Critical Care Exam #1

palliative care

Care designed not to treat an illness but to provide physical and emotional comfort to the patient and support and guidance to his or her family.

Difference between palliative care and hospice

Both palliative care and hospice care provide comfort. But palliative care can begin at diagnosis, and at the same time as treatment.

Hospice care begins after treatment of the disease is stopped and when it is clear that the person is not going to survive the illness

Main priority of palliative care

reduce severity of symptoms

How do you consent to hospice care?

in writing

What rules eligibility for hospice care?

2 physicians certify terminal illness

<6 months to live

4 main tasks of a hospice care nurse

-pain control

-symptom management

-spiritual assessment

-assessment and management of family needs

When is hospice care available?

24/7

three reasons why palliative care is beneficial

-improve quality of life

-reduce cost

-ease caregiver burden

Who performs an assessment for brain death

physician

At whats GCS do you call the donor network?

less than 5

Different tests to determine brain death

-No spontaneous respirations(#1 test)

-(cold caloric test)Ice water in ear while holding eyes open to see if they react

4 findings that confirm brain death

-no response cold caloric test

-no gasp for air or spontaneous breathing after vent disconnection

-Absent PERRLA

-Apnea despite adequate CO2 stimulation

Palliative sedation

the lowering of patient consciousness with medication for the express purpose of limiting the patient's awareness of suffering that is intractable and intolerable

NOT EUTHANASIA

latent tb

Inactive TB infection without symptoms.

active TB

Infected, symptomatic and contagious

TB tx

RIPE (rifampin, isoniazid, pyrazinamide, ethambutol)

Most important consideration for RIPE

hepatotoxicity

When do you discontinue airborne precautions for TB

After 3 negative AFBs. This also allows discharge

miliary tb

Disseminated TB affecting multiple organs.

TB diagnostics

ABG: hypoxemia, respiratory acidosis

CXR:Cavitary lesions, infiltrates

Sputum test: AFB smear, PCR

How long do you use ripe

2 months

TB patient education

> Dispose of tissues immediately by flushing or put it on an airtight bag and dispose.

> Get more Vitamin B6, Vitamin C, iron, and protein in diet.

> Reassure client after 2-3 weeks of medication therapy, it is unlikely client will infect anyone.

How often will sputum cultures be needed for TB

Sputum culture will be needed every 2-4 weeks

ABGs for early and late stage asthma

early: Respiratory Alkalosis

Late: Respiratory Acidosis

Meds you'll give to asthmatic patient

-Albuterol(SABA)

-Ipratropium (anticholinergic)

-Methylprednisolone IV

-Mag Sulfate(smooth muscle relaxer)

80-100% peak flow reading

Green- your medication is working, resume normal activity

50-80% peak flow reading

Yellow-use caution in activities. Refer to your treatment plan for actions. Relax

Less than 50% peak flow reading

Red-Medical alert, seek medical attention

Evaluation of outcomes for asthma tx

-have minimal symptoms

-maintain activity level

-maintain 80% of best PEFR

-No adverse effects of meds

Step 1-5 of asthma treatment

1- wait

2- low dose ICS

3- Low dose ICS and LABA

4- High dose ICS and LABA

5- High ICS/MBA and add on treatment like tiotropium, anti IgE, anti-IL5

Status asthmaticus s/s

Severe bronchoconstriction: increasing airway obstruction, severe wheezing, extremely labored breathing and use of accessory muscles, hypoxia and respiratory acidosis.

Silent chest

no air movement indicating respiratory failure

Status asthmaticus treatment

Intubate

Hemodynamic monitoring

Analgesia and sedation

IV mag sulfate

Tx for stable asthma

ICS and LABA

Tx for unstable asthmatic patients

O2

SABA

corticosteroids

prepare for possible intubation

PEEP

positive end-expiratory pressure

-helps keep alveoli open on exhale

Who is most likely to be on PEEP

ARDS

Pulmonary Edema

Atelectasis

Pneumonia

COPD

What is the PEEP setting that is equal to the body

5cm H₂O

What can high level os peep compromise

venous return

Common side effects of PEEP

tachycardia and hypotension

First step for complications related to PEEP

consult respiratory therapist

Indication for intubation

-GCS less than 8

-Inability to protect own airway

-Severe hypoxemia

-Acute Respiratory failure

When is nasal intubation indicated

when head and neck manipulation is risky(ex. c spine injury)

True or false: You sedate before you paralyze

True

Examples of sedatives given for intubation

Etomidate

Examples of paralytics given before intubation

Rocuronium and Succinylcholine

What should you do if you can not visualize the trachea

suction

how is PEEP titrated in a patient with ARDS

upwards

What is low peep for?

keeps alveoli from collapsing usually in patients with atelectasis

What is moderate PEEP for?

keeps alveoli from collapsing usually in patients with ARDS

What is high peep for?

hemodynamic instability typically from severe ARDS

Preventative measures of VAP

-Head of bed 30-45

-Sedation vacation

-Oral care with Chlorhexidine

-DVT and ulcer prophylaxis

-Suction

-Hand hygiene

Sedation vacation

Daily pausing of sedation to assess readiness

s/s of Ventilator Associated Pneumonia (VAP)

-fever

-elevated WBC

-Positive sputum or tracheal culture

-tachycardia

-secretion(yellow/green, poor smell)

-crackles or rhonchi

-decreased O₂ level

What to do before intubation?

-preoxygenate to 100% for 3-5 mins

How long should an intubation attempt be?

less than 30 seconds

What do you do inbetween intubation attempts

ventilate with BVM to 100% o2

examples of continuous sedatives

propofol/midazolam/fentanyl

Medications sequence for RSI

Sedative->paralytic->continuous sedative

How to confirm et tube placement

ETCO2 detector

Chest x ray

Guidelines for weaning patient off vent

-ABG stable

-Minimal secretions

-Pass Spontaneous breathing test

-RR less than 30

-FiO2 less than 40%

-strong cough/gag

spontaneous breathing trial

Assessment of patient's ability to breathe independently.

Indication to extubate

Passed SBT

awake, alert, breathing on own

Monitor for stridor

AC mode and indication

assist control(full support)

-ARDS and sedation

Synchronized Intermittent Mandatory Ventilation (SIMV) mode and indication

partial support

-weaning

Noninvasive Positive-Pressure Ventilator (NIPPV) and types

CPAP-sleep apnea and CHF

BiPAP-COPD and hypercapnia

What is NIPPV contraindicated in

vomiting and altered LOC

PSV mode and indication

Pressure support ventilation(patient breathing on own)

-Spontaneous breathing patient weaning off vent.

How does PSV work?

applies a preset pressure to the pt's airway during spontaneous breaths to make breathing easier

CPAP

continuous positive airway pressure(no support)

-spontaneous trials

PCV mode and indications

Pressure Controlled Ventilation (full support)

-fully vent dependent, ARDS, lung injury

How does PCV work?

Vent delivers a breath with preset pressure over a set time

High pressure vent alarm

obstruction

kink

biting

Low pressure vent alarm

Disconnection

leak

What is the first thing you do when a vent alarm is going off?

Check the patient

COPD education

-quit smoking

-O2 maintenence

-Purse lip breathing

-Frequent check ups

What level should you keep a patients Oxygen at for COPD

88-92%

What is the diagnosis of COPD

FEV1/FVC ratio of less than 70%

Interventions for COPD patient

-high calorie food

-Small frequent meals

-Tripod positioning

-Hydration

-Encourage activity

Medications for COPD

SABA, LABA and ICS

Oral or IV steroids for COPD exacerbation

ABx for bacterial triggers

Why do you bipap before intubating a copd patient?

The patient is so high risk that they may never be able to get off intubation

When should you intubate a COPD patient?

If CO2 rises and LOC drops despite support

COPD exacerbation s/s

productive cough

increase O2 needs

Lower activity intolerance

risk respiratory failure

COPD ABG

respiratory acidosis

What confirms a COPD diagnosis

spirometry

Hypoxic drive

A "backup system" to control respiration; senses drops in the oxygen level in the blood.

Why does hypoxic drive play a role in COPD

giving too much o2 can reduce COPD patient's drive to breath leading to respiratory depression and CO2 retention

Type 1 respiratory failure

-hypoxemic respiratory failure

-PaO₂ < 60

ARDS and Pneumonia

Type 2 respiratory failure

Hypercapnic respiratory failure

-PaCO2 <50

COPD, OD, and ALS

Interventions for respiratory failure

LOW tidal volume and HIGH peep

-prone positioning

Different levels of PaO₂/FiO₂ ratio

<300=mild

<200=moderate

<100=severe

Normal=476

ABG for type one and type two respiratory failure

1-normal or alkalotic

2-acidotic

ARDS treatment

-low tidal volume and peep

-Prone position

-Sedation and paralytics

-Prevent barotrauma

-AC vent mode

ARDS priorities

lungs inflamed and full of fluid so you want to oxygenate without causing more damage

Normal ABG levels

pH: 7.35-7.45

PCO₂: 45-35

HCO₃: 22-26

Common causes of each ABG imbalance

Metabolic Acidosis- diarrhea

Metabolic alkalosis- throwing up

Respiratory acidosis-hypovent

Respiratory alkalosis-hypervent

Metabolic acidosis s/s

Kussmauls

Confusion

Headache

↓BP

Hyperkalemia

Warm, flushed skin

N/V/D

Respiratory alkalosis s/s

lethargy

lightheadedness

confusion

tachycardia

hypokalemia

n/v

numbness and tingling

deep rapid breathing

Respiratory acidosis s/s

Drowsiness

Disorientation

Dizziness

Headache

↓BP

Hyperkalemia

muscle weakness

Hypoventilation

Hypoxia

metabolic alkalosis s/s

Confusion

↑HR

n/v and diarrhea

Tremors

Muscle cramps and Tingling

Hypoventilation