Deck 66: Nursing Management: Critical Care

Question 1

Certification in critical care nursing (CCRN) by the American Association of Critical-Care Nurses indicates that the nurse

A) is an advanced practice nurse who cares for acutely and critically ill patients.
B) may practice independently to provide symptom management for the critically ill.
C) has earned a master's degree in the field of advanced acute and critical care nursing.
D) has practiced in critical care and successfully completed a test of critical care knowledge.

Answer 1

Advanced practise nurse caring for acutely and critically ill patients is no necessarily be possessing certification in critical care nursing (CCRN) as there is involvement of other assistive nurses in the care planning.
Hence, the option (a) is incorrect.
CCRN by the American Association of critical-care nurses does not license a nurse to independently provide management of symptoms of the critically ill patients and it is not verified that the nurse possess master's degree in this field.
Hence, the options (b) and (c) are incorrect.
CCRN indicates that the nurse is a registered nurse who has experience in progressive or critical nursing care and has completed a written test successfully.
Hence, the option (d) is correct.

Question 2

Patient Profile
R.K. is a 72-yr-old white man who collapsed on the street. He was unresponsive on admission and remains unresponsive. He has an oral ET tube in place and is receiving mechanical ventilation. He weighs 198 lb (90 kg). A subclavian central line was placed to monitor CVP and administer fluids.
Subjective Data
None. Patient is unresponsive to painful stimuli.
Objective Data
Physical Examination
• Noninvasive BP 100/75 mm Hg; heart rate 128 (atrial fibrillation with a rapid ventricular response); temperature 102° F (38.8° C); SpO₂ is 98%
• Purulent secretions from ET tube
• Breath sounds: rhonchi bilaterally, decreased breath sounds on the right
Diagnostic Studies
• Chest x-ray reveals right lower lung consolidation
• ABGs: pH 7.48; PaO₂ 94 mm Hg; PaCO₂ 30 mm Hg; HCO 3 34 mEq/L
• CT scan is positive for massive hemorrhagic stroke
Collaborative Care
• Positive pressure ventilation settings: assist-control mode
• Settings: FIO₂ 70%, V T 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O
• Enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube
• External condom catheter for urinary drainage
• HOB elevated at 40 degrees
• Reposition every 2 hr
• Azithromycin (Zithromax) 500 mg IV q24hr
• Cefotaxime (Claforan) 2 g IV q6hr
• D 5 NS with KCl 20 mEq/L at 100 mL/hr
1. Identify two reasons for intubating and providing mechanical ventilation for R.K.
2. What do R.K.'s ABGs indicate, and which ventilator setting(s) should be changed
3. What is his PaO₂ /FIO₂ ratio, and what does it indicate
4. R.K.'s BP drops to 80 mm Hg. Despite increasing doses of vasopressors and fluid challenges, his BP remains low. A central venous catheter and an arterial line are inserted. APCO monitoring is started. What would be the purpose of hemodynamic monitoring in this patient
5. Priority Decision: What are two priority nursing considerations for a patient with invasive monitoring
6. R.K.'s pulmonary condition deteriorates. PaO₂ drops to 70 mm Hg, and SpO₂ is 89%. PEEP is increased to 7.5 cm H 2 O. What implications does this have for R.K. given his hemodynamic status
7. Priority Decision: Based on the data presented, what are the priority nursing diagnoses Are there any collaborative problems
8. Delegation Decision: What patient care activities can you delegate to unlicensed assistive personnel
9. Evidence-Based Practice: R.K.'s family wants to know why he is getting tube feedings. What would you tell the family What is the evidence to support the use of tube feedings
10. After 4 days, R.K. remains unresponsive and has developed renal failure. The physician believes the patient will not recover from his neurologic injury and wishes to discuss goals of care with the patient's caregiver. What would be your role in this meeting

Answer 2

1.
The two reasons for which R.K. should be provided mechanical ventilation and intubation include his unconsciousness without responding to painful stimuli and ineffectiveness of airway clearance.
2.
The arterial blood gases (ABG) analysis of R.K. indicates respiratory alkalosis with too much blowing of carbon dioxide. Over-ventilation is one of the most common causes of R.K. who already has chronic alveolar hypoventilation with his kidneys retaining compensatory bicarbonate and chronic carbon dioxide.
The tidal volume and ventilator rate must be reduced in order to retain more carbon dioxide and prevent R.K. from developing seizures, hypocalcaemia, hypokalemia, and neuromuscular irritability.
3.
The partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio (PaO₂ /FIO₂ ) of R.K. is 134 much lower than normal PIO₂ /FIO₂ ratio (350-400). This indicates that lungs of the patient have limited ability to oxygenate the blood in arteries even with 70% of FIO₂.
4.
The hemodynamic monitoring of R.K. is required for further guidance of drug therapy and fluid balance. The status of the heart and volume of the fluid of the patient should be monitored for determining the adequate oxygenation of tissues.
5.
The two priority nursing considerations for the patient with invasive monitoring are as follows:
• Monitoring the patients for any signs of complicaions associated with the arterial and central catheters
• Monitoring the trends by collecting baseline data for evaluation of the successful implementation of interventions
6.
It is important to increase he mean airway pressure if positive-end expiratory pressure (PEEP) is added for improving the oxygenation. This is because of preventing the compression of thoracic vessels from increased intrathoracic pressure.
7.
The priority nursing diagnosis includes decreased cardiac output and ineffective clearance of airway. The collaborative problems associated with the conditions of patients include sepsis and barotrauma.
8.
The unlicensed assistive personnel (UAP) can be delegated to assist the registered nurse with repositioning and oral care and to empty and record the urine and nasogastric output.
9.
It is important to provide nutritional support for correcting the nutritional deficiencies which can be accomplished by provision of parenteral and enteral nutrition in early stages.
Tube feedings can be safely used as they preserve gut mucosa both structurally and functionally. They also prevent the movement of bacteria in gut into the bloodstream and are less expensive than parenteral nutrition.
10.
Your role would be to ensure that the health care team members and caregivers are attending the meeting and would serve as an advocate for patient and caregivers.

Question 3

Situation
B.W., a new nurse, is undergoing orientation in the surgical intensive care unit (ICU). He asks his preceptor why the patients' families are permitted on the unit throughout the day and even the night. B.W. states that, in his last position, visiting hours in the ICU were 10 AM to noon and 4 to 6 PM. He adds that families make him nervous when they watch what he is doing and ask him multiple questions. B.W. states that he intends to tell the visitors to leave the patient's room when he is providing care.
Ethical/Legal Points for Consideration
• The majority of nurses in adult ICUs prefer unrestricted visiting policies, but research indicates that most ICU policies limit visitation.
• Family visitation was thought to cause the patient physiologic stress and interfere with care. Additionally, it was believed that family visitation was mentally exhausting to patients and families, and even contributed to increased infection rates. Evidence does not support any of these beliefs.
• Evidence suggests several positive patient benefits to flexible family visitation: decreases in anxiety, confusion, and agitation; reductions in cardiovascular complications; decreases in length of ICU stay; and reports that patients feel more secure and satisfied with care.
• Similar evidence exists for the benefits of flexible visitation for family members: increases in satisfaction, decreases in anxiety, promotion of better communication, and increases in opportunities for patient and family teaching as the family becomes more involved in care.
• Some conditions may require restricting visitation: a legal reason is documented in the chart; visitor behavior presents a risk to the patient, family, staff, or others; visitor behavior disrupts the functioning of the unit; visitor has a contagious illness or has been exposed to a contagious disease that could endanger the patient's health; or the patient requests fewer or no visitors.
1. How should the preceptor respond to B.W.'s statement of his intentions
2. Does B.W. have an ethical or legal obligation to permit family visitation regardless of his personal concerns Defend your position.

Answer 3

NO ANSWER

Question 4

Differentiate the various certification opportunities for critical care nurses.

Question 5

What are the appropriate nursing interventions for the patient with delirium in the ICU (select all that apply)

A) Use clocks and calendars to maintain orientation.
B) Encourage round-the-clock presence of caregivers at the bedside.
C) Sedate the patient with appropriate drugs to protect the patient from harmful behaviors.
D) Silence all alarms, reduce overhead paging, and avoid conversations around the patient.
E) Identify physiologic factors that may be contributing to the patient's confusion and irritability.

Question 6

Select appropriate nursing interventions to manage common problems and needs of critically ill patients.

Question 7

The critical care nurse recognizes that an ideal plan for caregiver involvement includes

A) a caregiver at the bedside at all times.
B) allowing caregivers at the bedside at preset, brief intervals.
C) an individually devised plan to involve caregivers with care and comfort measures.
D) restriction of visiting in the ICU because the environment is overwhelming to caregivers.

Question 8

Develop strategies to manage issues related to caregivers of critically ill patients.

Question 9

To establish hemodynamic monitoring for a patient, the nurse zeros the

A) cardiac output monitoring system to the level of the left ventricle.
B) pressure monitoring system to the level of the catheter tip located in the patient.
C) pressure monitoring system to the level of the atrium, identified as the phlebostatic axis.
D) pressure monitoring system to the level of the atrium, identified as the midclavicular line.

Question 10

Apply the principles of hemodynamic monitoring to the collaborative care and nursing management of patients receiving this intervention.

Question 11

The hemodynamic changes the nurse expects to find after successful initiation of intraaortic balloon pump therapy in a patient with cardiogenic shock include (select all that apply)

A) decreased SV.
B) decreased SVR.
C) decreased PAWP.
D) increased diastolic BP.
E) decreased myocardial oxygen consumption.

Question 12

Differentiate the purpose of, indications for, and function of circulatory assist devices and related collaborative care and nursing management.

Question 13

The purpose of adding PEEP to positive pressure ventilation is to

A) increase functional residual capacity and improve oxygenation.
B) increase FIO₂ in an attempt to wean the patient and avoid O₂ toxicity.
C) determine if the patient is in synchrony with the ventilator or needs to be paralyzed.
D) determine if the patient is able to be weaned and avoid the risk of pneumomediastinum.

Question 14

Differentiate the indications for and modes of mechanical ventilation.

Question 15

The nursing management of a patient with an artificial airway includes

A) maintaining ET tube cuff pressure at 30 cm H 2 O.
B) routine suctioning of the tube at least every 2 hours.
C) observing for cardiac dysrhythmias during suctioning.
D) preventing tube dislodgment by limiting mouth care to lubrication of the lips.

Question 16

Select appropriate nursing interventions related to the care of an intubated patient.

Question 17

The nurse monitors the patient with positive pressure mechanical ventilation for

A) paralytic ileus because pressure on the abdominal contents affects bowel motility.
B) diuresis and sodium depletion because of increased release of atrial natriuretic peptide.
C) signs of cardiovascular insufficiency because pressure in the chest impedes venous return.
D) respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO₂ levels.

Question 18

Relate the principles of mechanical ventilation to the collaborative care and nursing management of patients receiving this intervention.