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Week 13 ICU VRD
Which is an appropriate nursing intervention to reduce anxiety in the non-verbal ICU patient? a. Ensure the patient remains in bed at all times b. Maintain a constant level of deep sedation c. Reduce excessive light and noise in the room d. Do not allow any personal items in the patient's room - correct answer Reduce excessive light and noise in the room Patients in the ICU are at high risk for anxiety. Early mobility has many benefits and prolonged bedrest has a number of risks which include increased anxiety. Deep sedation should be avoided in patients when at all possible. Allowing personal items in the room such as photos can help reduce anxiety. Turning off excessive light and reducing any unnecessary noise can reduce anxiety. A mechanically ventilated patient is trying to communicate with the nurse and appears frustrated. Which nursing intervention is most appropriate? a. Ask the patient to speak more slowly and clearly b. Increase the sedation drip rate c. Use a picture board to have the patient point to general categories of concern d. Ask the patient why they feel frustrated - correct answer Use a picture board to have the patient point to general categories of concern Mechanically ventilated patients will not be able to vocalize requests which can impede communication. Asking the patient to speak more slowly or clearly will not help. Also, asking the patient about why they feel frustrated is not a simple yes/no question and could actually increase frustration. Increasing the sedation drip rate will make it more difficult to communicate with the patient. Using a picture board with images such as "pain" or "reposition" can be helpful in understanding what a patient's concerns may be. Which nursing interventions can promote quality sleep in an ICU patient? (Select all that apply) a. Opening the curtains in the patient's room during the day b. Ensuring a constant sedative medication is infusing c. Provide eye masks and ear plugs at night d. Spread out components of the nursing assessment to every 30 minutes rather than completing it all at once e. Playing soothing music in the patient's room - correct answer Opening the curtains in the patient's room during the day Provide eye masks and ear plugs at night Playing soothing music in the patient's room
To promote quality sleep, the nurse can implement measures to enhance sleep/wake cycles. This includes opening the curtains during the day and turning down lights at night, providing eye masks and ear plugs to reduce noise, and playing soothing music. Sedative medications often reduce REM sleep which is key to quality sleep. Also, nurses should cluster their care when appropriate so patients can be left to rest for longer periods of time. Which statement is true about pain for patients in the ICU? a. ICU patients are at lower risk for pain due to continuous infusions b. Treating pain in the ICU is only a compassionate measure c. Under-treatment of pain can reduce healing d. Pain assessment is not required when caring for non-verbal patients - correct answer Under- treatment of pain can reduce healing ICU patients are at a high risk for pain. Pain can cause negative physiological consequences if untreated- and thus treatment of pain is not just compassionate, but important to general patient care. All ICU patients must have their pain routinely assessed. Which is an appropriate tool to assess pain? a. CPOT b. RASS c. Ramsey d. CAM-ICU - correct answer CPOT The CPOT, or Critical-Care Pain Observation Tool, is appropriate for assessing pain in a non- verbal patient. the RASS and Ramsey tools are used to assess sedation, and the CAM-ICU is used to assess delirium. A mechanically ventilated patient receiving continuous fentanyl and propofol infusions presents with hypertension, tachycardia, and tachypnea and the mechanical ventilator is alarming. What should the nurse do first? a. Increase the propofol drip rate per protocol b. Increase the fentanyl drip rate per protocol c. Assess the patient's facial expression and muscle rigidity d. Administer an antihypertensive medication - correct answer Assess the patient's facial expression and muscle rigidity This patient is showing signs of pain and/or agitation, but more assessment information is needed. The patient's facial expression and muscle rigidity can provide helpful information to assess pain in this nonverbal patient. Increasing sedation or analgesia drip rates is not indicated until the cause of the patient's presentation is identified. The cause of the patient's hypertension could be pain and/or
f. Calculate the drip rate and verify with the pump - correct answer Verify the drip rate with the protocol and nursing report Ensure the medication is infused using guardrails Check that the concentration of the IV bag matches the concentration input into the IV pump Calculate the drip rate and verify with the pump Prior to starting or assuming care of a patient with a continuous infusion, the nurse should always make sure that the rate of infusion falls within the continuous infusion orders and protocol. The infusion should be programmed into the pump using guardrails and with the correct concentration. The nurse will need to document the infusion in the patient's EHR including in the I&O documentation. Also, the nurse should calculate the drip rate using the IV bag concentration and intended dose, and then verify this rate with what is showing on the pump. Which is an appropriate strategy to manage and organize care for a patient receiving the following intravenous infusions: Midazolam, Fentanyl, Norepinephrine, Vasopressin, and Normal Saline? a. Ask the provider to eliminate either the Norepinephrine or Vasopressin b. Stop the normal saline because the patient is getting volume from the other medications c. Label each pump and IV tubing with the name of the infusion d. Run one infusion after another in one hour increments - correct answer Label each pump and IV tubing with the name of the infusion It is common for ICU patients to receive multiple IV infusions- and even those with similar actions (eg Vasopressin and Norepinephrine targeting blood pressure). To organize and manage multiple drips, the nurse should continue to run all of these drips as prescribed, but can label the IV pump with the name of the drip and also label the IV tubing itself so that it is clear what drug is infusing through which line. Which are appropriate reasons to sedate a patient? (Select all that apply) a. To reduce anxiety about an upcoming procedure b. To manage agitation interfering with lifesaving measures c. To facilitate mechanical ventilation d. To minimize psychological disturbance e. To reduce sensitivity to pain - correct answer To manage agitation interfering with lifesaving measures To facilitate mechanical ventilation To minimize psychological disturbance Sedation is appropriate to facilitate lifesaving measures such as mechanical ventilator. It can also be used to minimize psychological disturbances. Sedation does not always target pain and is not appropriate to minimize mild anxiety.
A patient has been receiving a continuous midazolam drip for 5 days without any breaks in sedation. The nurse recognizes this patient is at an increased risk for which problem? a. Increased REM sleep b. Reduced tolerance c. Prolonged length of stay d. Quick offset of the medication - correct answer Prolonged length of stay When at all possible, patients should receive breaks in sedation or "sedation vacations" A patient receiving continuous midazolam is at risk for decreased REM sleep, increased tolerance and dependence on the drug, prolonged length of stay, and accumulation of the drug in their tissues- requiring more time for the drugs effects to diminish once it is turned off. A patient is receiving continuous fentanyl and propofol infusions. What is this patient most at risk for? a. Respiratory depression b. Hypertension c. Liver failure d. Tachycardia - correct answer Respiratory depression Propofol puts a patient at risk for respiratory depression. These effects are increased when fentanyl is added as a continuous drip. Propofol actually puts the patient at risk for hypotension and renal failure. Which medication does NOT place patients at risk for respiratory depression? a. Fentanyl b. Midazolam c. Propofol d. Dexmetatomidine - correct answer Dexmetatomidine All of these medications, except for Dexmetatomidine (or Precedex) place patients at risk for respiratory depression. In preparation to intubate a patient, the nurse loudly announces administration of midazolam IV push. What is the reason for this? a. So that another nurse can document the drug b. So that the patient is aware they are about to be sedated c. So that the physician intubating the patient is aware the patient could likely soon lose respiratory drive
Inform all personnel who enter the room that the patient is COVID-19 positive If a patient codes in the hospital setting, only essential personnel should enter- but all should be informed of the patient's COVID-19 status and be required to don appropriate PPE (N-95 mask, gown, gloves, face shield or goggles). The door should remain closed and the patient should be in a negative pressure room if possible. A 55 year old male who has been mechanically ventilated due to COVID-19 ARDS for two days has just gone into cardiac arrest. Which collaborative intervention is appropriate according to the AHA guidelines? a. Supine, defibrillator pads in the traditional anterior position b. Prone, defibrillator pads in the anterior posterior position c. Prone, defibrillator pads in the traditional anterior position d. Supine, defibrillator pads in the anterior posterior position - correct answer Prone, defibrillator pads in the anterior posterior position If a patient has an advanced airway, it is recommended that they are placed in the prone position with defibrillator pads in the anterior/posterior position. Enumerate the steps to appropriately donning PPE in the correct order. - correct answer Identify and gather the proper PPE to don Perform hand hygiene using hand sanitizer Put on isolation gown Put on NIOSH-approved N95 filtering facepiece respirator or higher (use a facemask if a respirator is not available) Put on face shield or goggles Perform hand hygiene before putting on gloves Healthcare personnel may now enter patient room Enumerate the steps to appropriately doffing PPE in the correct order. - correct answer Remove gloves Remove gown Healthcare personnel may now exit patient room Perform hand hygiene Remove face shield or goggles Remove and discard respirator (or facemask if used instead of respirator) Perform hand hygiene after removing the respirator/facemask and before putting it on again Which of the following statements is consistent with the CDC recommendations related to COVID-19 and PPE? a. Healthcare workers can re-tie or adjust PPE once in the patient room
b. PPE should be removed as quickly as possible once care is provided c. Facemasks are an acceptable alternative if an N95 respirator is not available d. Healthcare workers should wear at least 2 pairs of gloves when caring for COVI-19 patients - correct answer Facemasks are an acceptable alternative if an N95 respirator is not available Adjustments to PPE should not be made after entering an isolation room. The CDC does not emphasize speed at which PPE should be removed. If N95 masks are not available, face masks are an acceptable alternative according to the CDC. Only one pair of clean non-sterile gloves is listed as preferred and acceptable PPE. Which of the following are considered contaminated surfaces when doffing PPE? (Select all that apply) a. Outside of gloves b. Outside of face shield or goggles c. Gown front d. Gown sleeves e. Inside of gloves f. Front of mask or respirator - correct answer Outside of gloves Outside of face shield or goggles Gown front Gown sleeves Front of mask or respirator All exposed surfaces are considered contaminated, therefore the inside of gloves are not considered contaminated. Which of the following is considered a "best practice" when caring for a critically ill patient with COVID-19 according to the most recent Surviving Sepsis Campaign? a. The most experienced healthcare professional should intubate the patient b. Prone positioning for at least 24 hours c. Hydroxychloroquine administration for severe COVID- 19 d. Use of a surgical mask when providing care - correct answer The most experienced healthcare professional should intubate the patient Best practices were backed by the strongest evidence in the Surviving Sepsis Campaign. These include: Recommended use of a fitted respirator mask (N95, FPP2 or equivalent) Aerosol-generating procedures should be conducted in a negative pressure room For patients requiring endotracheal intubation, the most experienced healthcare professional should intubate the patient to minimize number of attempts
Your patient appears to have developed ARDS. Which statement about ARDS is true? (SELECT ALL THAT APPLY) a. It is characterized by refractory hypoxemia b. Patients with ARDS present with a "black out" chest X-ray c. ARDS begins at the alveolar capillary membrane d. Patients with ARDS may require higher levels of PEEP - correct answer ARDS begins at the alveolar capillary membrane It is characterized by refractory hypoxemia Patients with ARDS may require higher levels of PEEP ARDS begins at the alveolar capillary membrane and is characterized by refractory hypoxemia, a "white-out" chest x-ray. When on the ventilator, these patients often require higher levels of PEEP. Your patient is now only speaking to you in one-word sentences and doesn't look up when you come in the room. Which of the following are signs of respiratory distress? (SELECT ALL THAT APPLY) a. Diaphoresis b. HR: 120 c. Auscultating scattered crackles in the bases d. of his lungs e. BP: 160/ f. RR: 12 g. ABG shows a PaO2 of 80mmHg - correct answer Diaphoresis HR: 120 BP: 160/ Diaphoresis: he's working too hard to breathe/activation of the SNS HR: 120: another sign that he's working too hard- this is his sympathetic nervous system responding Auscultating scattered crackles in the bases of his lungs: this might be a problem, but it does not definitively tell you that he is in respiratory distress. BP: 160/95: another sign that he's working too hard- this is his sympathetic nervous system responding RR: 12: a normal respiratory rate. Respiratory distress appears as tachypnea and is often a RR in the 30's ABG shows a PaO2 of 80mmHg: this is a normal PaO2 (80-100mmHg) The healthcare team decides to get an ABG on your patient. Interpret the results:
pH: 7. CO2: 65 HCO3: 25 PaO2: 58 a. Fully compensated metabolic acidosis with hypoxemia b. Uncompensated respiratory acidosis with hypoxemia c. Partially compensated respiratory acidosis d. Partially compensated metabolic acidosis with hypoxemia - correct answer Uncompensated respiratory acidosis with hypoxemia pH: 7.29 --> acid (Acidosis) CO2: 65 --> acid (Respiratory) HCO3: 25 --> normal (uncompensated) PaO2: 58 --> low (qualifies as respiratory failure since it's below 60mmHg Considering this ABG, pH: 7.29; CO2: 65; HCO3: 25; PaO2: 58 The physician asks you what you recommend. Which statement is most correct? a. This patient needs sodium bicarbonate b. This patient needs to breathe into a paper bag c. This patient needs a non-rebreather mask d. This patient needs to be intubated and mechanically ventilated - correct answer This patient needs to be intubated and mechanically ventilated Uncompensated respiratory acidosis with hypoxemia should be treated with ventilatory support. Providing sodium bicarbonate will not exacerbate the problem, but does not address the core issue. Increasing oxygen flow will decrease respiratory drive and not address the main ventilatory issue. Breathing into a paper bag will exacerbate the problem. The physician states she would like to intubate the patient. You position the patient in a sniffing position at the head of the bed and provide the physician with supplies. You then announce that you have administered neuromuscular blocking agents, sedation, and analgesia. She begins to attempt the first intubation. What should you do first? a. Document the patient's vital signs b. Assist with visualizing the vocal cords c. Announce changes in the patient's oxygen saturation d. Auscultate both lungs - correct answer Announce changes in the patient's oxygen saturation Documenting the patient's vital signs takes you away from the patient at this moment in time. Assisting with visualizing the vocal cords is not in the nursing scope as this can only be done by
b. Every hour c. Only in the case of a respiratory code d. Only when indicated by clinical presentation - correct answer Only when indicated by clinical presentation Closed in-line suctioning should not happen routinely- only when the patient presents with hypoxia or the respiratory assessment indicates that secretions need to be removed. This is not reserved only for respiratory codes. Your patient's tube is secured and connected to the mechanical ventilator. The physician orders the following mode and settings: SIMV RR: 12 Vt: 450 PEEP: 5cmH FiO2: 40% Which accurately describes what will happen in this ventilator mode? a. If this patient takes a 13th breath on his own, the ventilator will support that breath with 450mL of volume b. If this patient takes a 13th breath, the ventilator will provide a pressure of 12cmH c. If this patient takes a 13th breath, the patient will determine the volume of that breath d. This patient will not be permitted to take a 13th breath - correct answer c. If this patient takes a 13th breath, the patient will determine the volume of that breath In SIMV, the ventilator will guarantee that the patient receives 12 breaths a minute at a set tidal volume of 450mL, but if the patient decides to take any more breaths over 12, the ventilator will not help them- thus, the tidal volume will be a natural volume, not a pre-set volume delivered by the ventilator. The patient's first ABG comes back after being in SIMV mode. pH: 7. CO2: 50 HCO3: PaO2: 70 Which recommendation by the nurse is most appropriate? a. Increase the respiratory rate setting b. Decrease the FiO2 setting c. Change the mode to Pressure Support d. Increase the sedation drip rate - correct answer Increase the respiratory rate setting
The ABG shows uncompensated respiratory acidosis with hypoxemia. This patient has a failure to ventilate causing failure to oxygenate. We need to either increase the respiratory rate setting for this SIMV mode or change the patient to Assist Control mode so that the patient receives more breaths, blowing off more CO2, correcting the respiratory acidosis. The patient is changed from SIMV to AC mode ventilation: Assist Control: RR: 15; Vt: 500; PEEP: 5; FiO2: 50% He appears anxious when you walk in the room. You review the ABG results from approximately 20 minutes after the ventilator mode change. pH: 7. CO2: 30 HCO3: 24 PaO2: 1 10 What recommendation to the healthcare team is most appropriate? a. Decrease the respiratory rate setting b. Increase the sedation drip rate c. Increase the tidal volume setting d. Increase the FiO2 setting - correct answer Increase the sedation drip rate This ABG shows uncompensated respiratory alkalosis with hyperoxia. This patient is hyperventilating. We could reduce the respiratory rate setting which can reduce hyperventilation. However, if the patient is triggering a lot of breaths on his own due to anxiety, each of those breaths is getting the pres-set tidal volume (causing hyperventilation). Therefore, in that case we would consider sedating the patient more. Two days later, your patient is doing much better. His pneumonia is resolving, his chest x-ray is improved, and he appears to be taking some of his own breaths when you look at the ventilator. The physician asks if he is ready to wean. Which of these indicate that he is ready? (SELECT ALL THAT APPLY) a. He holds up 2 fingers when you ask him to b. He is on continuous norepinephrine and vasopressin c. His WBC count is normal d. He becomes aggressive during sedation vacations e. His heart rate is 130 - correct answer He holds up 2 fingers when you ask him to His WBC count is normal To consider weaning successful, patients should demonstrate mental readiness, not agitation. Patients should be able to follow commands and not show signs of sympathetic nervous system response (eg. tachycardia). We should also consider if the underlying problem is resolving (eg. improving WBC count).
