Acutebiologicalcrisis.. Skills

AcuteBiologicalCrisis • Pacemakers • Dialysis Pacemakers  Clinical Indications ◦ Symptomatic bradydysrhythmias ◦ Symptomatic heart block Mobitz II second-degree heart block Complete heart block Bifascicular and trifascicular bundle branch blocks ◦ Prophylaxis After acute MI: dysrhythmia and conduction defects Before or after cardiac surgery During diagnostic testing Cardiac catheterization EPS Percutaneous transluminal coronary angioplasty (PTCA) Stress testing Before permanent pacing ◦ Tachydysrhythmias; to break rapid rhythm disturbances Supraventricular tachycardia Ventricular tachycardia  Temporary Pacemaker ◦ Non-invasive Pacemaker Non-invasive – used as an emergency measure or when a client is being transported and the risk of bradydysrythmia exist A large electrode patch is placed in the chest and back Wash the skin with soap and water before applying the electrodes Do not shave the hair or apply alcohol or tinctures on the skin Place the posterior electrode between the spine and left scapula behind the heart avoiding placement over a bone Place the anterior electrode between V2 and V5 positions over the heart Do not place the anterior electrode over female breast tissue; rather, displace the breast tissue and place under the breast Do not take the pulse or BP on the left side; the result will not be accurate because of the muscle twitching and electrical current Ensure that electrodes are in good contact with skin If loss of “capture” occurs, assess the skin contact of the electrodes and increase the current until capture is regainded  Temporary Pacemaker ◦ Transvenous invasive temporary pacing

pacing lead wire is placed through anctecubital, femoral, jugular, or subclavian vein into the right atrium fro atrial pacing or through the right ventricle and is positioned in contact with the endocardium monitor cardiac rhythm continuously Monitor VS Monitor pacemaker insertion site Restrict client movement to prevent lead wire displacement  Permanent Pacemaker ◦ A pulse generator is internal and surgically implanted in a SQ pocket under the clavicle or abdominal wall ◦ The leads are passed transvenously via the cephalic or subclavian vein to the endocardium on the right side of the heart ◦ May be single chambered- the lead wire is placed in the chamber to be paced; ◦ Dual chambered- lead wires are placed in the atrium and right ventricle ◦ It is programmed when inserted and can be reprogrammed if necessary by non-invasive transmission from an external programmer to the implanted generator ◦ They are powered by a lithium battery that has an average life span of 10 years; those that are nuclear powered has a life span of 20 years or longer; or are designed to be recharged externally ◦ Pacemaker function can be checked in the physician’s office or clinic by a pacemaker interogater/programmer or from home using telephone transmission devices ◦ The client may be provided with a device that is placed over the pacemaker battery generator with an attachment to the telephone; the heart rate then can be transmitted to the clinic ◦

Provide client instructions instruct client on how to take the pulse; take pulse daily and maintain a diary of pulse rate wear loose-fitting clothing avoid contact sports instruct client to inform airport officials that a pacemaker is present advise client not to operate electrical appliances directly over the pacemaker site avoid transmitter towers and anti-theft devices in stores instruct client that if any unusual feelings occur when near any electrical devices to move 5-10 feet away and check the pulse emphasize the importance of follow-up with the physician

 Equipments ◦ Disposable electrode pads ◦ External pacing module ◦ Resuscitative equipment

 Procedure ◦ Preparatory phase Explain procedure to patient. Explain sensation of discomfort with external pacing.  Performance phase ◦ Gradually increase milliamp output until a pacing spike and corresponding QRS complex are seen. Palpate pulse to ensure adequate response to electrical event. ◦ Check pad placement frequently.  Follow-up phase ◦ Check vital signs at least every 15 minutes while continuous pacing is employed. ◦ Monitor ECG continuously for pacer functioning. ◦ Assure patient that treatment is temporary. ◦ Prepare patient for transvenous or permanent pacemaker insertion as indicated. •

Endotracheal Intubation

 Clinical Indications ◦ Acute respiratory failure, CNS depression, neuromuscular disease, pulmonary diseases, chest wall injury ◦ Upper airway obstruction (Tumor, inflammation, foreign body, laryngeal spasm). ◦ Anticipated upper airway obstruction from edema or soft tissue swelling due to head and neck trauma, some post operative head and neck procedures involving the airway, facial or airway burns, decreased level of consciousness (GCS = <8) ◦ Aspiration prophylaxis ◦ Fractured cervical vertebrae with spinal cord injury requiring ventillatory assistance  Complications of Endotracheal Tubes ◦ Laryngeal or tracheal injury Sore throat, hoarse voice Glottic edema Ulceration or necrosis of tracheal mucosa Vocal cord ulceration, granuloma, or polyps Vocal cord paralysis Postextubation tracheal stenosis Tracheal dilation Formation of tracheal-esophageal fistula Formation of tracheal-arterial fistula Innominate artery erosion ◦ Pulmonary infection and sepsis ◦ Dependence on artificial airway

 General Care Measures ◦ Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation as indicated. ◦ Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi, crackles), which suggests need for suctioning. ◦ Provide adequate humidity when the natural humidifying pathway of the oropharynx is bypassed. ◦ Provide adequate suctioning of oral secretions. ◦ Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or hydrogen peroxide diluted with water. ◦ Ensure that aseptic technique is maintained when inserting an ET tube. ◦ Elevate the patient to a Semi-Fowler's or sitting position, when possible;.  Equipment ◦ Laryngoscope with curved or straight blade and working light source (Check batteries and bulb periodically) ◦ Endotracheal tube with low-pressure cuff and adapter to connect tube to ventilator or resuscitation bag ◦ Stylet to guide the endotracheal tube ◦ Oral airway (assorted sizes) or bite block to keep patient from biting into and occluding the endotracheal tube ◦ Adhesive tape or tube fixation system ◦ Sterile anesthetic lubricant jelly (water-soluble) ◦ Syringe ◦ Suction source ◦ Suction catheter and tonsil suction ◦ Resuscitation bag and mask connected to oxygen source ◦ Anesthetic spray ◦ Sterile towel  Nursing Action ◦ Assessment Remove the patient’s dental bridgework and plates Remove headboard of bed (optional) Prepare equipment If time allows, inform the patient of impending inability to talk and discuss alternate means of communication If the patient is confused, it may be necessary to apply soft wrist restraints  Nursing Action ◦ Performance Phase Insert oral airway or bite block if necessary Ascertain expansion of both sides of the chest by observation and auscultation of breath sounds Mark proximal end of tube with marking pen or tape at the point where the tube reaches the corner of the patient’s mouth

◦

Secure tube to the patient’s face with adhesive tape or apply a commercially available endotracheal tube stabilization device Obtain chest x-ray to verify tube position Evaluation Phase Record tube type and size, cuff pressure and patient tolerance of the procedure. Auscultate breath sounds every one to two hours or if signs and symbols of respiratory distress occur. Assess arterial blood gases after intubation if requested by the physician

 External Tube Site Care ◦ Secure an ET tube so it cannot be disrupted by the weight of ventilator or oxygen tubing or by patient movement. ◦ Have available at all times at the patient's bedside a replacement ET tube in the same size as patient is using, resuscitation bag, oxygen source, and mask to ventilate the patient in the event of accidental tube removal. Anticipate your course of action in such an event.  Psychological Considerations ◦ Assist patient to deal with psychological aspects related to artificial airway. ◦ Explain the function of the equipment carefully. ◦ Inform patient and family that speaking will not be possible while the tube is in place. ◦ Develop with patient the best method of communication. ◦ Anticipate some of patient's questions by discussing, Is it permanent?ﾝ Will it hurt to breathe? Will someone be with me?ﾝ