Acute Care of the Chronically Ill Flashcards
introduction
- many life sustaining therapies are handled by families and patients
- mechanical ventilation IV medication
patients and caregivers are often experts in their condition or impairment
- have an open mind and willingness to listen
- demonstrate confident in enlisting patient expertise
care of patients with terminal illness
-many terminally ill may forgo invasive and marginally effective medical treatment
terminal illness
-disease process expected to cause death (no cure) within about 6 months
palliative care
- treatment of terminally ill without search for cure
- cutting back on care
- improving quality of life not treatment
- deescalating care
may enter hospice programs near end of life
- provide social and emotional support
- treat discomfort
- help patient/family cope with impending death
- embracing death
- palliative care on steroids
ventricular assist device
-supports heart conditions but does not cure
tracheostomy tubes
- long term replacement for ET tubes, used for:
- long term ventilatory support
- frequently tracheal suctioning -> no humidity, no filtering
- airway protection
- stoma- the hole
- takes out upper airway structures
- may be bc ventilation at home
- prone to lung infections and issues because there is no humidity or filtering from the mouth/nose
- not necessarily on a ventilatory
- unexpected loss of tube may or may not create an emergency
- can be placed emergently by health care providers in cases of profound upper airway obstruction
tracheostomy structure
- passes directly from opening in anterior neck into trachea
- consists of:
- outer cannula
- inner cannula
- obturator
- separated so you can take one part out without taking out the whole thing
fenestrated tracheostomy
- used for:
- patients being evaluated for tube removal
- patients requiring intermittent ventilator support
- may be able to speak
- breath around it
- for patients who dont need complete support
- patients who are wheening off of it
- has holes
follow DOPE acronym for troubleshooting: tracheostomy
- dislodged/displaced/disconnected
- obstruction
- pneumothorax
- equipment- thing that is using the tracheostomy- ventilator, suctioning
long term ventilator
- may be used for:
- spinal cord injury
- neuromuscular disease
- lung injury
- depression of inspiratory muscles
- paralysis
- guillian barre syndrome
- positive pressure breathing
primary assessment of long term ventilators
- includes determining if the ventilatory is working effectively
- dont mess with ventilators that are working
- if it does not appear to be working effectively:
- work to adjust ventilator settings
- disconnect the ventilatory completely
CPAP, BPAP, BiPAP
- offer noninvasive option for oxygenation and ventilation support
- patient causes the breath
- ventilator causes the act of breathing-> CPAP, BPAP, BiPAP is supporting the breath
- BiPAP- breathing in is one pressure, breathing out is a different pressure -> people find it more comfortable bc its more natural
diaphragm and phrenic nerve stimulators
- allow some patients to breathe without ventilator assistance
- if device fail, you can use conventional bag-mask technique
- sleep apneic
- will need external support
bilevel positive airway pressure
-BiPAP
left ventricular ejection fraction
- if you don’t have heart failure -> 65-75% ejection fractoin
- less than 20% is severe heart failure -> medication
- less than 10% is critical heart failure
- ventricular assist device for critical heart failure
ventricular assist device (VAD)
- provide life saving bridge for patients with critical heart failure
- used by patients who:
- are awaiting heart transplant- VAD to bridge
- need long term treatment when not candidates for heart transplantation
- terminal VAD- cannot survive without the heart transplant but are not a candidate
complication for ventricular assist device
- bleeding- must be on blood thinners for VAD
- infection
- device failure
few interventions available for EM
- correcting problems with battery or power
- supportive treatment
- contacting care team - 24 hour service
apnea monitors
- used for:
- infants with high risk of SIDS or apnea
- premature infants*
- diagnosis and evaluation of sleep apnea
- monitors vary depending on purpose
long term vascular access devices
- someone requires regular vascular access
- blood draws, IV access
- chemotherapy
- regular need for antibiotics
- for administering
- placed for a number of reasons
- many are maintained with heparin (prevents blood clotting)
- contaminated catheters can cause serious infections
- sterile technique must be used -> devices are under the skin and will require reimplantation via surgery if it is infection
common long term vascular access devices
- peripherally inserted central catheter (PICC) - peripheral inserted in the vein but the end of it is at the center -> 6 months or less
- midline catheter- higher up , indwelling at home catheter, for patients that may need central lines
- double or triple lumen central catheter
- hickman, broviac, and groshong, catheters
- implanted ports
- dialysis catheter
CLABC
-hospital infection
-central line
Central line-associated bloodstream infection
-insurance doesnt pay for anything once you get one -> hospital is responsible
medication infusion pumps
- many IV medications are administered with infusion pumps
- specific intervals , reasons, timings
problems with long term vascular access devices
- devices have a limited life span
- mechanical failure or accidental removal may occur
insulin pumps
- electronic devices allowing diabetic patients to titrate exogenous insulin needs
- potential to complicate emergency treatment of patients with insulin dependent diabetes who develop hypoglycemia
tube feeding
- allows nourishment and water to enter digestive system directly
- tube types that go into the stomach:
- nasogastric - sometimes can go home, move around
- orogastric- hospital in patient is intubated
other tube for feeing
- nasoduodenal
- Nasojejunal
- gastrostomy
- jejunostomy
- percutaneous endoscopic gastrostomy (PEG)
- percutaneous endoscopic jejunostomy (PEJ)
colonstomy
- surgery directing large intestine through a stoma
- colostomy bad collects stool and intestinal liquid for disposal
urostomy/urinary diversion
- urinary diversion is required for certain medical conditions such as:
- bladder cancer
- congenital anomalies
- massive urinary tract obstructions (tumor)
- dementia, stroke
urinary catheterization
- used when patients cannot urinate on their own
- may remain in placed (indwelling catheters -> replaced sometimes)
- may be used intermittently (straight catheter)
dialysis
- replacement for failed or failing kidneys
- as kidney functions declines, substances accumulate in the body
- if untreated, these substances may cause death
- electrolytes build up- Cl
- cardiac automaticity- mg, ca, k, Na
two types of dialysis
- hemodialysis- removes blood through a catheter or fistula
- peritoneal dialysis- solution is sent through a catheter to draw fluids from the body (can be done at home)
graff
-surgical connecition blood circulation
complications of dialysis include
- massive fluid and electrolyte abnormalities
- hypovolemia and fluid overload
- infection
complications of fistulas includes
- life threatening hemorrhage (artery connecting to vein)
- thrombosis
- stenosis
surgical drains and devices
- a variety of drains and devices are used after surgery
- prevent fluid from collecting at surgical site
- outside of scope of practice to manipulate most of these devices and drains
- can cause significant complications, including:
- hemorrhage
- infection
- need for more surgery
cerebrospinal fluid shunts
- hydrocephalus: excess volume of cerebrospinal fluid (CSF) around brain
- CSF shunt drains excess CSF
- leads to:
- headaches
- visual disturbances
- unsteady gait
- nausea, vomiting
- seizures
- altered mental status
ventricular peritoneal shunt
- ventricle of brain to peritoneal cavity
- most common
shunt consists of
- inflow catheter
- valve
- outflow catheter
cerebrospinal fluid shunts: increased ICP suggests
- infection
- shunt valve
- malnutrition
- catheter damage
- altered mental status
suspect shunt malfunction if
- headache
- visual disturbances seizures
paralysis, paraplegia, and quadriplegia
- often accompanied by sensor deficits and loss of bowel or bladder control
- caused by many medical conditions:
- head trauma
- cerebrovascular accident (CVA, stroke)
- spinal cord injury
- malignancy
- other neuromuscular diseases
paralysis
inability to move
- may require:
- urinary catheterization
- total lifting assistance
paraplegia
affects lower extremities
quadriplegia
-affects upper and lower extremities
complications of paralysis, paraplegia, and quadriplegia
- respiratory muscle paralysis
- pressure ulcers
- autonomic dysreflexia
external devices are often used to stabilize spinal structures
- require additional consideration in patient movement
- after spinal surgery
- head mounts are usually screwed directly into skull- halo
- urinary catheterization
- autonomic
