test 1 Flashcards
types of ethical dilemmas
emotionally charged
significant change in pt condition
confusion about facts (pt or fam)
hesitancy about correct set of actions
deviation from custody practice - something that’s not typically done
need for secrecy regarding actions
process of ethical decision making
specify ethical dilemma
assess factors
develop plan
act on plan
evaluate
autonomy
right of self determination concerning medical care
ex- pt has right to decline treatment
beneficence
duty to prevent harm, remove harm, and promote good
nonmaleficence
not to intentionally inflict harm, but could have caused it
justice
equal treatment to all patients
veracity
truthfulness
fidelity
commitment to pt. advocate
confidentiality
respect right to control information. HIPPA
what is needed for advocacy
open communication of pt wishes
collaboration of healthcare team
abandonment of pt
nurse must assure pt is cared for if nurse has to step out
is a nurse requires ro practice if a situation violates their moral or religious beleif
no, but care must be transferred to someone else
elements of informed consent
- competence- ability to understanding
- voluntariness- consent with out pushing a decision
- disclosure of info
what does disclosure of info include
diagnosis
proposed treatment
probable outcome
benefits and risks
alternative treatment
prognoses if treatment is not provided
who gets consent
Drs, we just witness it
ordinary care
common, noninvasive, and tested treatment
ex- nutrition, hydration, abx
extraordinary care
complex, invasive, experimental treatment
ex- ACLS, dialysis, unproved therapies
how to know if a pt should be coded
CHECK THE CHART.
if there is not a DNR order then resuscitate.
if pt is getting surgery can they be DNR
no, but they can change it back as soon as they are out of surgery
patients self determination act
pt right to initiate advance directive
pt right to consent to or refuse treatment
types of advanced directives
DNR
living will
communication about preferences for treatments if pt is incapacitated
natural death
brain death criteria
No cough, no gag, no corneal (blink reflux), no motor function (complete flaccid), no pupillary
how to know when pts end is coming
when they start posturing.
this is when to call organ services
organs that can be taken in brain death vs cardiac death
brain- all
cardiac- kidneys, pancreas and liver only
unreceived pain can do what to pts
disorientation
anxiety
inadequate sleep
negative effects of pain/anxiety
activates sympathetic nervous system
tachycardia/htn
increased o2 consumption
tachypnea
pup dilation
urinary retention
sleep disturbance
gluceonogenesis
nausea/constipatoin
what to do for icu pt
cluster care, promote rest, reorient
Richmond agitation sedation scale (RASS)
Sedation tool for ICU pt
score goes from negative 5 to pos 4
4 is insanely combative
0 is alert and calm
-5 is completely unarousable
we want them to be in a light sedation, score -2 to +1
bispectral sedation index (BIS)
Probe that goes on head to monitor anesthesia/sedation level
0 to 100
0 is completely unarousable
Above 90 is completely awake
Goal is 40-60
types of delirium
hyperactive- agitated, combative, disoriented
hypoactive- quiet delirium
mixed- fluctuating btwn the two
assessment for delerium
CAM-ICU (confusion assessment method)
drug for delirium
haloperidol
neuromuscular blockades
chemical paralysis
in icu used for - intubation, ventilation, control in ICP, procedures
must admin sedative prior to this
common drugs- Rocuronium, denatonium
train of 4
used to monitor paralytic agent
Leads go on either the ulnar nerve or facial nerve- they give a impulse which causes a twitch
0 twitches= complete paralysis. Decrease drug
4 twitches= no paralysis. Increase drug
The goal is 2 of 4 twitches
what sedative is drug of choice in icu
precedex. it has mild analgesia unlike propofol
monitor for rebound bradycardia
what does propofol contain
lipids
change lipid tubing every 12 hours
when should nutritional assessment be done
first 24 hours by RN
what’s included in nutritional assessment
A&O
gag reflux
swallow study
labs- f&e, BG
hx
Enteral feeding
should start within 24-48 hours if no PO intake
Delivers into GI tract via nose or mouth
Must be hemodynamically stable, no N/V, intact GI, have access (a tube) cant be NPO
parenteral feeding
should be started immediately if enteral not possible
through vein
used for those who can’t tolerate enternal related to GI issue
tubing change every 24 hours
may contain insulin and dextrose
must be its own line, no meds can be pushed or can cause electrolyte issues due to electrolytes in solution
salem pump vs dobbhoff
salem pump can be from mouth to nose to stomach. placement must be verified by chest x-ray
dobbhoff bypasses stomach and goes straight to intestine from nose. nurse must have certification to do this
both are enteral feedings
trophic feeding
Trophic is small volume 10-30 mL/hr. usually start out with this then advance as tolerated
targeted hourly feeding
50-100 mL/hr
volume based feeding
bolus feeding, large volume over 24 hours. This is for more longterm feedings
signs of intolerance of internal nutrition
n/v
absent bowel sounds
abdominal distention
cramping
diarrhea
drug that helps speed up GI tract w enteral feedings
promotility (reglan)
AACN guidelines for aspiration for enteral feedings
HOB at least 30 degrees unless contraindicated
use sedatives sparingly
placement= 4 hour intervals
tolerance= 4 hour intervals
avoid bolus if high risk for aspiraron
swallow study before oral feedings restarted
maintain ETT pressure 20-30 cm H2o
PPN vs TPN
PPN delivered into peripheral IV. isotonic
TPN into large central vein (PICC). hypertonic
behavioral pain scale
assess facial expression, upper limps and compliance with vent
worst score- 12
best - 3
critical care pain observation scale
looks at facial expression, body movements, muscle tension in upper extremities and either compliance with vent to if not vented then vocalization
best score is 0
worst score is 10
diff between critical care from 1950s vs now
more specialized now
for ex, cardiac icu, neuro icu, etc
ICU noises affects what the most
sleep
medication reconciliation
Taking meds they take at home and compare them to the ones they are taking in hospital
VALUE mnemonic
Value what the family tells you
Acknowledge family emotions
Listen to family members
Understand the pt as a person
Elicit questions from family members
