...Professor/Instructor: Type of the Report: ? Individual,...
...Tr (Rise time) and Ts (Settling time)...
............................. 13 Introduction The main objectives of...
...were to study the performance of the...
...the performance of the proportional-integral (PI) and...
...the proportional-integral (PI) and proportional-integral-derivative (PID) controllers...
...controllers in controlling the 1 liquid level...
...a tank using the Cascade control system...
...system via LabView and investigate the properties...
...LabView and investigate the properties of the...
...the properties of the open and closed...
...of the open and closed control loops....
...closed control loops. The selection of proper...
...was assisted through the use of LabView,...
...for control system. The simulation package was...
...in cascade mode. The performance of the...
...The performance of the different type of...
...controllers; P, PI and PID was for...
...examined by adjusting the tuning parameters Kc,...
...parameters Kc, Td and Ti. In this...
...In this experiment, The Multi-Process Control Trainer...
...cascade control system. The simulation process involved...
...simulation process involved the tuning of the...
...the tuning of the PI and PID...
...of the PI and PID controllers to...
...controllers to control the liquid level of...
...liquid level of the lower and upper...
...of the lower and upper tank at...
...a set point. The main objective of...
...objective of using the PI and PID...
...using the PI and PID controllers was...
...was to investigate the control response of...
...control response of the system and reduce...
...of the system and reduce the effect...
...system and reduce the effect of various...
...disturbances such as the change of the...
...the change of the liquid level rate...
...level rate in the system. However, the...
...the system. However, the control process was...
...order to accelerate the response of the...
...the response of the control process, and...
...the control process, and 0.010 for the...
...and 0.010 for the Ti in order...
...might occur in the control system. The...
...the control system. The PID parameters were...
...system to obtain the liquid level set...
...of 20% for the upper tank and...
...the upper tank and 10% for the...
...and 10% for the lower tank. The...
...the lower tank. The three control setting...
...parameters used throughout the experiment for PID...
...Td = 1.0 and Ti= 1.3. The...
...and Ti= 1.3. The experimental result was...
...of Kc, Td and Ti to illustrate...
...Ti to illustrate the effect of the...
...the effect of the tuning parameters on...
...tuning parameters on the control system at...
...setting using trial and error. Theoretical Background...
...process by determining the action 2 needs...
...needs to control the process variable. To...
...variable. To control and manipulate a process...
...In this experiment, the upper tank and...
...the upper tank and lower tank liquid...
...controller after allowing the system to reach...
...feedback controller sends the output information back...
...information back to the controller in order...
...set point. When the liquid level was...
...was higher than the set point, the...
...the set point, the valves were opened...
...opened to reduce the level by allowing...
...level by allowing the liquid to flow...
...flow out of the tank. Alternatively, when...
...tank. Alternatively, when the liquid level was...
...level was below the desired set point,...
...an order by the controller is sent...
...sent to close the valves and allow...
...close the valves and allow the liquid...
...valves and allow the liquid level to...
...this is called the reverse action controller....
...used to monitor and record the data...
...monitor and record the data for both...
...for both tanks. The mechanism is continues...
...is continues until the system reaches stability...
...system reaches stability and levels of both...
...both tanks reaches the set points. This...
...done by calculating the error between the...
...the error between the controller variable value...
...controller variable value and the desired set...
...variable value and the desired set point...
...desired set point and it can be...
...be represented by the following equation: ...

...Development by Identification and PID Control of...
...2 Type of the Report: ? Report...
...6 4.0 Results and Discussion .......................................................................................................... 10...
...1: Schematic of the Double Pipe Heat...
...Time (sec) for the half-open water valve.............................
...13 Figure 4: The Change in Temperature...
...15 Figure 5: The Change in Temperature...
...15 Figure 6: The Change in Temperature...
...100% step change and semi-open water valve...
...65% step change and semi-open water valve...
...100% step change and semi-open water valve...
...100% step change and semi-open water valve...
...100% step change and fully-open water valve...
...100% step change and fully-open water valve...
...pipe heat exchanger. The heat exchanger consisted...
...two concentric tubes, the water flowed through...
...water flowed through the inner pipe and...
...the inner pipe and steam flowed in...
...steam flowed in the annular space between...
...annular space between the two tubes. The...
...the two tubes. The first objective was...
...was to analyze the behavior between open...
...between open loop and closed loop control...
...heat exchanger operations. The second objective of...
...parameters of Ti and Td to evaluate...
...Td to evaluate the performance of P,...
...of P, PI and PID controllers (proportional,...
...cases were completed and analyzed. The first...
...completed and analyzed. The first 6 cases...
...control operations while the remaining 8 cases...
...parameters to choose the most suitable feedback...
...was observed that the closed loop control...
...system errors with the use of a...
...in comparison to the open loop control...
...feedback action. From the results obtained, the...
...the results obtained, the PID controller was...
...selected to be the most appropriate type...
...in comparison to the other two controllers....
...other two controllers. The PID controller also...
...used in industry. The double pipe heat...
...heat 2 exchanger and the shell and...
...2 exchanger and the shell and tube...
...and the shell and tube heat exchanger...
...heat exchanger are the most commonly used....
...In this experiment, the double pipe heat...
...used to study the different control performances....
...different control performances. The double pipe heat...
...concentric pipes with the cold effluent passing...
...effluent passing through the annulus 1 of...
...annulus 1 of the pipe, while the...
...the pipe, while the hot fluid passes...
...fluid passes over the inner pipe. The...
...the inner pipe. The double pipe heat...
...known to be the simplest in comparison...
...heat exchangers. In the heat exchanger two...
...are possible, co-current and counter current. The...
...and counter current. The mechanism of the...
...The mechanism of the co-current flow 1...
...is represented by the hot and cold...
...by the hot and cold fluid flowing...
...fluid flowing in the same direction. However,...
...direction. However, if the hot and cold...
...if the hot and cold fluids flow...
...flow is in the opposite direction the...
...the opposite direction the mechanism of flow...
...order to control the temperature and pressure...
...control the temperature and pressure for the...
...and pressure for the heat transfer operations,...
...are adjusted to the desired set points....
...open 3 loop and closed loop controllers....
...closed loop controllers. The open loop controller...
...have a feedback and the input is...
...a feedback and the input is selected...
...selected based on the current state of...
...current state of the system. The closed...
...of the system. The closed loop controller...
...a feedback controller and operates by identifying...
...operates by identifying the difference between the...
...the difference between the output and reference...
...between the output and reference input. In...
...closed loop process, the error of the...
...the error of the output signal is...
...signal is reduced and system disturbances or...
...will not impact the output. There are...
...proportional, proportional integral and 4 proportional integral...
...integral derivative controllers. The stability of the...
...The stability of the response from controllers...
...for industrial applications. The PID controller is...
...used in industry and from tuning operations...
...from tuning operations the controller parameters are...
...parameters are selected. The stability of response...
...parameters such Ti and Td.The following equation...
...such Ti and Td.The following equation can...
...to 4 represent the output of the...
...the output of the PID controller: 4...
...= derivative gain The integral and derivative...
...gain The integral and derivative gain can...
...its relationship to the 4 proportional gain...
...proportional gain by the following equations: Ki...
...= derivative time The transfer function of...
...transfer function of the P, PI and...
...the P, PI and PID controllers can...
...be expressed through the relation 4 of...
...relation 4 of the proportional response by...
...proportional response by the following equations: Kp...
...where: Kp is the controller gain ?D...
...gain ?D is the derivative time ?i...
...time ?i is the integral time ?...
...time ? is the time constant 5...
...1: Schematic of the Double Pipe Heat...
...order to begin the experiment, all inlet...
...all inlet water and steam valves were...
...when turning on and off all steam...
...avoid burns. 3. The vent valves were...
...be present. 4. The main steam valve...
...opened fully. 5. The control box (which...
...box (which housed the Fisher-Rosemount apparatus, steam...
...steam valve controller and multi-point temperature readout)...
...was turned on and the thermocouple reading...
...turned on and the thermocouple reading number...
...Manual Mode 6. The system was set...
...for co-current in the first trail. 7....
...first trail. 7. The water inlet valve...
...half way. 8. The steam inlet valve...
...was opened all the way. 9. The...
...the way. 9. The steam controller was...
...set to 100% and the starting water...
...to 100% and the starting water flow...
...was recorded. 10. The steam was allowed...
...to run through the heat exchanger until...
...state. This allowed the steam to enter...
...to enter from the steam valve, flow...
...flow parallel in the shell portion of...
...shell portion of the cold water and...
...the cold water and then exit through...
...steam valve 3 and then finally enter...
...then finally enter the drainage valve. 7...
...valve. 7 11. The inlet water valve...
...valve was opened and set up to...
...rate. To determine the exact water flow...
...water flow rate, the odometer was used...
...pass through. 12. The inlet water valve...
...avoid cracking. 13. The steam valve was...
...then opened. 14. The initial water flow...
...rate was recorded. The temperature was recorded...
...were seen in the temperature. This showed...
...This showed that the system was at...
...at steady state. The final water volume...
...was recorded. 15. The steam controller was...
...set at 65% and the initial water...
...at 65% and the initial water flow...
...was repeated. 17. The steam controller was...
...set at 100% and the starting water...
...at 100% and the starting water volume...
...was repeated. 19. The water inlet valve...
...opened three quarter and the steam controller...
...three quarter and the steam controller was...
...to 65% of the way. 20. Step...
...Automatic Mode 21. The steam controller was...
...automatic mode. 22. The Kp (Proportional gain)...
...set at 3 and the Ti (Proportional...
...at 3 and the Ti (Proportional integral...
...set at 50 and the Td (Proportional...
...at 50 and the Td (Proportional derivative...
...set at 0. The set point was...
...set at 40% and the starting water...
...at 40% and the starting water volume...
...recorded 8 23. The temperatures were recorded...
...temperature was reached. The final water volume...
...was recorded. 24. The set point was...
...changed to 60% and with the same...
...60% and with the same Kp, Ti...
...same Kp, Ti and Td values the...
...and Td values the water flow rate...
...was repeated. 26. The set point was...
...back to 40% and Ti value was...
...with same Kp and Td values. The...
...and Td values. The starting water flow...
...was repeated. 28. The set point was...
...changed to 60% and Ti value was...
...with same Kp and Td values. The...
...and Td values. The starting water flow...
...was repeated. 30. The Ti value was...
...set at 25 and the Td value...
...at 25 and the Td value change...
...change to 25. The starting water flow...
...values were recorded, the steam valve was...
...as well s the main steam valve...
...steam left over and the cold water...
...left over and the cold water valves...
...9 4.0 Results and Discussion The first...
...Results and Discussion The first set of...
...was performed in the manual mode, where...
...manual mode, where the temperature set point...
...100% to 65%, and temperature readings were...
...10 seconds. In the second run, the...
...the second run, the set point was...
...65% to 100%, and the temperature readings...
...to 100%, and the temperature readings were...
...in 10-second increments. The first 2 two...
...both performed while the water valve was...
...valve was half-open. The data trends from...
...data trends from the first two runs...
...Time (sec) for the half-open water valve...
...water valve For the run where the...
...the run where the set point was...
...100% to 65%, the water flow rate...
...be 0.1852 gal/s. The resulting values for...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...change, time constant, and controller gain are...
...are summarized in the table below. A...
...is shown in the appendix section of...
...7.9 63.2% of the Temperature Change 4.9928...
...at 63.2% of the Change 35.8 Corresponding...
...- Kp 0.225714286 The general equation for...
...general equation for the transfer function is...
...(??s)+1 By substituting the controller gain and...
...the controller gain and time constant value...
...for run 1, the transfer function for...
...(8) (0.60?s)+1 For the run where the...
...the run where the set point was...
...65% to 100%, the water flow rate...
...be 0.92 gal/s. The resulting values for...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...change, time constant, and controller gain are...
...are summarized in the table below. 11...
...9.6 63.2% of the Temperature Change 6.0672...
...at 63.2% of the Change 29.1 Corresponding...
...0.274285714 By substituting the controller gain and...
...the controller gain and time constant value...
...for run 1, the transfer function for...
...(0.55?s)+1 From analyzing the two trends in...
...that they are the complete opposite of...
...of each other, and are mirror image...
...if reflected across the x-axis. For the...
...the x-axis. For the trend where the...
...the trend where the set point goes...
...100% to 65%, the curve decreases from...
...value of 30°C, and continues to decrease...
...of 23°C. For the trend where the...
...the trend where the set point goes...
...65% to 100%, the curve increases from...
...value of 23°C, and continues to increase...
...value of 30°C. The values of controller...
...gain are 0.23 and 0.27 for runs...
...for runs 1 and 2, respectively. The...
...and 2, respectively. The values of time...
...constant are 0.60 and 0.55 for runs...
...for runs 1 and 2 respectively. This...
...in both runs, the amount of time...
...65% was approximately the same amount of...
...points at approximately the same amount of...
...of time. 12 The next runs were...
...different flow rates, and the change in...
...flow rates, and the change in set...
...100% to 65%. The trends for the...
...The trends for the two flow rates...
...of 0.92 gal/s and 0.25 gal/s are...
...various flow rates The raw data for...
...raw data for the run using the...
...the run using the flow rate of...
...of 0.92 gal/s and 0.25 gal/s is...
...in Table 8. The resulting values for...
...temperature, 63.2% of the step change, temperature...
...at 63.2% of the step change, time...
...change, time constant, and controller gain for...
...are summarized in the tables below. Table...
...9.6 63.2% of the Temperature Change 6.0672...
...at 63.2% of the Change 29.1 Corresponding...
...8.8 63.2% of the Temperature Change 5.5616...
...at 63.2% of the Change 28.8 Corresponding...
...0.251428571 By substituting the controller gain and...
...the controller gain and time constant value...
...value calculated for the flow rate of...
...of 0.92 gal/s, the transfer function for...
...(0.55?s)+1 By substituting the controller gain and...
...the controller gain and time constant value...
...value calculated for the flow rate of...
...of 0.25 gal/s, the transfer function for...
...(0.48?s)+1 By comparing the two transfer functions...
...transfer functions for the two different flow...
...evident that both the controller gain and...
...the controller gain and time constant values...
...are larger for the run at 0.92...
...at 0.92 gal/s. The controller gain and...
...The controller gain and time constant values...
...values are 0.27 and 0.55 for the...
...and 0.55 for the run at 0.92...
...at 0.92 gal/s, and 0.25 and 0.48...
...gal/s, and 0.25 and 0.48 for the...
...and 0.48 for the run at 0.25...
...gal/s. Due to the direct proportionality between...
...proportionality between increasing the water flow rate...
...water flow rate and heat transfer coefficient,...
...our results of the higher flow rate...
...flow rate allowing the system to reach...
...system to reach the desired set-point faster...
...set-point faster than the system with a...
...flow rate. 14 The next set of...
...data was for the automatic mode, where...
...automatic mode, where the performance of various...
...4 below demonstrates the temperature change of...
...(sec) Figure 4: The Change in Temperature...
...5 below demonstrates the temperature change of...
...of 40%, where the Kp value is...
...set at 3, and two Ti values...
...values of 25 and 50 are used....
...(sec) Figure 5: The Change in Temperature...
...Td =0) 15 The behavior of a...
...(sec) Figure 6: The Change in Temperature...
...4 above represented the performance of a...
...SP of 40%. The curve shows typical...
...a P-controller as the response does not...
...not oscillate over and under the desired...
...over and under the desired set point,...
...instead only approaches the set point. Figure...
...Figure 5 shows the performance of a...
...values, of 25 and 50. As per...
...As per theory, the system with a...
...we see that the response with Ti=25...
...was stabilized at the desired set point...
...point faster than the response of the...
...the response of the system where Ti=50....
...system where Ti=50. The PI controller is...
...is represented using the following equation when...
...a disturbance in the system. ...

... Determinants and Assessment of Pulmonary...
...Objectives 1. Explain the conducting airways and...
...the conducting airways and the concept of...
...conducting airways and the concept of ventilation....
...Discuss external respiration and pulmonary gas diffusion....
...Describe pulmonary perfusion and its components. 4....
...Differentiate between respiratory and metabolic acid-base imbalances...
...metabolic acid-base imbalances and levels of compensation....
...respiratory nursing history and assessment. 7. Describe...
...8. Discuss noninvasive and invasive methods of...
...monitoring gas exchange and applications. I. Mechanics...
...components: ventilation, diffusion, and perfusion. A. The...
...and perfusion. A. The conducting airways 1....
...divided into conducting and respiratory airways. 2....
...move air to and from the atmosphere...
...to and from the atmosphere and alveoli....
...from the atmosphere and alveoli. a) Protective...
...that removes pathogens and foreign materials. a)...
...captures them on the mucus layer and...
...the mucus layer and removes them through...
...foreign particles toward the pharynx, where they...
...can be swallowed and destroyed in the...
...and destroyed in the stomach. b) In...
...an artificial airway, the initial conducting airway...
...is bypassed, reducing the protective functions and...
...the protective functions and placing patients at...
...risk of aspiration and ventilator associated pneumonia...
...pneumonia (VAP). 5. The tracheobronchial tree consists...
...tree consists of the trachea, with right...
...trachea, with right and left bronchi. a)...
...left bronchi. a) The junction of the...
...The junction of the “Y” formed by...
...“Y” formed by the two primary bronchial...
...bronchial branches is the carina, which is...
...is heavily enervated and very sensitive to...
...stimulation. (1) When the carina is touched...
...severe coughing. b) The right bronchus is...
...bronchus is shorter and larger in diameter...
...larger in diameter and at almost a...
...straight angle with the trachea. c) The...
...the trachea. c) The left bronchus is...
...bronchus is longer and smaller in diameter...
...smaller in diameter and at a more...
...angle. d) Size and positioning of the...
...and positioning of the right bronchus makes...
...vulnerable to pathogens and foreign particles and...
...and foreign particles and misplacement of endotracheal...
...endotracheal tube. 6. The trachea and bronchial...
...6. The trachea and bronchial walls contain...
...present down to the bronchiole level that...
...that gives structure and protection to larger...
...airways. 7. Toward the terminal end of...
...terminal end of the bronchial tree are...
...bronchial tree are the bronchioles, surrounded by...
...a) Bronchioles have the ability to regulate...
...airflow through bronchoconstriction and bronchodilation. B. Ventilation...
...1. Ventilation is the first of the...
...the first of the three components of...
...three components of the respiratory process. a)...
...is defined as the mechanical movement of...
...of airflow to and from the atmosphere...
...to and from the atmosphere and the...
...from the atmosphere and the alveoli. b)...
...the atmosphere and the alveoli. b) Ventilation...
...b) Ventilation involves the actual work of...
...nervous system control and adequate functioning of...
...adequate functioning of the lungs and conducting...
...of the lungs and conducting airways, thorax,...
...conducting airways, thorax, and ventilatory muscles. 2....
...to move in and out of the...
...and out of the lungs as a...
...a result of the changing size of...
...changing size of the thorax caused by...
...activity. a) When the thorax enlarges, the...
...the thorax enlarges, the intrapulmonary pressure drops...
...then moves from the area of higher...
...higher pressure to the area of lower...
...lower pressure. c) The result is air...
...air flowing into the lungs (inspiration) until...
...lungs (inspiration) until the pressure in the...
...the pressure in the lungs becomes slightly...
...back out of the lungs (expiration) until...
...to collapse. a) The fluid lining of...
...fluid lining of the alveoli has a...
...II cells in the alveoli secrete a...
...action that reduces the surface tension of...
...surface tension of the fluid lining the...
...the fluid lining the alveolar sacs, decreasing...
...alveolar sacs, decreasing the tendency to collapse....
...elastic fibers. (1) The elastic force of...
...state. To maintain the lungs in an...
...an inflated state, the elastic forces must...
...opposing forces. 4. The thorax is the...
...The thorax is the primary opposing force...
...force that keeps the lungs expanded. 5....
...lungs expanded. 5. The thoracic bony structure...
...framework that maintains the lungs in a...
...rest, because of the attraction between the...
...the attraction between the visceral and parietal...
...between the visceral and parietal pleurae. 6....
...parietal pleurae. 6. The pleura is a...
...moist membrane. 7. The parietal pleura adheres...
...pleura adheres to the thoracic walls, diaphragm,...
...thoracic walls, diaphragm, and mediastinum. 8. The...
...and mediastinum. 8. The visceral pleura adheres...
...pleura adheres to the lung parenchyma. a)...
...parenchyma. a) Normally, the parietal and visceral...
...Normally, the parietal and visceral pleurae act...
...membrane. 9. As the thorax increases and...
...the thorax increases and decreases in size,...
...size, so will the lungs increase and...
...the lungs increase and decrease in volume....
...Lung Compliance 1. The ease with which...
...ease with which the lungs can be...
...lung volume (mL) and pressure (cm H2O)...
...in volume (mL), and deltaP is change...
...it becomes overexpanded and can burst. a)...
...burst. a) As the alveoli approach their...
...4. Many pulmonary and extrapulmonary problems influence...
...conditions that affect the lung’s tissues, particularly...
...tissues, particularly if the disorder causes a...
...Decreased compliance increases the work of breathing...
...work of breathing and causes a decreased...
...tidal volume. d) The breathing rate increases...
...to compensate for the decreased tidal volume....
...a person ages, the diaphragm flattens, the...
...the diaphragm flattens, the chest wall becomes...
...becomes more rigid, the respiratory muscles weaken,...
...respiratory muscles weaken, and the anterior–posterior diameter...
...muscles weaken, and the anterior–posterior diameter of...
...anterior–posterior diameter of the chest increases. a)...
...altered pulmonary mechanics, and air trapping. 3....
...air trapping. 3. The lung’s functional ability...
...has never smoked and has maintained normal...
...through aging. 5. The aging person with...
...history of smoking and some degree of...
...symptomatic with aging and is at increased...
...Breathing—Ventilation Slide 2 The Conducting Airways Slide...
...Pulmonary Gas Exchange—Respiration and Diffusion A. Respiration...
...A. Respiration is the process by which...
...process by which the body’s cells are...
...supplied with oxygen and carbon dioxide is...
...eliminated. 1. Internal and external respiration a)...
...1. Diffusion is the second of the...
...the second of the three components of...
...three components of the respiratory process. 2....
...for both external and internal respiration. 3....
...respiration. 3. Diffusion: the movement of gases...
...is very thin and offers little resistance...
...to diffusion. a) The membrane can thicken...
...diffusion is reduced, the carbon dioxide tension...
...than oxygen, but the oxygen tension decreases...
...a) Partial pressures and gradient b) Surface...
...oxygen, carbon dioxide, and water vapor. a)...
...sea level. 2. The respiratory process only...
...exchange of oxygen and carbon dioxide, which...
...certain percentage of the total air pressure....
...tension. (1) When the PO2 refers to...
...called PCO2. c) The other abbreviations used...
...blood returning to the lungs from the...
...the lungs from the tissues is oxygen-poor...
...is oxygen-poor because the blood has dropped...
...of oxygen for the tissues’ use. 4....
...for removal from the lungs. 5. The...
...the lungs. 5. The differences in gas...
...partial pressures between the alveoli and pulmonary...
...between the alveoli and pulmonary capillary blood...
...pulmonary capillary blood and the systemic capillary...
...capillary blood and the systemic capillary blood...
...systemic capillary blood and tissues dictate which...
...flow based on the law of diffusion....
...will dissolve in the liquid. The partial...
...in the liquid. The partial pressure of...
...partial pressure of the gas and its...
...of the gas and its solubility determine...
...its solubility determine the amount that dissolves....
...soluble in plasma, and only 3% of...
...pressures is called the pressure gradient. a)...
...gradient exists between the atmosphere and the...
...between the atmosphere and the alveoli and...
...the atmosphere and the alveoli and between...
...and the alveoli and between the alveoli...
...alveoli and between the alveoli and the...
...between the alveoli and the pulmonary capillaries....
...the alveoli and the pulmonary capillaries. b)...
...pulmonary capillaries. b) The greater the pressure...
...b) The greater the pressure difference, the...
...the pressure difference, the more rapid the...
...the more rapid the flow of gases....
...factors can increase the gradient—for example, exercise,...
...pressure mechanical ventilation, and intermittent positive pressure...
...d) Air enters the alveoli from the...
...the alveoli from the atmosphere because the...
...the atmosphere because the atmospheric air pressure...
...gradient exists between the alveoli and the...
...between the alveoli and the pulmonary capillaries,...
...the alveoli and the pulmonary capillaries, causing...
...of gases across the alveolar-capillary membrane. f)...
...In internal respiration, the process is reversed....
...process is reversed. The arterial blood is...
...rich in oxygen and poor in carbon...
...carbon dioxide, whereas the cells are poor...
...poor in oxygen and rich in carbon...
...carbon dioxide. (1) The pressure differences between...
...pressure differences between the PO2 and PCO2...
...between the PO2 and PCO2 in the...
...and PCO2 in the blood and cells...
...in the blood and cells cause oxygen...
...to move from the circulating hemoglobin into...
...circulating hemoglobin into the cells. (2) The...
...the cells. (2) The cells release carbon...
...carbon dioxide into the bloodstream. Lung Surface...
...surface area of the lung is very...
...very large. 2. The greater the available...
...2. The greater the available alveolar-capillary membrane...
...membrane surface area, the greater the amount...
...area, the greater the amount of oxygen...
...amount of oxygen and carbon dioxide that...
...disorder that destroys the alveolar-capillary membrane. a)...
...This greatly reduces the functional surface area...
...functional surface area and consequently impairs gas...
...lung tumors, pneumothorax, and pneumonectomy—can significantly reduce...
...1. Thickness of the alveolar-capillary membrane is...
...is important. 2. The thinner the membrane,...
...2. The thinner the membrane, the more...
...thinner the membrane, the more rapid the...
...the more rapid the rate of diffusion...
...a) Fluid in the alveoli or interstitial...
...inflammatory process involving the alveoli c) Lung...
...blood flows through the alveolar-capillary system in...
...Diffusion of oxygen and carbon dioxide requires...
...is faster through the alveolar-capillary system. 4....
...1. Hemoglobin is the primary carrier of...
...of oxygen in the blood. a) It...
...molecules. 2. In the pulmonary capillaries, oxygen...
...oxygen binds loosely and reversibly to hemoglobin,...
...for transport to the tissues. a) Amount...
...(percent SaO2). 3. The affinity of hemoglobin...
...physiologic factors. 4. The oxyhemoglobin dissociation curve...
...dissociation curve represents the relationship of the...
...the relationship of the partial pressure of...
...of arterial oxygen and hemoglobin saturation. 5....
...hemoglobin saturation. 5. The percentage saturation of...
...direct relationship with the PaO2. 6. The...
...the PaO2. 6. The top portion of...
...top portion of the curve is flattened...
...this portion of the curve, a large...
...might significantly increase the patient’s PaO2, the...
...the patient’s PaO2, the resulting SaO2 increase...
...proportionally small. 7. The bottom portion of...
...bottom portion of the curve is steep....
...sufficient to increase the PaO2 should yield...
...Low PaO2 at the tissue level stimulates...
...High PaO2 at the pulmonary capillary level...
...life-threatening tissue hypoxia. The Effects of Aging...
...surface area decreases, the alveolar-capillary membrane thickness...
...membrane thickness increases, and alveoli are destroyed...
...decreased diffusion across the alveolar-capillary membrane, altering...
...alveolar-capillary membrane, altering the ventilation–perfusion relationship. 2....
...less efficient, placing the high-acuity older patient...
...risk for hypoxemia and/or hypercapnia problems. 3....
...3. Over time, the airways become larger,...
...dead space ventilation, and terminal airways lose...
...trapping. a) Both the gas exchange and...
...the gas exchange and airway changes can...
...Pulmonary Gas Exchange—Respiration and Diffusion Slide 2...
...Curve Slide 5 The Effects of Aging...
...A. Perfusion is the third component of...
...third component of the respiratory process. 1....
...Perfusion refers to the pumping or flow...
...blood into tissues and organs. 2. Perfusion...
...ventricle, running through the lungs and back...
...through the lungs and back into left...
...adequate perfusion in the systemic system (3)...
...of varying sizes and functions (5) Pulmonary...
...stroke volume (SV) and heart rate (HR):...
...is between 4 and 8 liters per...
...ventricular preload, afterload, and contractility. 4. Common...
...be approximated using the equation MAP =...
...organs, such as the brain, heart, and...
...the brain, heart, and kidneys. c) Clinical...
...to organ ischemia and multiple organ dysfunction...
...Blood has weight and, therefore, is gravity...
...dependent areas of the body. 3. Gravity...
...major influence on the relationship between ventilation...
...relationship between ventilation and pulmonary perfusion. Ventilation–Perfusion...
...of alveolar ventilation and pulmonary perfusion. 2....
...greatly affected by the PAO2 and PACO2....
...by the PAO2 and PACO2. 6. This...
...diffusion of oxygen and carbon dioxide across...
...carbon dioxide across the alveolar-capillary membrane and...
...the alveolar-capillary membrane and movement of oxygen...
...of oxygen into and carbon dioxide out...
...dioxide out of the alveoli. 7. When...
...naturally moves toward the diaphragm, which results...
...air movement into the bases and peripheral...
...into the bases and peripheral lung during...
...perfusion greatest in the dependent areas of...
...dependent areas of the lungs. 9. Because...
...9. Because ventilation and perfusion are both...
...both greatest in the bases of the...
...the bases of the lungs, the greatest...
...of the lungs, the greatest amount of...
...this portion of the lung fields. 10....
...moderate alveolar ventilation and significantly reduced perfusion...
...V/Q ratio. 12. The clinical significance of...
...will shift from the lung bases to...
...area is in the dependent position while...
...be drawn toward the diaphragm. Pulmonary Shunt...
...shunt refers to the percentage of cardiac...
...that flows from the right heart and...
...the right heart and back into the...
...and back into the left heart without...
...problems in ventilation and perfusion originate. 4....
...true shunts: anatomic and capillary Anatomic Shunt...
...that flows through the lungs participates in...
...from right heart and back into left...
...of emptying of the bronchial and several...
...of the bronchial and several other veins...
...other veins into the lung’s own venous...
...Capillary shunt is the normal flow of...
...Blood flowing by the affected units will...
...or fluid in the alveoli. Absolute Shunt...
...Absolute Shunt 1. The combined amount of...
...of anatomic shunt and capillary shunt is...
...absolute shunt. a) The total percentage of...
...true shunt because the shunting is not...
...admixture refers to the effect that pulmonary...
...shunt has on the contents of the...
...the contents of the blood as it...
...it drains into the left heart and...
...the left heart and out into the...
...and out into the system as arterial...
...blood. 2. Beyond the shunted areas, the...
...the shunted areas, the fully reoxygenated blood...
...blood mixes with the completely or relatively...
...unoxygenated blood. 3. The oxygen molecules remix...
...molecules remix in the combined blood to...
...Intrapulmonary Shunt 1. The simplest way to...
...is by calculating the P/F ratio (PaO2/FIO2)....
...best used when the patient’s PaCO2 is...
...1. PVR measures the resistance to blood...
...blood flow in the pulmonary vascular system,...
...main factors determine the amount of pulmonary...
...pulmonary resistance: a) The length of the...
...The length of the vessels b) The...
...the vessels b) The radius of the...
...The radius of the vessels c) The...
...the vessels c) The viscosity of the...
...The viscosity of the blood (1) Of...
...Of these factors, the major determinant of...
...altered by: (a) The volume of blood...
...of blood in the pulmonary vascular system...
...vascular system (b) The amount of vasoconstriction...
...of vasoconstriction (c) The degree of lung...
...Factors related to the volume of blood...
...of blood in the pulmonary vascular system...
...include capillary recruitment and distention. a) Recruitment...
...most influential. (1) The small pulmonary capillaries...
...low (e.g., shock), the smaller capillaries can...
...(1) By distending, the capillaries can accommodate...
...capillaries can accommodate the increased flow. (2)...
...to hypoxia, hypercapnia, and acidosis. a) Vasoconstriction...
...increased PVR in the high-acuity patient. b)...
...b) Hypoxia is the strongest stimulant for...
...an area of the lung becomes hypoxic,...
...functional areas of the lungs and results...
...of the lungs and results in reduction...
...decreases their diameter and increases PVR. b)...
...artery catheter. a) The calculation measures resistance,...
...function of pressure and flow. b) Pressure...
...pulmonary artery pressure and pulmonary capillary wedge...
...right ventricular hypertrophy and dilation secondary to...
...of both restrictive and obstructive pulmonary diseases....
...right heart failure and is a major...
...IV. Acid–Base Physiology and Disturbances 1. Acid-base...
...is crucial to the effective functioning of...
...reacts with acids and bases to maintain...
...concentration lowers pH and increases acidity. b)...
...concentration increases pH and increases alkalinity. 7....
...include volatile acids and nonvolatile acids. a)...
...for excretion from the lungs. b) Nonvolatile...
...be excreted through the kidneys. (1) The...
...the kidneys. (1) The kidneys are capable...
...acid each day, and they respond slowly...
...are excreted in the proximal and distal...
...in the proximal and distal tubules of...
...distal tubules of the kidneys in exchange...
...Balance: Buffer Systems and Compensation 1. Buffer...
...reactions between acids and bases to maintain...
...hydrogen ions (H+), and acids react with...
...in pH. c) The buffering mechanisms are...
...2. Compensation a) The process whereby an...
...in terms of the degree or level...
...level to which the body has achieved...
...Uncompensated (acute) (a) The pH is abnormal...
...because other buffer and regulatory mechanisms have...
...begun to correct the balance. (2) Partially...
...Partially compensated (a) The pH is abnormal,...
...but body buffers and regulatory mechanisms have...
...Compensated (chronic) (a) The pH has returned...
...buffer system is the major buffering system...
...buffering system in the body. 2. Its...
...are regulated by the lungs (CO2) and...
...the lungs (CO2) and kidneys (HCO3). 3....
...hemoglobin, serum proteins, and the phosphate system....
...serum proteins, and the phosphate system. 4....
...phosphate system. 4. The bicarbonate system is...
...to days. 5. The metabolic compensation mechanism...
...compensation mechanism controls the rate of elimination...
...reabsorption of hydrogen and bicarbonate ions in...
...bicarbonate ions in the kidney. 6. With...
...loads, H+ elimination and bicarbonate reabsorption are...
...H+ is reabsorbed, and HCO3 is excreted....
...Compensation Mechanism 1. The respiratory buffer system...
...within minutes. 2. The lungs have two...
...in changes in the PaCO2. a) Normal...
...1. Occurs when the PaCO2 moves above...
...above 45 mmHg and the pH drops...
...45 mmHg and the pH drops below...
...alveolar hypoventilation. a) The lungs are not...
...cause of hypoventilation and correct it when...
...over many years; the body can compensate...
...pH by elevating the bicarbonate. 6. Additional...
...treatment involves determining the cause of the...
...the cause of the hyperventilation and providing...
...of the hyperventilation and providing the necessary...
...hyperventilation and providing the necessary intervention. 5....
...alkalosis is uncommon. The same factors causing...
...chronic state if the problem remained uncorrected....
...A measure of the amount of buffer...
...required to return the blood to a...
...is present if the BE is greater...
...mEq/L. a) Signals the presence of a...
...mEq/L. a) Signals the presence of a...
...from cellular breakdown and anaerobic metabolism. 2....
...anaerobic metabolism. 2. The normal range for...
...associated with shock and other severe physiologic...
...precedes decompensatory signs and can be an...
...trauma, diabetic ketoacidosis, and hepatic failure. Metabolic...
...pH > 7.45, and a base excess...
...1 Acid–Base Physiology and Disturbances Acid-base physiology...
...Balance: Buffer Systems and Compensation Metabolic (Renal)...
...on patient’s acid-base and oxygenation status. 2....
...oxygenation status. 2. The following section focuses...
...section focuses on the determinants of oxygenation...
...of oxygenation status and interpretation of the...
...and interpretation of the entire ABG. A....
...1. This represents the partial pressure of...
...partial pressure of the oxygen dissolved in...
...80–100 mmHg), not the total amount of...
...oxygenation because PaO2 and oxygen saturation (SaO2)...
...is reflected in the oxyhemoglobin dissociation curve....
...dissociation curve. SaO2 and SpO2 1. Oxygen...
...saturation (SaO2) is the measure of the...
...the measure of the percentage of oxygen...
...hemoglobin compared with the total amount it...
...> 95%). 2. The degree of saturation...
...important in determining the amount of oxygen...
...for delivery to the tissues. Hemoglobin 1....
...or Hb is the major component of...
...composed of protein and heme, which contains...
...Oxygen binds to the iron atoms on...
...iron atoms on the four heme groups...
...4. Hemoglobin is the major carrier of...
...of oxygen in the blood and is...
...in the blood and is an important...
...air (21% oxygen), and a blood temperature...
...approximately 25–30% (in the 30- to 80-year...
...with other values, and incorporated into the...
...and incorporated into the overall clinical picture....
...level of compensation, and oxygenation status. 4....
...oxygenation status. 4. The severity of hypoxemia...
...or severe, but the exact associated PaO2...
...on patient’s need and person performing analysis...
...Status PaO2 SaO2 and SpO2 Slide 3...
...Respiratory Nursing History and Assessment 1. Many...
...is admitted to the hospital in acute...
...in acute distress, the nurse initially assesses...
...assesses airway, breathing, and circulation, and the...
...breathing, and circulation, and the nurse immediately...
...and circulation, and the nurse immediately takes...
...feasible, information regarding the immediate events leading...
...as to etiology and chain of events...
...events related to the current problem. 3....
...current problem. 3. The presence of severe...
...respiratory distress limits the amount of health...
...questions directed to the patient to reduce...
...1. Assess tobacco and alcohol use. a)...
...smoked per day and number of years...
...problems of pulmonary and cardiovascular etiology. 2....
...interfere with sleep and rest. 2. If...
...rest. 2. If the respiratory problem is...
...to cause hypoxia, the patient often exhibits...
...inadequate oxygenation of the brain. 3. Pulmonary...
...disorders can increase the work of breathing,...
...interfere with sleep and rest. 4. Patients...
...discomfort. 6. Dyspnea and air hunger are...
...hunger are anxiety-producing and threatening experiences for...
...obtain information about the most common respiratory...
...pain, cough, sputum, and hemoptysis. 2. Interview...
...hemoptysis. 2. Interview the patient or family...
...family (subjective data), and perform a nursing...
...1. Dyspnea is the feeling of having...
...work of breathing and supply-and-demand imbalance. a)...
...of breathing and supply-and-demand imbalance. a) The...
...supply-and-demand imbalance. a) The body’s ability to...
...in both restrictive and obstructive pulmonary disorders....
...state in which the patient assumes a...
...out of bed, the dyspnea is relieved,...
...dyspnea is relieved, and the patient can...
...is relieved, and the patient can resume...
...been congested in the lower extremities during...
...lower extremities during the day shift to...
...day shift to the heart and lungs,...
...to the heart and lungs, causing a...
...volume overload when the person becomes horizontal...
...minute, significantly increases the work of breathing....
...note how long the pain has been...
...whether it radiates, and the triggering and...
...it radiates, and the triggering and alleviating...
...and the triggering and alleviating factors. 2....
...Described as sharp and knifelike (2) When...
...between breaths or the breath is held,...
...be auscultated at the focal pain point...
...to pain. 4. The attached visceral pleurais...
...as well. 5. The parietal pleura is...
...is well innervated, and when inflammation occurs,...
...associated with pain, and increased blood pressure...
...increased blood pressure and pulse. Cough Subjective...
...congested), duration, triggers and pattern of occurrence,...
...pattern of occurrence, and alleviating factors. Objective...
...Observe strength, character, and frequency of cough....
...usual quantity, characteristics, and color, as well...
...regularly for quantity and characteristics. 2. Sputum...
...should be noted and documented. 3. Normal...
...secretions are thin and clear. Hemoptysis 1....
...causes: pulmonary embolism and cardiogenic pulmonary edema...
...includes color, consistency and quantity, and frequency...
...consistency and quantity, and frequency and duration....
...quantity, and frequency and duration. Objective data...
...consistency, quantity, frequency, and duration. Focused Respiratory...
...Respiratory Assessment 1. The onset of acute...
...can be rapid and severe. 2. The...
...and severe. 2. The nurse should be...
...assessed baseline data and data trends. 3....
...observe lips, earlobes, and beneath tongue for...
...observed on lips and tongue. 3. Cyanosis...
...shape of chest, and observe chest movement...
...movement for symmetry and rate, depth, and...
...and rate, depth, and pattern of breathing....
...for tactile fremitus and chest expansion. 7....
...most breath sounds and comparing one lung...
...one lung with the other. Normal Breath...
...Vesicular, bronchial (tubular), and bronchovesicular. Abnormal Breath...
...other breath sounds and are never normal....
...nurse should assess and document location and...
...and document location and when in respiratory...
...Conditions include: atelectasis and pneumonia (2) Coarse...
...Conditions include: bronchitis and pulmonary edema Rhonchi...
...common during expiration and are auscultated over...
...inspiration or expiration and is of long...
...heard during breathing and ceases between breaths...
...an area of the lungs. a) When...
...nurse should document the location. b) In...
...pulmonary disease (COPD) and acute asthma, generalized...
...situation. Vital Signs and Hemodynamic Values 1....
...crucial baseline data and are important indicators...
...pressure, pulse rate and rhythm, respiratory rate...
...rhythm, respiratory rate and rhythm, and temperature....
...rate and rhythm, and temperature. 3. Pulse...
...mean arterial pressure, and cardiac output. 5....
...is questioned. 6. The presence of pulmonary...
...Respiratory Nursing History and Assessment Slide 2...
...12 Vital Signs and Hemodynamic Values VII....
...status 2. Implementation and interpretation of tests...
...provide baseline data and a means to...
...pulmonary volumes, capacities, and air flow. 6....
...associated with immobility and respiratory muscle fatigue....
...volume, vital capacity, and minute ventilation. a)...
...a) Tidal volume and vital capacity help...
...a respiratory spirometer and frequently are part...
...that moves in and out of lungs...
...hypoventilation becomes severe and results in hypercapnia....
...1. VC is the maximum amount of...
...gender, height, weight, and age. 3. It...
...decreases with age and in the presence...
...age and in the presence of acute...
...Ventilation (VE) 1. The total amount of...
...to >10 L/minute, the work of breathing...
...from obstructive problems and measure airway resistance....
...not conducted at the bedside. PowerPoint Slides...
...(FEVs) VIII. Noninvasive and Invasive Monitoring of...
...as pulse oximetry and capnography are used....
...arterial oxygen saturation, and provide ready access...
...hemoglobin saturation (SpO2) and pulse rate. 2....
...differentiate between venous and arterial blood. 4....
...nose, or ear, and an oximeter provides...
...considered when choosing the best sensor location....
...status. 7. Ideally, the continuous arterial oxygen...
...oxygen readings reflect the patient’s oxygenation status...
...patient’s oxygenation status and alert the clinician...
...status and alert the clinician to subtle...
...measurements if acid–base and ventilation are not...
...factors can alter the accuracy of pulse...
...of false alarms and inaccurate readings b)...
...can compete with the pulse light source...
...lower saturation reading, and alkalosis can cause...
...of shifts in the oxyhemoglobin dissociation curve....
...from distal sites and attached to a...
...1. Capnometry is the numeric measurement of...
...2. Capnography is the noninvasive measurement of...
...value measurement called the PETCO2 (partial pressure...
...A capnogram displays the capnometry measurements as...
...by breath, throughout the breathing cycle. 7....
...used to monitor the adequacy of ventilation...
...ventilation in surgical and procedural anesthesia, postoperative...
...critical care units, and emergency departments (EDs)....
...guidelines for CPR and emergency care call...
...care call for the use of capnography...
...endotracheal tube placement and monitor the adequacy...
...placement and monitor the adequacy of ventilation...
...of ventilation 3. The Agency for Healthcare...
...for Healthcare Research and Quality (AHRQ) recommends...
...(using pulse oximetry and respiratory rate) and...
...and respiratory rate) and ventilation (using capnography)...
...(PCA) to reduce the risk of potentially...
...Other applications include the detection of mechanical...
...mechanical ventilator problems and confirmation of enteric...
...assess ventilatory status and provide an early...
...neuromuscular diseases). 6. The usefulness of bedside...
...or ventilation–perfusion abnormalities, the etco2 may not...
...correlation between Paco2 and etco2 can be...
...can be established and used for trending....
...which may limit the usefulness of etco2...
...is diverted from the main airway circuit...
...a small tube and is analyzed in...
...chamber apart from the airway circuit. a)...
...as part of the airway circuit, and...
...the airway circuit, and continuous ETCO2 directly...
...Major disadvantage: requires the patient to be...
...color based on the patient’s exhaled pH...
...commonly used in the ED to assess...
...Also used in the field by emergency...
...by emergency squads and in ICU settings....
...is attached to the ET tube following...
...following tube insertion, the patient is given...
...given six breaths, and the device is...
...six breaths, and the device is read...
...full-end expiration. 4. The device rapidly responds...
...rapidly responds to the patient’s exhaled CO2...
...(Nellcor, Boulder, CO), the detector device has...
...is not in the trachea (2) Color...
...may be in the esophagus, and patient...
...in the esophagus, and patient may have...
...properly located in the trachea 5. While...
...precise etco2 data and therefore has limited...
...has limited applications The Capnogram 1. The...
...The Capnogram 1. The pattern that is...
...is visible on the capnography screen. 2....
...arterial Paco2 at the end of the...
...the end of the plateau phase (the...
...the plateau phase (the end-tidal CO2). 3....
...a normal capnogram, the carbon dioxide concentration...
...is zero at the beginning of expiration,...
...a plateau. 4. The end-tidal carbon dioxide...
...carbon dioxide is the highest concentration at...
...highest concentration at the end of exhalation....
...is used in the clinical setting as...
...Gas Monitoring 1. The arterial catheter is...
...blood gases from the arterial line, is...
...causing additional trauma and pain to the...
...and pain to the patient from repeated...
...Capnography Slide 5 The Capnogram Slide 6...
...Classroom Activities Discuss the different mechanisms the...
...the different mechanisms the body uses to...
...acid–base imbalances. Discuss the impact on the...
...the impact on the respiratory system when...
...implemented to reduce the risk factors for...
...acid–base imbalances. Compare and contrast the oxygenation...
...Compare and contrast the oxygenation levels of...
...adult of 40, and an older adult...
...factors will change the findings between the...
...the findings between the generations? Wagner et...

...in cardiac cells and the relationship between...
...cardiac cells and the relationship between membrane...
...between membrane permeability and serum electrolyte levels....
...levels. 2. Describe the cardiac conduction system,...
...cardiac conduction system, the normal electrocardiogram (ECG)...
...electrocardiogram (ECG) complex, and nursing responsibilities for...
...nursing responsibilities for the patient who requires...
...dysrhythmias arising from the sinoatrial (SA) node...
...sinoatrial (SA) node and their treatments. 6....
...treatments. 6. Compare and contrast basic atrial...
...basic atrial dysrhythmias and their treatments. 7....
...common functional dysrhythmias and their treatments. 8....
...common ventricular dysrhythmias and their treatments. 9....
...9. Distinguish among the four conduction abnormalities,...
...as heart blocks, and their treatments. 10....
...10. Discuss pharmacologic and counter shock interventions...
...counter shock interventions and their nursing implications....
...indications for pacemaker and implantable cardio version...
...types of devices, and nursing implications for...
...nursing implications for the patient receiving these...
...myocardial cell permeability and is affected by...
...electrolytes. 2. During the resting state, the...
...the resting state, the inside of the...
...the inside of the cell is more...
...negative relative to the outside of the...
...the outside of the cell due to...
...cell due to the differences in ion...
...potential 1. Depolarization and repolarization a) The...
...and repolarization a) The transmission of electrical...
...produces changes in the myocardial cell membrane’s...
...electrical charge, stimulating the cardiac cells extending...
...cells extending across the myocardial muscle to...
...to produce contraction and relaxation. b) As...
...relaxation. b) As the cardiac cell receives...
...in cardiac depolarization and repolarization of the...
...and repolarization of the cardiac muscle. 2....
...a) Depolarization (Phase 0)—the cell is almost...
...b) Repolarization (Phases 1–3)—the process of repolarization...
...phases 1, 2, and 3. c) Resting...
...potential (Phase 4)—during the resting membrane potential...
...repolarization is completed, the original electrochemical gradient...
...is in place, and the cell is...
...in place, and the cell is ready...
...again. 3. Refractory and supranormal periods a)...
...a) Absolute refractory period—the cell cannot respond...
...stimulus regardless of the strength of the...
...the strength of the stimulus. b) Relative...
...b) Relative refractory period—the cell is relatively...
...by electrolytes. Sodium and potassium main cations....
...is greater inside the cell. Sodium concentration...
...is greater outside the cell. Calcium concentration...
...is greater outside the cell. Produces intracellular...
...cycle 4. Refractory and Supernormal Periods Absolute...
...Produces changes in the cell’s membrane electrical...
...II. Cardiac Conduction and the Electrocardiogram 1....
...Cardiac Conduction and the Electrocardiogram 1. The...
...the Electrocardiogram 1. The cardiac cycle is...
...electrical circuit in the myocardium, where specialized...
...myocardial cells influence the electrical conduction pathway....
...Electrical conduction of the heart 1. The...
...the heart 1. The primary pacemaker of...
...primary pacemaker of the heart is the...
...the heart is the sinoatrial (SA) node,...
...node, which controls the heart rate normally...
...normally between 60 and 100 beats per...
...per minute (bpm). The impulse from the...
...The impulse from the SA node is...
...transmitted: a) From the atria b) To...
...atria b) To the ventricles c) Along...
...conduction pathway 2. The normal conduction pathway...
...conduction pathway a) The impulse from the...
...The impulse from the SA node is...
...transmitted: (1) From the atria (2) To...
...atria (2) To the ventricles (3) Along...
...b) Starting at the SA node, the...
...the SA node, the conduction pathways continues:...
...continues: (1) To the atrial-ventricular (AV) node...
...node (2) To the bundle of His...
...(3) Proceeding along the left and right...
...along the left and right bundle branches...
...(4) Terminating at the Purkinje fibers (5)...
...muscle cells B. The electrocardiogram 1. The...
...The electrocardiogram 1. The Normal ECG Pattern....
...a) P wave and PR interval. b)...
...c) ST segment and T wave d)...
...accurate cardiac monitoring, and lead placement is...
...is verified by the nurse at the...
...the nurse at the beginning of each...
...ECG. F. Patient and family education 1....
...Electrical Conduction of the Heart Intrinsic electrical...
...Conduction Pathway 4. The Electrocardiogram (ECG) Represents...
...Interpretation Guidelines 1. The ECG is printed...
...small block of the graph paper being...
...0.04 seconds on the horizontal axis. The...
...the horizontal axis. The horizontal axis also...
...also represents time. The vertical axis of...
...vertical axis of the graph paper represents...
...(0.1 mV) on the vertical axis. For...
...interpretation, time is the most important factor...
...R–R interval, examine the P wave, measure...
...P wave, measure the PR interval, determine...
...QRS complex, examine and measure the QRS...
...examine and measure the QRS complex, examine...
...QRS complex, examine and measure the QT...
...examine and measure the QT interval, and...
...the QT interval, and diagnose/interpret the rhythm....
...interval, and diagnose/interpret the rhythm. A. ECG...
...paper B. Measure the heart rate C....
...rate C. Examine the R–R intervals D....
...intervals D. Examine the P waves E....
...waves E. Measure the PR interval F....
...QRS G. Examine and measure the QRS...
...Examine and measure the QRS complex H....
...complex H. Measure the QT interval I....
...interval I. Diagnose the rhythm J. Clinical...
...both healthy hearts and diseased hearts. 2....
...both healthy hearts and diseased hearts. 4....
...heart rhythms Normal and abnormal cardiac events...
...are Prone to the Development of Dysrhythmias....
...it originates in the SA node. It...
...lethal ventricular dysrhythmias and can be treated...
...medication that blocks the parasympathetic innervations to...
...parasympathetic innervations to the SA node. B....
...100 to 150, and is not associated...
...produce angina if the cardiac output decreases...
...output decreases to the point of reducing...
...aimed at relieving the cause of increased...
...increased sympathetic stimulation and can include imagery,...
...include imagery, distraction, and drug therapy. 2....
...of atrial dysfunction, and can even require...
...ectopic impulses within the atria. They may...
...may develop when the SA node is...
...foci) develops in the atria. A. Premature...
...pacemakers located in the atria B. Supraventricular...
...rate between 150 and 250. The rhythm...
...150 and 250. The rhythm is regular;...
...is regular; however, the P waves are...
...are buried in the preceding T wave....
...complex indicates that the ectopic pacemaker is...
...is located above the ventricles. 2. Treatment...
...Valsalva’s maneuver to the use of calcium...
...than 250 bpm. The ventricular rate depends...
...rate depends on the number of impulses...
...that pass through the AV node. D....
...condition in which the atria are contracting...
...Rate between 150 and 250 Regular rhythm...
...waves Described by the number of atrial...
...dysrhythmias occur because the SA node fails...
...to fire, so the AV node initiates...
...AV node initiates the impulses. The junctional...
...initiates the impulses. The junctional area is...
...is located around the AV node. 2....
...Pacemaker cells around the AV node have...
...bpm. 3. Once the pacemaker cell discharges,...
...pacemaker cell discharges, the impulse spreads upward...
...upward to depolarize the atria and downward...
...depolarize the atria and downward to depolarize...
...downward to depolarize the ventricles. 4. The...
...the ventricles. 4. The QRS complex appears...
...complex appears normal, the atria are depolarized...
...abnormal manner; therefore, the P wave might...
...might be inverted. The timing of the...
...The timing of the P wave is...
...abnormal; it precedes the QRS complex, and...
...the QRS complex, and the PR interval...
...QRS complex, and the PR interval is...
...than 0.12 seconds. The P wave also...
...be buried in the QRS complex, and...
...the QRS complex, and might not be...
...or might follow the QRS complex. 5....
...100 bpm. If the rate is between...
...is between 60 and 100, it is...
...on patient symptomology and can consist of...
...of drug therapy and/or the insertion of...
...drug therapy and/or the insertion of a...
...that originate in the ventricle and can...
...in the ventricle and can be life-threatening....
...from loss of the atrial kick from...
...from backwards depolarization and from pushing ventricular...
...that originate in the ventricle and discharge...
...in the ventricle and discharge before the...
...and discharge before the next normal sinus...
...During ECG interpretation, the nurse assesses and...
...the nurse assesses and describes the patient’s...
...assesses and describes the patient’s underlying cardiac...
...underlying cardiac rhythm and the type of...
...cardiac rhythm and the type of PVCs...
...major responsibility of the nurse is to...
...is to assess the patient for factors...
...that contribute to the development of PVCs...
...development of PVCs and the presence of...
...of PVCs and the presence of specific...
...ventricular tachycardia (VT) and ventricular fibrillation (VF)....
...respiratory therapists, pharmacists, and physicians. C. Ventricular...
...fatal rhythm, is the most common cause...
...2. Defibrillation is the treatment of choice...
...or vasopressin. If the patient remains pulseless,...
...remains pulseless, CPR and attempts at defibrillation...
...of electrical impulses. The patient is unconscious...
...patient is unconscious and pulseless. 2. It...
...is imperative that the nurse check that...
...nurse check that the rhythm is verified...
...5. Ventricular Fibrillation The most common cause...
...arrest. Defibrillation is the treatment of choice...
...inhibited anywhere along the conduction pathway. Factors...
...digitalis, antiarrhythmic agents, and increased parasympathetic activity....
...activity. 2. When the delay occurs at...
...delay occurs at the antrioventricular (AV) node...
...have three classifications, and are based on...
...are based on the relationship of the...
...the relationship of the P wave to...
...P wave to the QRS complex. A....
...in conduction through the AV node; the...
...the AV node; the remainder of the...
...the remainder of the ECG is normal....
...asymptomatic; however, in the presence of acute...
...delay can increase and can lead to...
...is present, but the PR interval is...
...block, Mobitz I and Mobitz II. a)...
...constant before dropping the QRS complex. Nursing...
...management depends on the degree of block...
...degree of block and symptoms indicative of...
...are exhibited by the patient. c) Management...
...emergency treatment, because the atria and ventricles...
...because the atria and ventricles are contracting...
...inadequate filling of the ventricles. No impulses...
...are conducted through the AV node. The...
...the AV node. The atria and ventricles...
...node. The atria and ventricles fire at...
...regular, as is the R–R wave interval,...
...wave interval, but the PR intervals vary....
...no relationship between the P wave and...
...the P wave and the QRS complex,...
...P wave and the QRS complex, because...
...QRS complex, because the atria and the...
...because the atria and the ventricles are...
...the atria and the ventricles are paced...
...a separate pacemaker. The QRS complex is...
...wide because of the ventricular origin of...
...ventricular origin of the stimulus. In rare...
...In rare cases, the ventricular rate is...
...heart block is the same as for...
...in conduction through the bundle of His...
...blocked. Occurs in the AV nodal area....
...third-degree AV block and asystole. Management 4....
...emergency treatment. Atria and ventricles are contracting...
...not conducted through the AV node. Atria...
...AV node. Atria and ventricles fire at...
...single unit. P–P and R–R wave interval...
...No relationship between the P wave and...
...the P wave and QRS complex. Wide...
...in conduction through the bundle of His...
...Conduction through right and left bundle branches...
...travels slowly through the blocked side. 12-lead...
...necessary. X. Pharmacologic and Countershock Interventions and...
...and Countershock Interventions and Nursing Implications A....
...through class IV, and are classified according...
...their effects during the slow and fast...
...during the slow and fast action potentials....
...are summarized in the box called “Related...
...impulse conduction through the atria, ventricles, and...
...the atria, ventricles, and the bundle of...
...atria, ventricles, and the bundle of His....
...by reducing automaticity and prolonging the refractory...
...automaticity and prolonging the refractory period of...
...refractory period of the heart. They are...
...are indicated in the treatment of supraventricular...
...treatment of supraventricular and ventricular dysrhythmias. (2)...
...a great extent, and are used chiefly...
...used chiefly in the treatment of ventricular...
...delay ventricular repolarization, and are used as...
...II agents block the effects of catecholamines...
...SA node automaticity and slow AV conduction...
...AV conduction velocity and myocardial contractility. Their...
...(1) Most of the class II agents...
...are beta-blocking agents, and decrease cardiac stimulation,...
...decrease cardiac stimulation, and can produce vasodilation...
...can produce vasodilation and bronchoconstriction. Drugs in...
...failure, significant bradycardia, and second-degree or higher...
...II drugs decrease the heart rate, the...
...the heart rate, the heart rate might...
...thereby delaying repolarization and prolonging the refractory...
...repolarization and prolonging the refractory period. They...
...period. They increase the fibrillation threshold (making...
...fibrillation threshold (making the cell more resistant)...
...cell more resistant) and are indicated in...
...are indicated in the treatment of atrial...
...treatment of atrial and ventricular dysrhythmias. 5....
...These drugs block the entry of calcium...
...of calcium through the cell membranes, thereby...
...depolarization. Automaticity in the SA node is...
...conduction is slowed, and overall decrease in...
...IV agents. Verapamil and Diltiazem are calcium...
...agents  a) Adenosine and digoxin do not...
...not fit within the four major classes....
...as an antiarrhythmic and is first-line therapy...
...a cardiac glycoside and inotropic agent. It...
...tachycardia, atrial fibrillation, and atrial flutter. 7....
...any antiarrhythmic agent, the nurse assesses the...
...the nurse assesses the following baseline data:...
...ECG interpretation using the seven-step process b)...
...Physical assessment of the cardiac, respiratory, and...
...the cardiac, respiratory, and neurologic systems B....
...is synchronized with the patient’s heart rhythm....
...or atrial flutter, and ventricular tachycardia in...
...In preparation for the procedure, the nurse...
...for the procedure, the nurse obtains informed...
...obtains informed consent and educates the patient...
...consent and educates the patient as to...
...patient as to the purpose of the...
...the purpose of the cardioversion and what...
...of the cardioversion and what to expect...
...an unresponsive patient and ventricular fibrillation. Defibrillation...
...again depending on the type of defibrillator...
...II Agents Block the effects of catecholamines....
...AV conduction, velocity, and myocardial contractility. Four...
...interval. Treat atrial and ventricular dysrhythmias. 5....
...electrical stimulus to the heart when the...
...the heart when the heart fails to...
...cardiac output. a) The pulse generator is...
...electrical stimulus to the heart when necessary....
...exists: failure of the conduction system, failure...
...mechanisms: external, epicardial, and endocardial. 2. External...
...electric impulses to the myocardium transthoracically through...
...pads placed anteriorly and posteriorly on the...
...and posteriorly on the chest. b) This...
...painful experience for the patient, who should...
...medicated accordingly. c) The presence of an...
...an adequate pulse and blood pressure demonstrates...
...placed directly on the surface of the...
...the surface of the heart. b) Affixed...
...b) Affixed to the epicardium, the pacing...
...to the epicardium, the pacing wires are...
...are brought through the skin (below the...
...the skin (below the sternum) for access....
...electrical stimulation of the right ventricular or...
...direct insertion of the pacing wire or...
...port c) When the procedure is complete,...
...proper placement of the lead wire in...
...addition to assuring the patient did not...
...experience complications from the central line placement...
...d) Caring for the transvenous pacing wire...
...transvenous pacing wire and site is done...
...tissue pocket (above the muscles and ribs,...
...(above the muscles and ribs, below the...
...and ribs, below the clavicle) in the...
...the clavicle) in the chest wall. b)...
...chest wall. b) The leads are passed...
...passed transvenously into the heart and rest...
...into the heart and rest on the...
...and rest on the endocardium. c) The...
...the endocardium. c) The generator is a...
...contains a battery and is programmed according...
...programmed according to the needs of the...
...the needs of the patient (Fig. 8-38)....
...Ventricle— Pacemakers have the ability to pace...
...ability to pace the atrium, the ventricle,...
...pace the atrium, the ventricle, or both...
...sequential”) chamber. 2. Atrium—The atria can also...
...also be paced and can be noted...
...be noted on the ECG rhythm strip...
...appears just before the wave. This method...
...of pacing, both the atria and the...
...both the atria and the ventricles are...
...the atria and the ventricles are paced...
...Spikes appear before the wave and the...
...before the wave and the QRS complex...
...the wave and the QRS complex on...
...QRS complex on the ECG. C. Pacemaker...
...1. Pacemakers have the capability of sensing...
...generated) electrical activity and may be either...
...be set into the device. Pacemakers have...
...settings: sensitivity, output, and rate. E. Pacemaker...
...electrical events in the heart. There are...
...modes: triggered, inhibited, and double. F. Pacing...
...Pacing problems 1. The number of times...
...number of times the pacemaker fires is...
...is determined by the sensitivity setting of...
...sensitivity setting of the pacemaker. If the...
...the pacemaker. If the sensitivity is too...
...is too low, the pacemaker may not...
...may not sense the patient’s own cardiac...
...cardiac electrical activity and will pace more...
...more frequently. If the sensitivity is too...
...is too high, the pacemaker is better...
...able to sense the patient’s own cardiac...
...cardiac electrical activity and is inhibited from...
...to describe how the device functions according...
...according to where the pacing leads are...
...pacing leads are and the mode of...
...leads are and the mode of pacing....
...of cardiomyopathy. b) The device is a...
...designed to recognize and terminate ventricular tachyarrhythmias...
...Patients must understand the difference between heart...
...between heart attack and cardiac arrest. e)...
...cardiac arrest. e) The ICD does not...
...Patient education a) The patient is taught...
...is taught that the ICD can “reorganize”...
...well as stimulate the heart. (Pacemaker action...
...received, activities before and after treatment, symptoms,...
...after treatment, symptoms, and response after shock....
...care, including preparing the patient for insertion...
...pacemaker or applying and using an external...
...electrical stimulus to the heart Used when...
...electrical stimulus to the myocardial cells Used...
...different areas of the heart. Most common...
...Designed to recognize and terminate ventricular tachyarrhythmias...
...Distinguish between VT and VF Provide backup...
...by both medical and non-medical personnel Taught...
...Classroom Activities Have the students practice identifying...
...ECG wave forms, and identifying and measuring...
...forms, and identifying and measuring intervals and...
...and measuring intervals and complexes associated with...
...ventricular contractions using the seven steps in...
...predisposing factors for the development of premature...
...Clinical Activities Have the students obtain ECG...
...from several patients and practice wave form...
...wave form identification and interval and complex...
...identification and interval and complex measurements. Discuss...
...predisposing factors for the development of ventricular...

...Acute Pain in the High-Acuity Patient Objectives:...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...Describe potential sources and effects of pain....
...acute pain in the high-acuity adult patient...
...of pain for the high-acuity adult patient....
...focused assessments of the patient receiving opioid...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...International Association for the Study of Pain...
...“An unpleasant sensory and emotional experience associated...
...2. Differentiating nociception and pain. a) Nociception...
...pain continually changing and transient. (2) Rapid...
...(2) Rapid onset and relatively brief duration...
...of pain 1. The multifaceted conceptualization of...
...is based on the theoretical model by...
...model by Loeser and Cousins (1990), which...
...nociception, pain, suffering, and pain behaviors 2....
...pain behaviors 2. The First Facet: Nociception—refers...
...Facet: Nociception—refers to the activation of special...
...activate nociceptors in the affected tissue. a)...
...(2) Begins in the peripheral nervous system...
...peripheral nervous system and initiates the exchange...
...system and initiates the exchange of sodium...
...exchange of sodium and potassium across the...
...and potassium across the neuronal membranes, causing...
...to conduction of the pain impulse through...
...pain impulse through the nervous system once...
...small in diameter and are myelinated, conducting...
...impulses rapidly along the myelin sheath, causing...
...slow conduction rate and transmission of deep...
...(2) Role of the central nervous system...
...pain. (i) Periventricular and periaqueductal gray (PAG)...
...(i) Can decrease the patient’s pain threshold,...
...be more intense and to prolong the...
...and to prolong the duration of pain....
...sensitization (i) Is the increased excitability of...
...of neurons in the CNS and is...
...in the CNS and is a complex...
...c) Modulation (1) The body’s attempt to...
...such as pain and stress. (2) Analgesic...
...perception refers to the patient’s subjective experience...
...subjective experience surrounding the pain. 3. The...
...the pain. 3. The second facet: Pain...
...are transmitted to the brain along multiple...
...pathy). b) Neospinothalamic and paleospinothalamic tract (1)...
...primarily transmit thermal and mechanical pain. (2)...
...(3) Upon reaching the lamina marginalis in...
...lamina marginalis in the dorsal horn, the...
...the dorsal horn, the impulse excites second-order...
...excites second-order neurons and immediately crosses to...
...immediately crosses to the opposite side of...
...opposite side of the spinal cord. (4)...
...broad area of the brainstem. c) Person...
...(1) Transmission of the noxious stimulus terminates...
...stimulus terminates within the brain. d) Unknown...
...d) Unknown whether the patient’s ability to...
...chemically altered. 4. The third facet: Suffering...
...nervous centers of the brain. b) Closely...
...Closely connected to the personal meaning of...
...personal meaning of the pain. c) Clinician’s...
...chronic pain. 5. The fourth facet: Pain...
...lessen or control the pain PowerPoint Slides...
...PowerPoint Slides 1. The International Association for...
...International Association for the Study of Pain...
...“an unpleasant sensory and emotional experience associated...
...2. Differentiating nociception and pain Nociception Physiological...
...that patient. 3. The first facet: Nociception...
...to pain. Periventricular and periaqueductal gray areas...
...Beta-endorphins Dynorphins 8. The Second Facet: Pain:...
...are transmitted to the brain along multiple...
...Paleospinothalamic tract 9. The Third Facet: Suffering...
...Closely connected to the personal meaning of...
...personal meaning of the pain Clinician’s assessment...
...Chronic pain 10. The Fourth Facet: Pain...
...Acute Pain in the High-Acuity Patient A....
...Acute pain of the initial insult. (1)...
...b) Invasive lines and tubes irritate delicate...
...intravenous lines, endotracheal and tracheostomy tubes c)...
...skin, muscle, joints, and tendons 2. Visceral...
...of receptors in the viscera 3. Neuropathic...
...signal processing in the nervous system C....
...nervous system C. The effects of stress...
...effects of stress and pain on the...
...and pain on the body 1. Tissue...
...muscle spasm. 2. The stress response is...
...events that increase the body’s chances of...
...organ damage. When the sympathetic nervous system...
...Pulmonary complications (atelectasis and stasis pneumonia) (1)...
...Acute pain of the initial insult Invasive...
...chronic conditions 2. The three major types...
...Stress associated with the hospital environment 4....
...home. B. Unidimensional and multidimensional pain assessment...
...useful in evaluating the effectiveness of interventions,...
...simple to use, and take little time...
...(3) Patient self-reports the level of pain...
...10 cm). (4) The point is then...
...(1) Variation of the VAS. (2) Uses...
...numbers from which the patient chooses. (3)...
...(3) Most common and clinically proven NRS...
...proven NRS is the 0–10 scale. (4)...
...= “no pain” and 10 = “worst...
...within any of the pain dimensions (2)...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...with both children and adults (2) Consists...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Assessment Tool for the Severely Ill Patient...
...VAS to indicate the “point.” b) Point...
...b) Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. c) Raise the number of fingers...
...fingers that indicate the level of pain:...
...Pain Assessment provides the patient with a...
...means to expresses the affective and evaluative...
...expresses the affective and evaluative aspects of...
...evaluative aspects of the pain experience. a)...
...measurement of sensory and affective pain. b)...
...from which category the pain is originating...
...of pain in the adult with altered...
...Patients rely on the nurse to advocate...
...nurse to advocate and intervene for them....
...c) Review of the patient’s medical history...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...coping skills. e) The patient’s use of...
...use of distraction and relaxation techniques can...
...(cues) to indicate the presence of pain....
...Vocal: crying, moaning, and grunting b) Facial:...
...agitation, stiffening, rocking, and tapping 4. Acute...
...with stimulation of the sympathetic nervous system...
...useful in evaluating the effectiveness of interventions...
...Simple to use, and take little time...
...tools Patient expresses the affective and evaluative...
...expresses the affective and evaluative aspects of...
...evaluative aspects of the pain experience. Work...
...imaginable.” Patient self-reports the level of pain...
...along this line. The point is then...
...(NRS) Variation of the VAS. Uses a...
...numbers from which the patient chooses. Most...
...chooses. Most common and clinically proven NRS...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...with both children and adults Consists of...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...the scale for the severely ill patient....
...VAS to indicate the “point.” Point to...
...“point.” Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. Raise up the number of fingers...
...fingers that indicates the level of pain....
...measurement of sensory and affective pain. Measures...
...from which category the pain is originating....
...Patients rely on the nurse to advocate...
...nurse to advocate and intervene for them....
...them. Review of the patient’s medical history...
...(cues) to indicate the presence of pain....
...agitation, stiffening, rocking, and tapping 12. Acute...
...with stimulation of the sympathetic nervous system...
...pain. Use of the sympathetic response criteria...
...pain management 1. The World Health Organization...
...choices based on the level of pain:...
...working peripherally at the site of injury....
...combination of opioid and nonopioid therapy. (1)...
...addition to opioid and nonopioid analgesics (4)...
...Note: Dosing needs and analgesic response vary...
...use of subcutaneous and intramuscular routes is...
...time between injection and absorption. c) Intraspinal...
...in combination (6) The epidural route (a)...
...small catheter into the space located just...
...located just before the dura mater. (b)...
...combination. (d) Minimizes the potential for side...
...small catheter into the cerebrospinal fluid (CSF)...
...Opioid flows through the CSF and rapidly...
...through the CSF and rapidly binds to...
...nerve path transmitting the pain is located)...
...injected medial to the point of pain...
...(2) Duration of the analgesia depends on...
...analgesia depends on the half-life of the...
...the half-life of the local anesthetic. (3)...
...nerves medial to the insertion site of...
...is placed into the pleural space, and...
...the pleural space, and a local anesthetic...
...to incorporate into the care plan. b)...
...Choices based on the level of pain...
...by combining opioid and nonopioid Better level...
...addition to opioids and nonopioids 5. Opioid...
...Note: Dosing needs and analgesic response vary...
...use of sc and intramuscular routes is...
...time between injection and absorption. 9. Intravenous...
...of analgesic. Minimizes the potential for side...
...Small catheter into the CSF space. Opioid...
...Opioid flows through the CSF, binds to...
...Duration depends on the half-life of the...
...the half-life of the local anesthetic. 14....
...catheter placed in the pleural space. Local...
...is multifactorial (social and health care system...
...b) Clinical, human, and economic consequences of...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...are less than the duration of action...
...Administering less than the physician orders (2)...
...Taking less than the amount prescribed (4)...
...Refusing to take the drug at all...
...dependence). a) Probably the major cause of...
...interval or increasing the dose. 5. Fear...
...depression a) Physicians and nurses fear respiratory...
...depression. b) In the majority of hospitalized...
...close observation of the patient’s response. (1)...
...are administered before the patient complains of...
...of analgesic in the bloodstream. c) Diminishes...
...bloodstream. c) Diminishes the likelihood of undertreatment...
...based on effects the drug is having...
...than based on the milligrams being administered...
...b) Goal: Gain the desired level of...
...route of administration, and choice of drug...
...challenge Multifactorial (social and health care system...
...respiratory depression Physicians and nurses fear respiratory...
...respiratory depression. In the majority, it is...
...based on effects the drug is having....
...dose, interval, route, and choice of drug....
...variables a) Age and disease or compromise...
...variables a) Modality and level risk: (1)...
...are unfamiliar with the patients’ needs. (2)...
...communication, poor staffing and less education of...
...Sedation assessment a) The nurse’s recognition of...
...both respiratory effort and rate, relaxes pharyngeal...
...relaxes pharyngeal tone and depresses the response...
...tone and depresses the response to hypoxia...
...response to hypoxia and hypercarbia. (1) POSS...
...hypercarbia. (1) POSS and the RASS are...
...(1) POSS and the RASS are valid...
...RASS are valid and reliable tools for...
...in arterial blood and pulse rate. (2)...
...order to facilitate the identification of trends....
...changes in ventilation (the exchange of air...
...of air between the lungs and the...
...between the lungs and the atmosphere) earlier...
...the lungs and the atmosphere) earlier than...
...which simply measures the oxygen saturation of...
...only measures oxygenation and EtCO2 only measures...
...Nursing interventions 1. The plan of care...
...a greater frequency and intensity of monitoring....
...Working collaboratively with the prescribing health care...
...provider to consider the omission of, or...
...effective in reducing the risk of advancing...
...of advancing sedation and respiratory depression. 3....
...be required if the patient develops severe...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...extreme pain. c) The exact PCA opioid...
...be specified by the prescribing health care...
...policy. d) Sedatives and analgesics in large...
...frequently administered in the ICU and contribute...
...in the ICU and contribute to delirium,...
...longer hospital stay and decreased quality of...
...after discharge from the ICU. e) Decreasing...
...ICU. e) Decreasing the mean doses of...
...doses of opioids and sedative use was...
...accomplished by individualizing the care of each...
...Opioid analgesia POSS and the RASS 3....
...analgesia POSS and the RASS 3. Use...
...only measures oxygenation, and EtCO2 only measures...
...Interventions Greater frequency and intensity of monitoring...
...Working collaboratively with the prescribing health care...
...reversal protocol Sedatives and analgesics in large...
...large doses Decreasing the mean doses of...
...doses of opioids and sedative use VII....
...Populations A. Pharmacology and aging 1. Several...
...abuse 2. Pharmacology and aging: a) Aging...
...to absorb, metabolize, and excrete drugs. b)...
...less body water and increased body fat....
...d) Financial factors and limited transportation can...
...about: a) Prescription and OTC preparations, OTC...
...b) Alcohol, caffeine, and tobacco use. c)...
...function of liver and kidneys has serious...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...depression, deep sedation, and intractable nausea. e)...
...must be reduced and the patient monitored...
...be reduced and the patient monitored closely....
...C. Management of the tolerant patient with...
...1. Management of the tolerant patient with...
...titrated to manage the incidence of acute...
...acute pain. d) The continuous dose and...
...The continuous dose and the incremental dose...
...continuous dose and the incremental dose can...
...Hyperalgesia a) Both the use of high...
...a prolonged time and the effects of...
...prolonged time and the effects of chronic...
...chronic pain on the CNS can produce...
...opioids only makes the pain worse. d)...
...hyperalgesia requires careful and appropriate detoxification when...
...when appropriate. D. The known active or...
...(1) Experts in the fields of pain...
...fields of pain and addiction answer “Yes”...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...(1) Pain relief–seeking and drug-seeking behaviors often...
...exist to determine the level of monitoring...
...(ORT) (2) Screener and Opioid Assessment for...
...therapy c) Evaluate and treat comorbid psychiatric...
...symptoms e) Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...b) Choose extended-release and long-acting analgesics rather...
...abuse 2. Pharmacology and the effect of...
...2. Pharmacology and the effect of aging...
...to absorb, metabolize, and excrete drugs. Older...
...less body water and increased body fat....
...history—Ask about: Prescription and OTC preparations, OTC...
...supplements Alcohol, caffeine, and tobacco use Home...
...function of liver and kidneys has serious...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...must be reduced and the patient monitored...
...be reduced and the patient monitored closely....
...monitored closely. 6. The opioid-tolerant patient—management of...
...opioid-tolerant patient—management of the tolerant patient with...
...titrated to manage the incidence of acute...
...of acute pain. The continuous dose and...
...The continuous dose and the incremental dose...
...continuous dose and the incremental dose can...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...behaviors. Pain relief–seeking and drug-seeking behaviors often...
...exist to determine the level of monitoring...
...Tool (ORT) Screener and Opioid Assessment for...
...for therapy Evaluate and treat comorbid psychiatric...
...withdrawal symptoms Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...drug. Choose extended-release and long-acting analgesics rather...
...a patent airway and responds to stimuli....
...clear understanding of the different stages of...
...assesses sedation in the intensive care unit....
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...strict policies, guidelines, and protocols. a) Age-appropriate...
...b) Necessary equipment and supplies c) Mandatory...
...with risk management and quality improvement f)...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...Do not leave the patient unattended or...
...Have knowledge of the legal liability of...
...sedation. f) Understand the principles of respiratory...
...available. 3. During the procedure. a) Continuously...
...heart rate, rhythm, and level of consciousness....
...a) Post-procedure (after the conscious sedation procedure):...
...procedure): b) Monitor the patient’s level of...
...level of consciousness and vital signs. c)...
...nausea, vomiting, intake/output, and neurovascular status. d)...
...it’s necessary for the patient to go,...
...patient to go, the nurse must accompany....
...combination of analgesics and sedatives is selected....
...intravenous lines. c) The patient’s level of...
...as indicated by the patient’s condition. E....
...conscious sedation. b) The nurse must be...
...a call to the Rapid Response Team...
...does not meet the standard. d) It...
...acceptable to continue the procedure if the...
...the procedure if the patient is oversedated....
...assesses sedation in the ICU. Sedation definitions....
...strict policies, guidelines, and protocols. Age-appropriate considerations...
...considerations Necessary equipment and supplies Mandatory education...
...with Risk Management and Quality Improvement Required...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...Have knowledge of the legal liability. Understand...
...legal liability. Understand the principles of respiratory...
...available. 6. During the conscious sedation procedure:...
...7. Post-procedure (after the conscious sedation procedure):...
...sedation procedure): Monitor the patient’s LOC and...
...the patient’s LOC and vital signs. Assess...
...wounds, nausea/vomiting, intake/output, and neurovascular status. Patient...
...combination of analgesics and sedatives needed. Medications...
...does not meet the standard. Do not...
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...psychological dependence (addiction), and opioid pseudoaddiction. Ask...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...the undertreatment of pain—and who they believed...
...a few moments and write their definition...
...definition of pain and then of pain...
...impressions. What similarities and differences are found...
...are found within the class? Suggestions for...
...pain. Ask about the four common misconceptions...
...dependence, of tolerance, and of respiratory depression....
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...management policies for the clinical facility. Discuss...
...clinical facility. Discuss the policy with the...
...the policy with the clinical group. What...
...group. What are the specific nursing responsibilities?...
...nursing responsibilities? Do the students feel they...
...they are seeing the guidelines in the...
...the guidelines in the policy upheld on...
...regular basis on the clinical unit? Wagner...

...Acute Pain in the High-Acuity Patient Objectives:...
...Objectives: 1. Explain the multidimensional nature of...
...issues related to the under treatment of...
...Describe potential sources and effects of pain....
...acute pain in the high-acuity adult patient...
...of pain for the high-acuity adult patient....
...focused assessments of the patient receiving opioid...
...populations. 8. Discuss the nursing management of...
...sedation populations. I. The Multifaceted Nature of...
...acute pain 1. The International Association for...
...International Association for the Study of Pain...
...“An unpleasant sensory and emotional experience associated...
...2. Differentiating nociception and pain. a) Nociception...
...pain continually changing and transient. (2) Rapid...
...(2) Rapid onset and relatively brief duration...
...of pain 1. The multifaceted conceptualization of...
...is based on the theoretical model by...
...model by Loeser and Cousins (1990), which...
...nociception, pain, suffering, and pain behaviors 2....
...pain behaviors 2. The First Facet: Nociception—refers...
...Facet: Nociception—refers to the activation of special...
...activate nociceptors in the affected tissue. a)...
...(2) Begins in the peripheral nervous system...
...peripheral nervous system and initiates the exchange...
...system and initiates the exchange of sodium...
...exchange of sodium and potassium across the...
...and potassium across the neuronal membranes, causing...
...to conduction of the pain impulse through...
...pain impulse through the nervous system once...
...small in diameter and are myelinated, conducting...
...impulses rapidly along the myelin sheath, causing...
...slow conduction rate and transmission of deep...
...(2) Role of the central nervous system...
...pain. (i) Periventricular and periaqueductal gray (PAG)...
...(i) Can decrease the patient’s pain threshold,...
...be more intense and to prolong the...
...and to prolong the duration of pain....
...sensitization (i) Is the increased excitability of...
...of neurons in the CNS and is...
...in the CNS and is a complex...
...c) Modulation (1) The body’s attempt to...
...such as pain and stress. (2) Analgesic...
...perception refers to the patient’s subjective experience...
...subjective experience surrounding the pain. 3. The...
...the pain. 3. The second facet: Pain...
...are transmitted to the brain along multiple...
...pathy). b) Neospinothalamic and paleospinothalamic tract (1)...
...primarily transmit thermal and mechanical pain. (2)...
...(3) Upon reaching the lamina marginalis in...
...lamina marginalis in the dorsal horn, the...
...the dorsal horn, the impulse excites second-order...
...excites second-order neurons and immediately crosses to...
...immediately crosses to the opposite side of...
...opposite side of the spinal cord. (4)...
...broad area of the brainstem. c) Person...
...(1) Transmission of the noxious stimulus terminates...
...stimulus terminates within the brain. d) Unknown...
...d) Unknown whether the patient’s ability to...
...chemically altered. 4. The third facet: Suffering...
...nervous centers of the brain. b) Closely...
...Closely connected to the personal meaning of...
...personal meaning of the pain. c) Clinician’s...
...chronic pain. 5. The fourth facet: Pain...
...lessen or control the pain PowerPoint Slides...
...PowerPoint Slides 1. The International Association for...
...International Association for the Study of Pain...
...“an unpleasant sensory and emotional experience associated...
...2. Differentiating nociception and pain Nociception Physiological...
...that patient. 3. The first facet: Nociception...
...to pain. Periventricular and periaqueductal gray areas...
...Beta-endorphins Dynorphins 8. The Second Facet: Pain:...
...are transmitted to the brain along multiple...
...Paleospinothalamic tract 9. The Third Facet: Suffering...
...Closely connected to the personal meaning of...
...personal meaning of the pain Clinician’s assessment...
...Chronic pain 10. The Fourth Facet: Pain...
...Acute Pain in the High-Acuity Patient A....
...Acute pain of the initial insult. (1)...
...b) Invasive lines and tubes irritate delicate...
...intravenous lines, endotracheal and tracheostomy tubes c)...
...skin, muscle, joints, and tendons 2. Visceral...
...of receptors in the viscera 3. Neuropathic...
...signal processing in the nervous system C....
...nervous system C. The effects of stress...
...effects of stress and pain on the...
...and pain on the body 1. Tissue...
...muscle spasm. 2. The stress response is...
...events that increase the body’s chances of...
...organ damage. When the sympathetic nervous system...
...Pulmonary complications (atelectasis and stasis pneumonia) (1)...
...Acute pain of the initial insult Invasive...
...chronic conditions 2. The three major types...
...Stress associated with the hospital environment 4....
...home. B. Unidimensional and multidimensional pain assessment...
...useful in evaluating the effectiveness of interventions,...
...simple to use, and take little time...
...(3) Patient self-reports the level of pain...
...10 cm). (4) The point is then...
...(1) Variation of the VAS. (2) Uses...
...numbers from which the patient chooses. (3)...
...(3) Most common and clinically proven NRS...
...proven NRS is the 0–10 scale. (4)...
...= “no pain” and 10 = “worst...
...within any of the pain dimensions (2)...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain: (a) E.g.,...
...choose words from the middle. d) Wong-Baker...
...with both children and adults (2) Consists...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 2. Adapting the Unidimensional Pain Assessment...
...Assessment Tool for the Severely Ill Patient...
...VAS to indicate the “point.” b) Point...
...b) Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. c) Raise the number of fingers...
...fingers that indicate the level of pain:...
...Pain Assessment provides the patient with a...
...means to expresses the affective and evaluative...
...expresses the affective and evaluative aspects of...
...evaluative aspects of the pain experience. a)...
...measurement of sensory and affective pain. b)...
...from which category the pain is originating...
...of pain in the adult with altered...
...Patients rely on the nurse to advocate...
...nurse to advocate and intervene for them....
...c) Review of the patient’s medical history...
...pain adapt to the stress response. (2)...
...frequently subjectively interpret the patient’s self-report of...
...attitudes frequently alter the assessment of pain....
...inappropriate use of the self-report tools. d)...
...self-report tools. d) The patient might be...
...coping skills. e) The patient’s use of...
...use of distraction and relaxation techniques can...
...(cues) to indicate the presence of pain....
...Vocal: crying, moaning, and grunting b) Facial:...
...agitation, stiffening, rocking, and tapping 4. Acute...
...with stimulation of the sympathetic nervous system...
...useful in evaluating the effectiveness of interventions...
...Simple to use, and take little time...
...tools Patient expresses the affective and evaluative...
...expresses the affective and evaluative aspects of...
...evaluative aspects of the pain experience. Work...
...imaginable.” Patient self-reports the level of pain...
...along this line. The point is then...
...(NRS) Variation of the VAS. Uses a...
...numbers from which the patient chooses. Most...
...chooses. Most common and clinically proven NRS...
...proven NRS is the 0–10 scale. 6....
...within any of the pain dimensions. Useful...
...Using a list, the patient chooses the...
...the patient chooses the adjective that best...
...that best describes the pain. Potential disadvantages....
...with both children and adults Consists of...
...Patient points to the face that represents...
...face that represents the current level of...
...pain 8. Adapt the scale for the...
...the scale for the severely ill patient....
...VAS to indicate the “point.” Point to...
...“point.” Point to the number on an...
...NRS or to the location on the...
...the location on the line of a...
...VAS. Raise up the number of fingers...
...fingers that indicates the level of pain....
...measurement of sensory and affective pain. Measures...
...from which category the pain is originating....
...Patients rely on the nurse to advocate...
...nurse to advocate and intervene for them....
...them. Review of the patient’s medical history...
...(cues) to indicate the presence of pain....
...agitation, stiffening, rocking, and tapping 12. Acute...
...with stimulation of the sympathetic nervous system...
...pain. Use of the sympathetic response criteria...
...pain management 1. The World Health Organization...
...choices based on the level of pain:...
...working peripherally at the site of injury....
...combination of opioid and nonopioid therapy. (1)...
...addition to opioid and nonopioid analgesics (4)...
...Note: Dosing needs and analgesic response vary...
...use of subcutaneous and intramuscular routes is...
...time between injection and absorption. c) Intraspinal...
...in combination (6) The epidural route (a)...
...small catheter into the space located just...
...located just before the dura mater. (b)...
...combination. (d) Minimizes the potential for side...
...small catheter into the cerebrospinal fluid (CSF)...
...Opioid flows through the CSF and rapidly...
...through the CSF and rapidly binds to...
...nerve path transmitting the pain is located)...
...injected medial to the point of pain...
...(2) Duration of the analgesia depends on...
...analgesia depends on the half-life of the...
...the half-life of the local anesthetic. (3)...
...nerves medial to the insertion site of...
...is placed into the pleural space, and...
...the pleural space, and a local anesthetic...
...to incorporate into the care plan. b)...
...Choices based on the level of pain...
...by combining opioid and nonopioid Better level...
...addition to opioids and nonopioids 5. Opioid...
...Note: Dosing needs and analgesic response vary...
...use of sc and intramuscular routes is...
...time between injection and absorption. 9. Intravenous...
...of analgesic. Minimizes the potential for side...
...Small catheter into the CSF space. Opioid...
...Opioid flows through the CSF, binds to...
...Duration depends on the half-life of the...
...the half-life of the local anesthetic. 14....
...catheter placed in the pleural space. Local...
...is multifactorial (social and health care system...
...b) Clinical, human, and economic consequences of...
...physical adaptation of the body to the...
...the body to the presence of opioids...
...are less than the duration of action...
...Administering less than the physician orders (2)...
...Taking less than the amount prescribed (4)...
...Refusing to take the drug at all...
...dependence). a) Probably the major cause of...
...interval or increasing the dose. 5. Fear...
...depression a) Physicians and nurses fear respiratory...
...depression. b) In the majority of hospitalized...
...close observation of the patient’s response. (1)...
...are administered before the patient complains of...
...of analgesic in the bloodstream. c) Diminishes...
...bloodstream. c) Diminishes the likelihood of undertreatment...
...based on effects the drug is having...
...than based on the milligrams being administered...
...b) Goal: Gain the desired level of...
...route of administration, and choice of drug...
...challenge Multifactorial (social and health care system...
...respiratory depression Physicians and nurses fear respiratory...
...respiratory depression. In the majority, it is...
...based on effects the drug is having....
...dose, interval, route, and choice of drug....
...variables a) Age and disease or compromise...
...variables a) Modality and level risk: (1)...
...are unfamiliar with the patients’ needs. (2)...
...communication, poor staffing and less education of...
...Sedation assessment a) The nurse’s recognition of...
...both respiratory effort and rate, relaxes pharyngeal...
...relaxes pharyngeal tone and depresses the response...
...tone and depresses the response to hypoxia...
...response to hypoxia and hypercarbia. (1) POSS...
...hypercarbia. (1) POSS and the RASS are...
...(1) POSS and the RASS are valid...
...RASS are valid and reliable tools for...
...in arterial blood and pulse rate. (2)...
...order to facilitate the identification of trends....
...changes in ventilation (the exchange of air...
...of air between the lungs and the...
...between the lungs and the atmosphere) earlier...
...the lungs and the atmosphere) earlier than...
...which simply measures the oxygen saturation of...
...only measures oxygenation and EtCO2 only measures...
...Nursing interventions 1. The plan of care...
...a greater frequency and intensity of monitoring....
...Working collaboratively with the prescribing health care...
...provider to consider the omission of, or...
...effective in reducing the risk of advancing...
...of advancing sedation and respiratory depression. 3....
...be required if the patient develops severe...
...respiratory depression. b) The half-life of naloxone...
...time during which the patient may be...
...extreme pain. c) The exact PCA opioid...
...be specified by the prescribing health care...
...policy. d) Sedatives and analgesics in large...
...frequently administered in the ICU and contribute...
...in the ICU and contribute to delirium,...
...longer hospital stay and decreased quality of...
...after discharge from the ICU. e) Decreasing...
...ICU. e) Decreasing the mean doses of...
...doses of opioids and sedative use was...
...accomplished by individualizing the care of each...
...Opioid analgesia POSS and the RASS 3....
...analgesia POSS and the RASS 3. Use...
...only measures oxygenation, and EtCO2 only measures...
...Interventions Greater frequency and intensity of monitoring...
...Working collaboratively with the prescribing health care...
...reversal protocol Sedatives and analgesics in large...
...large doses Decreasing the mean doses of...
...doses of opioids and sedative use VII....
...Populations A. Pharmacology and aging 1. Several...
...abuse 2. Pharmacology and aging: a) Aging...
...to absorb, metabolize, and excrete drugs. b)...
...less body water and increased body fat....
...d) Financial factors and limited transportation can...
...about: a) Prescription and OTC preparations, OTC...
...b) Alcohol, caffeine, and tobacco use. c)...
...function of liver and kidneys has serious...
...metabolized primarily in the liver. b) Kidneys...
...b) Kidneys have the major responsibility for...
...depression, deep sedation, and intractable nausea. e)...
...must be reduced and the patient monitored...
...be reduced and the patient monitored closely....
...C. Management of the tolerant patient with...
...1. Management of the tolerant patient with...
...titrated to manage the incidence of acute...
...acute pain. d) The continuous dose and...
...The continuous dose and the incremental dose...
...continuous dose and the incremental dose can...
...Hyperalgesia a) Both the use of high...
...a prolonged time and the effects of...
...prolonged time and the effects of chronic...
...chronic pain on the CNS can produce...
...opioids only makes the pain worse. d)...
...hyperalgesia requires careful and appropriate detoxification when...
...when appropriate. D. The known active or...
...(1) Experts in the fields of pain...
...fields of pain and addiction answer “Yes”...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...(1) Pain relief–seeking and drug-seeking behaviors often...
...exist to determine the level of monitoring...
...(ORT) (2) Screener and Opioid Assessment for...
...therapy c) Evaluate and treat comorbid psychiatric...
...symptoms e) Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. b)...
...b) Choose extended-release and long-acting analgesics rather...
...abuse 2. Pharmacology and the effect of...
...2. Pharmacology and the effect of aging...
...to absorb, metabolize, and excrete drugs. Older...
...less body water and increased body fat....
...history—Ask about: Prescription and OTC preparations, OTC...
...supplements Alcohol, caffeine, and tobacco use Home...
...function of liver and kidneys has serious...
...metabolized primarily in the liver. Kidneys have...
...liver. Kidneys have the major responsibility for...
...must be reduced and the patient monitored...
...be reduced and the patient monitored closely....
...monitored closely. 6. The opioid-tolerant patient—management of...
...opioid-tolerant patient—management of the tolerant patient with...
...titrated to manage the incidence of acute...
...of acute pain. The continuous dose and...
...The continuous dose and the incremental dose...
...continuous dose and the incremental dose can...
...substances abusers, have the right to pain...
...pain temporarily overrides the problem of addiction....
...behaviors. Pain relief–seeking and drug-seeking behaviors often...
...exist to determine the level of monitoring...
...Tool (ORT) Screener and Opioid Assessment for...
...for therapy Evaluate and treat comorbid psychiatric...
...withdrawal symptoms Consider the impact of tolerance...
...analgesics that have the same pharmacologic basis...
...pharmacologic basis as the abused drug. Choose...
...drug. Choose extended-release and long-acting analgesics rather...
...a patent airway and responds to stimuli....
...clear understanding of the different stages of...
...assesses sedation in the intensive care unit....
...being performed outside the operating room. C....
...Nursing management of the patient undergoing moderate...
...strict policies, guidelines, and protocols. a) Age-appropriate...
...b) Necessary equipment and supplies c) Mandatory...
...with risk management and quality improvement f)...
...unstable) 2. Before the procedure a) Before...
...procedure a) Before the conscious sedation procedure:...
...b) Verify that the patient has given...
...c) Verify that the physician has explained...
...physician has explained the procedure to the...
...the procedure to the patient. (1) E.g.,...
...Do not leave the patient unattended or...
...Have knowledge of the legal liability of...
...sedation. f) Understand the principles of respiratory...
...available. 3. During the procedure. a) Continuously...
...heart rate, rhythm, and level of consciousness....
...a) Post-procedure (after the conscious sedation procedure):...
...procedure): b) Monitor the patient’s level of...
...level of consciousness and vital signs. c)...
...nausea, vomiting, intake/output, and neurovascular status. d)...
...it’s necessary for the patient to go,...
...patient to go, the nurse must accompany....
...combination of analgesics and sedatives is selected....
...intravenous lines. c) The patient’s level of...
...as indicated by the patient’s condition. E....
...conscious sedation. b) The nurse must be...
...a call to the Rapid Response Team...
...does not meet the standard. d) It...
...acceptable to continue the procedure if the...
...the procedure if the patient is oversedated....
...assesses sedation in the ICU. Sedation definitions....
...strict policies, guidelines, and protocols. Age-appropriate considerations...
...considerations Necessary equipment and supplies Mandatory education...
...with Risk Management and Quality Improvement Required...
...training 5. Before the conscious sedation procedure:...
...sedation procedure: Verify the patient has given...
...informed consent. Verify the physician has explained...
...physician has explained the procedure. Do not...
...Do not leave the patient unattended. Have...
...Have knowledge of the legal liability. Understand...
...legal liability. Understand the principles of respiratory...
...available. 6. During the conscious sedation procedure:...
...7. Post-procedure (after the conscious sedation procedure):...
...sedation procedure): Monitor the patient’s LOC and...
...the patient’s LOC and vital signs. Assess...
...wounds, nausea/vomiting, intake/output, and neurovascular status. Patient...
...combination of analgesics and sedatives needed. Medications...
...does not meet the standard. Do not...
...Classroom Activities Read the original AHCPR guideline...
...definition document. Discuss the AHCPR guideline definitions...
...psychological dependence (addiction), and opioid pseudoaddiction. Ask...
...or thoughts on the undertreatment of pain,...
...have personally experienced the undertreatment of pain—and...
...the undertreatment of pain—and who they believed...
...a few moments and write their definition...
...definition of pain and then of pain...
...impressions. What similarities and differences are found...
...are found within the class? Suggestions for...
...pain. Ask about the four common misconceptions...
...dependence, of tolerance, and of respiratory depression....
...play out in the actual clinical setting—how...
...avoided, etc. Obtain the pain management policies...
...management policies for the clinical facility. Discuss...
...clinical facility. Discuss the policy with the...
...the policy with the clinical group. What...
...group. What are the specific nursing responsibilities?...
...nursing responsibilities? Do the students feel they...
...they are seeing the guidelines in the...
...the guidelines in the policy upheld on...
...regular basis on the clinical unit? Wagner...