Nursing Advanced Concepts and Skills Class 7, 8, 9 and 10

Non-Invasive Ventilation

• High Flow

• CPAP

• BiPAP

Invasive Ventilation modes

• PRVC

• PC

• PSV

Tidal Volume (VT)

• air inhaled and exhaled in one breath

• 6-8 ml/kg

• max 40 mls

• Lower VT = stiffer lungs, underventilation notify MD/RT (CO2 retention)

• high VT = volumtrauma notify MD/RT

Respiration Rate (RR)

• 12 -20 breaths per minute

• high = increased metabolic demand

Minute Ventilation (MV)

• MV = VT +RR

• 5-8 L/min

Positive End Expiratory Pressure (PEEP)

• Pressure in lungs at the end of expiration to prevent collapse of airway

• 5-8 cmH2O

Peak Inspiratory Pressure (PIP)

• highest pressure reached during inspiration

• if high PIP assess pt for kinks, biting, poor compliance, and notify MD/RT

• low = leaking, ett displaced

Fraction of inspired oxygen (FiO2)

usually 21% = room air

Set pressure

• amount of pressure delivered to achieve desired VT

Pressure vs VT

• if pressure is set lungs compliance will cause VT to vary

• if VT set lungs compliance will cause pressure to change

Pressure Regulated Pressure Control (PRVC)

• safest mode - fully supported

• consistent VT

• provides a set volume using safest pressure

  • if pt lungs get stiffer, the pressure will increase to ensure volume is delivered (alarm as high PIP)

• set limits the PIP

  • if high PIP assess pt for kinks, biting, poorcomplience and notify MD/RT

Pressure Control (PC)

• set pressure (will not exceed limit)

  • VT changes based on complience

  • lower VT = stiffer lungs, underventilation notify MD/RT (CO2 retention)

  • high VT = volumtrauma notify MD/RT

• Fully supported

Pressure Support Ventilation (PSV)

• spontaneous mode - effort required from pt

• no set RR or VT

  • watch closely

  • poor tolerance (high RR low VT) = needs support

  • good tolerance = ready for weaning

• backup ventilation for apnea

• VT determined by level of PS, pt effort, lung mechanics (compliance)

Nursing actions during Ventilation

assessmnet

• ETT placemnet

• breath sounds

• vent settings

• LOC

• Pain, Agitation, delirium

• suctioning

• sedation

• turn and position

• hygine

Palliative care

• relieving symptoms of an incurable, life-limiting illness

  • pain, nausea, fatigue, anxiety, depression

• holistic care

when should palliative are be implemented

• as soon as diagnosis with life-limiting illness is made

• progression of disease

• poorly managed symptoms, high symptom burden

role of the nurse during palliative care

• knowledgeable about illness and symptoms

• advocate

• ask questions

• be present

• acknowledge difficulties

• ask about rites and ceremonies, religious or cultural needs

diffrence between end of life and palliative care

Palliative Care

• Follows the patient along their illness trajectory, for weeks, months and often sees ups and downs (bumps in the road) with some plateaus

• Gradual decline in status

End of Life Care

• More predictable, steady decline

• Weeks, days, hours

how do we know patients are reaching end of life

• eating less

• spending more time in bed

• sleeping more

• increased pain

• incontinence

RN role in MAID

RN scope of practice in MAID is limited to aiding in the provision of MAID

• Providing information/education upon request

• support client and family

• IV insertion

• prepare meds

• independent witness

• check documentation and requirements

MAID Eligibility Criteria

• 18 years old +

• capable of making decisions

• grievous and irremediable medical condition

• voluntary request

• informed consent after other means trailed

two-track approach to MAID

• death is in the near future

  • no wait period

  • 2 MD or NP need to assess and confirm eligibility

• death is not in the reasonably foreseeable future

  • safeguards - 90 days between first assessment and MAID

Registered Dietitian

do not need MD referral

food security

• people at all times have access to food (physically and economically)

  • adequate amount, safe, culturally appropriate

What is a discharge planning liaison nurse?

• link between acute care and community

• community nurse relies on liaison nurse to provide accurate info on clients coming home

• acute care relies on to see what resources are available to support pt and how to get them out safely

What is discharge planning?

• Helping clients move safely from the hospital back to home or to another setting

• Using an interdisciplinary, integrated approach to getting clients home efficiently and safely while trying to prevent readmission or a "failed discharge"

Balanced food plate

• ½ non starchy fruit and veg

• ¼ whole grain and starchy veg

• ¼ protein

Barriers to discharge

• Lack of allied health (especially social workers)

• Transportation

• Equipment

• Trying to get appointments for O2, Bipap, Cpap

• Family not wanting or not ready to take clients home

• Homeless

• family cant manage anymore

• too much to handle

• wander risk

• lives alone

• cant find home care

roles of a DPLN

• Pallitive care

• complex wound care

• vent set up (BiPAP or CPAP)

• IV antibiotics

• delegation of function

  • insulin, ostomy, foly care in PCH

• short term home support

Canadian Nutrition Screening Tool (CNST)

identifies pts who are at risk for malnutrition

strategies to support food intake

• position pt properly

• assist with opening containers and packages

• avoid scheduling tests and exams at meal times

• consider snacks and supplements between meals to support intake

• consider why pt is not eating and try to rectify

  • pain, depression, anxiety → meds or social support

Discharge Facilitator

• assigned to a medicine team

• meets pt in emerge

• discharge risk assessment completed (meditech)

• put in essential home situation, dischargeinfo and potential barriers in ticks

• consult allied health members early on

• round with team

• follow client from admission to discharge

discharge planning

• starts on admission

• continuously evaluated via team approach (involve all disciplines needed, make suggestion to add)

• as client health changes, discharge plan changes

• plan needs to be sustainable and safe

• we want clients home and staying there