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Week 1 Study Guide

Chapters 65: pages 1554-1558
1. The American Association of Critical-Care Nurses (AACN) defines critical care nursing as:
 A specialty dealing with human responses to life- threatening problems.

2. Being a critical care nurse involves

 Assessing life threatening conditions
 Starting appropriate interventions
 Evaluating the outcomes of the interventions
 Providing teaching
 Emotional support to caregivers

3. What is the differences between the ICU and PCU?

 ICU meets the special needs of acutely and critically ill patients
 PCU provides transition between ICU, AT RISK , but risk is lower than ICU patients

4. A critical care nurse needs to have in-depth knowledge of

 Anatomy
 Physiology
 Pathophysiology
 Pharmacology
 Advanced assessment skills
 Ability to use advanced technology

5. Why is it important to do frequent assessment and follow trends such as vital signs and labs?

6. How does the AACN define a critically ill patient?

One who is at high risk for actual or potential life threatening health problems and who requires
intense and vigilant nursing care.

7. What are the 3 possible reasons why a patient is admitted to the ICU?
 Patient physiologically unstable requiring advanced clinical judgements by RN and HCP
 Patient may be at risk for serious complications and need frequent assessments and often
invasive interventions
 Patient may need intensive and complicated nursing support related to the use of IC
polypharmacy and advanced technology

8. Why is it important to be skilled in palliative and end-of-life care?

 Palliative care page 129 is defined as?
Reducing the severity of disease symptoms.
 The overall goals of palliative care are to (page 129).
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o Prevent and relieve suffering

o Improve quality of life for patients with serious life limiting illnesses

 Older adults often have multiple chronic illnesses resulting in increased health care utilization.
How has palliative care helped this population (page 129)?
o Improve quality of life for those with chronic illness
o Decrease the associated economic costs for their health care
o Alleviate the burden of caregivers for those with chronic and terminal illnesses

 What are some life-limiting illnesses that qualify for palliative care (page 129-130)?
CA
Heart failure
COPD
Dementia
ESKD – end stage kidney disease

 What are the goals of end-of-life care? (page 130)

o Symptom management
o Advance care planning
o Spiritual care
o Family support

 What is the death rattle (page 132)?

o Noisy- wet sounding respirations
o Caused by mouth breathing and accumulation of mucus in the airways

Table 9-2: physical manifestations of end of life

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 Define spirituality (page 134):

o Beliefs, values, and practices that relate to the search for existential meaning and
purpose.

 What are advanced directives? (page 135)

o Written documents that provide information about the patient’s wishes and his or her
designated spokesperson

 What is a do-not-resuscitate (DNR) order? (page 135) Note: a patient without this order will
receive CPR.
o A written medical order that documents a patient’s wishes regarding resuscitation and
more important the patients desire NOT TO RECEIVE CPR

 Describe postmortem care (page 139).

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o After the patient is pronounced dead

o Preparation of the patient’s body for immediate viewing by the family (consider
cultural customs)
o Close the patient’s eyes, replace dentures, wash the body, remove tubes and dressings

9. Critically ill patients that are intubated are at risk for what complications (back to page 1556)?
 Skin problems
 Venous thromboembolism
 Immobile

10. The use of multiple invasive devices predisposes the patient to health care-associated infections. Which
can cause Heath care associated infections (HAIs)and Sepsis and multiple organ dysfunction syndrome
(MODS)

11. Anxiety:
 What is the primary sources of anxiety?
o Perceived or anticipated threats to health or life
o Loss of control of body functions
o Environment that is foreign
 Why do patients/family members feel uncomfortable?
o Complex equipment
o High noise and light levels
o Intense pace of activity
 How can we (nurses) help to reduce anxiety?
o Teach patients and caregivers to express concerns, ask questions, state their needs
o Include in all conversations and explain procedures and equipment
o Encourage family to bring in photographs, personal items
12. Pain:
 What is the % of ICU patients report moderate to server unrelieved pain?
o 70%
 What is the consequences to uncontrolled pain? What ICU patients are at high risk?
o Agitation and anxiety
o Medical conditions that include ischemic, infectious, or inflammatory processes
o Immobilized
o Invasive monitoring devices: endotracheal tubes
o Invasive or noninvasive procedures
 What is “sedation holiday” and why is this important?
o A scheduled interruption of sedation to awaken the patient and CONDUCT
NEROULOGIC EXAMINATION.
 Access a free educational video to learn more about using the CPOT in the ICU at
http://pointers.audiovideoweb.com/stcasx/il83win10115/CPOT2011-WMV.wmv/play.asx. Funded and created
by Kaiser Permanente Northern California Nursing Research.(will be doing in class)
o The CPOT handout is in the files folder
13. Impaired communication:
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 The inability to communicate due to medications, intubation, etc. can be distressing to

patients. What other options for communication?
o Picture boards
o Notepads
o Magic slates
o Computer keyboards
 What is an important nonverbal communication the nurse can use?
o TOUCH
 Why do nearly all ICU patients have sleep disturbances?
o Difficulty falling asleep or disrupted sleep
1. Noise, anxiety, pain, frequent monitoring, treatment, procedures
 Sleep disturbance has been associated with Delirium and Delay

 What nursing interventions can the nurse use to improve sleep?

o Schedule rest periods, dimmed lights at nighttime, provide eye makes, ear plugs,
opening curtains during daytime, limit noise, provide comfort measures.
 What are collaborative interventions:
o
14. Sensory-Perceptual Problems:
 Why are patients at risk for delirium?
o Alterations in mentation, psychomotor behavior, sleep wake cycle
 What is the % of patients at risk?
o 80%
 What are risk factors?
o Preexisting dementia, hx of baseline htn, alcohol abuse, severe illness on admission
 What is the Confusion Assessment Method (table 59-15)?
o PAGE 1414???
 What are interventions to decrease delirium?
o Use of clocks and calendars
15. Nutrition:
 Why are patients malnourished prior to coming to the ICU or at risk for malnourishment in
the ICU?

 What is inadequate nutrition linked to?

Increased mortality and morbidity rates
 Why is enteral nutrition preferred over parenteral nutrition?
Enteral preserves the structure and function of the gut mucosa and stops the movement of gut
bacteria across the intestinal wall and into the bloodstream
Shorter hospital stays, less expensive
 Why could enteral nutrition cause underfeeding in patients?
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Frequent interruptions in enteral feeding to give drugs, tests, and procedures

 When is parenteral nutrition used?

The enteral route cannot provide adequate nutrition or is contraindicated.

16. Issues related to Caregivers:

 What roles do the caregivers play in the patient’s recovery?
o Advising patient in health care decisions or serving as the decision maker when patient
cannot

o Helping with ADLs

o Providing positive, loving, caring support

o Providing a link to the patient’s personal life

 To provide family-centered care effectively, you must be skilled in crisis intervention.

 What must the nurse complete on the family?

o What strategies should the nurse use?

 What are the major needs of the caregivers of critically ill patients?
o information
o reassurance
o access

 Regarding the lack of information, the nurse must assess caregivers understanding of the
patients status, treatment plan, and prognosis, and provide information appropriate and
identify a spokesperson for the family to help coordinate information exchange between the
inter-professional care team and family for visitation of the critical ill patient?

 What should the nurse do for the first time that caregivers visit?
o Prepare them for the experience.
o Describe the patient’s appearance and physical environment
o join them as they enter the room. Observe responses
o Invite caregivers to participate
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 Caregivers should have the option to be at the bedside for invasive procedures and CPR even
if the outcomes are not favorable. How does this help the caregivers?
o Overcome doubts and patients condition
o Reduce anxiety and fear
o Meet their need to be together with and support their loved one
o Begin the grief process if death occurs

Chapter 18: Intraoperative Care, pages 325-326 - Table 18-6 and 18-7

17. propofol (Diprivan)

 ideal for short outpatient procedures because of rapid onset, metabolic clearance. May be used
for induction as nonirritating to respiratory tract
 may cause bradycardia and other dysrhythmias, hypotension, apnea, transient phlebitis, nausea
and vomiting, hiccups, hypertriglyceridemia
 monitor post op hypotension, bradycardia, monitor serum triglycerides

18. ketamine (Ketalar)

 can be given IV or IM. Potent analgesic and amnesic

 may cause hallucinations and nightmares, increased intracranial and intraocular pressure.
Increased HR increased BP
 anticipate administration of a benzodiazepine if agitation and hallucinations occur. Calm, quiet
environment is essential in postop care

19. opioids
 fentanyl
 morphine
 hydromorphone

 induce and maintain anesthesia, reduce stimuli from sensory nerve endings, provide analgesia during
surgery and recovery
 respiratory depression, stimulation of vomiting center, possible bradycardia and peripheral
vasodilation. High incidence of pruritus in both regional and IV administration
 assess respiratory rate and rhythm, monitor pulse ox, protect airway in anticipation of vomiting
 use Naloxone (NARCAN) for reversal agent
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20. benzodiazepines
 midazolam (Versed)
 diazepam (Valium)
 lorazepam (Ativan)

 reduce anxiety preoperatively and postoperatively, induce and maintain anesthesia, induce amnesia,
treat emergence delirium. Supplement sedation in local and regional anesthesia
 synergistic effect with opioids, increased potential for respiratory depression. Hypotension and
tachycardia. Prolonged sedation or confusion
 monitor level of consciousness assess for respiratory depression, hypotension and tachycardia
 use FLUMAZENIL (ROMAZICON) for reversal agent

21. Neuromuscular blocking agents

 Succinylcholine (depolarizing agent)
 Rocuronium (non-depolarizing agent)

 Facilitate endotracheal intubation, promote skeletal muscle relaxation (paralysis) to enhance access to
surgical sites
 Non-depolarizing agents are usually reversed toward end of surgery by administration of
anticholinesterase agents
 Adverse effects – apnea related to paralysis of respiratory muscles. Duration of action of non-
depolarizing agents may be longer than surgery Reversal agents may not completely eliminate effects.
Confusion and nausea;

22. Antiemetics
 Ondansetron (Zofran)
 Metoclopramide (Reglan)
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 Scopolamine (Transerm-Scop)

 Counteract emetic effects of inhalation agents and opioids. prophylactic prevention of nausea and
vomiting related to histamine release, vagal stimulation, vestibular disturbance, surgical producers.
 Side effects = HA, dizziness, IV irritation, dysrhythmias, dysphoria, dry mouth, CNS sedation

23. Dexmedetomidine (Precedex)

 Induces and maintains sedation in non-intubated patients prior to and or during surgical
procedures
 Adverse effects = hypotension, bradycardia, sinus arrest, transient hypertension during
administration of loading dose.
 Monitor HR and rhythm and BP for side effects

Olmstead, J. A. Y Dahnke, M. D. (2016). The need for an effective process to resolve conflicts over medical
futility: A case study and analysis. Critical Care Nurse 36(6).
24. What is medical futility?

25. What is the ethical dilemma in this article?

26. How did this article make you feel?

Campbell, M. L. (2015). Caring for dying patients in the intensive care unit. AACN Advanced Critical Care 26(2).

27. Define dyspnea- shortness of breath; difficulty breathing that may be caused by certain heart or lung
conditions, strenuous exercise, or anxiety. (subjective experience of breathing discomfort_

28. What is the prevalence of dyspnea in critically ill patients? 33% experienced moderate to severe levels of
dyspnea
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29. What is the treatment for refractory dyspnea?

Positioning (optimize vital capacity and ventilation), oxygen, opioids, benzodiazepines, and mechanical
ventilation
30. Oxygen may reduce dyspnea in patients with hypoxemia. Note: no benefit has been found when the
patient has had mild or no hypoxemia.

31. What is the mainstay medication for treating refractory dyspnea?

Opioids (morphine and fentanyl)
32. Ventilator withdrawal is also known as terminal weaning. What medications are recommended for
premedication prior to ventilator withdrawal? (note if the patient is on propofol this must be stopped
prior to extubation-ICU nurses can only use this on intubated patients). Why are these medications
given?
Opioids and or benzodiazepines administered before, during, and after
33. What is the death rattle?
Naturally occurring patient condition during last hours of life. Noisy secretions that are aubile and ca nbe
distressing for the professional caregiver and families.

34. What is the treatment for the death rattle?

 Hyoscine transdermal or subcutaneous, atropine drops administered by mouth, parenteral
gycopyrrolate, no evidence shows that these agents are superior to placebo.

Milic, M. M., Puntillo, K., Turner, K., Joseph, D., Peters, N., Ryan, R., Schuster, C., Winfree, H. , Cimino, J., &
Anderson W. G., (2015, August). Communicating with patients'' families and physicians about prognosis and
goals of care. American Journal of Critical Care 24(4)
35. The role of the bedside nurse is outlined as The Four Cs. What are the 4 Cs?
 Conveying and identifying the needs
 Communication
 Checking and assessing the informational needs of patient
 Collaboration- clarifying information exchanged between team and family
36. Why is communication so important to an ICU nurse?

37. Additional medication you need to know

a. Heparin
i. Therapeutic: Treatment of condition (IV bolus and infusion)
ii. Prevention
b. Enoxaparin (Lovenox)
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i. Therapeutic: Treatment of (PE, DVT)

ii. Prevention
c. Haloperidol (Haldol)
d. Ulcer prevention
i. Famotidine (Pepcid)
ii. Pantoprazole (Protonix)

Chapter 35: Dysrhythmias

1. Table 35-2: ECG Waveforms and intervals
2. Need to know what the waveforms represent in the cardiac cycle

P Wave – time of the electrical impulse through 0.06 – 0.12

the atrium causing atrial depolarization
(CONTRACTION)

PR Interval – time taken for impulse to spread

through the atria, AV node and bundle of HIS,
bundle branches, and Purkinje fibers . 0.12 – 0.20
Immediately before ventricular contraction
QRS complex-
Q wave – first negative downward deflection Q < 0.03
after the P wave, short and narrow
R wave- first positive upward deflection in
complex
S wave- first negative downward deflection
after R wave
QRS interval - measured from beginning to end
of QRS complex . represents time taken for < 0.12
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depolarization (contraction of both ventricles)

(systole)
ST segment measured from S wave of the QRS
complex to the beginning of the T wave-
represents time between ventricular 0.12
depolarization and repolarization
(diastole)
T wave represents time for ventricular
repolarization 0.16

QT interval measured from beginning of QRS

complex to end of T wave. Represents time 1.34 – 0.43
taken for entire electrical depolarization and
repolarization of the ventricles.
Pages 757-760 focus on how to count the rate using the 6 second method and large boxes
a. Watch the following 2 videos
i. Heart conduction explained (need to watch)
https://www.youtube.com/watch?v=EMmjwgwHkO0
ii. Conduction measurements and counting rate explained (need to watch)
https://www.youtube.com/watch?v=FThXJUFWUrw
b. Need to know
i. SR (page 760) and 1 degree AV block (page 767)
Sinus Rhythm: starts in the SA node at rate of 60-100 and follows the normal conduction pathway.

First- degree AV block: AV block the impulse is conducted to the ventricles but the time of AV conduction is
prolonged. (usually associated with MI, CAD, rheumatic fever, hyperthyroidism, hypokalemia)
 HR is normal and rhythm is regular
 the P wave is normal
 the PR interval is prolonged
o PR interval > 0.20