NCM 118 Medical Surgical Nursing PRELIM PDF

NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading INTRODUCTION...

NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading INTRODUCTION 6. Sleep Disorders - Sleeping during mornings and awake CRITICAL CARE NURSING during at night due to lights. May feel uncomfortable due to - A specialty dealing with human responses to life threatening frequent monitoring and environment. problems. (AACN) Nursing Dim lights at night and do all activities - Involve assessing life- threatening conditions, initiating Responsibilities: during the day appropriate interventions, and evaluating the outcomes of the interventions. ISSUES RELATED TO CAREGIVERS CRITICAL CARE UNITS 1. Anxiety (conditions, prognosis & concerns) - AKA Intensive Care Unit (ICU) 2. Reassurance on patient care and decisions - Designed to meet the special needs of acutely and critically 3. Describe the patient’s appearance and environment ill patients. 4. Disruption of daily routine 5. Convenience of access to patient PROGRESSIVE CARE UNITS 6. Being present during invasive procedures and CPR - AKA Intermediate Care Unit, Step-down unit or Transitional Care unit CULTURALLY COMPETENT CARE - Provides a transition between the ICU and the general care - Meeting the patient’s physiologic needs is a priority and unit overshadows the influence of the patient’s culture on the - Lower risks than ICU but needs monitoring suck as pre-op illness experience. for heart surgery (arrhythmia), after stem placement, - Consider the cultural dimensions of the meaning of sickness angioplasty, blocked heart and health, pain, death and dying and grief when caring for - Lower level but needs constant monitoring patients. NOTE: Should be aware of culture and beliefs ——————————————————————————————— CRITICAL CARE NURSE NURSING MANAGEMENT - Care for patients with acute and unstable physiologic SHOCK, SYSTEMIC INFLAMMATORY RESPONSE SYNDROME problems as well as their caregivers (SIRS) & MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS) - Has in-depth knowledge of anatomy, physiology, pathophysiology, pharmacology and advanced assessment SHOCK skills. - A syndrome resulting from inadequate tissue perfusion NOTE: Every hour of monitoring VS, etc. to prevent further - creates an imbalance between oxygen delivery and nutrients complications - A life threatening condition - Loss of blood supply CRITICAL CARE PATIENT - Creates an imbalance between oxygen delivery and - critically ill patient who is at high risk for actual or potential nutrients—tissues will be hypoxic life-threatening health problems and requires intense and - SNS: increase HR, BP, cardiac contractility and output (loss vigilant nursing care (AACN) perfusion of the heart) Nursing responsibility: increase RR NOTE: Comatose patient GCS score is 8 and below. Minimum GCS 3 and angiotensin. and maximum of 15. - PNS: GI, GU, Skin - Catecholamines: norepinephrine and epinephrine (same REASONS FOR ICU ADMISSION action of vasoconstriction—increase venous return 1. Physiology Unstable - Requires advance and sophisticated NOTE: Loss of blood supply leads to decreased tissue perfusion clinical judgments by a CCN and Physician. (HTN, - Physiologic responses: arrhythmias) Hypoperfusion of tissues 2. Risk for Complications - requires frequent assessment and Hypermetabolism (cause of shock will activate invasive interventions. sympathetic nervous system —> hypermetabolism 3. Nursing Support - Requires intensive and complicates —> inflammatory response) -most common in nursing care related to the use of IV polypharmacy & physiologic shock advanced biotechnology. (Multiple IV lines, those who Inflammatory response require hydration, mechanical ventilation) COMMON PROBLEMS OF CRITICAL CARE PATIENTS 1. Nutrition - in a hypermetabolic state due to infections, and kidney failure, etc. needs a lot of calories. 2. Anxiety - perceive threat to physical health, isolation from family and friends, a lot of equipment. Nursing Let them ask questions, encourage Responsibilities: verbalizations, explain procedure, let them bring personal items. 3. Pain - invasive devices;can contribute to stress response 4. Impaired Communication - stroke patients, aphasia Nursing Explore alternative communications Responsibility: STAGES OF SHOCK 5. Sensory-Perceptual - some will have abnormal response to stimulus (delusions, short attention span, loss of memory, 1. Compensatory Stage delirium, agitation) - Stimulation of SNS (fight or flight response) - As much as possible VS ar normal since the body is still Nursing Correct underlying cause compensating. Responsibilities: ○ All goes up except GI, GU, and skin NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading ⬇️ ⬆️ ⬆️ ⬇️ ○ Once there is shock your body will compensate ○ Dehydration, edema, ascites ⬆️ ⬇️ ⬇️ ⬇️ SNS - BP , HR , RR , TEMP Managements Treat the underlying cause ICP- B , HR , RR , TEMP for Hypovolemic Fluid and blood replacement ○ Increased RR and CR Shock: Modified trendelenburg (promotes ○ Normal BP venous return) ○ Cold, clammy skin Monitor closely ○ Decreased UO(urinary output) GOAL: To increase intravascular fluid volume ○ Confused (decrease blood supply and anxious ○ Identify the cause 2. Cardiogenic Shock Nursing Responsibility: Identify the cause of shock. - Occurs when the heart’s contractility is impaired and O2 supply is 1. Progressive Stage inadequate for the heart. - Begins as compensatory mechanism fails - Coronary- common - Hypotension and declining mental status (restlessness, short - Acute MI term memory loss, agitation, delirium) - Non-Coronary - Number 1 cause: heart and lungs - Hypocalcemia - Hypoperfusion of alveoli— less surfactant— heart - Arrhythmias (ischemia—> MI) and lungs (alveoli) - Dysrhythmias - Report subtle changes in assessment are important - Cardiac tamponade - Admitted in ICU - Angina - Prevent further complications (infection, VAP [Ventilator Associated Pneumonia] ) - Aseptic technique and hand Managements Treatment of underlying cause hygiene for Cardiogenic Oxygenation (nasal cannula) Shock: Pain control - Morphine (Morphine Nursing Aseptic technique during suctioning, oral can also dilate blood vessels) Responsibilities: care, positioning (elevate head of bed at Vasoactive Medication - Dopamine/ least 30 degrees) Dobutamine, Nitroglycerin ECG monitoring (prevent further complications) 2. Irreversible/Refractory Stage Enhance safety and comfort - From progressive to irreversible - at least 2-3 organ are failing already - Severe organ damage - complete organ failure - death 3. Distributive Shock - No response to treatment (cannot process treatment du to - Results from excessive vasodilation, organ failure) impaired distribution of blood flow and - Carry out prescribed treatments, monitoring the patient, peripheral pooling of blood protecting the patient from injury and providing comfort. - There is something wrong in blood volume - Inform family of prognosis - Vasodilation— it won’t go back to the heart, does not promote venous return, and it stays Nursing Provide comfort and opportunities for at hand and legs. Responsibilities: the family to be with the patients. - Types: 1. Septic Shock - most common 2. Neurogenic Shock 3. Anaphylactic Shock Septic Shock - The presence of sepsis with hypotension despite fluid resuscitation along with the presence of inadequate tissue perfusion. Sepsis - A systemic inflammatory response to a documented or suspected infection Severe Sepsis - Sepsis complicated by organ dysfunction - Leading cause of death in non coronary ICU patients NOTE: MAP (Main arterial Pressure) = DBP (2) + SBP / 3 - Gram negative bacteria URINE OUTPUT normal range = 30mL/hr S/S of Septic Shock 0.5-1.5ml/kg/hr - shiver, fever or very cold Solve: UO in ml / kg x hr - Extreme pain in general discomfort - Pale or discolored skin TYPES OF SHOCK - Sleepy , difficult to rouse , confused - “I feel like I might die.” 1. Hypovolemic Shock - Short of breath - Most common Managements Rapid identification of infectious - Decrease Intravascular fluid volume for Septic sources and treatment within 3 - 750-1500 ml of blood loss (70kg Shock: hours. adult) Fluid replacement Therapy- 30ml/kg - Common cause: trauma, surgery, for 30 minutes. internal fluid shift Monitor For infection - elderly (confusion) External fluid loss Monitor laboratories (WBC, ○ Trauma, surgery, Procalcitonin) vomiting, Monitor VS and I&O diarrhea Hand hygiene and aseptic technique Internal fluid shift NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading Ineffective and or risk for ineffective perfusion: peripheral, Initiate antibiotic within first hour renal, cerebral, cardiopulmonary, gastrointestinal, and hepatic related to low blood flow or maldistribution of blood Neurogenic Shock Anxiety related to severity of condition - Within the nerves - the injury results in a massive vasodilation as a result of loss Planning of balance between SNS and PNS The overall goals in shock include: - SCI (Above T6), spinal anesthesia and nervous system 1. Evidence of adequate perfusion damage. SCI is the most common cause of injury due to the 2. Restoration of normal or baseline blood pressure inactivation of SNS 3. Return/ recovery of organ function - PNS is predominant 4. Avoidance of complications from prolonged states - Classic signs - hypotension and bradycardia, dry and warm of hypoperfusion skin - Blood volume is adequate Implementation General Measures (Collaborative Care) Managements Elevate and maintain the HOB - at Successful management of patient in shock includes: for Neurogenic least 30 degrees during anesthesia Shock: SCI - immobilized patient 1. Rapid assessment and early recognition Monitor for signs of VTE (Venous 2. Integration of the patient’s history, PE and clinical findings to thromboembolism)- lower extremity establish diagnosis pain, redness, tenderness and 3. Interventions to control or eliminate the cause of the warmth, decreased perfusion Passive ROM, compression devices 4. Protection of target and distal organs from dysfunction Heparin: to prevent DVT and 5. Provision of multisystem supportive care complications Collaborative care Anaphylactic Shock 1. Oxygenation and Ventilation - Severe allergic reaction Methods to optimize oxygen therapy are directed at - Displaced blood volume increasing supply and decreasing demand. - An acute and life threatening hypersensitivity (allergic) Supply inputs increased by: reaction to a sensitizing substance (e.g. drug, chemical, Optimizing the CO with fluid replacement or drug vaccine, food and insects). Increasing the HMG blood by the transfusion of - An immediate reaction causes release of cytokines causing whole blood or PRBC widespread vasodilation and an increase in capillary Increasing the arterial oxygen with supplemental permeability. oxygen and mechanical ventilation - Acute onset of symptoms, respiratory compromise, 2. Fluid resuscitation hypotension and arrhythmias. Most common food to cause The cornerstone of therapy for all types of shock is volume anaphylactic shock is PEANUTS expansion with the administration of the appropriate fluid “best” fluid- readily available Fluid therapy in shock Managements Assess all patients for allergies or for Anaphylactic previous reactions to antigens (e.g., Shock: medications, blood products, foods, contrast agents, latex) Remove the source of possible Prepare to administer IM epinephrine, diphenhydramine and nebulization (Albuterol) Obstructive Shock physical obstruction impedes the filing or outflow of blood resulting in reduced cardiac output any obstruction that impedes the blood flow from the heart to the lungs. Examples: 1. Cardiac tamponade 2. Tension pneumothorax– air accumulates in the pleural space 3. Pulmonary embolism– blocks pulmonary artery, there is no circulation 3. Drug therapy Treatment: treat the underlying cause Primary goal: the correction of decreased tissue perfusion DIAGNOSTIC STUDIES (IV, Infusion pump) There are no specific diagnostic studies to determine the Medication used to improve perfusion and are administered patient is in shock IV via infusion pump and central venous line History taking and physical examination (sympathomimetics, vasodilators) Medical and surgical history Risk for this are extravasation History of recent events (trauma, surgery, or chest pain) Diagnostic Studies: ○ 12-Lead ECG ○ Continuous Cardiac Monitoring ○ CXR ○ Continuous Pulse Oximetry ○ Hemodynamic Monitoring (CVP) Nursing Diagnoses: NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading 4. Nutritional therapy protein-calorie malnutrition ○ One of the main manifestations of hypermetabolism in shock Enteral feedings: 3000 cal/day needed due to skeletal muscle mass breakdown. Enteral nutrition is preferred. ○ GI function Patients should be weighed daily - an indicator of fluid status. Nursing intervention Health promotion (key) Rapid detection and intervention is the key to survival MODS. CLINICAL MANIFESTATIONS AND MANAGEMENT PER Acute intervention ORGAN SYSTEM 1. Monitoring the patient’s ongoing physical and emotional status 2. Identifying trends to detect changes in the patient’s RESPIRATORY SYSTEM condition Clinical Manifestations of Management 3. Planning and implementing nursing interventions Organ Failure and therapy 4. Evaluating the patient’s response to therapy Development of ARDS Prevention 5. Providing emotional support to the patient and Severe dyspnea Optimize oxygen family Bilateral fluffy delivery/minimize oxygen 6. Collaborating with other members of the health infiltrates on CXR consumption team to coordinate care. Pulmonary Mechanical ventilation hypertension Positive Increased respiratory end-expiratory SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) rate pressure - A systemic inflammatory response to variety of insults Refractory hypoxemia Positioning including infection sepsis), ischemia, infarction and injury. - Infection— any injury that can cause widespread CARDIOVASCULAR SYSTEM inflammation to the whole body Etiology Myocardial Volume Management 1. Mechanical tissue trauma depression Central venous or Burns, crush injuries, surgical procedures Massive vasodilation PA catheter for 2. Abscess formation Decreased SVR/BP hemodynamic Intraabdominal, extremities Decreased MAP monitoring Increased HR Increased preload 3. Ischemic or necrotic tissue Systolic/diastolic via volume Pancreatitis, vascular disease, dysfunction replacement 4. Microbial invasion Arterial pressure Bacteria, viruses, fungi, parasites monitoring most common— system will activate inflammatory Maintain MAP >65 response mmHg 5. Endotoxin release Vasopressors Continuous ECG Monitoring Gram-negative & gram-positive bacteria Circulatory assist devices Intraaartic ballon pump Venous thromboembolism prophylaxis Low molecular weight or unfractionated heparin Sequential compression devices CENTRAL NERVOUS SYSTEM Two or more of this criteria can indicate if you have SIRS MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS) Acute changes in neurologic Evaluate for The failure of 2 or more organ systems in an acutely ill status hepatic/metabolic patient such that homeostasis cannot be maintained without Fever encephalopathy interventions Hepatic encephalopathy Optimize cerebral Seizures blood flow MODS results from SIRS & is a complication of any form of Confusion/disorientation Decreased cerebral shock but is most commonly seen in sepsis. Failure to wean/prolonged oxygen requirements the higher the number the greater the severity of organ rehabilitation Prevent secondary failure tissue ischemia Calcium channel Sequential Organ Assessment blockers (reduce cerebral vasospasms) RENAL SYSTEM renal hypoperfusion Diuretics BUN/creatinine Loop diuretics increased (Furosemide) NCM 118 | Medical Surgical Nursing First Semester | PRELIM | LECTURE 🌸 🥰 🏎️ 🍑 Lecturer: Mr. Ray Jan D. Altar, RN By: myck , cliesha , kik , ynading Increased urine May need to specific gravity increase dose due to Anuria decreased glomerular filtration rate Dopamine Enhances renal blood flow Improves renal perfusion Increases urine output (if volume resuscitated) May work synergistically with diuretics Continuous renal replacement therapy GASTROINTESTINAL SYSTEM Mucosal Ischemia Stress ulcer prophylaxis Decreased Antacids (Maalox) intramucosal pH Histamine Potential translocation (H2)-receptor of gut bacteria blockers (famotidine) Hypoperfusion - Proton pump decreased peristalsis, inhibitors paralytic ileus (omeprazole) Mucosal ulceration on Sucralfate (carafate) endoscopy Monitor abdominal distention; GI bleeding intra abdominal pressures Dietary consultation Enteral feedings Stimulate mucosal activity Provide essential nutrients & optimal calories HEPATIC SYSTEM Increased liver enzymes Maintain adequate (ALT, AST) tissue perfusion Elevated bilirubin Provide nutritional Jaundice support (enteral Hepatic encephalopathy feedings) Careful use of drugs metabolized by liver HEMATOLOGIC SYSTEM Increased bleeding times, Observe for bleeding from Increased PT, Increased PTT obvious and/or occult sites Decreased platelet Replace factors being count lost (platelets) (thrombocytopenia) Minimize traumatic interventions (intramuscular injections, multiple venipunctures) ENDOCRINE SYSTEM Hyperglycemia Continuous infusion of insulin & Hypoglycemia glucose to maintain blood glucose