Pulmonary Two, Ethical and Legal Issues, End of Life Care, EKG Two, & Hemodynamics

What are some nursing interventions to prevent ventilator associated pneumonia (VAP)?

• raise the HOB to 30 degrees

• do daily sedation vacations

• do chlorhexidine oral care q12hr

• reposition pt q2hr

• fluid conservation

What is autonomy?

the patient has the right to make their own healthcare decisions

What is beneficence?

it is the acting in the patient’s best interest

What is nonmaleficence?

it is to do no harm; avoid actions that could harm the pateint

What is justice?

it is treating the patients fairly and equitably

What is veracity?

it is telling the truth; provide honest communication

What is fidelity?

it is keeping a promise; maintain trust and confidentiality

What is negligence?

it is the failure to act as a reasonably prudent nurse would

What is malpractice?

it is professional negligence resulting in harm

What is battery?

it is touching a patient without consent

What is assault?

it is threatening a patient with harm

What is false imprisonment?

it is restricting a patient’s movement without justification

What is informed consent?

it is when the provider explains risks/benefits; nurse verified understanding from patient

What is the philosophy of care for hospice?

• reserved for the terminally ill

• appropriate after the decision to withdraw care

• home, hospital, inpatient hospice

• DNR must be in place to be paid for by insurance or Medicare/Medicaid

• Emphasis is on comfort rather than cure

• Views dying as a normal human process

What are some nursing interventions for hospice care?

• assess changes in mobility, sleep, and weight

• educate patient and family on signs of transitioning and active dying

• removal of all lines, vent support, and therapies-PRIOR to the referral

• assure the family that the patient will not suffer or be abandoned

• provide emotional, spiritual care resources: grief counselors, spiritual care providers

• facilitate provider visitation and presence of family

• promote memory sharing, storytelling, and creation of the lasting legacy

What is palliation?

it is the act or process of relieving a patient’s suffering without curing the disease

What are the requirements when using restraints on a patient?

• must have provider orders (need new one every 24 hrs)

• check for skin breakdown q2hr

• document restraints

• make sure you can fit 2 fingers between patient’s skin and restraints

• tie restraint to bed frame

What is the rate for sinus bradycardia from the SA Node?

<60bpm

What is the rate for sinus tachycardia from the SA Node?

>100bpm but <150bpm

What is premature atrial contraction?

• an early ectopic beat

• interrupts regularity 

What is atrial flutter? 

• arises from a single irritable focus in the atria

• has flutter waves

What is atrial fibrillation?

• arises from multiple ectopic beats in atria

• no P waves seen

• always irregular

What is premature junctional contraction?

it is an early ectopic beat in the junction that interrupts the regularity

What is supraventricular tachycardia (SVT)? 

• improper electrical activity above the ventricles

• rhythm is regular except it may be hard to distinguish between a P wave and T wave if HR is really high

• rate >150-250bpm

What are the treatments for stable supraventricular tachycardia (SVT)? 

• vagal maneuvers (only done by provider)

• adenosine 6mg raid IVP followed by 20mL bolus of NS

• if not effective repeat adenosine with 12mg; may repeat 12mg x 2 times 

• synchronized cardioversion

What is the treatment for unstable supraventricular tachycardia (SVT)? 

immediate synchronized cardioversion

SVT

What rhythm does the picture attached depict?

supraventricular tachycardia (SVT)

What is premature ventricular contraction? 

• early ectopic beat in the ventricles that interrupts the regularity

• sided by side PVCs are called couplet

What is ventricular tachycardia (VTACH)?

• rapid life-threatening dysrhythmia that originates in the ventricles

• exists when three or more PVCs occur in immediate succession at a rate higher then 100 bpm

What will we see on the EKG strip if ventricular tachycardia (VTACH) occurs? 

• QRS wider than 0.10 sec

• absent p waves

• may present with or without pulse

What are the treatments for stable ventricular tachycardia (VTACH) and torsades?

• amiodarone 150mg IVP followed by 300mg IVP

• lidocaine 1.1-1.5mg/kg max dose in 3mg/kg

• synchronized cardioversion

What is the treatment for unstable ventricular tachycardia (VTACH) and torsades?

immediate synchronized cardioversion

v-tach & torsade

What rhythm does the pictures attached depicts?

ventricular tachycardia (v-tach)

What is the treatment for ventricular tachycardia (VTACH), torsades, and ventricular fibrillation with no pulse? 

• call for help/ Code Blue

• begin CPR until defibrillation is available; defibrillate as soon as possible

• on arrival of defibrillator, deliver unsynchronized shocks

• epinephrine 1mg IVP q3min; NO MAX DOSE

• administer magnesium 1-2gms IV if torsades

What will we see on the EKG strip if torsades occurs?

• may be regular or irregular

• no P wave or PR interval

• QRS is greater than 0.12 sec

• gradual alteration in amplitude & direction

• may present with or without a pulse

What will you give if torsades is shown on the EKG strip? 

administer magnesium 1-2hms IV

What rhythm is the photo attached depict?

torsades

What will we see on the EKG strip if ventricular fibrillation occurs?

• chaotic pattern (meaning a scribbly line)

• no discernible P, Q, R, S, or T waves

What is pulseless electrical activity?

it exists when organized electrical activity (other than VT) is present on the cardiac monitor, but the patient is pulseless 

What rhythm does the photo attached depict?

pulseless electrical activity (PEA)

What are the treatments for PEA and asystole?

• call for help/ Code Blue

• get crash cart/defibrillator (in case pt goes into a rhythm that can be defibrillated the defibrillator is already present) 

• preform immediate CPR

• epinephrine 1mg q3min; NO MAX DOSE

• consider possible causes of the rhythm

• prepare for endotracheal intubation

• NEVER cardiovert or defibrillate PEA or asystole

What is asystole?

• total absence of ventricular activity 

• there is no ventricular rate or rhythm 

• no pulse

• no cardiac output

• will see a flat line on EKG

What does the photo attached depict?

asystole

What is an arterial line? 

it is a catheter that is inserted into an artery that gives a direct, constant, and more accurate measurement of the blood pressure

• can be placed in the radial or femoral arteries

What things can we do with an arterial line?

• draw blood

• ABG values

• blood pressure readings

• NEVER give meds through line

What are some patient education points about arterial line care?

we need to protect this line, and if it comes out, a lot of bleeding will happen

What kind of dressing should be used for an arterial line?

clear transparent dressing
- assess circulation and hematoma

- we can use arm boards to keep the arm straight

What three pressures will an arterial line provide?

• systolic blood pressure

• diastolic blood pressure

• mean arterial pressure (70-100 is normal range)

How do you level the transducer on an arterial line??

level the transducer at the phelbostatic axis, 4th intercostal space mid axillary line (leveling at the heart) for a more accurate reading

How do we assess the site of the arterial line?

• check the dressing

• neurovascular assessment (check perfusion most distal to the site)
  -Pulse
  -Paralysis
  -Parasthesia
  -Pain
  -Pallor
  -Polkliothermia

What are the complications of an arterial line?

• bleeding

• thrombosis

• air embolism

• infection

• arterial spasm

• hematoma

What do we do after removing an arterial line? 

we want to hold pressure at the insertion site for at least 5 minutes 

What are pulmonary artery catheters?

aka "swan gans" is a specialized catheter placed directly into the pulmonary artery

What does a pulmonary artery catheters (PAC) measure?

• CVP (central venous pressure

• CO (cardiac output)

• PAP (pulmonary artery pressure)

• PAWP (pulmonary artery wedge pressure)

• SvO₂

• blood temp

How is pulmonary artery wedge pressure (PAWP) performed? 

a physician can inflate a balloon on the PAC with 0.8-1.5 mL of air with a special syringe for a MAXIMUM of 15 seconds

• this is an indirect measurement of the left side of the heart

What are the nursing interventions after a pulmonary artery catheter is placed? 

• x ray to confirm placement

• monitor EKG rhythm (if line gets pulled out into the RV, PVC can happen)

• correct positioning of the pt (anytime we move the pt, we have to re-level the arterial line or PAC to the phelbostaic axis

What nursing interventions should the nurse implement to avoid CLABSI?

• daily chlorahexadine baths

• changes tubing q 72 to 96 hrs

• aseptic treatment of tubing infusion ports (scrub hub)

• keep pressure on flush bag 300 mmHg and ensure fluid is in flush bag

• monitor waveform

• make sure tip is deflated

What medications do we give if a patient has increased preload? 

• diuretics

• venous vasodilators

What do we give to the patient with decreases preload?

• vasopressors

• fluids 

What medications do we give to increase contractility of the heart? 

• positive inotropes
  - digoxin
  - dobutamine