NCMB418 LEC PRELIM.pdf

NCMB418 LECTURE: Exam Week 06 BSN 4TH YEAR 1ST SEMESTER PRELIM 2...

NCMB418 LECTURE: Exam Week 06 BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Bachelor of Science in Nursing 4Y1 Professor: Michael Joseph Diño, PhD, MAN, RN, LPT Prelim Topics: - Comprehensive, specialized, and individualized Introduction to Critical Care Nursing nursing services which are rendered to patients with Quality & Safety in Critical Care life-threatening conditions. American Heart Association Standards Goals Electrocardiogram - Survival of the critically ill patients and restoring Basic Life Support (BLS) QUALITY of LIFE Advanced Cardiovascular Life Support (ACLS) - Helping families of critically ill patients in coping *kung ano lng tinuro ni sir sa f2f/ video lectures this prelim with stress - Some terms: INTRODUCTION TO CRITICAL CARE NURSING ECC (Emergency Cardiovascular Care Critical Care Nursing (CCrN) CPR (Cardiopulmonary resuscitation) - The delivery of specialized care to critically ill clients (with ACLS (Advanced Cardiac Life Support) life-threatening illness or injuries). Such patients may be unstable, have complex needs, and require intensive and Characteristics of a Critical Care Nurse vigilant nursing care. Attributes of critical care nurse = quality and behavior - Examples of Critical ill clients: Critical care nurses need to ACT Who needs immediate surgery 1) Advocate – a person who works on another person’s Post surgical behalf (protect his/her rights, assist with family decisions, With Comorbidities negotiate with other members of the healthcare team, Diagnosed with diseases that affects multiple parts of keeping patient and family informed) the body 2) Critical Thinker – a person with a complex mixture of Emergency conditions knowledge, intuition, logic, common sense, and experience. (outstanding qualities) Post accident 3) Team Player – collaborates with other members of the Post-operative clients with major surgery healthcare team to optimize patient outcomes. Illness involving vital organs 4) Educator – facilitator of patient, family, and staff education. Stable clients with signs of impending doom - Classification of Critical Care Clients: Responsibilities of Critical Care Nurse Level 0: normal ward care 1) Assessment – constant assessment of patient and Level I: at risk of deteriorating equipment. Level II: needs more observation or intervention 2) Planning – considerations: physiological and psychological. Level III: multisystem failure (Prioritize physiological over psychological) - Critical care nurses are responsible for making sure that 3) Implementation – interventions to existing and potential critically ill patients and members of their families receive problems. (Prioritize existing over potential problems, close attention and the best care possible. (not only we current problem muna unahin) focus to the patient, we should also focus to their families/ 4) Evaluation – patients response to interventions. significant others) - In most instances, the critical ill clients are unconscious, Multidisciplinary Teams in Critical Care to check their consciousness, we need to ask questions to - Nurses working with critically ill patients commonly the client, so that we can identify if the patient is conscious collaborate with a multidisciplinary team of health care or semiconscious. professionals. The team approach enables caregivers to - According to the AACCN (2019), the assessment of better meet the diverse needs of individual patients. critically ill patients and their families is an essential - Members commonly include: competency for critical care practitioners. Information Registered nurses, obtained from assessment identifies the immediate and Doctors, future needs of the patient and family so a plan of care can Physician assistants, be initiated to address or resolve these problems. Advanced practice nurses such as clinical nurse Critical: Crucial – Crisis – Emergency – Serious specialists and nurse practitioners, Critical Care Nursing – care of the seriously-ill clients Patient care technicians, from point of injury/ illness until discharge from Respiratory therapists and others. intensive care - Definitions: - Deals with human responses to life-threatening problems J.A.K.E 1 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Wound-ostomy-continence Nurse – skin integrity, situation is that he may be having a cardiac event or a bowel and bladder pulmonary embolism. (R) I recommend that you see him Occupational Therapist – assess activities of daily immediately and that we start his on O2 stat. Do you living agree?” Patient-care Technician – Direct patient care: bathes the patient, vital signs and transportation Critical Assessment Process Physical Therapist – Mobility and functional ability Phase 1: Pre-arrival Assessment The Doctor – cardiologist, neurologist, pulmonologist - Begins at the moment the information is received about the upcoming admission of the patient. (Otw plng si patient sa Rapid Response Teams (RRTs) hospital) - The use of RRTs was identified as an evidence-based, - It provides baseline perspectives of the patient and helps lifesaving strategy that would improve patient outcomes by nurses to predict the patient’s health needs and the preventing avoidable patient deaths outside the critical possible resources and setup that will be needed. care areas. - Determines the possible picture of the client and his or her - Most RRTs consist of a structured group and usually needs. (anticipate possible resources needed by the include a critical care nurse, a respiratory therapist and, patient) possibly, a doctor who collaborate with the patient’s nurse - Starts as soon as the nurse becomes aware of a patient and intervene appropriately. coming in the ICU, whether from the ward, operating room - The RRT may be called upon at any time (24/7) that a staff or emergency room member becomes concerned about a patient’s condition. - Usual documentation – abbreviated report on patient - Kapag nagka emergency or nag arrest un patient sa kahit Patient: Age, Gender, Chief Complaint, Diagnosis, anong ward or part ng hospital, tatawagan ang RRTs. CODE Pertinent history, Physiologic status, Invasive devices, BLUE Equipment, Laboratory/ diagnostic tests. Environment: Setup, Equipment Functioning: ECG and Communication in Healthcare electrodes Sphygmomanometer Pulse oxymeter - Because communication failures in health care can lead to Suction machine ad catheters Bag valve mask device errors and serious adverse events, health care Oxygenation equipment IV poles and infusion pumps professionals must pay close attention to communicating Bedside supply cart Admission kit Forms and care effectively. Consistent use of a structured communication documentations tool, such as SBAR, improves the effectiveness of - Critical care nurse responsibilities: communications, provides a safer environment for patients, 1) Patient (Client) and pro- motes collegial relationships among health care - U need to gather as much of information that u can team members. get from the patient while he/she is prearrival - SBAR is a communication tool for ensuring that the right (before the patient arrives) information gets to the right person in the most clear, 2) Environment (Hospital Equipment) concise, and effective way. - U need to prepare the hospi equiments na pwede - Initially, it was used in military. It is a structured gamitin sa patient. Ang pinaka importante na dapat communication tool used as a framework for improving iprepare ay FRC interprofessional communication and patient safety. As a - Hospital Equipment: FRC tool, it meets the quality requirements for safe and 1) Fluid – IV Pole, IV Fluids, Infusion pump, Syringe pump effective clinical documentation of care. 2) Respi – Suction machine, Catheters, Bag valve, Oxygen, - SBAR also improves the effectiveness of communications, Pulse oximeter, Ventilator provides a safer environment for patients, and promotes 3) Cardio – ECG, electrodes, Sphygmo, Defibrillator, AED collegial relationships among healthcare team members. S Situation What is going on at the present time? B Background What has happened in the past and is relevant to this situation? A Assessment What do you think is happening? R Recommendation What do you think needs to be done? - SBAR Example: Nurse Calling a Physician: "Dr. Garci, this is Nurse Gloria, I am calling from Fatima University Medical Center about your patient Renato. (S) Here’s the situation: Renato is having increasing dyspnea and is complaining of chest pain. (B) The supporting background information is that he had a total knee replacement two days ago. About two hours ago he began complaining of chest pain. His pulse is 120 and his blood pressure is 128 over 54. He is restless and short of breath. (A) My assessment of the J.A.K.E 2 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 - Defines the status of the patient prior to the illness - Assessment data includes: P – Past Medical Hx Medical conditions, Laboratory procedures, Hospitalizations, Medications, Allergies, Review of Body Systems S – Social Hx Age, Gender, Ethnic origin, Height, Weight, Education, Occupation, Marital Status, Religion, Significant others, Substance abuse, Domestic abuse P – Psychological Communication, Coping Styles, Anxiety, Stress, Family needs S – Spirituality Faith/preference, Spiritual practices PA – Physical Assessment o Nervous – GCS scoring, pupil assessment, LOC, trauma o Cardiovascular – check for pulses, check perfusion o Respiratory – breathing pattern, arterial blood gas result, auscultation, secretions o Urinary – amount, color, odor, Dx: BUN/ Crea/ UA o Gastrointestinal – nutrition, hydration status, contour and symmetry of abdomen o Integumentary – check the integrity, ulcer Phase 2: Admission Quick Check Phase 4: Ongoing Assessment - Starts immediately upon arrival of the patient. - - General appearance of the client is checked (i.e. - An abbreviated version of the comprehensive admission consciousness or responsiveness, allergies, etc.) assessment performed by the nurse at varying intervals. - It is a quick overview of ventilation (respiratory), circulation (short version ng comprehensive admission, to check if ur (cardiac), and chief complaint (diagnostic tests and client is responding well to the interventions) equipment). - Performed as long as the client is in the hospital, - Common diagnostic tests include: (a) serum electrolytes, - Continuous assessment is necessary to determine (b) glucose, (c) CBC with platelets, (d) coagulation studies, outcome of the client’s disease (e) arterial blood gases, (f) chest x-ray, and (g) ECG. - It is based on how frequent the patient should be assessed. - Based on the parameters represented by ABCDE: For unstable patients: every 15 minutes A – Airway For stable patients: every 2-4 hours. o Patency Position of artificial airway - Assessment frequency: B – Breathing Stability – Ability to maintain equilibrium. o Quantity and quality of respirations Complexity – Entanglement of 2 or more systems (mas o Breath sounds frequent ang assessment mo sa patient na maraming o Spontaneous breathing (presence) systems ang affected) C – Circulation, Cerebral Perfusion, Chief Complaint Predictability – Expectations on a certain course or o ECG events. (if u r expecting that the client will experience an o Blood pressure event, u need to frequently assess the patient. Yung o Peripheral pulses, capillary refill feeling mo, nagchicheat na sayo ung jowa mo, so o Skin color, temperature, moisture kailangan mo sya icheck lagi, or kaya sundan mo kung o Bleeding (presence) saan sya pupunta HAHA charot) o Level of consciousness, responsiveness Vulnerability – Susceptibility to actual or potential D – Drugs, Diagnostic Tests stressors o Drugs prior to admission Resiliency – Capacity to return to a restorative level of o Current medication functioning (Ex: 35 y/o or 84 y/o patient, mas frequent o Diagnostic test results mo iassess ung 84 y/o patient kasi mas resilient ung Equipment younger kaysa sa older) o Patency of vascular and drainage system o Equipment functioning and labeling American Heart Association Standards Phase 3: Comprehensive Admission Assessment The BLS Survey (Arrest) - An in-depth assessment of the past medical and social - The BLS Survey is a systematic approach to basic life history and a complete physical examination of each body support that any trained healthcare provider can perform. system. - This approach stresses early CPR and early defibrillation. It - Physical assessment is usually by system approach does not include advanced interventions such as advanced - Psychosocial assessment is performed, too, as this could airway technique or drug administration. determine prognosis J.A.K.E 3 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 - By using the BLS Survey, healthcare providers may achieve Survey Code Action their goal of supporting or restoring effective oxygenation, V Visualize ventilation and circulation until the Return of Spontaneous Verbalize Vital Signs (HR, BP, RR, O2, Circulation (ROSC) or initiation of ACLS interventions. T) O Supplementary oxygen (below 94%): Airway Nasal cannula (2-4 L/min) Face Mask (2-10 L/min) M Monitor (Pads on Chest) “White on the right, Smoke over Fire” Breathing Provide HRQCPR as needed Rhythm Circulation intervention (slow, fast) I Establish IV/IO T Treat reversible causes (5 Hs and 5 Ts): 5Hs: Hypovolemia, Hypoxia, Hydrogen Ion, Hyper/pokalemia, Differential Hypothermia 5Ts: Tension Diagnosis pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary/ coronary) Return of Spontaneous Circulation (ROSC: Post Arrest) - Return of spontaneous circulation (ROSC) is resumption of sustained perfusing cardiac activity associated with significant respiratory effort after cardiac arrest. 1) Check Responsiveness - Signs of ROSC include breathing, coughing, or movement o Verbalization: Tap and shout “Are you alright?”; and a palpable pulse or a measurable blood pressure o Check for absent or abnormal breathing (or only [PETCO 35-45]. Attachments: gasping) by looking or scanning the chest movement (5- 10 seconds) 2) Activate Emergency Response o Activate emergency response system and get an AED; send someone to get an AED 3) Circulation o Check carotid pulse for 5-10 seconds; o If no pulse, start HQCPR (30:2) beginning with chest compressions o If there is pulse, start rescue breathing at 1 breath every 5-6 seconds (10-12 breaths per minute); - ROSC Assessment/ Interventions o Check pulse every 2 minutes C – Circulation Fluids (PNSS/ PLRS) 1-2 L Perform 4 4) Defibrillation point auscultation o If no pulse, check for shockable rhythm with AED as AB – Airway Breathing Advanced airway Perform 5 point soon as it arrives; auscultation o Follow each shock immediately with CPR, beginning D – Disability Therapeutic hypothermia: PNSS/PLRS, with compressions 30cc/kg, 4 degrees Celsius 12-24 hours Core body The ACLS Survey (Pre-Arrest) temperature should be 32-34 degrees Celsius - In the ACLS survey, the healthcare provider continue to assess and perform an action appropriate until transfer to the next level of care. Many times, team members perform assessment and actions in ACLS simultaneously. - An important component of this survey is the differential diagnosis, where identification and treatment of the underlying causes may be critical to patient outcome. - REMEMBER! For unconscious patients, healthcare providers should conduct the BLS Survey followed by ACLS Survey. For conscious patients, providers should conduct ACLS Survey first. J.A.K.E 4 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 ETHICAL AND LEGAL CONSIDERATIONS IN CRITICAL CARE - end-of-life care includes physical, emotional, social, NURSING and spiritual support for patients and their families Foundations for Ethical Decision Making - Goal: to control pain and other symptoms to make the 1) Professional codes and standards patient as comfortable as possible; quality of life 2) Institutional policies a) Decisions to forego life-sustaining treatments 3) Legal standards b) Nutrition and hydration 4) Principles of ethics c) Pain management a) Beneficence – best interest of the patient remains more d) Resuscitation decisions – DNR, DNI important than self-interest 5) Paternalism – deliberate restriction of autonomy by health b) Nonmaleficence – not only the will to do good but the care professionals based on the idea that they know what equal commitment to do no harm is best for the client c) Autonomy – freedom from external control; acknowledge and protect a patient’s independence Forms of Advanced Directive d) Privacy – right of the patient to be free from unjustified Determining Capacity access by others - Reflects a medical decision on patient’s functional ability to e) Confidentiality – protection of information; patient participate in the decision-making process information should be shared within the healthcare - Patients are presumed to have the determining capacity team directly involved in patient care End-Of-Life-Issues f) Fidelity – agreement to keep promises - Care given to patients who are near death and/or stopped g) Veracity – being truthful or honest. treatment to cure or control his/her disease. - End-of life care includes physical, emotional, social, and Contemporary Issues spiritual support for patients and their families 1) Informed consent GOAL: To control pain and other symptoms to make the - patients must make decisions based on accurate and patient as comfortable as possible: quality of life. appropriate information; voluntary Nutrition and Hydration - The client understands the nature of the treatment and - Given through NGT, IV, or duodenal feedings, or its advantages and disadvantages gastrostomy - To indicate that NO COERCION was made before - Continue if the nutrition and hydration status signing expedite the patient’s return to an acceptable level - To PROTECT the client against unauthorized procedure of functioning - To PROTECT the surgeon and the hospital against legal - Discontinue if not beneficial. actions Pain management a) Emancipated minor - One of the main components of palliative care a college student living away from home - Done if there is a decision to forego life-sustaining in military service treatment Pregnant - “Should provide interventions to relieve pain and Anybody who has given birth other symptoms in the dying patient even when b) Authorized representatives for: those interventions entails risks of hastening death.” Minors ANA (Code for Nurses) Unconscious patients Do Not Resuscitate (DNR) Orders Psychologically incapacitated - Aka “no code” EXEMPTIONS: if experts agreed that the care is an - Withhold CPR EMERGENCY, has life-threatening conditions, or patient is - No other heroic act to be perform on the patient unconscious and authorized representative cannot be - Nurse documents participation in the discussion reached 2) Determining capacity – reflects a medical decision on Laws on Critical care Nursing patient’s functional ability to participate in the decision- 1) Scope of Nursing Practice based on R.A. 9173 making process; patients are presumed to have the 2) Nurses’ Code of Ethics determining capacity 3) Patient’s Bill of Rights and Obligations 3) Advance directives – statements made by a patient with 4) Dying Patient’s Bill of Rights decision-making capacity describing the care of treatment ***Senate Bill 586 - AN ACT PROVIDING PALLIATIVE AND END- he/she wishes to receive when no longer competent OF-LIFE CARE, APPROPRIATING FUNDS THEREFOR AND FOR a) Treatment directives (“living will”) – specify in advance OTHER PURPOSES his/her treatment choices and which interventions are desired The Process of Ethical Analysis (AACCN, 2019) b) Proxy directives – durable power of attorney for health 1) Assessment care a) Identify the problem – clarify the competing ethical 4) End of life care issues claims, conflicting obligations, and personal and J.A.K.E 5 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 professional values; acknowledge the emotional and Steps of Evidence-Based Nursing communication issues Step 1 – Ask Clinical Questions b) Gather data – distinguish the morally relevant facts, PICOT Format – framing a clinical question in EBP including medical, nursing, legal, social, and 1) Population psychological facts; clarify patient’s religious and - What are the characteristics and/or condition of the philosophical beliefs and values group? c) Identify the individuals involved in the problem’s - Patient/ population of interest/ problem (start with the development and who should be involved in the patient, or group of patients, or problem) decision making; discern factors that may impede the 2) Intervention patient’s ability to make the decision - What is the screening, assessment, treatment, or 2) Plan service delivery model that you are considering. a) Consider all options and avoid restricting choices to the - What is the proposed intervention? most obvious 3) Comparison b) Identify the pros and cons (“harms and goods’) - What is the main alternative to the intervention, c) Analyze if plan is in accordance with ethical theories assessment, or screening approach. and principles - (What is the main alternative, to compare with the d) Look into institutional policies and/or procedures that intervention? This might be no intervention.) address the issue 4) Outcome 3) Implementation – choose a plan and act (anticipate - What do you want to accomplish, measure, or improve objections) - What is the anticipated or hoped-for outcome? 4) Evaluation a) Outline the results 5) Time frame b) Identify what harm or good occurred as a result - How long will it take to reach the desired outcome? c) Identify necessary changes in the institutional Example 1: policy(ies) or other strategies to avoid similar issues in "I work in MICU where ventilator-related infections are a the future common problem. I've heard that oral care of ventilated patients even with water can help prevent this. I wonder if QUALITY & SAFETY IN CRITICAL CARE there's any evidence for that and whether it might help our Knowledge Translation patients?" - Applying research in nursing practice P – patients in MICU - Effective and timely exchange, synthesis and application of I – water knowledge among researchers and users to capture the C – oral care with water only benefits of research O – Prevention of ventilator-related infections T - (will depend on the time frame set) The SPIDER tool – can be used when dealing attitudes and experiences rather than scientifically measurable data since it focuses less on the intervention and more on the design. Deals with "samples" rather than a "patient" or "populations". 1) S – ample (group of participants) 2) PI – phenomenon of interest (how and why of behaviors and experiences) Evidence-Based Nursing (EBN) 3) D – esign (how the study was devised and conducted) - Under the umbrella of Evidence Based Practice 4) E – valuation (measurement of outcome; might be - Definitions of evidence-based nursing have varied in subjective and not necessarily empirical) scholarly literature 5) R – esearch Type (qualitative, or quantitative, or mixed) - Application of the best available evidence often from Research questions framed using the SPIDER tool tend to research findings into the clinical setting to ensure best begin with "What are the experiences of...?" practice Example: "What are the experiences of fourth year university - Scott & McSherry’s extensive literature review looked at students in using their critical care units related learning commonalities between EBN definitions and synthesized experience?" them to come up with the following definition: “An ongoing S Fourth year university students process by which evidence, nursing theory, and the PI CCUs RLE practitioners’ clinical expertise are critically evaluated and D Survey considered, in conjunction with patient involvement, to E Experiences (of having the RLE in CCUs) provide delivery of optimum nursing care for the individual.” R Qualitative (Melnyk, B, Fineout-Overholt, E., Stillwell, S., and Williamson, K., 2010). J.A.K.E 6 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Step 2 – Gather Evidence To describe if clinical practice is streamlined when questions are asked 1) Internal Evidence - Direct from client or institutions 2) External Evidence - Scientific literatures; research database - Kapag maghahanap ng research = Meta-analysis papers 3) Database Step 3 – Assess the Evidence - Once articles are selected for review, these must be rapidly appraised to determine those most relevant, valid, reliable, and applicable to the clinical question. (Guide: Are the results of the study valid? What are the results and are they important? Will the results help me care for my patients?) - Iassess kung quality sya or hindi, kung applicable ba sya sa setting mo 1) Internal Evidence – Does this study investigate a population similar to my client? 2) External Evidence – Is your client demonstrating a response to the intervention? Step 4 – Make your Clinical Decision - Synthesize the studies to determine if they come to similar conclusions, thus supporting an EBP decision or change - Research evidence alone is not sufficient to justify a change in practice. Clinical expertise, based on patient assessments, laboratory data, and data from outcomes management programs, as well as patients' preferences and values are important components of EBP 1) Define – Your clinical question 2) Extrapolate – Applicable information from external evidence 3) Consider – Clinical expertise 4) Incorporate – Needs and perspectives of clients 5) Develop – Assessment & treatment plan 6) Evaluate – Your clinical decision Forest plot - An essential tool to summarize information on previously published study findings. - Research figure - Invented by Richard Peto (Statistician and Epidemiologist, Pag nagcross ng line ung diamond = parehas lng, walang University of Oxford) difference ang intervention Pag hindi sya nag cross ng line = meron syang pagkakaiba Salient Points to consider in the use of EBN Practice: Promotes use of EBP among advanced practice nurses and direct care nurses Identifies a network of stakeholders who are supportive of the EBP project Cognitive behavioral theory underpinnings Emphasis on healthcare organizational readiness and identification of facilities and barriers Encompasses research, patient values, and clinical expertise as evidence. J.A.K.E 7 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Quality and Safety Monitoring 7) Reduce length of stay and health care costs. 1) Care bundles Format for the multidisciplinary approach categories: - A group of 3-5 evidence-based interventions, when 1) Discharge outcomes performed together, have a better outcome than if 2) Patient goals performed individually 3) Assessment and evaluation - can be used to ensure the delivery of the minimum 4) Consultations standards of care 5) Tests - can be used as an audit tool to assess the delivery of 6) Medications interventions 7) Nutrition - NOTE: cannot be used to assess how well individual 8) Activity interventions are performed 9) Education - encourage the review of evidence and modification of 10) Discharge planning clinical care guidelines, engendering staff education in NOTE: Primary consideration = patient’s safety best practice Information and communication technologies in CCU - key principle = high level of adherence to all 1) Clinical Information System components 2) Computerized provider order entry (CPOE) - Example: The sepsis care bundle, part of the 3) Hand-held Technologies international Surviving Sepsis campaign, is the most 4) Tele-health Initiatives (Tele-ICU) widely utilized bundle. 2) Checklists Advocacy: Access to social care services 3) Continuous quality improvement PhilHealth 4) PDCA - Plan-Do-Check-Act (PDCA) cycle (Deming Cycle, DOH Shewhart Cycle) DSWD - a management tool for continuous improvement of a PAGCOR business's products or processes. It can be applied to PCSO standardize nursing management and thus improve the nursing quality and increase the survival rate of patients AMERICAN HEART ASSOCIATION STANDARDS AND - Uses: implementation of change, solve problems, and ELECTROCARDIOGRAM continuously improve nursing management processes American Heart Association - cyclical nature; allows it to be utilized in a continuous - International organization based on the US. manner for ongoing improvement - Organization that studies and give some best practices P - PLAN the change or improvement when it comes to Cardiopulmonary Resuscitation (CPR) D – DO = conduct a pilot test of the change and emergency cardiovascular care (ECC) C – CHECK = gather data about the pilot change to BLS SURVEY (ARREST) ensure the change was successful - It is being done when the patient is unconscious. A – ACT = implement the change on a broader scale; - BLS survey means Basic Life Support Survey continue to monitor the change and repeat as - systematic approach to basic life support that any trained necessary by repeating the cycle healthcare provider can perform. - Expertise Required: easy to use and requires little or no - This approach stresses early CPR and early defibrillation. training. - It does not include advanced interventions such as - Advantages: advanced airway technique or drug administration. Makes sure that all appropriate steps are followed. - By using the BLS Survey, healthcare providers may achieve Offers a systematic improvement method. their goal of supporting or restoring effective oxygenation, Is an effective process improvement guide. ventilation and circulation until the Return of Spontaneous Informs future improvement by providing feedback. Circulation (ROSC) or initiation of ACLS interventions. Maintains order during problem solving. - NOTE: The first thing to do is to check alertness - Disadvantage: Requires significant commitment over 1) Unresponsive/No normal breathing/ No breathing (only time. gasping) 2) Check responsiveness (Hey, Hey, Hey are you okay? Multidisciplinary plans of care Hey, hey, hey are you alright?) - benefits to both patients and the hospital system: 3) Check if the scene is safe (NOTE: If outside the hospital) 1) Improve patient’s outcome 4) Active emergency response (OUTSIDE: Ask someone to 2) Increased quality and continuity of care get an AED or call 911) 3) Improve communications and collaboration 5) Breathing and circulation (Check for carotid pulse for 6- 4) Identification of hospital system problems 10 seconds while checking the rise and fall of the 5) Coordination of necessary services and reduced chest.) duplication Assess for 2 normal breaths w/in 10 seconds 6) Prioritization of activities Depth of Compression: 5-6 cm deep J.A.K.E 8 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Allow for full chest recoil Electrocardiogram Chest compression should be steady and fast Cardiac Monitoring RATE: 100-120 bpm - provides continuous observation of the patient’s heart rate When giving chest compression, one hand and rhythm and is a routine nursing procedure in critical (nondominant) is on the top of the other and care patients. interlace it. Keep the arms straight with locking - It is common in (a) emergency units, post-anesthesia elbows and place it on the center of the chest, lower recovery units and operating rooms. side of the breastbone - Cardiac Monitor – A device that shows the electrical and When performing ventilation, tilt the head back, pressure waveforms of the cardiovascular system for pinch the nose, and blow the victim’s mouth. Check measurement and treatment. Parameters specific to the chest if there’s a return of its normal position respiratory function can also be measured. while taking another breath. Repeat the cycle. Minimize interruptions and chest compression to last no more than 5 seconds. Alternate the 30 chest compressions and 2 ventilations until help arrives. If there’s 1 rescuer, switch position every 2-3 minutes Scenario Pulse Breathing Response Secondary 1 Yes Yes Assessment Rescue Breaths 1:5-6 2 Yes No secs 3 No No CPR C: 30 B: 2 Reassess (impossible Electrocardiograph (ECG) 4 No Yes to happen) - a graphic record or representation of the electrical activity Defibrillation (Use of Automated External of the heart muscles. Defibrillator) When seeing signs regaining consciousness, STOP CPR and put the victim into recovery position ACLS SURVEY (PRE-ARREST) - It is being done with conscious patient. - In the ACLS survey, the healthcare provider continues to assess and perform an action appropriate until transfer to the next level of care. - Many times, team members perform assessment and actions in ACLS simultaneously. - An important component of this survey is the differential diagnosis, where identification and treatment of the underlying causes may be critical to patient outcome. - REMEMBER: For unconscious patients, healthcare (Namemeasure ‘yung O2 sat kapag may nakaattach sa patient providers should conduct the BLS Survey followed by ACLS na pulse oximeter. Nareread yung capnography ng patient Survey. For conscious patients, providers should conduct kapag may nakaattach na capnography device. Same with the ACLS Survey first. blood pressure, may nakaattach na sphygmomanometer sa client to read the BP. ECG tracing may mga nakaattach ng electrodes) Electrode Placement - Electrodes detect the tiny electrical changes on the skin that arise from the heart muscle depolarizing during each heartbeat. - Electrodes are optimally placed directly on dry skin. - To prevent unclear ECG tracing, the following preparations are suggested: a) Shaving the skin if necessary, b) Removing dead skin cells by rubbing the area with a rough paper or cloth, c) Removing oil, grease and dirt using alcohol, and J.A.K.E 9 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 d) Using electrodes from airtight packages. Position Box size Equivalence - In emergency situation, healthcare providers use 3 or 5 Horizontal Small 0.04 second leads of electrodes because they have no plenty time to Large 0.20 second attach those electrodes. Vertical Small 0.1 mV Limb Leads Bipolar I, II, III Large 0.5 mV Augmented aVR, aVL, aVF Chest Leads Precordial V1, V2, V3, V4, V5, V6 3-Lead ECG System - Attaching 3 electrodes on the patient’s chest. - “White on the Right, Smoke over Fire” 5-Lead ECG System - Attaching 5 electrodes on the patient’s chest - “Snow over Grass, Melt Chocolate” - Add the green and brown electrodes for 5-lead electrodes. The Normal ECG A normal ECG contains traces of waves, intervals, segments, and one complex: Component Description Types Positive (above) and P-wave, Q-wave, negative (below) Rwave, Wave deflection S-wave, Twave from baseline The time between two PR interval, QRS specific ECG events. interval, QT Interval interval, ST interval The length between PR-segment, two specific points on STsegment, Segment the ECG which are TP-segment supposed to be at the baseline amplitude The combination of QRS complex Complex Multiple waves grouped together Conduction System of the Heart - The contraction and relaxation of cardiac muscle results V1 Fourth intercostal space at the right sternal edge from the depolarisation and repolarisation of myocardial V2 Fourth intercostal space at the left sternal edge cells. V3 Midway between V2 and V4 - The sinoatrial node acts as a natural pacemaker and V4 Fifth intercostal space in the mid-clavicular line initiates atrial depolarisation. - The impulse is propagated to the ventricles by the V5 Left anterior axillary line at same horizontal level as V4 atrioventricular node and spreads in a coordinated fashion V6 Left mid-axillary line at same horizontal level as V4 & V5 throughout the ventricles via the specialised conducting tissue of the His-Purkinje system. The ECG Grid Paper/Strip - The ECG grid on the paper consists of a series of small and large boxes. - Horizontal boxes measure time, while vertical boxes measure voltage: J.A.K.E 10 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 His-Purkinje Conduction system (Nagpupump ang heart because of electrical impulses ng heart and of course dahil ang heart is made up of muscles and yung muscles na yon ay nakakareceived ng electrical activity na nanggagaling sa SA node which came from the food that a person’s ate and a lot of factors that contributes to that) (The picture above ay parang wiring system ng heart kaya yung electricity nagdidisperse sa buong heart kaya nagfufunction ang heart) (In a normal person, ang electricity ay naproproduce sa Sinus Node. Kapag nag fail ang sinus node, magbaback up ang atrioventricular node. There’s something wrong with the client. J.A.K.E 11 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Kapag nag failed ang atrioventricular node, UPPER WAVES P-wave, R-wave, T-wave magcocompensate ang heart kaya kung ano ang natitirang LOWER WAVES Q-wave, S-wave electricity sa purkinje fibers ayon lang ang gagamitin ng heart. Between P and R waves PR Interval Malaking problema ito kasi puwedeng mag expire na ang Between Q, R, and S waves QRS Interval patient) Between Q (lower) and T QT Interval (upper) waves Between S and T waves ST Interval At the end of P-wave and PR Segment before the start of R-wave After S-wave and the start of ST Segment T-wave After T-wave and towards to TP Segment the P-wave of the next cycle Interpreting the ECG Strip: The 8-step Approach STEP 1: Determine Rate - Multiply the number of QRS complexes found over six seconds by a factor of 10 to get the heart rate in a minute. For example: (Ang flow ng electricity ay mayroong direction. SA node---- - Normal rate is 60-100 for adults. Rate of less than 60bpm Atrioventricular Node----- Purkinje Fibers. Therefore, kapag is bradycardia, while more than 100bmp is tachycardia. nagplace ng leads sa chest ng client at nagfunction ang heart ay mayroong connection) STEP 2: Determine the Rhythm - Check the P-P interval (atrial) of R-R interval (ventricular). Rhythm may be regular or irregular. STEP 3: Determine Presence of P-wave - This can be done by locating an evident p-wave before the QRS complex; and if each P-wave is related to a QRS with 1:1 conduction. STEP 4: Check PR Interval (Ang waves ay parang spaghetti, mayroong pataas at pababa. - Count the number of small squares between the start of Yung pataas ay tinatawag na positive deflection meaning yung the P- wave and the start of the QRS complex; then pinakalocation ng electrodes ay papunta roon sa positive pole. multiply the number of squares by 0.04 second; normal ‘Yung negative deflection naman ay pababa wherein ang duration is 0.12 to 0.20 second. direction naman nito ay papuntang negative pole.) STEP 5: Check QRS Complex - Check is QRS complex is evident and similar in size and shape. Normal duration is 0.06 to 0.10 second STEP 6: Determine Presence of T-wave - This can be done by locating an evident T-wave after the QRS complex; and if each t-wave has normal shape and size. STEP 7: Check QT Interval - Count the number of small squares between the beginning of the QRS complex and the end of the T wave, where the T wave returns to the baseline; normal duration is 0.36 to 0.44 second STEP 8: Evaluate other components - Check for rhythm abnormalities (for example, flutter, fibrillation, heart block, escape rhythm, or other arrhythmias). J.A.K.E 12 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Sinus Rhythm Normal Sinus Rhythm - refers to any cardiac rhythm where the sinoatrial node is - It is imperative for critical care nurses to recognize the generating impulses within the cardiac muscle. The normal sinus rhythm to ascertain deviations and presence of sinus rhythm is necessary, but not sufficient, abnormalities. for normal electrical activity within the heart. Normal Sinus Rhythm (NSR) - If there is sinus rhythm and the heart rate is greater than Characteristics Description 100, then “sinus tachycardia” is present. If the there is Rate 60-100 bpm sinus rhythm and the heart rate is less than 60, then “sinus Rhythm regular bradycardia” is present. If there are no P waves present or P-wave precede QRS, consistent shape the P wave morphology is not normal, then the exact PR Interval 0.12 to 0.20 second rhythm must be determined. QRS Complex 0.04 to 0.10 second Normal Sinus Rhythm Conduction normal flow Rhythms Originating in the Sinus Node Sinus Bradycardia Sinus Tachycardia Sinus Bradycardia - can be normal findings in athletes Cardiac Arrhythmia during sleep; may be a response to vagal simulation and - a problem with the rate or rhythm of the heartbeat. During certain medications (digitalis, beta-blockers, calcium an arrhythmia, the heart can beat too fast, too slow, or with channel blockers); seen in patients with increased ICP, an irregular rhythm. uremia, myxedema and obstructive jaundice. - Arrhythmias are any cardiac rhythm that is not normal sinus rhythm. It may result from altered impulse formation or conduction. Arrhythmias are named by the place where they originate and by their rate. The typologies of arrhythmias are as follows: (a) rhythms originating in the sinus node, (b) rhythms originating in the atria, (c) rhythms originating in the ventricle, and (e) AV blocks. Sinus Tachycardia - a normal response to exercise and emotion; and can be caused by some medications (e.g. ephinephrine, dopamine, caffein) J.A.K.E 13 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Sinus Arrhythmia - occurs when sinus node discharges Rhythms Originating in the Ventricles irregularly, and is a normal phenomenon during respiration; [NOTE: ventricular arrhythmias are considered to be more may be caused by digitalis toxicity. dangerous than other arrhythmias due to their potential to decrease cardiac output] Sinus Arrest - occurs when impulses from the sinus node are not formed as expected (p-wave absent at some point); also known as sinus pause; causes include vagal simulation and drugs (digitalis, beta-blockers, calcium channel blockers) Ventricular Asystole - absence of any ventricular rhythm. Rhythms Originating in the Atria Ventricular Fibrillation - rapid, ineffective quivering of the ventricles; no cardiac output or palpable pulse (fatal without immediate treatment) Supraventricular Tachycardia - rapid rhythm of the heart that begins in the upper chambers. Atrial Flutter - caused by fixed re-entry circuit in the right atrium on patients with health concerns (e.g. rheumatic heart disease, atherosclerotic heart disease, heart failure, myocardial infraction) Ventricular Tachycardia - rapid ventricular rhythm; commonly caused by coronary artery diseases. Atrial Fibrillation - an extremely rapid and disorganised pattern of depolarisation; most commonly seen in adults AV BLOCKS post cardiac surgery and with conditions such as rheumatic heart disease, pulmonary disease , MI, and First Degree AV Block - prolonged AV conduction to the congenital heart disease ventricles; due to coronary artery disease, rheumatic heart disease and administration of some drugs (e.g. digitalis, beta- blockers or calcium channel blockers). J.A.K.E 14 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 Second Degree AV Block (Type 1) - occurs when one ADVANCED CARDIOVASCULAR LIFE SUPPORT atrial impulse at a time fails to be conducted to the - Advanced cardiovascular life support is a very ventricles (occurs at AV node) comprehensive concept. - Nurses are an integral part of what we call “the multi- disciplinary team”. - The hospital is not only composed of nurses alone, but we are collaborating and coordinating with the doctors for collaborating with the pharmacist, nutritionist, respiratory therapist would care, ostomy nurse, etc. Second Degree AV Block (Type 2) - occurs when one - During emergency procedures, nurses are also part of what atrial impulse at a time fails to be conducted to the we call the different roles as far as the advanced cardiac ventricles (occurs below AV node) life support is concerned. (Kapag nag arrest si patient, hindi sya usually gnagawa magisa lng, may 5 roles tayo here) Roles in ACLS Third Degree AV Block - complete failure of conduction of all atrial impulses to the ventricles. 15 ECG Readings 4 - Sinus – Normal BUT… (Complete PQRST) Sinus Bradycardia – Hear rate is less than 60 Sinus Arrhythmia – irregular Sinus Arrest – with pauses Sinus Tachycardia – heart rate is more than 100 2 – Atria – Piercing (Pins) Atrial FLUtter – piercing Up 1) Team Leader Atrial FIBrillation – piercing up/down - Every resuscitation team must have a defined leader 4 – Ventricles – The Grass (No Negative Deflection) - Assign roles to team members Ventricular Asystole – no “grass” - Makes treatment decisions Ventricular Fibrillation – budding “grass” - Provides feedback to the rest of the team as needed Supra Ventricular Tachycardia – Medium “grass” - Assume responsibilities for roles not defined - If you are a team leader, you should know when to ask Ventricular Tachycardia – Wide “grass” others to prepare the medications, know how to read 4 – AV Blocks – With Defects (Deficient PQRST) ECG readings, know what would be the intervention for the next scenario 2) Compressor - Assesses the patient - Performs compressions according to the local protocols - Rotates every 2 minutes or earlier if fatigued - Tandem with monitor defibrillator or CPR Coach. They are interchanging their roles every now and then. (Kasi nakakapagod mag compress all the time, palitan sila) 3) Monitor Defibrillator - Brings and operates the AED monitor/defibrillator and acts as the CPR Coach if designated. - If the monitor is present, places it in position where it can be seen by the team leader (and most of the team) - Partner of compressor - He or she is the one who checks the cardiac monitor and provides shock if necessary. Some notes are from Ate Geraldine* J.A.K.E 15 of 16  CRITICAL CARE NURSING LECTURE: BSN 4TH YEAR 1ST SEMESTER PRELIM 2023 4) Airway Dopamine Infusion - Opens the airway - Pharmacological intervention - Provides bag-mask ventilation - Renal Dose = 2 mcg/kg/min - Inserts airway adjuncts as appropriate - Cardiac Dose = 5 mcg/kg/min 5) IV/ IO/ Medications - Vasopressin Dose = 10 mcg/kg/min - An ACLS provider role Epinephrine Infusion - Initiates IV/IO access - Pharmacological intervention - Prepares and administers the medications - Titrate to response (depende un dosage nya, doon 6) Timer/ Recorder sa response ng client) - Records the time of interventions and medications (and - Initial: 2 mcg/ min announces when these are next due) - Max: 10 mcg/min - Records the frequency and duration of interruptions in - It can increase up to 4 mcg/min if the client does not compressions response to the medication. Stop if there’s a - Communicates these to the team leader (and the rest response. of the team) Fast Rhythm (Tachycardia) - Documents all the procedures - Above the normal limits (>100 bpm)\ - Management: Managements in ACLS 1) Stable Physiologic (Natural) - Vagal maneuver (massaging the carotid) Allow the client to cough Pharmacologic - Adenosine: Min = 6 mg; Max = 12 mg 2) Unstable Sedate - Diazepam = 5 mg - Medazolam = 5 mg Synchronized Cardioversion (this is painful procedure that’s why we need to sedate the pt first) - SVT = 50 J - AF = 120 J Slow Rhythm (Bradycardia) - Below the normal limits (< 60 bpm) - Examples: Sinus Bradycardia, AV Blocks - Effective sya kapag bumibilis na ang heart rate WHO WILL PASS THE BOARD EXAM?? - Pharmacological intervention – ano ang dose, gaano ka YOU!! WILL PASS THE BOARD EXAM!!! frequent binibigay. GOOO FUTURE RN!!