Final Review

Question 1

What Temperature Should the Pt be Before the Apnea Test Begins

Answer 1

>34

Question 2

Confirmation of the Apnea Test

Answer 2

ALL of the following must be present

1. pH >/= 7.28
2. PaCO2 >=60 mmHg and a 20 mmHg change from baseline
3. No spontaneous efforts noted

Question 3

The Apnea Test Should Be Discontinued If

Answer 3

Spontaneous respiration noted

SpO2 <90% OR PaO2 <60 mmHg

Significant hypotension refractory to vasopressors

MAP < 60 and Systolic <90 mmHg

Question 4

What is the Purpose of the First ABG You Draw for the Apnea Test

Answer 4

To Make sure that the pt has a normal and stable ABG after you preoxygenate them

Question 5

Neurological Determination of Death

Answer 5

Testing for brain function from a known irreversible cause

Ex, Apnea test

Question 6

Code 66 Breathing Criteria

Answer 6

<8 or >35

SpO2 <90% on 5 L/min O2

Question 7

Code 66 Criteria

Other

Answer 7

Urine Output <50

Worried about the pt

Question 8

Code 66 Criteria

Circultaion

Answer 8

HR <40 or >140

Systolic <90 or >200

Acute change in systolic pressure

Question 9

Categorization of Code 66 Calls

Answer 9

Will be categorized with 10 min of arrival and may change over the course of the call

Question 10

Categorization of Calls

Level 1 Call

Answer 10

The Intensivist is needed to come and help

The team not the MRHP will make this call

Question 11

Code 66 Calling Criteria

Airway

Answer 11

Threatened airway – e.g. Stridor, gasping for air

Question 12

Code 66

Level 3 Calls

Answer 12

The MRHP will alway need to be informed that a code 66 was called and have them sign off on the call

The reason for this is in the case of “silent decompensation”, the patient is the MRHPs responsibility and they should be assessing their patient.

Question 13

Criteria for Code 66

Neurological

Answer 13

GCS <8 or Decreased by 2

Sudden and Prolonged Seizures

Question 14

The Outreach Team should consider notifying the Intensivist/delegate when:

Answer 14

A higher level of intervention and/or adminssion to ICU is needed

Unsure of what to do and pt not responding to therapies

Difficult to communicate with attending staff

–Non-invasive ventilation (NIV) is required

–Cardiac or respiratory crisis is imminent

–A call has lasted more than 1 hour with no apparent resolution

–3 or more calls for the same patient

Question 15

MRHP Expectations According to Category of the Call

Answer 15

Level 1 – Provide immediate direction of care for the patient in collaboration with the Outreach Team and provide handover to the Intensivist/delegate if/when necessary.

–Level 2 - Provide immediate direction of care for the patient in collaboration with the Outreach Team

–Level 3 – May/may not involve direction of care, however, will be notified of the call.

Question 16

What are the Initial Steps when the Call is Categorized as a Code 1

Answer 16

–Immediately contact the Intensivist/delegate

–If direct contact cannot be made within 5 minutes of this categorization, a Code Blue may be called

Question 17

GCS-Motor Response

Answer 17

Score of 6-Obey Commands

Score of 5-Localized Pain: Will use other appendage to stop the painful stimulus and is higher level response as opposed to withdrawal

Score of 4-Withdrawal: Attempt to pull away from painful stimuli

Score of 3-Abnormal Flexion: Arms come up and curl and toes will curl over tends to be bilateral

Score of 2-Abnormal Extension: Arms extend and tends to be a bilateral extension

Score of 1-Flaccid: No response completely limp

Question 18

GCS-Verbal Response

Answer 18

Score of 5-Oriented

Score of 4-Confused

Score of 3-Inappropriate Words

Score of 2-Inappropriate Sounds

Score of 1-No Response

Poorly suited for patients with impaired verbal response (e.g., aphasia, hearing loss, tracheal intubation)

If intubated put a “T” after the level (e.g. 5 T) because it will affect their score as they cant score higher than 1)

Question 19

GCS-Eye Opening Response

Answer 19

Score of 4-Spontaneously

Score of 3-To Speech

Score of 2-To Pain

Score of 1-None

Question 20

Head Bobbing

Answer 20

Chin up and neck extended on inspiration

Chin falling during expiration

=Respiratory Failure

Question 21

Seesaw Respiration

Answer 21

Seesaw respiration indicted by chest retractions and abdomen expanding during inspiration

Question 22

Oxygen Therapy and Cardiac Anomalities

Answer 22

These babies may be dependant on intracardiac shunts and increased saturation will promote the constriction of these shunts

Hyperoxia can increase aortic pressure and systemic vascular resistance decreasing the cardiac index and O2 transport in children with acyanotic congenital heart disease

Question 23

Nebulizer Treatment

Answer 23

If more than one tx is needed it is common to give 3 onsective treatments

If a patient continues to be symptomatic continuous bronchodilators therapy may be delvered with a nebulizer attached to an infusion pump set to administer a bronchodilator continuously

Question 24

What is the BORG Scale

Answer 24

Exertional scale for Dyspnea and Respiratory Distress

Question 25

Transfer to Hospice

Answer 25

Patient feels/is unsafe at home Steep rapid decline over 2 weeks Gradual decline but increasing care needs with family exhaustion Death expected within 3 months

Question 26

Hospice Care

Answer 26

When remaining at home is no longer possible, and a hospital admission is no longer required 24 hr palliative care Family are included as part of the team “ to whatever extent they are comfortable” No daily accommodation fee Oxygen is provided (some costs covered by AADL) Pharmacy-Alberta Blue Cross Palliative Coverage Program (30% of the cost to a max of $25 per prescription. Lifetime maximum an individual will pay is $1000)

Question 27

End of Life Care in COPD Pt Profile

Answer 27

Very Severe Airflow obstruction (FEV1 \<0.30 % Predicted) and hyperinflation Poor functional status Poor nutritional status Older age Recurrent AECOPD Pulmonary Hypertension

Question 28

MRC Dypnea Scale

Answer 28

**Grade 0:** Only get breathless with strenous activity **Grade 1:** I get short of breath when hurrying on level grounf or walking up a slight hill **Grade 2:** On level ground I walk slower becuase of breathlessness or have to stop for breath **Grade 3:** I stop for breath after walking about 100 yeard or after a few minutes on level ground **Grade 4:** I am too breathless to leave the house

Question 29

Sudden Changes in COPD in EOL

Answer 29

SOB with any activity (eating, talking etc.) Cachectic, very frail Bilateral ankle edema Sleeping much of the day SpO2 becoming refractory to increasing oxygen

Question 30

Sudden Changes in ALS/NM in EOL

Answer 30

Swallowing Nausea/vomiting Discomfort / transferring Communication Constipation Anxiety Breathing (dyspnea) Infection Restlessness

Question 31

Medications for Dyspnea

Answer 31

Opioids e.g. morphine, fentanyl, other Lorazepam (Ativan) Midazolam (Versed)

Question 32

Medications for a Cough

Answer 32

Opioids e.g. codeine, morphine

Question 33

Medications for Retained Scretions

Answer 33

Anticholinergics e.g. glycopyrolate, scopolamine, atropine Acetylcycsteine (mucomyst)

Question 34

Dyspnea and O2 saturation in EOL

Answer 34

No correlation between dyspnea and hypoxemia in chronic diseases Asses for dyspnea on using intervention other than O2 to mange SOB O2 when already in use should be titrated carefully to manage dyspnea and not necessarily the O2 saturation.

Question 35

Pallitaive Sedation

Answer 35

Medication to induce and maintain deep sleep Purpose is to relieve symptoms when all other interventions are: 1. inadequate of providing relief OR 2. Associated with intolerable side effects OR 3. Cannot provide relief in an acceptable time frame AND When the patient is expected to die imminently

Question 36

Pallitaive Sedation Versus MAID Goal

Answer 36

**Goal** * PS: Decreased suffering * MAID: Decrease suffering

Question 37

Pallitaive Sedation Versus MAID Timeline

Answer 37

Palliative Sedation: Unpredictable MAID: Immediate

Question 38

Pallitaive Sedation Versus MAID Immediate Outcome

Answer 38

Palliative Sedation: Decreased level of consicouness MAID: Death

Question 39

Pallitaive Sedation Versus MAID Process

Answer 39

Palliative Sedation: Administration of sedation drugs, titrated to effect MAID: Administration of a lethal dose of drugs

Question 40

Pallitaive Sedation Versus MAID Intent

Answer 40

Palliative Sedation: To Sedate MAID: To Euthanize