...16,000 days (55 ICU beds) 216 Excess Cost2 $46,000,000 1Based on attributable mortality of 5.8% cost cost methodology 2Ontario Clinical Criteria for Suspicion of VAP • New or persistent infiltrate on CXR without another cause • Plus any 2 of the following: • • • • Purulent endotracheal secretions Increasing oxygen requirements Core temperature > 38.0o C WBC < 3.5 or > 11.0 Adapted from N Engl J Med 2006;355:2619-30. Host Risk Factors for VAP • Underlying pulmonary disease (e.g. COPD) • • • • • Sepsis ARDS Major surgery Multiple organ failure Head injury (traumatic and nontraumatic brain injury) Ann Intern Med. 2004;141:305-13. Other Risk Factors for VAP • Enteral nutrition • GI prophylaxis • Patient position (Head of bed elevation) • Patient receiving paralytic agent • Reintubation • Witnessed aspiration Ann Intern Med. 2004;141:305-13. Ann Intern Med. 1998; 129:433-40....
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...Post-tracheostomy tube management has traditionally been managed by the surgery service. However, it has been questioned whether or not an advanced practitioner is able to safely change a TT. Therefore this retrospective study was completed to assess the SLP’s success with changing TT in the acute care setting with physician support as needed. Our retrospective study revealed 107 TT change procedures that were initiated under the supervision of a SLP. A total of 106 (99%) of the referrals successfully underwent a TT change without complications under the supervision of the SLP without physician intervention. One (1%) of the procedures was aborted secondary to a complication with the attempt to remove the TT through the stoma. This patient was referred back to the surgical team for successful management. 83(78%) of these TT changes were the first one completed post tracheotomy which tends to be more complicated than a routine TT change with mature stomas. Variables to consider, when changing a TT, include the maturation of the endotracheal-cutaneous tract, neck and airway anatomy. Complications rates are reported to be 2.1-20% and include the potential for airway loss and extratracheal tube placement resulting in subcutaneous emphysema, pneumomediastinum, and cardiac arrest or death. (Schmidt, Hess, Kwo, Lagambina, Gettings, Khandwala, 2008; Fikkers, Briede, Verwiel, Van Den Hoogen, 2002; Ritter, Lakshmanan, Sakabu, Troop, Trottier, 2002). Premature changing a TT tube prior...
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...Research Article: Standard Tracheal Secretion Assessment versus an acoustic Secretion Detector Endotracheal intubation and mechanical ventilation are life-saving procedures in patients with respiratory insufficiency. But this can profoundly impair the defensive mechanisms which keep the lower respiratory tract sterile, increasing the risk of bacterial colonization and ventilator-associated pneumonia. Although endotracheal suctioning is a standard of care in all mechanically ventilated patients, clear guidelines regarding the technique and timing of suctioning are lacking. The applicable American Association for Respiratory Care (AARC) guideline suggests that endotracheal suctioning should be performed at some minimum frequency or when clinically indicated. Since endotracheal suctioning can cause hypoxemia, mechanical trauma, bronchospasm, and hemodynamic instability, an accurate assessment of the need for suctioning might decrease the frequency of suctioning complications. TBA Care is a novel device designed to generate a signal when secretions are present in the respiratory tract of an intubated patient, indicating the need for endotracheal suctioning. This is the first prospective randomized trial to compare different indications for endotracheal suctioning. This study compares the efficacy of TBA Care in detecting the presence of secretions in the airways to standard indications, and tested the hypothesis that different suctioning indications could impact the incidence of...
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...google scholar, http://scholar?q=+in+infant+after+intubation&btnG=&h1=en&as_sdt=0%2c11. I use google search engine all the time so I felt like google scholar would be an easy transition into looking for scholarly resources. Google scholar was very user friendly. It pulled up several relevant articles. It was easy to put in the time frame you want the article to be published in. The main problem I have seen with google scholar is that when trying to read the full text article, it often required payment. The second database I decided to explore was PubMed, http://www.ncbi.nlm.gov/pubmed/20334332 . I found this data to also be user friendly. Like google scholar you can go to advance search and put in the time frame of the publication. You could also check whether you wanted to only search full text and peer reviewed articles. The problem I had with PubMed is finding relevant articles in the time frame I needed them to be in. When searching with databases I had to use correct word phrases to get relevant articles. My topic is stridor in infants after intubation. We intubate infants in the Neonatal Intensive Care Unit (NICU) all the time. It is usually an emergency and we intubate as quick as possible, sometimes causing injury. The topic is an interest to me not only because I am a NICU nurse, but because I am a parent of an infant born at 27 weeks gestation, who was intubated at delivery. He had a difficult intubation where the Nurse Practitioner tried to intubate him...
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...ventilations but he doesn’t seem to tolerate ventilations via bag valve mask. His blood pressure is 110/60, pulse rate of 50, with snoring respirations at a rate of 6 breaths a minuet that are very shallow. With an Oxygen saturation of 80%. He is extremely hypoxia and needs an advanced airway his jaw is clenched tightly and impossible to inset a tube. You decide to prepare for intubation, but first decide a dose of Versed at 1.5mg to open his clenched jaw and will take effect while you prepare all equipment. Using a jaw thrust maneuver you open his airway and visualize that an ET tube is appropriate and viable. You prepare 100mg of succinylcholine estimating the man’s weight is 100kg as a sedative. After administering the drug you will have your partner aggressively monitor vital signs. You now use a laryngoscope and blade to open the epiglottis and hold the tongue for clear visualization. You choose an 8mm diameter tube to insert and you’ve already made sure the balloon inflates with a 10ml syringe. Lubricant will assist in tube placement as well as putting a slight bend in it prior to intubation. The tube is then slid along the right side of the mouth and visualized entering 1/2 to I inch into the vocal cords. Make sure you do not take your eyes off the vocal cords once you see them. If you need something have it passed to you by your partner. Watch the tube pass through the cords. A helpful trick is to vocalize what you see and what you are doing to ensure proper technique...
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...Introduction: A tracheotomy is a surgical procedure to create an opening in the neck at the front of the windpipe (trachea). A tube is inserted into the opening and connected to an oxygen supply and /or ventilator to assist with breathing. Fluid may accumulate in the throat and windpipe and the removal through the opening is allowable. Dawson (2014) states nurses caring for patients with tracheostomy require an appreciation of the breadth of knowledge needed to provide individual and safe care. A tracheostomy may be performed as: • An emergency procedure - if someone is unable to breathe following an injury or accident. • A planned procedure - to assist someone who is unable to breath as part of treatment in intensive care, or due to a long-term condition such as laryngeal cancer etc. Details: According to the student clinical suggestion trachea care is the topic of choice for clinical simulation. The clinical coaching sessions, contain 5 groups; each group will have 2 students with a preceptor. According to Devine, Houssemand and Meyers (2013) coaching is an influential instrument to support knowledge and development for students, teachers, school leaders and educational establishments. This is why group coaching will be utilized. Your instructor will grade your progress as you move through the stations. A pass or fail grade will be indicated at the end of the session. Review the trachea care section in your Mosby skill assessment guide prior to the check off and bring the certificate...
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...ventilator. It will look at the problems associated with prolonged intubation vs. premature extubation, and what healthcare professionals can do to assess a patients readiness to begin the weaning process. A patient care scenario will be given and an explanation of how nursing practice can evolve with the knowledge from this study will be shown. The accountability of the nursing professional in regards to mechanical ventilation will be visited as well. Accountability of Nursing Professionals: Weaning from Mechanical Ventilation “Mechanical ventilation refers to the use of life-support technology to perform the work of breathing for patients who are unable to do so on their own.” This is the definition of mechanical ventilation according to Cook, Meade, and Guyatt (2000). They performed a study to determine the optimal time to wean a patient off of mechanical ventilation. When weaning a patient you have to find the right time to extubate. Prolonged mechanical ventilation can lead to nosocomial pneumonia, cardiac associated morbidity, and possible death. However, extubating a patient too soon may result in having to reintubate which can result in the same illnesses as prolonged intubation. “Research to date suggests that the best answer to ‘when to start weaning’ is to develop a protocol implemented by nurses and respiratory therapists that begins testing for the opportunity to reduce support very soon after intubation and reduces support at every opportunity” (Cook 2000). The nurse...
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...Paramedic Case Studies Name Institution Table of Contents Introduction 3 1.1 Clinical plans are prior to arrival on the scene. 4 1.2 Patient selection Criteria for RSI 5 1.3 Steps in an RSI Procedure 6 Step 1 - Preparation 6 Step 2- Preoxygenation 6 Step 3- Pretreatment 7 Step 4- Rapid sequence Induction and Paralysis 7 Step 5- Protection and Positioning 7 Step 6- Placement of the Endotracheal Tube in the Trachea 8 Step 7- Post-intubation Management 8 1.4 Risks and benefits associated with RSI 9 Case 2 10 2.1 Discussion 10 2.2 Clinic plan and initial management 10 2.3 Notification of Arrival 11 Conclusion 11 Case 3 12 Introduction 12 Incident 1 12 Incident 2 13 Incident 3 13 Incident 4 14 Case 4 15 Conclusion 16 References 17 Introduction The basic concept of retrieval medicine is a combination of transfer and care of a patient from one medical institution, site of trauma, and pre-hospital management to a medical institution to provide higher and better level of care. The transfer and retrieval of severely ill and wounded patients entail high-risk activities (Ellis & Hooper, 2010). This paper looks into various case studies to determine the various control measures that might and should be put in place in various retrieval situations so as to increase patient safety and efficiency in pre-hospital care. This comprises of communication procedures, team resource management...
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... VAP accounts for 6 of every 10 deaths attributed to healthcare-associated infections (Doyle, Fletcher, Carter, Blunt, & Young, 2011). VAP extends the time a patient is in the intensive care unit by approximately a week and increases cost by $10000 per episode (Doyle et al., 2011). BioMed Central, a peer research group, performed a quantitative research study on VAP and the PneuX System addresses issues surrounding the prevention of VAP. This device incorporates and proprietary endotracheal tube and tracheal cuff seal monitor which is not used with traditional endotracheal intubation. When selecting the sample study, each patient was over the age of 18 years and intubation was required within their plan of care. PneuX System was implemented only of patients expected to be intubated over 24 hours (Doyle et al., 2011). For all patients included in the study, the PneuX System was used and intubation time was at least 48 hours. All patients intubated using the PneuX System were included in study results. First to review VAP and the role the PneuX system plays in VAP prevention. Often when placed on a ventilator a patient is sedated. Bacteria in the surrounding environment and within the patient’s mouth continue to multiply (Grammatikos, 2006). Due to sedation, the patient does not have the ability to cough or otherwise clear the airway. Bacteria can bypass an improperly filled endotracheal tube cuff or can freely enter the lung through the tube itself. Continued sedation...
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...Medications: * Bronchodilators: * Beta2-agonists: terbutaline, albuterol, metaproterenol * Short: rescue meds. ADEs: increased SNS response. STOP if chest pain. * Parasympatholytics: Atrovent * Given in combo with beta 2 agonists. AntiACh effect * Xanthines: theophylline, aminophylline * Increase SNS response, broken down into caffeine. STOP if chest pain. Not maintenance med. * Magnesium * Relaxes bronchioles. Acute use only. Can cause HOTN * Expectorants: guaifenesin * Can cause drowsiness. HYDRATE. * Mucolytics: acetylcysteine (mucomyst) * Decrease viscosity of secretions. Used to tx Tylenol OD, and given to protect kidney from contrast dyes. * CAUTION: sedatives (if anxiety r/t hypoxia fix hypoxia), antitussives (hydrododone, codeine) Medications: * Bronchodilators: * Beta2-agonists: terbutaline, albuterol, metaproterenol * Short: rescue meds. ADEs: increased SNS response. STOP if chest pain. * Parasympatholytics: Atrovent * Given in combo with beta 2 agonists. AntiACh effect * Xanthines: theophylline, aminophylline * Increase SNS response, broken down into caffeine. STOP if chest pain. Not maintenance med. * Magnesium * Relaxes bronchioles. Acute use only. Can cause HOTN * Expectorants: guaifenesin * Can cause drowsiness. HYDRATE. * Mucolytics: acetylcysteine (mucomyst) * Decrease viscosity...
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...Report Situation: The patient is a 60-year-old male in room 425 on the Orthopedic Unit who is recovering from an anterior-posterior interbody fusion of L4 – L5 performed two days ago. His has had an uneventful recovery. He is in his room eating breakfast. Background: Hypertension, hypercholesterolemia and obesity. The hypertension has been well controlled by his medication. He is wearing a soft neck collar for support following a minor car accident three weeks ago in which he sustained whiplash. The patient has no known drug allergies and is awake and alert. Assessment: Vital signs: HR 87, BP 128/62, RR 18, SpO2 has been 98% on room air, Temp 37.1oC Cardiovascular: No telemetry; HR regular Respiratory: Clear in both lung fields GI: Advanced to full liquid diet and tolerating it well GU: Voiding clear, yellow urine Extremities: Pink, warm and with adequate turgor; Movement is strong in all four extremities (4+) Skin: Warm and dry; No signs of infection at his surgical site Neurological: Alert and oriented to person, place and time; pupils equal, round, reactive to light and accommodation; no neurological deficits IVs: No IV access; saline lock became dislodged during the night and was not restarted as he will be discharged soon Labs: No labs ordered Fall Risk: Low-risk Pain: Well controlled Recommendations: Provide a complete...
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...Lithium: Ther. class. mood stabilizers Indications Manic episodes of manic depressive illness (treatment, maintenance, prophylaxis) Therapeutic Effect(s): Prevents/decreases incidence of acute manic episodes S/E: CNS: SEIZURES, fatigue, headache,impaired memory, CV: ARRHYTHMIAS, ECG changes GI: abdominal pain, anorexia, bloating,diarrhea, nausea, GU: polyuria,Derm: acneiform eruption, folliculitis, Endo: hypothyroidism, Hemat: leukocytosis. MS: muscle weakness Neuro: tremors.S Lithium Toxicity: Assess patient for signs and symptoms oflithium toxicity (vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, or twitching). If these occur, report before administering next dose.The therapeutic range for lithium has been established at 0.6 - 1.2 mmol/L." Shellys list Block1 lithium: • Tx of Manic (opposite of depression) Depression • Monitor lithium lab level PP 24 • Tx of bipolar disorder involves variety of drugs used to stabilize mood. Lithium, valproate, divalproex, carbmazepine, olanzapine, oxcarbazepin, lamotregine, quetiapine, and risperidone are examples of drugs used. Only lithium is approved by FDA for use in those 12-18 years. Early treatment is key to preventing chronic, serious mental illness. Nurses are instrumental in identifying children with this disorder, providing info to families and monitoring drugs and psychotherapy. Nurses should observe for side effects to specific drug regimen used and assist parents to find...
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...Medications: None. Code Status: Full Code Social/Family History: Employed as a mail carrier; Divorced: has two adult children who live out of town, but visit frequently. Latest Assessment: Vital Signs: HR 82, BP 124/75, RR 14, SPO2 98% on 36% tracheostomy collar, T 99 Cardiovacular: Normal sinus rhythm Respiratory: Breath sounds with ronchi bilaterally; equal expansion, trach tube intact, and insertion site clean and dry. GI: normal bowel sounds, PEG tube intact dressing dry GU: WNL Extremities: equal bilaterally, strong peripheral pulses Neurological: Alert and oriented to time, place and person, pupils equal and reactive to light and accommodation Pain: no complaints of pain Learning objectives * Perform assessment on the patient * Demonstrates appropriate tracheal suctioning techniques, including ongoing assessment of respiratory status * Intervenes appropriately to resolve acute respiratory distress in patient with tracheostomy Preparation questions: 1. What are some of the indications for a tracheostomy? * Prolonged intubation during the course of a critical illness * Severe neck or mouth injuries * Long term unconsciousness or coma, * To maintain an airway where the ability to do this via normal mechanisms is temporarily or permanently compromised * To facilitate longer-term respiratory support such as mechanical ventilation or...
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...Burns- Assessment of such as age and the depth of the burn , bsa, inhalation injury , injury of other special surfaces such as the face the perineum , hands or feet or genital areas as well as medical hx. Burns are classified as : superficial partial thickness --- deep partial thickness--- full thickness injuries, it is important to remember that these are similar to but not the same as first second and third degree burns. Fourth degree burn if used is classified as a full thickness burn that destroys also tendons and muscle usually from high voltage injury or prolonged flame contact. Superficial partial thickness- the epidermis is destroyed or injured and portion of the dermis may be injured to Deep partial thickness – the epidermis is destroyed and the upper layers of the dermis with possible involvement of the deep layers, cap refill and tissue blanching, hair follicle still in tact Full thickness- destroys everything up to and including the underlying tissue of bone and muscle, color ranges from pale white to red and charred brown and black. No sensation due to destruction of the nerve. Wound is leathery no hair or sweat glands. Wound must be grafted to heal BSA: Rule of nines: head is 9, arms are 9, chest is 18 anterior and 18 posterior , belly is 18 anterior and posterior, legs are 18 and genitals are 1. Lund/bowder method is more accurate it determines BSA based on proportion of the area to the whole body and is more precise. Usually is given estimate then...
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...Crisis Hepatic Coma ARDS Diabetic Ketoacidosis CVD End Stage Renal Stage The Concept of Critical Care Nursing Delivery of specialized care to critically-ill patients with life-threatening such as major surgery, trauma, infection, and shock as well as prevention of potential life-threatening conditions. The critical care nurse is responsible for ensuring that all critically-ill patients and families receive optimal care. Common Illnesses and Injuries seen in ICU: 1. GSW (Gunshot Wounds) 2. Traumatic Injuries (car collision & falls) 3. CV D/O (heart failure, acute coronary syndrome, unstable angina, MI) 4. Surgeries (abdominal aortic aneurysm repair and endarterectomy) 5. Renal D/O (acute and chronic renal failure) 6. GI and Hepatic D/O (acute pancreatitis, acute UGIB or Upper Gastro Intestinal Bleeding, acute liver failure) 7. Cancer (lungs, esophageal & gastric) 8. Shock due to hypovolemia PRINCIPLES OF CRITICAL CARE NURSING Maintains the establishment standards of CCN practice Continually updates knowledge necessary for competence as an integral part of the multidisciplinary health care team, coordinates care delivered to patient and supports families within the CC environment. Must...
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