Rasmussen College: MDC III NUR2759MCD4_work_and_class_LATEST UPDATED,100% CORRECT

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Rasmussen College: MDC III NUR2759MCD4_work_and_class_LATEST UPDATED Diseases of the Peripheral Nervous System Guillain-Barre Syndrome Guillain-Barre Syndrome (GBS) is a result of overac... tive immunity. It is rare and affects men more than women. The myelin sheath is attacked by circulating antibodies resulting from an immune response. There are various triggers from bacterial to viral. The most common presentation is a viral-like illness one to three weeks prior to GBS symptoms. The result of the overactive immunity results in destruction of the myelin sheath which slows the transmission of impulse from node-to-node. The slowing of impulses produces the symptoms of GBS. The hallmark of the disease is ascending weakness. Stages of GBS Acute Stage – Onset of symptoms Plateau – Symptoms remain for a few days to a few weeks Recovery May take up to 2 years Diagnostics Lumbar puncture to evaluate cerebral spinal fluid (CSF) for increase in protein--results are non- conclusive Electrophysiologic studies (EPSs)--demonstrates demyelinating neuropathy Treatment Options Plasmapheresis – Remove circulating antibodies Start within several days of onset of illness 3 to 4 treatments – 1-to-2 days apart Weigh the client before and after procedure IV immunoglobulin (IVIG) Is as effective as Plasmapheresis Infuse slowly observing for any side and adverse effects Nursing Care Frequent monitoring of the respiratory and cardiovascular system Inability to maintain airway--potentially fatal with ascending paralysis Aspiration precautions Suction equipment at the bedside HOB elevated 45 degrees Change position every 2 hours Breathing exercises, cough and deep breathing Incentive spirometer Oxygen Report change in HR and BP to primary healthcare provider Interdisciplinary – Respiratory therapy Chest physiotherapy Managing airway if compromise occurs Oxygen During the recovering period involve other disciplines PT/OT Speech therapy Nutritionist Myasthenia Gravis Myasthenia Gravis is a progressive-acquired autoimmune disease. It is a breakdown in the relaying of signals from the nerves to the muscles. This breakdown in communication at the synapses causes muscle weakness. The typical area where symptoms are first noticed is visual disturbances. Other symptoms can include drooping of the eyelids and difficulty swallowing. Death can result from a rapid development of muscle weakness which can induce respiratory failure. Signs and Symptoms Ptosis Diplopia Dysphagia Fatigue Respiratory compromise Progressive muscle weakness that worsens with repetitive use - improves with rest Decreased sense of smell and taste Paresthesias Diagnostics Repetitive nerve stimulation (RNS) Imaging for Thymoma Treatment Anticholinesterases or cholinergic drugs Immunosuppressive drugs or corticosteroids Plasmapheresis Thymectomy Nursing Care Administer meds 45 minutes to 1 hour after taking ChE inhibitors to avoid aspiration Cholinergic crisis Side effect of medication used for treatment Manifested by nausea, vomiting, diarrhea Can cause life-threatening symptoms such as bronchospasm and bradycardia Myasthenic and Cholinergic Crises Myasthenic Crisis Myasthenic Crisis can occur for a number of reasons. The client may need an adjustment in their medication, or the client may be suffering from a stressor such as an infection. The result of the crisis is muscles of the respiratory system become so weak that the client may need mechanical ventilation. Cholinergic Crisis Think of an overdose; Cholinergic Crisis is caused by taking too much of the anticholinesterase drugs. It causes an over-stimulation at a neuromuscular junctions. The causes the following symptoms: Salivation Lacrimation Urination Defecation Similar to Myasthenic Crisis, muscle weakness occurs in which the client may need mechanical ventilation. Cranial Nerve Disorders Trigeminal Neuralgia Click for more options Trigeminal Neuralgia is a disorder of cranial nerve V that causes severe facial pain. A client that experiences Trigeminal Neuralgia literally stops in their tracks due to the severity of the pain. The client may actually cry out in pain, cradle their face, and then become silent. The client may also experience facial twitching or tics, hence the secondary name of tic douloureux. The pain is unilateral and may have a precipitating factor such as dental work or may have a sudden, unprovoked onset. The priority of care for the client is pain management with drug management being the first choice. Carbamazepine (Tegretol) or gabapentin (Neurontin) may be used. There are other options for treatment which include peripheral chemical nerve block with ropivacaine or stereotactic radiation treatments. The utilization of a gamma knife is a surgical approach that disrupts trigeminal neuralgia to provide pain relief. The client may avoid facial movement in fear of aggravating the pain cycle. When caring for the patient, they may seem withdrawn, depressed, or uninterested in conversation. This is simply a self- protecting mechanism to avoid the sudden onset of Trigeminal Neuralgia. Bell’s Palsy (Facial Paralysis) Click for more options Bell’s Palsy will scare a client into thinking that they have had a stroke (CVA). This is because the symptoms are just like those of a stroke, such as facial paralysis, drooping eyelid, and drooping mouth. The symptoms are occurring not because of brain injury, but because of a virus such as herpes simplex virus type 1 affecting the 7 th cranial nerve. approximately 2 to 5 days. The client will not be able to close the affected eye, wrinkle the forehead, smile, whistle, or grimace. The client may experience tinnitus, pain behind the affected ear, and change in taste. Treatment is administration of corticosteroids, 30 to 60 mg daily and acyclovir (Zovirax). Nursing care revolves around the psychological care and reassurance that this is not a stroke, and the symptoms will resolve. Since the eyelid will not close, the eye has to be protected. Teach the client to manually close the eyelid at intervals and apply artificial tears during the day. Since the eye doesn’t close on its own, there is no natural lubricant. At night wear an eye patch or tape the eye shut and use an ophthalmic ointment to supply moisture to the eye. Fluids may be challenging as the weak side of the mouth will droop and drool. Encourage the client to drink, chew, and swallow on the unaffected side. For a short period of time, a soft diet may be beneficial. Monitor the client’s hydration status. Anticipate that the client suffering from Bell’s Palsy will benefit from physical therapy. The therapist will teach muscle strengthening exercises that can be done at home with great benefit. In rare cases a permanent sense of pain may linger which can be treated with gabapentin (Neurontin). Perioperative Overview The words “you need surgery” may cause anxiety in clients. The surgical client has known risks that occur which the surgical team works to prevent. Complications and errors that have occurred in the surgical suite have influenced how we practice today. Progression through this module will center around three areas; perioperative, intraoperative, and postoperative. Let’s begin with perioperative. Perioperative The perioperative period begins when the client is placed on the surgical schedule and ends when the client is transferred to the surgical suite. There are specific reasons for surgery, such as: diagnostic, curative, transplant, restorative, palliative, or even cosmetic. There are also different levels of urgency. For example, a total joint replacement is an elective surgery and is a planned procedure. A displaced bone fracture is urgent and intervention should not be delayed more than 24-48 hours. As compared to a gunshot wound, which is emergent due to the life-threatening nature of the injury, the client would immediately go to the surgical suite. The next consideration in surgery is the surgical approach. Simple, Minimally-Invasive, and Radical Surgical Approaches The simple surgical approach only applies to the areas involved in the surgery. An example of this surgery would be simple/partial mastectomy. Another surgical approach is minimally-invasive surgery. Most of the surgeries fall within this category. Examples include: lung lobectomy, arthroscopy, and cholecystectomy. The last surgical approach is termed radical which involves removing surrounding structures as well as lymph nodes. Examples of the procedures are radical prostatectomy and hysterectomy. Surgical Checklist No matter where surgery takes place, either as an inclient or outpatient, client safety is a priority. It is standard practice for facilities to have a comprehensive surgical checklist to complete. Lists of this nature are only as good as the person completing them. The RN completes the pre-operative checklist, the anesthesiologist also completes a checklist, interviews the patient, and assesses the airway preparing for safe administration of anesthetics. One of the most important steps that is now standard practice is the Time-Out. This occurs right before the skin incision is made. The designated team member calls for a Time-Out to review and confirm that the correct procedure is going to be performed on the correct client at the correct site. Other verifications include that a signed informed consent by the client or designated health care surrogate is within the records. Is the site marked clear and is it the correct site verified with consent? In other words, is the team operating on the correct limb? Any other concerns are raised by the team at that time. Remember, this step prevents errors. The Older Adult and Surgery Open Book Click for more options The Older Adult and Surgery At-Risk for Complications The older adult is at risk for complications related to surgery as well as anesthesia. As the health history is taken, questions will revolve around lifestyle and life choices. Encourage the client to answer truthfully. Concerns would focus on the following: Comorbidities Age-related changes in the kidneys and liver Drugs and substance use Tobacco use Alcohol use Prescription medications Over-the-counter medications Herbal supplement use Completeness It is essential that the client has a complete history and physical. Have the client or family bring in every medication that the client takes. Prepping a client for surgery can increase both stress levels and induce anxiety. Many healthcare workers are asking lots of questions, and some are repetitive. Reassure the client that every question is asked to ensure a safe journey through the surgical experience. The client may be asked many times: State your name and date of birth? What are your allergies? Have you had any previous anesthesia? If the answer is yes, how did you react to the anesthesia? Do you have any loose teeth, dentures, partial plates, etc.? What surgeries have you had in the past? When able, and if you sense frustration, give the client a mental break for a moment. The perioperative period can feel overwhelming to the older adult. Allergies Open Book Click for more options Allergies A part of the medical history is client allergies. Here are some relational allergies that may impact decisions for the OR team. Allergy to povidone-iodine (Betadine) is the same allergens found in shellfish. Allergy to avocados, bananas, strawberries--alerts the team to a possible latex allergy. Allergy to egg, peanut, or soy should be an alert for the anesthesiologist. The client may adversely react to propofol (Diprivan). Allergy to metal. Joint replacements are made from metal. Clients with a known nickel allergy will receive an implant that is made from titanium to prevent a systemic allergic response to the implanted item. Age-Related Changes in the Older Adult (over 65 Years of Age) Open Book Click for more options Age-Related Changes in the Older Adult (over 65 Years of Age) As the person ages, there are changes that occur in all body systems. During the surgical journey, the client will endure the gathering of their medical history and multiple physical exams from several providers as well as the RN. Each body system is reviewed and evaluated. Let’s looks at changes that occur simply due to aging by body system: Cardiovascular System Decreased cardiac output Increased blood pressure Decreased peripheral circulation Respiratory System Reduced vital capacity Loss of lung elasticity Decreased oxygenation of blood Renal/Urinary System Decreased blood flow to kidneys Reduced ability to excrete waste Decline in glomerular filtration rate Nocturia common Neurological System Sensory deficits Slower reaction time Cognitive impairment Musculoskeletal System Osteoporosis Arthritis Decreased mobility Skin Dry skin Less subcutaneous fat Greater risk for injury Blood Loss Open Book Click for more options Blood Loss In preparation for blood loss during surgery, the client has the option to donate their own blood. This is called an autologous blood transfusion and is preferred if there is time prior to an elective surgery to do so. This must occur several weeks prior to the scheduled surgery. The client should alert the perioperative personnel that they have donated their own blood prior to the surgery. The client will provide documentation from the donation center. A client may refuse the administration of blood products because of religious beliefs. There are processes in place to respect those beliefs and have positive surgical outcomes. If the surgery is elective, there is time to prep the client by administering epoetin alpha (Epogen, Procrit) to stimulate red blood cell production. The client can also take supplements such as iron, folic acid, vitamin b12, and vitamin C also for red blood cell formation. During surgery, the use of a cell saver machine can collect, wash, and return blood loss during surgery. There is an increased use of minimally-invasive surgery among surgeons which minimizes blood loss during surgery (Ignativacius,D., et. al., 2018). It is a better option for the client to receive their own blood than from a donor’s blood that could carry diseases . Laboratory and Imaging Studies Open Book Click for more options Laboratory and Imaging Studies The laboratory tests and radiology imaging is ordered before surgery depends on the client’s age, medical history, and type of anesthesia planned. It is important to report abnormal results to the surgeon. The most common tests include: Urinalysis Blood type and screen Complete blood count or hemoglobin & hematocrit Clotting studies Prothrombin time (PT) International ratio (INR) Activated partial thromboplastin time (aPTT) Platelet count Electrolyte levels Serum creatinine Blood urea nitrogen levels Pregnancy test Arterial Blood Gas Imaging Assessment Chest x-ray CT Scan MRI Other Diagnostics ECG Informed Consent Open Book Click for more options Informed Consent An informed consent is a process to educate the client of the planned invasive procedure. The client should be informed of the following: The name of the surgery Who will be performing the procedure All available options including benefits and risks Risks associated with the procedure and potential outcomes Risk associated with anesthesia Risks, benefits, and alternatives of the use of blood or blood products during the procedure It is the responsibility of the surgeon to provide a complete explanation of the surgical procedure and to have the consent form signed BEFORE sedation is given and before surgery is performed. The nurse’s role is to clarify facts that have been presented by the surgeon. The nurse will sign the consent as a witness to the signature not to the fact that the client is informed. NPO Status Open Book Click for more options NPO Status During the perioperative time in preparation for surgery, it is important for a client to refrain from eating, drinking, or smoking before surgery. This is referred to as nothing by mouth (NPO). The recommended time for a client to maintain NPO status is 6-8 hours prior to surgery. Longer than 8 hours for an older adult may inadvertently cause unwanted fluid imbalances. NPO status ensures that the client’s stomach is empty of solid food and has limited volume of gastric secretion. This will decrease the risk for aspiration during the administration of anesthesia. Preventing Post-Operative Complications During the Perioperative Period Open Book Click for more options Preventing Post-Operative Complications During the Perioperative Period Client education during the perioperative period may prevent complications during post-operative time. Provide education regarding early mobility and how to use the incentive spirometer. Teach the client and family what to expect after surgery such as pain management, dressings, and DVT prophylaxis. Communication is a key element in caring for clients and directly impacts client outcomes. Intraoperative Open Book Click for more options Intraoperative The operating room or suite is a complex foreign environment to most. When the client is transferred to the surgical suite, the intraoperative experience begins. Once the client is then transferred to the post anesthesia team, the intraoperative experience ends. It is a time of anxiety, fear, and a feeling of vulnerability for the patient. Keep an open, honest line of communication with the patient. The intraoperative nurse should explain to the client what is happening and what is coming next. Keeping the client informed provides a level of comfort and a sense of control. While in the care of the intraoperative team, SAFETY is the priority. The intraoperative team focuses on preventing, decreasing, and avoiding risk factors such as: Risk for infection Impaired skin tissue integrity Increased anxiety Inadequate thermoregulation Altered body temperature Injury related to positioning Other safety concerns in the OR suite revolve around electrical and fire hazards. All equipment in the OR is inspected per facility protocols, and should be in good working order. The client has grounding pads placed on his/her body, and no contact with any metal surfaces is confirmed by the intraoperative nurse. The OR team also work on preventing fire. The fire triangle is having an ignition source, oxidizer, and fuels, which together increase the risk for fire. See the example below: The use of minimally-invasive surgery has improved and advanced over the years. This type of surgery requires injection of gas or air into the cavity beforehand to separate organs and improve visualization for the surgeon. The injection is known as insufflation. The gas discomfort and fullness that the client experiences after surgery is due to this injection of air or gas. It will be reabsorbed but can take several days. If there are no contraindications, the client is encouraged to ambulate to assist the reabsorption of injected gas or air. Activity - Risk of Fire Mobile Click for more options Activity - Risk of Fire Click the “Activity - Risk of Fire” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. Complications of General Anesthesia Open Book Click for more options Complications of General Anesthesia Over the years, improvement in surgery and anesthesia has decreased mortality rates. However, the complications can range from minor to death. The anesthesia provider stays alert and monitors for changes in the client’s condition. A serious complication of anesthesia is malignant hyperthermia (MH). It is an inherited (genetic) muscle disorder which involves increased levels of calcium and potassium which increases muscle metabolism. The increased metabolic rate produces acidosis, cardiac dysrhythmias, and a high body temperature. The onset of symptoms can occur shortly after anesthesia is started or after completion of anesthesia during the postoperative period. Symptoms include: Tachycardia Dysrhythmias Muscle rigidity of the jaw and upper chest Hypotension Tachypnea Skin mottling Cyanosis Myoglobinuria Unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation Extremely elevated temperature as high as 111.2 degrees F--late sign If a client has early signs of malignant hyperthermia, diagnosis and intervention with the administration of dantrolene sodium is live saving. The AORN recommends having an intervention cart available to intervene quickly . The cart should include the following: Normal saline (administer iced NS at 15mL/kg every 15 minutes as needed) dantrolene IV 3 mg/kg Sodium bicarbonate (treats metabolic acidosis) Insulin (treats hyperkalemia) 50% dextrose Lidocaine (treats dysrhythmias) Calcium chloride Use cooling blankets and ice down body hot spots such as groin and axillae The client experiencing MH will need continuous monitoring until crisis has passed. The best way to avoid such complication occurs in preoperative screening of any complications related to past use of anesthesia or any family that has had complications with the use of anesthesia. The OR is a specialty area, but as a medical surgical nurse, one has to have a basic knowledge of how to recover and manage clients that receive various types of anesthetics. Types of Anesthesia The types of anesthesia available are general anesthesia, local, and regional. Local anesthesia is delivered topically to the skin or injected into mucous membranes. Regional anesthesia is administered to block multiple peripheral nerves and reduces sensation to a specific body region. The type of anesthesia delivered is determined by the anesthesiologist. Sedation At times, the client may need a combination of sedative, hypnotic, and opioid drugs which are delivered to sedate the patient, but does not need the intervention of intubation to maintain a patent airway. It is the responsibility of the RN to monitor the client during and after the sedation until full recovery has occurred. This includes the client being fully awake and responsive with vital signs returning to pre- procedural baseline. Care of the Postoperative Client Open Book Click for more options Care of the Postoperative Client The postoperative period begins when the client is transferred to the appropriate unit for continued recovery. It is the recommendation of the Joint Commission that a hand-off report takes place between healthcare professionals . The report should include the following: Surgical procedure Type of anesthesia Special report such as traumatic intubation Length of time the client was under anesthesia Comorbidities Vital signs Pulse oxygenation Intake and output IV fluids Type of fluids administered Blood loss totals Type of blood products delivered intraoperatively Medications administered Time last dose of pain med Type of incision, dressings, catheters, tubes, drains, or packing Wound care orders from surgeon Communication that has occurred with family Once the RN has received report and the client is settled comfortably and safely in their room, the RNs next focus is performing a shift assessment. Nursing monitoring and management to establish a baseline for the client is as follows: Airway Oxygen saturation Cough and deep breath at least every 2 hours Splint wound to minimize pain Incentive spirometer every 2 hours Reposition every 2 hours Ambulate early and regularly Positioning Do not place pillows under knees or gatch bed Decreases venous return Ambulate early to prevent DVT Fluid status and oral comfort Hydration is based on client needs for hydration, electrolyte replacement Encourage ice chips and fluids as prescribed Advance diet as tolerated and as ordered Provide oral hygiene Pain Assess pain level frequently using standardized pain scale Educate the client to ask for pain medication before pain becomes severe Assess vital signs for manifestation of pain Kidney function Output should equal intake with a minimum urine output of 30-50 mL/hour Report urine output less than 30 mL/hour Palpate bladder during focused assessment to monitor for urine retention Use bladder scanner to assess for urine retention if suspected Bowel function NPO until gag reflex returns Reduces risk for aspiration Monitor for return of bowel sounds in all four quadrants Monitor for passing of gas Ambulate early Advance diet as tolerated and as ordered Prevention of thromboembolism Pneumatic compression stocking Elastic stocking Administer prescribed anticoagulants or antiplatelet medications Monitor extremities for calf pain, warmth, erythema, and edema Monitor incisions and drain sites Drainage should change from sanguineous to serosanguineous to serous Monitor staples, sutures, and dressing Report changes in bleeding to surgeon Monitor drains and empty to allow for continued drainage from wound Report increase in drainage or a change to sanguineous drainage to surgeon Follow specific orders for dressing changes Surgeons may order that they perform the first dressing change Administer antibiotics as prescribed Promote wound healing Nutrition Diet high in calories, protein, and vitamin C Diabetic client maintains glycemic control by monitoring blood glucose and administration of antidiabetic medications Prepare client and family for discharge Medications Activity restrictions Dietary guidelines Wound care, drain care, dressing change instructions When to call provider While caring for the postoperative patient, also consider their psychosocial, cultural, and spiritual assessments. Surgery is stressful, and can cause an increase in anxiety for the client as well as the family. Answer questions raised by both the client and family honestly. During the recovery, encourage and praise the client’s smallest accomplishments. It may seem strange that a client passing gas is cause for celebration. Pulmonary Emboli Click the “Pulmonary Emboli” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. Acute Respiratory Failure Open Book Click for more options Acute Respiratory Failure Acute respiratory failure is a mismatch of ventilation (V) or perfusion (Q), or a combination of both. When there is a VQ mismatch, gas exchange is decreased, which can cause respiratory failure. ABGs are ordered to evaluate the client’s gas exchange anticipating that the client is hypoxemic. Critical Values ABG Result PaO2 Less than 60 mm Hg PaCO2 Greater than 45 mm Hg pH <7.35 SaO2 Less than 90% Remember Ventilation = air movement (V) Perfusion = blood flow (gas exchange) (Q) Ventilatory Failure There are many causes of ventilatory failure. The causes can range from neuromuscular disorders, central nervous system dysfunction, and chemical depression. Paramedics wheeling man on gurneyClick for more options Let’s look at one example. Drug overdose continues to rise in the US to epidemic levels as reported by the CDC (Opioid Overdose, 2019). Fentanyl is quickly rising as the drug of choice among abusers. Fentanyl is a potent opioid either prescribed or manufactured illegally. Unfortunately, fentanyl can quickly depress the respiratory system. In this example, there is nothing mechanically wrong with the lungs, no V/Q mismatch. Without the drug in the client’s body, the lungs would perform both ventilation and perfusion normally. However, as the drug depresses the central nervous system, it depresses the drive to breathe (V), which then slows perfusion (Q). During an overdose, breathing ceases completely as the client slips into unconsciousness. In this example, the client has a V/Q mismatch and a resulting respiratory failure. Recognizing Symptoms As a nurse, assessing and recognizing the symptoms of acute respiratory failure (ARF) can save a client’s life. A way to evaluate compromised respiratory status is to assess for shortness of breath (dyspnea) while the client is performing everyday tasks. The common term used to describe the work of breathing while performing a task is dyspnea on exertion (DOE). Dyspnea Another sign of respiratory failure is dyspnea that occurs when the client is no longer able to lay flat in a bed which is also known as orthopnea. This client will find it easier to rest or sleep in an upright position. Clinically, the primary care physician will monitor for hypercapnia and hypoxia by monitoring Arterial Blood Gases (ABG). The nurse needs to be alert for signs and symptoms of hypoxic respiratory failure. The signs and symptoms are as follows: Restlessness Irritability Agitation Confusion Tachycardia Hypercapnia Hypercapnia has different signs and symptoms, but the same end result of respiratory failure can occur. The nurse should understand the difference between hypoxia and hypercapnia. The signs and symptoms are as follows: Decreased level of consciousness (LOC) Headache Drowsiness Lethargy Seizures Acidosis The onset of acidosis is associated with respiratory failure. Signs and symptoms of acidosis include: Decreased LOC Drowsiness Confusion Hypotension Bradycardia Weak peripheral pulses Oxygenation as Early Intervention As a nurse, think about oxygenation as an early intervention. The goal is to maintain the PaO2 level above 60 mm Hg and treat the underlying cause. Depending on the urgency and how quick the onset of respiratory failure occurs determines the aggressiveness of the treatment. If the situation allows, start with oxygen delivered by nasal cannula or mask. The next, more aggressive, intervention would be the use of BiLevel Positive Airway Pressure (BiPAP). This is a non-invasive approach to forcing air into the lungs to improve oxygenation (gas exchange). The invasive procedure of endotracheal intubation with mechanical ventilation is utilized as a last resort. Additional Interventions Another treatment option used to open the airway is a nebulizer treatment which is administered to dilate the bronchioles and promote gas exchange. This can be administered while the client is using either oxygen or BiPAP. Further intervention is determined by identifying the underlying cause of impending respiratory failure. Once the cause is determined, then a clear course of treatment is developed. The nurse may administer corticosteroids, antibiotics, diuretics, analgesics, or antianxiety medications. The nurse should continue to monitor the client closely. Other interventions to allow for maximum lung expansion are to place the client semi-high Fowler’s position. As a nurse, stay calm. If you are anxious, the client will become anxious and use more energy to breathe. Also, consider holding off on any unnecessary procedures that cause energy expenditures. Acute Respiratory Distress Syndrome Open Book Click for more options Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome (ARDS) is a life-threatening disorder that may cause permanent damage to the lungs. There is a high mortality rate associated with ARDS. The occurrence of ARDS is associated with acute lung injury (ALI) in people without pulmonary disease. As the nurse, pay close attention to oxygenation (gas exchange). A hallmark sign is hypoxemia that persists even when 100% oxygen is given, which is known as refractory hypoxemia (Ignatavicius, et. al., 2018). Other key features are as follows: Decreased pulmonary compliance (elasticity) Lowered production of surfactant Dyspnea Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates on x-ray known as ground-glass appearance SIRS There are many causes of acute respiratory distress syndrome (ARDS). No matter the cause, it triggers the body’s systemic inflammatory response (SIRS). Because of the SIRS response, the symptoms of ARDS are similar even though the causes vary. The following list are some of the possible causes: Shock Trauma Pulmonary infections Sepsis Inhalation of toxic gases Pulmonary aspiration – aspiration from gastric contents High risk are clients with feeding tubes Drug ingestion Submersion in water with water aspiration (especially in fresh water) Assessing the Client with ARDS Open Book Click for more options Assessing the Client with ARDS During your education, you have learned that counting respirations is an important part of vital signs. Taking vital signs can be delegated to an unlicensed assistive personnel (UAP). Assessing the respiration effort and the work of breathing is accomplished by the RN. Pay close attention to the effort or work of breathing. Evaluate the following, and determine if the client is experiencing the following: Signs of hyperpnea (rapid and deep breaths) Don’t confuse this with hyperventilation The body is trying to meet its own metabolic needs Noisy respirations Cyanosis Pallor Retractions Intercostal substernal Lung sound are normal Assess vital signs at least hourly Depends on client acuity Monitor for hypotension and tachycardia Telemetry Monitor for cardiac dysrhythmias Temperature Core body temperature The Client with ARDS The client with Adult Respiratory Distress Syndrome (ARDS) will often need mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). The current recommendation is to keep to tidal volumes low at 6 mL/kg of body weight. PEEP is started at 5 cm H2O and increased to keep oxygen saturations adequate (Ignatavicius, et al., 2018). Treatment Treatment options do not reverse or treat the lung damage that has occurred. The treatment is centered around preventing further lung damage and treating underlying cause such as sepsis. Endotracheal Intubation: Nursing Responsibilities for Intubation Open Book Click for more options Endotracheal Intubation: Nursing Responsibilities for Intubation Recognizing the need for intubation is critical for the client’s survival. This is often a fast-paced procedure in which quick thinking is required. Equipment to secure an airway is either available two ways: in a box on the top of the crash cart, or inside the cart. It is the responsibility of the RN to know exactly where the equipment is located and how to retrieve it. Perform the Airway assessment by positioning the person in the head chin tilt position, and provide oxygen by the bag-mask-valve (BMV) device until the discipline performing intubation and medications are on board. A sedative and a paralytic drug combination are administered to facilitate intubation. Suction equipment is an absolute must to clear oral and pharyngeal secretions. The actual intubation is performed by either a respiratory therapist or physician. It is the responsibility of the RN to know the limitations of practice while the RT is placing the ETT. While intubation is taking place, it is the responsibility of the RN to monitor the vital signs of hypoxia, hypoxemia, dysrhythmias, and aspiration. Monitor the time that it takes to intubate. The whole procedure should take no longer than 30 seconds, preferably less. At 30 seconds, the RN reminds the team to BMV the client until the next attempt of intubation takes place. Once the ETT is placed, the RN may verify correct placement by listening to lung sounds. A chest x-ray is ordered to verify that the tube lies above the carni. Once the tube is placed and lung sounds verified, the respiratory therapist will secure the tube. There are many types of devices that secure the tube in place. The RN will make note of the cm, marking at lip line and will document this as a comparative for future assessments. The priority of nursing care for the intubated client is to maintain a patent airway. One common guideline implemented after intubation is to secure the hands at the client’s side to prevent accidental dislodgement of the ETT. Other Nursing Considerations of an Intubated Patient Open Book Click for more options Other Nursing Considerations of an Intubated Patient Other nursing care considerations for an intubated client are as follows: Keep the HOB elevated 30 degrees. Be sure that all alarms are set. Do not ignore or silence ventilator alarms without assessing. Empty the ventilatory tubing when moisture collects. Assess the client for the need to suction. Perform mouth care every 2 hours. Turn and reposition every 2 hours. Communicate with both the client and the family by explaining all procedures. Keep the family informed and be supportive of their concerns, questions, and anxieties. The intubated client is in the ICU (intensive care unit) and depending on the acuity may be a 1:1 ratio. Mechanical Ventilation Open Book Click for more options Mechanical Ventilation The use of mechanical ventilation is a way for the client to rest while the machine takes over and handles the work of spontaneous breathing. It is also a way to protect and secure the airway. It is also a way to maintain homeostasis between the gasses, oxygen, and carbon dioxide within the body. Mechanical ventilation is often called a ventilator as a shortened version of the name. It is invasive in that the ETT rests in the trachea. The client is no longer able to communicate verbally once the tube is placed. There are settings that you should be aware of. Let’s review some of the common settings. The first setting is what mode of ventilation is being delivered to facilitate breathing. Assist Control or Continuous Mandatory Ventilation (CMV): This mode responds to the client’s effort to take a spontaneous breath. The ventilator senses the client’s effort to take a breath which then triggers the ventilator to deliver the preset volume. The preset rate protects the client if there is not enough spontaneous breaths occurring. A typical setting is a rate of 12. Synchronized Intermittent Mandatory Ventilation (SIMV): Similar to AC ventilation. Tidal volume and ventilatory rate are preset. The difference is that this setting allows for spontaneous breaths controlled by the client rate and volume. This is a weaning mode as the rate of ventilatory breaths are decreased as the client is able to take over breathing on their own. Now let’s consider the ventilatory control and settings. Tidal volume (Vt): amount of air the client receives with each breath. Rate: the rate is set between 10 and 14 breaths/min. This setting can vary. Fraction of inspired oxygen (Fio2): the oxygen level delivered to the patient. Range 21%-100%. The oxygen delivered is always warmed and humidified by the ventilator. Peak airway (inspiratory) pressure (PIP): This is the number that indicates elasticity of the lung or lung compliance. If the number rises, a number of concerns are raised. Consider the following: There is a high-pressure alarm setting that sounds when the maximum PIP has been reached. Do not ignore or silence this alarm. This alarm is set to prevent injury to the lung (barotrauma). Questions to ask yourself during while assessing high-pressure alarms: Is the client having a bronchospasm? Is the tubing pinched? Is the client biting the ETT? Does the client need suctioning? Is pulmonary edema now occurring? Is the lung or chest wall stiffer and now harder to inflate? Consider onset of ARDS. Continuous Positive Airway Pressure (CPAP): This is positive airway pressure delivered throughout the entire respiratory cycle for spontaneous breathing clients. It pushes the alveoli open as well as keeps the alveoli open at end expiration (preventing alveoli collapse). Mild sedation is given with caution not to suppress respiratory effort. This setting can be used as a weaning process. Positive End-Expiratory Pressure (PEEP): Positive pressure exerted during expiration. It is used to treat persistent hypoxemia. If a client is on PEEP, it is an indication of a severe Gas Exchange problem. The usual setting is between 5-to-15 cm H20. One goal for this client will be to decrease to amount of Fio2 delivered as soon as possible to prevent lung damage and oxygen toxicity. Important: “When caring for a ventilated patient, be concerned with the client first and the ventilator second (Ignatavicius, et al., 2018)” Pneumothorax Open Book Click for more options Pneumothorax A pneumothorax is caused by air that suddenly enters the pleural space. This sudden addition of air causes a loss of negative pressure and a reduction in vital capacity which can cause the lung to collapse. Hemothorax Hemothorax is the same concept with the difference is hemo=blood. Blood is shifting into the pleural space causing a loss of negative pressure. Tension Pneumothorax A tension pneumothorax is a life-threatening complication. Remember the word tension, and it will help you understand the concept. For example, a client suffers from a gunshot wound to the chest. Air continues to enter the pleural space, but cannot escape. The pressure builds until the lung completely collapses and compression of the great vessels occurs. This is noted by decreased or absent lung sounds on the affected side. Asymmetry of chest movement as well as deviation of the trachea toward the unaffected side occur. Remember the pressure that builds up pushes the vessels and internal structure away from the injured side. This causes a dramatic decrease in Cardiac Output. Other notable assessments include: severe respiratory distress, cyanosis, distended neck veins, as well as the client is hemodynamically unstable. Treatment is immediate needle thoracotomy performed by emergency personnel or primary care physician, followed by the insertion of a chest tube. Module 05 - ATI Open Book Click for more options Module 05 - ATI To help you prepare for the ATI Proctored Content Mastery Series Assessment – Adult Medical Surgical, ATI Practice Assessments are provided. It is recommended you begin ATI Practice Assessment A - Adult Medical Surgical now to achieve a benchmark of 70% or higher before completing the ATI Proctored Content Mastery Series Assessment scheduled for Module 08. You must obtain a Level 2 or higher on all ATI Proctored Content Mastery Series Assessments before taking the required ATI Comprehensive Predictor. Your nursing faculty will provide more information regarding the use of ATI in this course Burns Everyone has probably accidently burned themselves. There are different types of burns which include thermal, electrical, chemical, and radiation burn. Some burns are minor and can treated at home, while other burns need medical intervention. Burns are also classified by depth. Let’s take a closer look at the classification of burns. Burns are classified by the depth of injury to the skin. Before exploring the classification of burns, take a moment to review the video of the skin layers to fully understand the depths of burns which are reviewed next. Skin Layers and Functions Partial-Thickness Burns Partial-thickness burns involve the entire epidermis and varying depths of the underlying dermis. Partial- thickness burns are divided into 2 categories: superficial partial-thickness burns and deep partial- thickness burns. Click for more options Superficial Partial- Thickness Wounds Injury to the upper third of the dermis Has a good blood supply Wounds are pink and moist and blanch when pressure is applied Blister formation occurs Heal in 10-21 days Usually no scar, but pigment changes can occur Deep Partial Thickness Wounds Deeper into the dermis Blisters usually do not form Wound is red and dry with white areas in deeper parts Blanches slowly or not at all Edema is moderate Pain is less as nerve endings are destroyed Blood flow to the area is reduced Heal in 2-to-6 weeks Scar formation Skin grafting Full Thickness Wounds Click for more options Destruction of the entire epidermis and dermis Requires grafting Wound is hard, dry, leathery eschar Color may vary from white, deep red, yellow, brown, or black Wound requires debridement Edema is severe under the eschar Healing takes longer, up to several months Full Thickness Wound Edema treatment: If the injury is circumferential (completely around the body or body part), this could impair or completely cut off blood flow and chest movement necessary for breathing. Escharotomies are incisions made through the eschar to relieve pressure. Fasciotomies are incision through the eschar and fascia for the same reason. Deep Full Thickness Wounds Click for more options Deep wounds that extend beyond the skin Damage to muscle, bone, and tendons Wound is blackened, depressed Sensation is completely absent Need early excision and grafting Amputation may be necessary Burn Classification For further exploration into the classification and general treatment of burns, view the video below. Rule of Nines The Rule of Nines chart is used to determine the percentage of the body involved in the injury. (Ignatavicius, et al., 2018). The images below depict the percentages of TBSA breakdown for both a child and adult. Click for more options Click for more options Practice Using the Rule of Nines A quick and handy tool is the size of the client’s palm. The average palm size is 1% of total body surface area (TBSA) burned. If you are trying to estimate a wound size, use your own palm as a visual guide to estimate. Using the adult diagram, calculate the TBSA for a client that has a flash burn injury on the face, both arms (only the front surface area), and upper chest. The client threw gasoline on an existing fire, and the fire flashed back on him. What is the total body surface area burned? + 4.5 + 9 + 4.5 = 22.5% TBSA burned. With the Rule of Nines, we are just calculating the TBSA at this point. Next, the primary care provider and RN will evaluate with the depth and grade each part with a percentage and a depth. For example: Face: superficial partial thickness 4.5%; right arm full thickness burn 4.5%; left arm deep partial thickness 4.5%; and upper chest superficial partial thickness 9%. Fluid Shifts Open Book Click for more options Fluid Shifts With the damage occurring to the skin from burns, injury to blood vessels causes fluids to shift in the body. Initially, vasoconstriction of blood vessels occurs, and then the vessels dilate and leak fluids into the interstitial space. This gives the burn the wet or moist appearance and is the fluid trapped inside blisters. There is also a shift occurring in spaces that are not as visible, known as third spacing. This shifting of fluids results in electrolyte imbalances and fluid loss, particularly the loss of plasma fluids and proteins, which decreases blood volume and blood pressure, which results in decreased C.O. This fluid shift occurs for up to 36 hours after the insult of injury, which can result in the following complications: Acid-base imbalances Hypovolemia (associated with a high mortality rate of burn victims) Metabolic acidosis Hyperkalemia Hyponatremia Hemoconcentration (increases blood osmolality=increased blood viscosity = tissue hypoxia) Warn the family that if the burn is 25% or greater of total body surface area (TBSA) burned that within the first 12 hours there will be a lot of swelling as fluid shifts into the interstitial space. The fluid shift will cause weight gain as well as edema. If the burn, for example, involves the face, then the eyes will swell shut, the lips will excessively swell, and the client may be unrecognizable to family. Reassure the family that the swelling will begin to decrease in 48-72 hours after the time of injury. The swelling and weight gain are also due to the rapid replacement of fluid that occurs within the first 24 hours to prevent death from hypovolemia. The following is the formula used for fluid replacement: Parkland Formula: 4 mL/kg/%TBSA burns of crystalloid solution. Example of Parkland Formula 165 lb. male with 50% TBSA burned would calculate as follows: 4mL x 75 kg x 50% TBSA = 15,000 mL over the first 24 hours. Then, divide 15,000/2 = 7,500 ml = the amount delivered in the first 8 hours. The 8-hour clock begins at the time of injury. The remaining 7,500mL is delivered over the remaining 16 hours. The fluid replacement may need adjustment if urine output is less than 30 mL per hour. Also, remember the cardiac function determines the amount of fluid needed to maintain blood pressure and organ perfusion. This client is at risk for hypovolemic shock, which can quickly lead to multiorgan failure and death. Nursing Management of a Burn Victim Open Book Click for more options Nursing Management of a Burn Victim The standard of care today involves admitting a burn victim to a burn unit. This practice and the very specialized care that is provided has increased the chance of survival. However, no matter where the client arrives for care, the first hour is a critical one and can greatly impact the client’s survival. The priorities of care are the same for burn victims as they are for other gravely ill and/or trauma victims. Airway and breathing is your top priority, then circulation. Next is limiting the extent of the injury and maintaining the function of vital organs (Ignatacivius, 2018). Now that the priorities have been established, it’s time to break burn care down by phases and how to approach the care of the burn victim. Resuscitation Phase Open Book Click for more options Resuscitation Phase The resuscitation phase is the first intervention that takes place with the victim. The resuscitation phase begins at the time of injury and can last up to 48 hours. The focus is on the following: Fluid imbalance (loss) Edema Blood flow (perfusion) Priorities during the resuscitation phase are the following: Airway Provide oxygen therapy Evaluate for direct airway injury that occurs by inhalation of smoke, heat, or chemicals Ask the client the following Source of the fire Duration of exposure Was the fire in an enclosed space? If the hair is singed off, or the skin is burned further, assess the inside of the mouth for debris Also, evaluate inhalation injury by soot around the nose Client may become progressively hoarse Client may drool or have difficulty breathing Listen for wheezing, stridor, and crowing BE ALERT FOR THESE AS IT INDICATES THAT THE CLIENT IS ABOUT TO LOSE THEIR AIRWAY. Support circulation and organ perfusion = accomplished by fluid replacement (Parkland formula) Be alert for signs and symptoms of pulmonary edema Be cautious with diuretics to increase urine output (UO). Rather, adjust fluids to increase UO. The one exception is for clients with electrical burns. Electrical burns can cause damage to the muscles which can realesase myoglobulin into the bood which can cause acute renal failure. Pain management Prevent infection = wound care Maintain body temperature Emotional support for victim and family Anticipate the following laboratory orders: Hemoglobin/Hematocrit Blood urea nitrogen Glucose Electrolyte panel ABGs Acute Phase Open Book Click for more options Acute Phase As the client progresses in time, the acute phase begins at 36 hours and last up to 48 hours. There is an overlap in the resuscitative phase simply because depending on the client’s response during this phase; it may continue past 24 hours. The focus of care remains on the airway and cardiovascular systems as well as a new focus on preventing complications. The client is at risk for infection and sepsis. During any traumatic event to the body, the GI system responds with shunting blood away to other vital organs. This complicated response can produce Curling’s ulcers, which puts the client at risk for bleeding ulcers. Assessment of each body system is necessary to anticipate, recognize, and prevent potentially deadly complications. While the client is in the Acute Phase, nutrition should become a focus. The metabolic energy needed to heal a burn is such that the client may begin to lose weight. Weigh the client daily and increase caloric intake to prevent weight loss. A priority of care, besides the obvious airway management, is wound care. Let’s take a moment to evaluate wound care management and restoring of skin integrity. Debridement: preparing the skin for grafts Removing the dead tissue Non-surgical through mechanical or enzymatic actions (Santyl) Hydrotherapy twice daily Submersion in a whirlpool bath is no longer best practice Leave small blisters intact Open and debride large blisters Prevent infection by application of dressings Apply topical antibiotics then apply a dressing Standard wound dressings Gauze and gauze wrappings Biologic Dressings Skin or membranes obtained from human tissue, donors, or animals The dressing adheres and promotes healing Prepares the wound for permanent skin graft coverage Homografts or allografts Human skin donated from a cadaver Costly Risk of transmission of bloodborne infections Heterografts or xenografts From animals – porcine Cultured skin Grown from a small specimen of epidermal cells The cell sheets are costly, and it takes a long time for the sheet to grow Artifical skin A two-layer skin substitute A silastic epidermis and a porous dermis made from beef collagen and shark cartilage Creates a structure similar to normal skin – neodermis Once the neodermis is stable, then an autograft is placed once the silastic layer is removed Synthetic dressings Stay inplace until they fall off or are removed Transparent dressings Wound can be observed and assessed without removing the dressing Remember, the goal of this phase is to protect and cover the wound and prevent infection. Rehabilitative Phase Open Book Click for more options Rehabilitative Phase This phase begins with wound closure and ends with the client reaching the highest level of function. While the healthcare team is focused on the wound and healing, it’s important not to forget the psychological aspect of trauma. The client may experience PTSD and depression. A victim of burns may have life long scars or disfigurations that may even include amputations of limbs. On discharge, consider community resources and follow up with mental health resources to assist the client’s adjustment back into daily life. Module 06 - ATI Open Book Click for more options Module 06 - ATI At this point in the course, you should have completed ATI Practice Assessment A - Adult Medical Surgical and achieved a benchmark of 78% or higher. If you have not attained the benchmark, remediation is recommended. You can continue to remediate before the ATI Proctored Content Mastery Series Assessment – Adult Medical Surgical in Module 08. It is recommended that you begin ATI Practice Assessment B – Adult Medical Surgical now to achieve a benchmark of 78% or higher before completing the ATI Proctored Content Mastery Series Assessment - Adult Medical Surgical scheduled for Module 08. Your nursing faculty will provide more information regarding the use of ATI in this course Shock Mobile Click for more options Shock Click the “Shock” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. Rapid Response Team (Medical Emergency Team) Open Book Click for more options Rapid Response Team (Medical Emergency Team) The purpose of the Rapid Response Team is intervening early before a client’s change in their status evolves into a medical emergency, such as cardiac arrest. Deciding when to alert the Rapid Response Team is usually standardized with specific alert criteria. In facilities that have an EHR (electronic health record) the trigger to activate a response team may be a pop-up alert that notifies the RN that the client is meeting one of the criteria. Below are some examples of criteria. Heart rate greater than 140 beats/min or less than 40 beats/min Respiratory rate over 28 breaths/min or less than 8 breaths/min Systolic blood pressure greater than 180 mm Hg or less than 90 mm Hg Oxygen saturation less than 90% despite supplementation Acute change in mental status Urine output less than 50 cc over 4 hours A staff member has significant concern about client’s condition Chest pain unrelieved by nitroglycerin Seizure Threatened airway Uncontrolled pain The goal of the team is collaboration to improve client outcomes. The team members may vary but minimally consist of a respiratory therapist and a critical care nurse. The team collaborates and makes clinical decisions based on assessment data and provides interventions to change the course of the impending crisis. The team is an additional support for the RN as well as the patient. Pulmonary Artery Catheter (PAC) Open Book Click for more options Pulmonary Artery Catheter (PAC) One of the options that may be used to monitor a client in shock is a Pulmonary Artery Catheter. The PAC is an invasive catheter that is inserted by a physician into the pulmonary capillary bed via the internal jugular, femoral, or subclavian vein. The PAC is used to measure pulmonary venous pressure and provide data about right and left-sided heart pressures, cardiac output, core temperature, and oxygen saturation, as well as systemic pulmonary vascular resistance. The catheter is attached to a pressurized IV line which keeps the blood from exiting the line open with a slow IV drip. The line requires periodic flushing. The mechanical energy transmitted through the catheter from the heart is converted to electrical energy that is viewed on the cardiac monitor. The line also can monitor the core body temperature, which is also displayed on the monitor (Terry & Weaver, 2011). The nurse interprets the monitor waveforms and treats the client based on prescribed parameters. Why assess hemodynamics? Evaluates tissue perfusion Poor tissue perfusion = shock Guides treatments that would improve oxygen deficits o Fluids versus pharmacological support Provides a comprehensive picture of cardiac function However, the PAC is not without risks and potential complications. The following are complications associated with the pulmonary artery catheter: Arrhythmias Thromboembolism Infection Venous air embolism Pulmonary artery rupture In the chart provided below, review the different types of pressures that can be monitored by a Pulmonary Artery Catheter (PAC). Pressures Obtained by Pulmonary Artery Catheter (PAC) Pressures Normal Value Interpretation Right atrial (RA) or central venous pressure (CVP) 1-8 mm Hg Preload of the right heart. This is the amount of blood that is coming into the right atrium. RA = CVP Right Ventricular (RV) 15-15 mm Hg Systolic 0-8 mm Hg Diastolic Pressure in the RV, only seen on insertion. The nurse will monitor for backward catheter migration which indicates the catheter is resting in the right ventricle. This can cause life-threatening dysrhythmias. Pulmonary artery pressure 15 to 26 mm Hg systolic 5 to 15 mm Hg diastolic With a mean of 15 Indication of pressures within the pulmonary artery. This is a constant number reflected on the monitor waveform. Pulmonary 4 to 12 mm Hg Measure left ventricular preload or amount/pressures of blood coming into the left ventricle. This measurement is obtained by inflation of the balloon on the PCWP port of the PAC. References Ignatavicius, D., Workman, L., & Rebar, C. (2018). Medical Surgical Nursing Concepts for Interprofessional Collaborative Care. St. Louis: Elsevier. Terry, C., & Weaver, A. (2011). Critical Care Nursing. New York: McGraw Hill. Module 07 - ATI Open Book Click for more options Module 07 - ATI At this point in the course, you should have completed ATI Practice Assessment A – Adult Medical Surgical and ATI Practice Assessment B – Adult Medical Surgical and achieved a benchmark of 78% or higher on both. If you have not attained the benchmark on both ATI Practice Assessments remediation is recommended. You can continue to remediate and retake the ATI Practice Assessments A and B – Adult Medical Surgical before the ATI Proctored Content Mastery Series Assessment - Adult Medical Surgical in Module 08. Your nursing faculty will provide more information regarding the use of ATI in this course. SIRS, Sepsis, & Septic Shock Mobile Click for more options SIRS, Sepsis, & Septic Shock Click the “SIRS, Sepsis, & Septic Shock” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. References Ignatavicius, D., Workman, L., & Rebar, C. (2018). Medical Surgical Nursing Concepts for Interprofessional Collaborative Care. St. Louis: Elsevier. Jones, D., DeVita, M., & Bellomo , R. (2011). Rapid-Response Teams. English Journal of Medicine, 365, 139-146. Retrieved from Client Safety Network. Sepsis. (2018). Retrieved from CDC.gov: http://www.cdc.gov Cardiogenic Shock and MOFS Open Book Click for more options Cardiogenic Shock and MOFS Scenario We are going to explore multiple organ failure by following a progressive case study. Click for more options Your client Richard loves to play basketball on the weekends. Richard is a 45-year-old male client with no medical history, no surgical history, and no known allergies to medications. He does have a strong family history of heart disease with his father dying at 51 from a massive MI. Richard is in good physical health, with no complaints. He works out twice a week and would work out more if his busy schedule would allow time to do so. He is under a lot of stress in his current role as a business owner. He drinks a 6-12 pack of beer every weekend. He takes no medications except Tylenol for the headaches that he gets daily. He does not get annual check-ups. Richard hasn’t been to see a physician in many years. He has two boys and loves to play basketball on the weekends. Sometimes he has to stop because he becomes so short of breath. Heart attack in workplace Click for more options Richard doesn’t know it yet, but he is experiencing a myocaridal infarction. While at work, Richard suddenly clutches his chest. His coworkers see his distress and call 911. While in the ambulance on the way to the hospital, Richard complains of severe chest pain and shortness of breath, he is diaphoretic, and appears to go in and out of consciousness. EMS note that his BP is 84/58 mm Hg. Richard states that he has felt dizzy all morning and almost passed out when he stood up. Richard is experiencing an acute MI and is in the beginnin stages of shock as the body is not able to maintain blood pressure to perfuse his organs. Because of the area of infarct and the resulting dysrhythmias that occurs with an MI, the heart is not an effective pump. The brain, kidney, and liver are sensitive to the low oxygen levels. The longer that the heart is not pumping effectively--and importantly, the longer that the blood pressure remains low--the worse the outcome for the patient. A few things are going on in this scenario that we need to prioritize. Richard is having a heart attack (MI). When he arrives to the emergency department, he will go directly to the cardiac cath lab emergently, and the medical team will identify the blocked artery and open the blockage to revascularize the left ventricle. 90% of Richard’s LAD was blocked. This is still a dangerous time for Richard as the first 24 hours after an MI the client will have dysrhythmias. The concern here is that Richard’s BP was low for more than 30 minutes causing damage to his vital organs (lack of perfusion and oxygenation). Richard was started on vasopressors to maintain his MAP above 65 mm Hg. This may be only a temporary fix for the patient. On assessment, the nurse notices that the urine output is only averaging about 10 mL/hr. A fluid challenge is not recommended as it may cause pulmonary edema. The nurse also assesses and notes that the bowel sounds are hypoactive in two of the four quadrants and absent in the other two quadrants. The P.O. is low at 90% on 4 L oxygen by nasal cannula; this is a worsening change from admission. The nurse suspects the onset of pulmonary edema. We have now noted that there are at least three systems that are compromised directly due to the MI event. Richard is experiencing Multiple Organ Dysfunction Syndrome (MODS), which is defined as the failure of two or more organs. This occurs during the refractory stage of shock and occurs when too much cell death and tissue damage has occurred from too little oxygen being delivered to the tissues (. The prognosis is not favorable as each of the systems fail. A focus for treatment will be specific support for each organ. For example, our priority in this particular scenario is the heart and hemodynamic support for the rest of the organ to ensure perfusion. The airway is also equally important, and we will increase the delivery of oxygen to maintain a P.O. above 92%. We can advance airway management and support as necessary up to mechanical ventilation. There are many medications that we can anticipate including low dose administration of steroids. Lastly, there is now the need to prevent further complications of immobility. Caring for a client in MODS is complicated and challenging. Support the family and the client during this time of uncertainty. Emergency Health Care Team The emergency room is a fast-paced and often chaotic environment. RNs care for a spectrum of clients from birth-to-death. The emergency health care team consists of a wide variety of qualified individuals. Let’s look at some common team members and their duties. Team Members and Duties Forensic Nurse Examiners (RN-FNEs) Knowledgeable on the correct procedures to collect evidence for victims of rape, child abuse, and domestic violence cases. The Forensic nurse is trained how to correctly document evidence. This specialized nurse also assists the client to develop a safety plan and involves outside agencies to accomplish this goal. Psychiatric Crisis Nurse Team The crisis team is called upon to evaluate and assist in determining the disposition of a client that is suicidal. The team may assist with admission to local psychiatric hospitals. This team also offers support and education to the ER staff in managing cases. The goal is to assist in developing a discharge plan of care and follow-up. Emergency Medical Technicians EMS responders. Emergency medical technician (EMT). They can provide basic life support. Their duties may vary from state-to-state. Paramedics Offer Advanced Life Support (ALS). The pre-hospital team (first responder) initially assess and evaluates the patient. The assessment is communicated to the ER so that preparation for the client’s arrival and activation of the appropriate teams takes place before their arrival. Paramedics are a valuable part of the ER team. Emergency Medicine Physician A highly-specialized and trained physician that cares for complex client populations. Emergency Nurse Partners closely with all personnel of the health care team. The nurse cares for the client as well as coordinates care by working with departments in the hospital, such as radiology and the laboratory. The ER nurse is also key in the transition of the patient. The nurse ensures that they have proper discharge instructions and follow-up care, or if admitted, that a hand-off report is provided to the receiving nurse. Staff Safety Safety is a top concern for the emergency patient, but it is also a concern for the staff. Each hospital decides the level of security necessary for staff safety. Let’s review some ways relating to how to keep staff safe: Use standard precautions at all times. Follow transmission precautions such as airborne. Ensure security guards are present. Triage area is vulnerable and should have bulletproof glass between staff and visitors. Put metal detectors in place. Panic buttons are strategically located in rooms. Client Safety As mentioned above, the ER is a fast-paced and often chaotic place. The nurse has to slow down and take care to be diligent about medication delivery or treatments. Therefore, let’s take a look at client safety: Client Identification Ensure each client wears an identification bracelet. Use two identifiers, name and DOB. Protect the Client from Falls Keep the side rails up on stretchers. Keep the stretcher in the low position with wheels locked Keep the call light within reach of the patient. Skin Breakdown in Vulnerable Populations Protect skin. Turn or reposition every 2 hours. High-Risk for Medication Errors or Adverse Events Check for allergies. Check for med-alert bracelets or necklaces. Search clothing for drugs and drug paraphernalia when the client has altered mental status. Follow the rights of safe medication administration. ER Nurse Training and Certifications Open Book Click for more options ER Nurse Training and Certifications The ER nurse cares for clients from birth-to-death and all diseases and disorder across the spectrum. Two of the cornerstone skills necessary for the ER nurse to posses is assessment and prioritization. Assessment and Prioritization Priority setting depends on accurate assessment along with good critical-thinking and clinical decision- making skills. The ER nurse also has a general knowledge of legal implications of problems such as domestic violence, child maltreatment, elder abuse, and sexual assault. The ER nurse must have the ability to prep for, assist with, and recover clients from many different types of procedures. The training of the ER nurse is extensive, including: Basic life support (BLS) Advanced cardiac life support (ACLS) Pediatric advanced life support (PALS) Certifications It is recommended that ER nurses obtain the certification of Certified Emergency Nurse (CEN). There is also a certification that focuses on trauma called, Trauma Nursing Core Course (TNCC). If you are the type of person that loves experiencing a variety of clients, enjoys autonomy, likes the challenge of thinking on your feet, and loves continual learning, then the ER department could be for you. Triage Open Book Click for more options Triage Triage is an organized system used to sort and classify client priority. Triage Nurse The triage nurse is the gatekeeper of the emergency care department. The triage nurse determines the flow of the department by prioritizing client complaints by performing a rapid assessment and determining the acuity of every patient. Triage Systems There are triage systems available that are standardized. The most common is the three-tiered triage system. There is also a four and five-tiered system, which further breaks out the client into categories of acuity and priority. Severity Examples Emergent Life-Threatening Respiratory distress, chest pain, stroke, unstable vital signs Urgent Severe abdominal pain, renal colic, displaced fractures, pneumonia in older adults Non-Urgent Skin rashes, strains, sprains, colds The triage nurse may begin interventions in the triage area by performing EKGs, drawing blood samples and sending to the laboratory, and ordering radiography studies based on standardized triage protocols. Common Environmental Emergencies Open Book Click for more options Common Environmental Emergencies Heat Exhaustion (Syndrome) Heat-related illness is a common environmental emergency that affects the most vulnerable, at-risk populations such as the older adult, those who work outside, the homeless, as well as athletes training outdoors. Certain conditions or medications that a person takes can also increase their risk for illness related to heat. Heat exhaustion and heat stroke are two heat-related illness. Causes Due to dehydration Hyponatremia – caused by excessive perspiration Symptoms Flu-like symptoms Headache Weakness Nausea Vomiting Treatment Stop physical activity Move to a cool place Cold pack on the neck, chest, abdomen, groin Fan the victim-cools with water evaporation Use sports drinks-has electrolytes to replace sodium Plain water may deplete the sodium level further If no improvement transport to a local hospital In Hospital Monitor vital signs IV 0.9 % Normal saline Laboratory assessment: Electrolytes Heat Stroke If heat exhaustion is not treated, it can progress to heat stroke, which is a true medical emergency associated with a high mortality rate . Below is further information relating to heat stroke: Causes and Symptoms Body temperature rises to about 104 degrees (F) Two types Exertional heat stroke A person wearing too many clothes while doing strenuous physical activity Classic heat stroke Exposure to heat and humidity Skin may be dry or perspiring Mental status change due to heat injury to the brain Hypotension, tachycardia, and tachypnea Seizures – coma Treatment Nothing by mouth- keep NPO Initiate advanced life support measures Airway Remove from hot environment Follow protocols of heat exhaustion to cool the patient Transport to hospital In Hospital Protect airway IV with large bore catheter Administer 0.9% NS – used cool solutions if available Use cooling blankets Use rectal probe to measure core body temperature Obtain baseline VS and monitor VS Administer muscle relaxants (benzodiazepines) if the client shivers Stop cooling once core body temperature reaches 102 degress F. Complications Multi-system organ dysfunction sydrome Severe electrolyte imbalances Lightning The next medical emergency that we will explore is lightning injuries. If there is a thunderstorm around, take shelter to protect yourself from potential injury. Lightning is pure energy, and if the victim is struck, there is injury as well as explosive reactions as the electricity travels through the body and exits. Commonly, the clothing and shoes of the victim are damaged, burned, or blown off the victim. The victim may also be thrown a distance from the force of the energy. If one were to come upon a victim of a lightning strike, be aware that lightning can strike in the same place twice. Move the client to a safe covered area as quickly as possible. Priority is evaluating for cardiac arrest and initiating CPR. There may be internal injuries, so a full physical assessment with laboratory assessment should be performed. EKG Angina and dysrhythmias may occur Central nervous system Keraunoparalysis Immediate but temporary paralysis Other injuries Cataracts Tympanic membrane rupture Cerebral hemorrhage Depression PTSD Skin burns Lichtenberg figures or keraunographic marking Tree-like branching or ferning marks on the skin Treatment Pre-hospital Extent of internal injury is difficult to determine at site ALS including CPR Rhabdomyolysis Can cause acute renal failure If a person survives a lightning strike, they will more than likely have some type of permanent impairment. The easiest way to prevent injury from a lightning strike is to stay inside somewhere safe during thunderstorms. Hypothermia Hypothermia is defined as a core body temperature below 95 degrees F. The risk factors are not as dramatic as one might think they should be. A temperature of below 82 degrees F can put older adults and homeless populations at risk. Hypothermia is divided into three categories: Mild – 90 to 95 degrees F Moderate – 82.4 – 90 degrees F Severe - below 82.4 degrees F Treatment for Categories of Hypothermia Mild Provide shelter Remove wet or damp clothing Provide sources of warmth Drink warm high-carbohydrate liquids No alcohol No caffeine Moderate and Severe Hospital Care Keep victim supine Maintain airway, breathing, circulation Administer drugs with caution Cold slows the body's metabolism Drugs can become potentially toxic when rewarming takes place Withhold medications except for vasopressors until the core body temperature is 86 degrees F Closely monitor cardiac response CPR if no spontaneous circulation is present Monitor for V-tach/V-Fib Rewarm the core first and then the extremities Use warm IV fluids Heated oxygen Heated peritoneal, pleural, gastric, and bladder lavage Severe hypothermia Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis. Watch for signs of potential complications Fluid and electrolyte imbalances ARDS Acute renal failure pneumonia The key to rewarming is that no one is pronounced dead until he or she is warm and dead . Keep providing warm and resuscitative measures until the body temperature is above 86 degrees F. Frostbite Click for more options Frostbite to the ear. Frostbite can occur when the skin is not properly protected from extremes in cold temperature. Frostbite has degrees, much like burns, with fourth-degree being the deepest. At stage four, gangrene may develop, and amputation may be necessary. Treatments Stop the exposure to cold If the client has frostnip don’t rub the skin to rewarm. For frostbite the client is submerged in a warm tub for rewarming The rewarming process is painful Administer analgesics Watch for the development of compartment syndrome from the swelling Severe frostbite is managed much like a thermal burn Drowning Sadly, drowning is the leading cause of accidental death in the United States. Prevention is key when it comes to drowning incidents. Drowning in either fresh or saltwater removes the surfactant from the lungs, which increases airway resistance. Saltwater draws protein-rich fluid from the vascular space into the alveoli. In both freshwater and saltwater drownings, pulmonary edema results. Another consideration is contaminants in the water that could result in further damage for a severe infection of the lung. If you were to come upon a potential drowning victim, remove them safely from the water. Consider their spinal column and other potential injuries that occurred during the accidental drowning. Rescuers need to consider protecting their own well-being to avoid becoming another victim. If drowning victims are conscious, the person is more than likely panicked and will grab onto anything to keep them afloat. Once the victim is on safe ground, then begin the ABCs of rescue. If the victim is conscious, stay with them, and have them lay on their side. When EMS arrives, an artificial airway will be secured if the client is unable to breathe on their own. When the victim arrives at the hospital, the need for gastric decompression is determined if the stomach is distended. The decompression protects the airway and prevents aspiration of the stomach contents into the already-damaged lungs. The client is usually admitted to the critical care unit as the care is complex, and the client is at risk for ARDS. Drowning Safeguards Never swim alone Never leave children unattended in a bathtub Always keep an eye on children Have a pool gate or cage Never dive into a body of water or pool headfirst that you are not familiar with Avoid alcohol when swimming and boating Have the appropriate water rescue equipment available and use it When swimming in the ocean know the currents and how to avoid rip tides Disaster Preparedness Click the “Disaster Preparedness” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. When Disaster Strikes Open Book Click for more options When Disaster Strikes tropical hurricane approaching the USA.Elements of this image are furnished by NASAClick for more options When disaster strikes, the local community has to be prepared to respond. For some natural disasters, there is time to prepare. For example, hurricanes can be tracked for days with ample warning and time to prepare. With certain other disasters, like earthquakes, there is neither warning nor time to prepare. In both cases the local government and community is responsible for responding. Let’s take a look at how the disaster unfolds at a local level. Acting as the primary first responder Activating the Emergency Operations Center (EOC) and Comprehensive Emergency Management Plan Collaborating and coordinating with public and private organizations and agencies Notifying the State Emergency Management Agency of the situation Activating responses from State and Federal Departments or agencies Here is a big key factor in this process: proclaiming a state of emergency. What this does is provides authorization of use local resources, including funds, and waiving the usual bidding process for goods and services. State Emergency Management Next, the State government responds. The State EOC is activated, and the State’s Governor will monitor the situation and report to the Federal agencies. When the disaster is so severe that it overwhelms the State, resources from the Federal Emergency management Agency (FEMA) is activated to implement the Federal Response Plan (FRP). Let’s look at one example of a disaster. A hurricane is expected to hit a coastal area in the next 2 days. The first part of the plan is to involve the local EOC and activate the local Emergency Operations Plan. While that is occurring, the Governor is informed of the threat or impact. At the hospital level, the Disaster Plan is implemented with decisions on staffing and client safety being considered. Hospitals may prepare to accept an influx of clients from other facilities that have to evacuate. Emergency shelters are open, or evacuation routes are opened. Deployment of state resources begin, as well as relief organizations are put on alert. This part of the plan is put into motion to prepare for the disaster. After the disaster occurs, then it is time for the initial assessment of damage. All parties are involved and mobilized. There are always dangers after a disaster. Part of the assessment is identifying immediate needs of the community and meeting those needs, such as water, food, shelter, and medical care. Activation of a Crisis Action Team, or the military, may take place during this phase. This plan is to control the chaos, and continue rescue. A door-to-door search, such that occurred after Hurricane Katrina, takes places accounting for all citizens involved in the disaster. The rescues part of the disaster will continue for many days, depending on the size of the area impacted. Last is the recovery phase which involves FEMA and or other Public Assistance programs activated during the disaster. This may take years to accomplish. The role of the nurse is critical in a disaster and may vary greatly. A nurse may be the neighborhood triage person when a tornado strikes. A nurse could be a part of a response team or work in a facility that has a specific disaster plan in place that they are a part of. Disasters are occurring more frequently and the nurse must be trained on how to react, not only to treat and protect the client but to protect themselves. References Achora, S., & Kamanyire, J. (2016). Disaster Preparedness. Sultan Qaboos Univeristy Med J, 16(1), 15-19. Ignatavicius, D., Workman, L., & Rebar, C. (2018). Medical Surgical Nursing Concepts for Interprofessional Collaborative Care. St. Louis: Elsevier. The Joint Commission . (2019). Retrieved from https://www.jointcommission.org/emergency_management.aspx Disaster Preparedness Click the “Disaster Preparedness” link above to begin this interactive activity that contains supplemental materials to enhance your learning experience. Enjoy! importantClick for more options If you have a pop-up blocker turned on you will get a message with a Launch Course button. Click the button to continue. When Disaster Strikes Open Book Click for more options When Disaster Strikes tropical hurricane approaching the USA.Elements of this image are furnished by NASAClick for more options When disaster strikes, the local community has to be prepared to respond. For some natural disasters, there is time to prepare. For example, hurricanes can be tracked for days with ample warning and time to prepare. With certain other disasters, like earthquakes, there is neither warning nor time to prepare. In both cases the local government and community is responsible for responding. Let’s take a look at how the disaster unfolds at a local level. Acting as the primary first responder Activating the Emergency Operations Center (EOC) and Comprehensive Emergency Management Plan Collaborating and coordinating with public and private organizations and agencies Notifying the State Emergency Management Agency of the situation Activating responses from State and Federal Departments or agencies Here is a big key factor in this process: proclaiming a state of emergency. What this does is provides authorization of use local resources, including funds, and waiving the usual bidding process for goods and services. State Emergency Management Next, the State government responds. The State EOC is activated, and the State’s Governor will monitor the situation and report to the Federal agencies. When the disaster is so severe that it overwhelms the State, resources from the Federal Emergency management Agency (FEMA) is activated to implement the Federal Response Plan (FRP). Let’s look at one example of a disaster. A hurricane is expected to hit a coastal area in the next 2 days. The first part of the plan is to involve the local EOC and activate the local Emergency Operations Plan. While that is occurring, the Governor is informed of the threat or impact. At the hospital level, the Disaster Plan is implemented with decisions on staffing and client safety being considered. Hospitals may prepare to accept an influx of clients from other facilities that have to evacuate. Emergency shelters are open, or evacuation routes are opened. Deployment of state resources begin, as well as relief organizations are put on alert. This part of the plan is put into motion to prepare for the disaster. After the disaster occurs, then it is time for the initial assessment of damage. All parties are involved and mobilized. There are always dangers after a disaster. Part of the assessment is identifying immediate needs of the community and meeting those needs, such as water, food, shelter, and medical care. Activation of a Crisis Action Team, or the military, may take place during this phase. This plan is to control the chaos, and continue rescue. A door-to-door search, such that occurred after Hurricane Katrina, takes places accounting for all citizens involved in the disaster. The rescues part of the disaster will continue for many days, depending on the size of the area impacted. Last is the recovery phase which involves FEMA and or other Public Assistance programs activated during the disaster. This may take years to accomplish. The role of the nurse is critical in a disaster and may vary greatly. A nurse may be the neighborhood triage person when a tornado strikes. A nurse could be a part of a response team or work in a facility that has a specific disaster plan in place that they are a part of. Disasters are occurring more frequently and the nurse must be trained on how to react, not only to treat and protect the client but to protect themselves. References Achora, S., & Kamanyire, J. (2016). Disaster Preparedness. Sultan Qaboos Univeristy Med J, 16(1), 15-19. Ignatavicius, D., Workman, L., & Rebar, C. (2018). Medical Surgical Nursing Concepts for Interprofessional Collaborative Care. St. Louis: Elsevier. The Joint Commission . (2019). Retrieved from http [Show More]

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