Rationale response: Both options must be correct for points  Generating Solutions Thyrotoxicosis (Thyroid Storm) Myxedema Coma & Block adverse effects Cant to) Maintain airway propanol - beta blockers drop temp - in room Medications antipyretics/ cooling blanket Thyroid hormone replacement Levothyroxive doses loading IV - , a , -a spirit or antiseizure (prn?) IV dextrose administration - if low Suppress hormones: antithyroid IV glucocorticoid PTU, methimazole, iodine agents, Cardiac monitor as trigger - steroids ↳ after - stops Secretion - adrenal issue ? - Sick E blocks gland didn't take med control Rewarming - release of T4 of hormone > - T3 Cardiac monitor, obtain ECHO coexisting wadr -. Cylucose) Supportive measures IVF - -monitor heart function https://emcrit.org/ibcc/myxedema/ conversion Take Action: Nursing Interventions For each potential nursing intervention for a client with thyrotoxicosis, click to specify whether the intervention is indicated, nonessential, or contraindicated. Mark only one response per intervention Potential Interventions Indicated Nonessential Contraindicated Propylthiouracil 300mg - PO Q4hr # Օ Օ Օ Ibuprofen 400mg Q6hr PRN Օ Օ Օ* would & TB/T4 Place client in high fowler’s position Օ ՕD Օ Methimazole 10mg PO TID Օ Օ X Օ takes longer Place on cardiac monitor - Օ Օ Օ Allow uninterrupted rest in a cool room ~ Օ Օ Օ Consult registered dietician Օ Օ~ Օ Implement seizure precautions Օ- Օ Օ Matrix Multiple Choice (0/1 scoring) Earn point for correct response, but no points for incorrect response. The score is the sum of all correct responses.  Evaluation of Outcomes: Review initial client presentation; what signs would indicate improvement or worsening of the client’s thyrotoxicosis? Assessment Finding Improved Worsening No change 32 Օ Օ * Օ was Respirations 30 145 A Օ Օ Օ was Heart rate 105 I Օ Օ Օ Temperature 100.5 Օ D Օ Օ Delirium with agitation Օ ՕD Օ Pulse oximetry 91% on 4L/M Օ D Օ Օ Blood pressure 175/92 Matrix Multiple Choice (0/1 scoring) Earn point for correct response, but no points for incorrect response. The score is the sum of all correct responses.  Case Study Progresses… Despite administration of PTU, client has not improved. While providing supportive therapies, client is administered Lugol’s solution (saturated solution of potassium block iodide-) for 10 days prior to a complete thyroidectomy. The client is now two hours post operative. Which postoperative thyroidectomy finding is a priority to report to provider? A. Sore throat with swallowing - energy tracheostomy B. Perioral tingling Have at bedside: trach kit C. Pain when turning head Oral suction IV calcium gluconate O D. Difficulty vocalizing, stridor Ceal. replacements - compression from internal hemerhage/edura, nerve , damage from or larged spam hypocalcemia - tetary Clocking) - due to remove of parathyroid grand - tingling Cuscle) Postoperative Drains & Expected Drainage Jackson-Pratt (grenade drain) Davol Hemovac (accordion drain) should hav so-120/24m Sanguineous Serosanguineous Serous < 30m to remove /24 m Case Study Continues… Critical Thinking Application: Two days later, discharge teaching which includes a prescription for levothyroxine sodium after her thyroidectomy. Which instructions will the nurse include in the teaching plan? Select all that apply. A. Drowsiness is a common side effect; taking the dose at bedtime will make this less noticeable. B. Notify the health care provider if you become pregnant as this medication is harmful to the fetus C. Notify the health care provider if you feel a fluttering or a rapid heartbeat overbose/too O - much D. Take a medication with a meal to prevent upset stomach take zomins before d O E. You will need to take this medication for the rest of your life C am Is stop > - myxedema cara Pharm Review Takes 2 weeks to onset  Acute Adrenal Insufficiency Triggers - Adrenal cortex vs adrenal medulla - need cortisol to trigger metilla - epi/nor-epi adrenal Primary, secondary, or tertiary adrenal insufficiency insuff withdrawal steroids - acte advenal. = abrupt What is the most common cause of acute adrenal insufficiency? Why? storats withdrawa of Abrupt -cortisol The most common cause of secondary acute adrenal insufficiency/crisis in the ICU is SEPSIS Manifestations: Labs: - confusion - Hypoglycemia BS hypotensive Hyponatremia ↓ Na - - tachycardic Crying hyperkalemia - to K compensate - ↓ cortisol - Critical Thinking Application: A client presents to the ED with lethargy, N/V, BP 80/50, HR 145, RR 36 Na 130 mEq/L K 6.8 mEq/L and blood glucose 65 mg/dL. Acute adrenal crisis secondary to sepsis due to severe bilateral pneumonia is diagnosed. The nurse anticipates to provide the following prescriptions immediately. Select all that apply O A. administer one-liter IV Normal saline bolus over one hour O B. continuous IV fluid of D5NS @ 150mL/hr C. fludrocortisone (Florinef) PO O D. monitor VS every 15 minutes > - BP 8 E. hydrocortisone 100mg IV push > - trigger F. sodium polystyrene (Kayexalate) 15 gm PO K K inter G. O 10 units of regular insulin and dextrose 50% 12.5mL IV push > - , insulin pushes cell O H. azithromycin 500mg IVPB > - Pneumonia = J O I. place on cardiac telemetry  Case Study #2: Recognizing Cues Initial brief nursing assessment: An elderly male client is diagnosed with an upper respiratory infection yesterday and prescribed an Alert and oriented antibiotic. This morning, he presents to provider’s Productive cough office and stated, “I just don’t feel right.” Medical history includes insulin dependent diabetes mellitus, Serum blood glucose 486 mg/dL hypertension, peripheral neuropathy, vascular Hemoglobin A1c 6.8% disease, and retinopathy. insulin d Serum potassium 3.5 mEq/L reg. rapid > - 15 long onset I hr + mins , , k Meds: Insulin lispro, Insulin glargine, metoprolol, Rhinitis with pale yellow, thick drainage gabapentin Seizure + neuropathic pair Reports urinating multiple times every hour hyperglycemia > - + osmosis Highlight the 4 assessment findings that require Burning pain from bilateral toes to mid- follow-up by the nurse calves neuropathy > - Highlight (+/- scoring) Earn a higher score on an item for identifying and selecting the most pertinent information. Points for selecting correct information, lose point incorrect option. Not penalized for not selecting correct options  Let’s Take a Look inside the blood vessel at fluid movement DIA intravasale system RBC G G G G -- RBC WBC G G G RBC G G PLT + G G G G G G -- RBC PLT GG G WBC + PLT +GGGGG + +GGGGGG +GG WBC GGG RBC WBC G G G G G G G G PLT + GG -- G G G G G RBC ++ G G WBC G RBC GGGGG RBC PLT - too quick RBC G -- RBC WBC G G+ -- RBC PLT G WBC + PLT + + + +GG -- + WBC PLT -- RBC G WBC PLT + G G ++ G G -Hyperchlaeni acidosis Nat P - bicarb-acidotic Overload tr PLT WBC GG - - Na impacts (NS (shirk if 4) G > - cell w/k - HCOg- (swell = 5) ament of tonicity stays HCO5 of C shock/hypotensive/dhyd) chloride= isotonic same too much gets rid - : , Cancel) & - NS0. 9 %, LR => VPH KT Nat , , - balanced pH DIA bolus scale insilir 9/R Chart intronach4) Sliding - Fluids (#) 0 give. - Planning: Consider the Client’s Social Context alone - Hep , varsopressor , insulin = -nice + steaty - not secondar 2 lives : 2 Iv Be sure to include client specific details/ cultural humility - Client partnership = adherence to therapy, aids health literacy -can't stop insulin Evidence of increase in diabetes: utic acidosis ~ clears o Native Americans (example- 50% in Pima Indians in Az) o Alaska Natives 16.5% anion gep - o