Critical care exam 1 personal notes

Critical care Chapter 3 Laws: EMTALA: Emergency room law - everyone who comes in ER room must be treated whether they have insurance or not. Torts: Doing something legally wrong  Intentional: Assault (Verbal threat ...

Critical care Chapter 3 Laws: EMTALA: Emergency room law - everyone who comes in ER room must be treated whether they have insurance or not. Torts: Doing something legally wrong  Intentional: Assault (Verbal threats), battery (Physical harm, putting your hands on them without permission), false imprisonment (medical restraint is a necessity) (Haldol to sedate them is chemical restraint)  Unintentional: Negligence (no harm to patient we just didn’t do what we were supposed to), Malpractice (when harm is done to the patient). ON TEST Dilemmas: No right or wrong Principlism is a widely applied ethical approach based on four fundamental moral principles to contemporary ethical dilemmas: respect for autonomy, beneficence, nonmaleficence, and justice.  Autonomy states that all persons should be free to govern their lives to the greatest degree possible. This implies a strong sense of self-determination and an acceptance of responsibility for one's own choices and actions. To respect autonomy of others means to respect their freedom of choice and to allow them to make their own decisions.  Beneficence is the duty to provide benefits to others when in a position to do so and to help balance harms and benefits. In other words, the benefits of an action should outweigh the burdens. Actions intended to benefit the patients or others.  Nonmaleficence is the explicit duty not to inflict harm on others intentionally.  The principle of justice requires that health care resources be distributed fairly and equitably among groups of people. Other principals  The principle of veracity states that persons are obligated to tell the truth in their communication with others.  The principle of fidelity requires that one has a moral duty to be faithful to the commitments made to others. These two principles, along with confidentiality, are the key to the nurse-patient relationship. Bioethics committees – Address ethical concerns. Typical membership of a bioethics committee includes physicians, nurses, chaplains, social workers, and, if available, bioethicists. Informed consent: Three elements must be present. Informed consent is not a form. It is a process that entails the exchange of information between the health care provider and the patient or patient's proxy. 1. Competence (or capacity) refers to a person's ability to understand information regarding a proposed medical or nursing treatment. Patients providing informed consent should be free from severe pain and depression. Critically ill patients usually do not have the mental capacity to provide informed consent because of the severe nature of their illness or their treatment (e.g., sedation). If the patient is not mentally capable of providing consent, informed consent is obtained from the designated healthcare surrogate or legal next of kin. Advance directive: Witnessed written document or oral statement in which instructions are given by a person to express desires related to healthcare decisions. Living will: A witnessed written document or oral statement voluntarily executed by a person that expresses the person's instructions concerning life-prolonging procedures. Proxy: A competent adult who has not been expressly designated to make health care decisions for an incapacitated person, but is authorized by state statute to make healthcare decisions for the person. Surrogate: A competent adult designated by a person to make health care decisions should that person become incapacitated. Life-prolonging procedure: Any medical procedure or treatment, including sustenance and hydration, that sustains, restores, or supplants a spontaneous vital function. Does not include the administration of medication or treatments deemed necessary to provide comfort care or to alleviate pain. In hospice AND (allow natural death) - don’t treat just about comfort y DNR in hospice (you do treat like antibiotics but if they code you do nothing) Extraordinary care includes complex, invasive, and experimental treatments such as resuscitation efforts by CPR or emergency cardiac care, maintenance of life support through invasive means, or renal dialysis. Experimental treatments such as gene therapy also are extraordinary therapies. Ordinary care usually involves common, noninvasive, to tested treatments such as providing nutrition, hydration, or antibiotic therapy. In the critical care setting the noninvasive criterion does not apply; ordinary care is defined as usual and customary for the patient's condition. Maintenance of hydration and nutrition through a tube feeding is an example of a treatment that falls somewhere between ordinary and extraordinary care and is a highly debatable issue. Therefore it is important for individuals to document their wishes rather than relying on the members of the healthcare team to assist in the decision-making process related to nutrition and hydration. ON TEST Withholding or stopping extraordinary resuscitation efforts is ethically and legally appropriate if patients or surrogates have previously made their preferences known through advance directives. It is also acceptable if the physician determines that resuscitation is futile or has discussed the situation with the patient, family, and/or surrogate as appropriate, and there is mutual agreement not to resuscitate in the event of cardiopulmonary arrest. In brain death, complete and irreversible cessation of brain function occurs, whereas in irreversible coma or persistent vegetative state, some brain function remains intact. ON TEST Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations would indicate some brain function. All orders except antibiotic adjustment may be considered withdrawal or withholding of life support and should be written only after informed consent from the healthcare surrogate or family has been obtained. Because the patient has expressed a request to not have food or fluids withdrawn, it would not be appropriate for the physician to write an order to discontinue the tube feeding. Patient Self-Determination Act: This act requires that all healthcare facilities that receive Medicare and Medicaid funding inform their patients about their right to initiate an advance directive and the right to consent to or refuse medical treatment. Chapter 4 Nursing care in the critical care setting at the end of life is focused on five dimensions. These dimensions of nursing care consist of alleviation of distressing symptoms (palliation); communication and conflict resolution; withdrawing, limiting, or withholding of therapy; emotional and psychological care of the patient and family; and caregiver organizational support. Signs of suffering include dyspnea, tachypnea, diaphoresis, grimacing, accessory muscle use, nasal flaring, and restlessness. Chapter 5: Comfort, Sedation, and Delirium in Critical Care Hospitals and healthcare accrediting agencies have recognized that pain and anxiety are major contributors to patient morbidity and length of stay. Defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is whatever the patient says it is. Anxiety is a state marked by apprehension, agitation, autonomic arousal, fearful withdrawal, or any combination of these. It is a prolonged state of apprehension in response to a real or perceived fear. Anxiety must be assessed in the same way used to assess pain. Anxiety may contribute to pain perception by activating pain pathways, altering the cognitive evaluation of pain, increasing aversion to pain, and increasing the report of pain. Anxiety stimulates the SNS response. SNS activation is known as the “fight-or-flight” response. If the patient is mechanically ventilated, an increased respiratory rate leads to feelings of breathlessness. As the patient “fights” the mechanical ventilator (dyssynchrony), further alveolar damage ensues, and the endotracheal or tracheostomy tube creates a “choking” sensation and increased anxiety. Manifestations of inadequate pain control and anxiety management  Patient feeling of powerlessness  Suffering  Psychological changes (such as):  Agitation  Delirium  Elevating BP indicates pain When possible, patients should be asked about any herbal remedies used as complementary and alternative medical therapies and whether they take them along with prescription or over-the-counter medications. These products may lead to adverse herb-drug interactions, especially in the elderly who are more likely to be taking multiple drugs. Interventions to manage pain may differ from those used to manage anxiety. If pain is being treated in a patient who is experiencing anxiety only, the anxiety may worsen while potentially ineffective management strategies are used. Pain is managed with anti-inflammatory and analgesic medications, whereas anxiety is treated with sedative medications.  Physiological responses to pain and anxiety: Tachycardia, Tachypnea, HTN, Increased cardiac output, Pallor and/or flushing, Cool extremities, Mydriasis (If the patient is mechanically ventilated, an increased respiratory rate leads to feelings of breathlessness. As the patient “fights” the mechanical ventilator (dyssynchrony), further alveolar damage ensues, and the endotracheal or tracheostomy tube creates a “choking” sensation and increased anxiety, pillary dilation), Diaphoresis, Increased glucose production (gluconeogenesis), Nausea, Urinary retention, Constipation, Sleep disturbance